Global Burden Report
                                                                                  Leonor Guariguata, MPH
                                                                                  Selvi Jeyaseelan, PhD

                                                                                  Editorial Committee:
                                                                                  Mychelle Farmer, MD, FAAP
                                                                                  Jonathan Klein, MD, MPH, FAAP
                                                                                  Marie Hauerslev, MD
                                                                                  Alafia Samuels, MBBS, MPH, PhD

                                                                                  © 2019, NCD Child

Table of Contents
Executive Summary                                                            3
Introduction                                                                 6
       Trends in major risk factors                                          8
       How are children vulnerable?                                          10
The Global Burden                                                            12
       Cardiovascular disease                                                13
       Cancer                                                                16
       Chronic respiratory disorders                                         19
       Diabetes                                                              22
       Mental Health                                                         24
       Injuries and Violence                                                 27
Cross-cutting issues                                                         29
       The social determinants of health                                     30
       Early life experiences                                                32
       Treatment and care                                                    34
       Systems and sustainability                                            37
Best practice and the future                                                 38
       Building for the future                                               39
       Policy Best Buys                                                      41
       The work of NCD Child                                                 43
Additional resources                                                         45

NCD Child is a global multi-stakeholder                 the health of all children, has served as NCD
coalition, championing the rights and needs of          Child Secretariat since 2014. NCD Child
children, adolescents, and young people living          continues to be a voice for the rights of
with or at risk of developing NCDs. We work             children, adolescents, and young people at risk
with health professionals, NGOs, government,            of, living with and affected by NCDs through
private donors, and most importantly, young             education, raising awareness, and broader
people, to advocate for the rights of children,         participation in the global health and
adolescents, and young people and promote               development discourse.
policies to minimize preventable death and
disability in young people. The American                For additional information on NCD Child,
Academy of Pediatrics (AAP), a US-based                 please visit, and follow us on
membership organization of 67,000                       Twitter at @NCDChild.
pediatricians and pediatric medical sub-
specialists and surgical specialists dedicated to
“For goals to be met, it is
                                                                               crucial that NCD
                                                                      prevention and risk factor
EXECUTIVE                                                                  control starts during
SUMMARY                                                                             childhood.”

     Young people under the age of twenty account              changes to the environment in which NCDs
     for more than one-third of the world’s                    develop.
     population. In 2017, more than 2.1 billion                     The key drivers of NCDs in children are
     children were affected by non-communicable                unhealthy diet, obesity, physical inactivity,
     diseases (NCDs). NCDs, a set of diseases                  alcohol and tobacco use. Risk for NCDs can be
     resulting from the interaction of a combination           established as early as life in the womb. All of
     of genetic, physiological, environmental and              these risk factors are on the rise. Three in every
     behavioral factors, present a significant burden          four adolescents are not getting enough
     on individuals, communities and economic                  exercise and 42 million children are considered
     resources. Children affected by NCDs often                obese. These contribute to increases in the
     face a lifelong challenge to manage and treat             prevalence of type 2 diabetes in youth, high
     their conditions. Much is written about NCDs              blood pressure and cholesterol.
     and premature mortality, but this definition starts            In recognition of this increasing burden,
     at 30 years of age. Indeed, children,                     heads of government and ministers of health
     adolescents and young people are increasingly             convened in 2011 for the United Nations
     affected by NCDs and this population remains              General Assembly Special Session (UNGASS)
     hidden from global surveillance, targets and              for the first ever UN High Level Meeting (HLM)
     priorities.                                               on non-communicable diseases (NCDs). They
          For many NCDs, the best option for                   committed to a set of targets for reducing what
     reducing the disease burden is prevention.                was recognized as the overwhelming and rising
     Over two thirds of the antecedents to NCDs                burden of NCDs across the globe. Since then,
     emerge during childhood and adolescence.                  leaders in government and health have
     Thus, prevention must start with children and in          reconvened to monitor progress on these
     families, working with communities to make                targets and evaluate new issues. The third HLM

