Improving Child Survival Around the World

Improving Child Survival Around the World

Duncan Hau, MD
Assistant Professor of Clinical Pediatrics
Weill Cornell Medicine

Despite dramatic improvements in childhood mortality in recent decades, around 5 million children continue to die every year around the world. There are widespread disparities in the chance of survival of a child born today. Two regions of the world that carry the most burden in child mortality are Africa (54%) and Southern Asia (27%), which together account for 80% of the share of global under-five deaths. In sub-Saharan Africa, one child in 13 dies before the age of five and in Southern Asia, one child in 26 dies before the age of five. Infectious and communicable diseases continue to be the leading causes of death for children. While efforts to reduce mortality have focused on prevention of diseases (i.e. vaccinations and nutrition) or treatment of acute illnesses during hospitalizations, an often-neglected aspect has been care following hospital discharge.

Mortality following hospitalization often exceeds in-hospital mortality. Poor post-hospital outcomes may be explained partly by the “post-hospital syndrome”, which has been described as an acquired transient period of vulnerability following discharge. Stressors experienced during hospitalization, like sleep deprivation, poor nutrition, pain, and adverse medication effects can contribute to a vulnerable state in which a patient is more prone to deterioration after discharge. Certain risk factors for children under five make them more vulnerable to the “post-hospital syndrome”. These include young age, malnutrition, multiple previous hospitalizations, HIV infection and pneumonia. Another factor contributing to poor post-hospital outcomes is weak linkage from hospitals to primary care clinics. Most post-hospital deaths occur shortly after discharge, therefore it is critical for patients to be followed closely after leaving the hospital. Unfortunately, the COVID-19 pandemic has overstretched health systems and disrupted linkages to clinics, which makes children more vulnerable to poor health outcomes during our current pandemic. 

Moving forward, Sustainable Development Goal 3 of the United Nations is to reduce under-fives mortality to at least as low as 25 per 1,000 live births. In 2020 (the most recent data), the under-five mortality rate was 37 per 1,000 live births. One focus critical to reaching Sustainable Development Goal 3 is improving the transition from hospital to home. Cost-effective, feasible and novel interventions are needed where the burden of child mortality is greatest. A couple of interventions have shown promising results. Firstly, a post-hospital intervention study which included post-discharge referrals for follow-up visits and a discharge kit that had brief educational counseling along with preventive items (soap, a mosquito net, and oral rehydration salts) given at the time of discharge, was shown to affect care during illness recovery and lead to improved outcomes for children. Another low-cost intervention has been the use of social workers to improve linkages to care for children discharged from the hospital. Addressing this critical transition from hospital to home for children will be essential to achieving the aims of Sustainable Development Goal 3 and improving child survival around the world.




  1. United Nations Inter-agency Group for Child Mortality Estimation (UN IGME), ‘Levels & Trends in Child Mortality: Report 2021, Estimates developed by the United Nations Inter-agency Group for Child Mortality Estimation’, United Nations Children’s Fund, New York, 2021.


  1. Nemetchek B, English L, Kissoon N, et al. Paediatric postdischarge mortality in developing countries: a systematic review. BMJ Open. 2018;8(12):e023445. Published 2018 Dec 28. doi:10.1136/bmjopen-2018-023445


  1. Krumholz HM. Post-hospital syndrome--an acquired, transient condition of generalized risk. N Engl J Med. 2013;368(2):100-102. doi:10.1056/NEJMp1212324