                        Burden of major NCDs in children (
What are NCDs?
on NCDs was held in 2018 and continues the
important work set out to turn the tide on NCDs.        Cardiovascular disease (CVD) in
     Despite progress made in monitoring and            children can be congenital or acquired.
combating the rising trends of NCDs and their           Globally, 13.9 million children are
risk factors, many people, including children are
being left behind. Children represent a                 affected by CVD. Rheumatic heart
vulnerable group in health as they may have             disease (RHD) is the most common
limited agency to advocate for their own care, or       chronic heart disease in children.
depend on the knowledge and access to care of
a parent or guardian. They are often the most           Cancer is a leading cause of death for
vulnerable to complex issues like violence and
                                                        children and adolescents worldwide.
injuries, poverty and a lack of education. As
such, systems must be coordinated to ensure             Existing data suggests close to 6 million
the health and safety of children.                      children had cancer in 2017. This may
     Many of the risk factors increasing NCDs in        be an underestimate as many countries
children are driven by changes brought on by            do not have adequate surveillance
economic development. NCDs                              systems for childhood cancer.
disproportionately affect people in low- and
middle-income countries where more than three
quarters of global NCD deaths. Although                 Chronic respiratory disorders (CRDs),
significant gains in child survival have been           including asthma, respiratory allergies
achieved over the past 25 years, most of these          and lung diseases, are a major source of
are the result of focused efforts on reducing           disability in children. More than 108
under-5 mortality and especially in infectious          million children in 2017 were affected by
disease. Trends in NCD burden are increasing.
These shifts require a more holistic approach           CRDs. Children with CRD often
that includes all aspects of health across all          experience high rates of hospitalization.
years of life.
     In 2018, the World Health Organization             Diabetes is a condition where the body
(WHO) set the 5 x 5 framework for tackling              cannot adequately manage blood
NCDs including five diseases (cardiovascular            glucose or insulin and affects more than
disease, chronic respiratory disease, cancer,
diabetes, and mental and neurological                   8.8 million children. Children who do not
conditions) and five key risk factors (unhealthy        have access to care and essential
diet, tobacco use, harmful use of alcohol,              medicines, especially insulin, may face
physical inactivity, and air pollution). NCDs and       serious complications or early death.
their risk factors rarely exist in isolation and
reducing the burden of even one of these
                                                        Mental health disorders (MHDs) affect
elements can affect the others. Indeed, NCDs
are themselves a risk factor for developing             as many as 231 million children and
mental health disorders, whose complex                  adolescents are especially vulnerable.
determinants include: exposure to sexual                MHDs encompass a wide range of
violence, bullying, experiencing discrimination,        conditions from depression and anxiety
living in a conflict or early pregnancy.                to psychosis. Mental health can have an
     Early prevention of NCDs and their
                                                        impact throughout life, especially for
complications should be at the heart of health
policy and management. Effective policies               people living with other NCDs.
cannot ignore the importance of the social
determinants of health including gender,                Injuries affected about 131 million
socioeconomic status, age and ethnicity. These          children in 2017. Injury can be divided
social determinants are can help highlight and          into two categories: intentional or
understand inequalities in health. In general,
                                                        unintentional. Unintentional injuries
developing countries tend to have a more
limited capacity to respond to the rising NCD           account for almost 90% of all injuries
burden, leading to misdiagnosis, a lack of              but the Global Burden of Disease study
adequate treatment and thus higher mortality            estimates 39 million children died as a
rates. NCDs disproportionately affect people in         result of interpersonal violence. Sexual
low- and middle-income countries (LMICs)                violence is the most prevalent type of
                                                        intentional injury for both boys and girls.

where more than three quarters of global NCD
deaths occur. However, inequalities can exist
within countries so that the life of a child and
the likelihood of adequate prevention, treatment
and care for NCDs can depend greatly on their              WHO Policy Best Buys for NCDS
socioeconomic status.
     The rising trends of NCDs require a child-            • Tobacco - Implement the WHO
centered and sustained effort to prevent                     Framework Convention on
disease and improve the quality of life and                  Tobacco Control. Ban smoking in
survival of children. This is especially true in             public places, schools, and
developing countries where there is a double
burden of infectious diseases and NCDs.                      hospitals.
Prevention requires a reduction of risk and the            • Alcohol - Tax alcoholic beverages.
adoption of a life-course approach, starting in              Enforce age limits. Ban promotion
prenatal and neonatal care and continuing
through the development of a child into                      of alcohol to young people.
adulthood. Policy efforts must be supported by             • Unhealthy diet - Reduce salt, fat,
a coherent and coordinated response from                     and sugar content in foods. Limit
government across sectors including education,
health, finance, labor and employment                        promotion of unhealhy foods to
strategies. Civil society also has a role to play in         children.
the prevention, treatment, and management of
                                                           • Physical inactivity - Empower
NCDs, championing the needs of those at risk
and affected by NCDs with strong and                         schools and communities to
consistent advocacy.                                         promote physical activity in safe
     NCDs must have a permanent place on the                 and convenient spaces.
global agenda for all countries, and children
must be explicitly considered within that                  • Strengthen health systems -
agenda. To aid this goal the WHO has proposed                Integrate NCDs into primary care.
a list of policy “best buys” for NCDs, many of               Build capacity for care
which have a direct and important impact on the              professionals managing children.
lives of children. Unfortunately, even in
countries where policies for adults are in place,          • Essential medicines and care -
children are often left behind. One of the most              Ensure equitable, affordable
significant gaps with regard to NCDs and                     access to essential medicines and
children is a lack of surveillance and monitoring            palliative care.
for these age groups. Data on NCD risk factors
and prevalence along with appropriate research             • Monitoring and surveillance - As
will enable the development of evidence based                with adults, regular data on the
prevention and management strategies that are                burden of NCDs and their risk
tailored to children.                                        factors should be routinely
     NCD Child advocates for the unique needs
                                                             collected for children.
of children, adolescents, and young people
through its collaborations with civil society,
government, youth advocates, and young
people affected by NCDs.

“Seventy percent of the
preventable adult deaths
from NCDs are linked to risk
factors that start in
adolescence, providing a
key opportunity for                                                      INTRODUCTION

     Defining children and NCDs                             linked to risk factors that start in adolescence,
     There is no universally agreed age range for           providing a key opportunity for prevention.
     what constitutes childhood. It is a concept that            The five most common NCDs in adults are:
     varies considerably across cultures. This report       cardiovascular diseases, cancer, chronic
     uses the definition of a child specified in the        respiratory disorders, mental health disorders,
     Convention on the Rights of the Child (
Table 1.1: Definitions of child and subcategories

Term                          Definition

Child                         Anyone under the age of 18.

Adolescents                   Children between the ages 10 and 19. Used more for understanding the
                              biological changes rather than social transitions. Recent literature suggests
                              extending the upper limit to 24 years.2

Infant and neonate            A child younger below one year of age.

Young people                  Used interchangeably with “youth” the terms often are used for ages 15 to 24.
                              Although the UN recognize that member states may use different definitions.

Youth                         Persons between the ages 15 and 24.

  for child health and is a major cause of
  morbidity.                                                Mental health is a term used to describe a
  Cancer is a term used to describe a large group           state of well-being that allows a person to
  of diseases that involve the growth of abnormal           realize their own potential, cope with the normal
  cells. These abnormal cells grow beyond their             stresses of life, work productively, and
  usual boundaries and then invade other parts of           participate in the community. Mental health
  the body. Cancer can affect almost any part of            disorders (MHDs) comprise a broad range of
  the body and there are many different types, all          problems that affect mental health (including
  need specific treatment and management                    a n x i e t y, d e p r e s s i o n , b i p o l a r d i s e a s e ,
  strategies.                                               schizophrenia and other disorders). Symptoms
                                                            range from any of or a combination of abnormal
  Chronic respiratory disorders (CRDs) are                  thoughts, emotions, behavior and relationships
  chronic conditions affecting lungs, airways and           with others.
  related structures. CRDs range from rhino-
  sinusitis, asthma, and chronic obstructive                In addition to these five key NCDs, this report
  pulmonary disease (COPD) to lung cancer.                  covers injuries and violence which also play an
                                                            important role in determining the health of
  Diabetes (diabetes mellitus) is the result                children.
  reduced levels of insulin production or
  ineffective insulin sensitivity. Increases in blood       Injury is defined as “the physical damage that
  glucose resulting from problems with insulin can          results when a human body is suddenly
  damage many of the body's systems. There are              subjected to energy in amounts that exceed the
  two main forms of diabetes:                               threshold of physiological tolerance – or else
       •   Type 1 diabetes occurs when the                  the result of a lack of one or more vital
           pancreas does not produce the                    elements, such as oxygen.”3 They can be a
           hormone insulin. This type develops              result of intentional (acts of violence against
           most commonly in children and                    others or oneself) or unintentional road traffic
           adolescents.                                     crashes, burns, drowning, falls, and poisonings.

       •   Type 2 diabetes is caused by the
           body not responding properly when
           insulin is released from the pancreas.
           Type 2 diabetes becoming more
           common in children. Unlike type 1
           diabetes, many cases of type 2
           diabetes may be preventable.                      Citations
                                                             1 UN General Assembly, Convention on the Rights of the Child, 20
  Diabetes may also develop during pregnancy in              November 1989, United Nations, Treaty Series, vol. 1577, p. 3
  a condition known as gestational diabetes.                 2 Sawyer, S. M., Azzopardi, P. S., Wickremarathne, D. & Patton, G.
  Untreated gestational diabetes puts mothers                C. The age of adolescence. Lancet Child Adolesc. Health (2018).
  and children at risk for complications and                 3 Holder Y, Peden M, Krug E, Lund J, Gururaj G, Kobusingye O.
                                                             Injury surveillance guidelines. Geneva: World Health Organization;
  developing type 2 diabetes later in life.                  2001.

                  RISK FACTORS

                  A risk factor is any characteristic or exposure of
                  an individual that increases their likelihood of                                                                     Fig. 1.2. Prevalence (%) of insufficient
                  developing a disease or injury. These include                                                                        physical activity (11-17 years), by sex
                                                                                                                                               and income group, 2010
                  but are not limited to pollution, obesity, unsafe
                  sex, high blood pressure, poor sanitation,                                                                   100                                         Boys
                  tobacco and alcohol consumption and others.                                                                                                              Girls

                                                                                                                                                                                    Source: WHO, Global Health Observatory
                  These risk factors often combine to increase the
                  chances that children to develop certain NCDs.                                                                75
                  Understanding risk factors is key to the
                  prevention and control of NCDs. Policies                                                    Prevalence (%)
                  geared towards risk factors can have benefits                                                                 50
                  for the whole population, but understanding
                  which groups are most at risk can also provide
                  a targeted approach to prevention.                                                                            25

                  Tobacco use
                  Globally, an estimated 24 million children aged                                                                 0
                                                                                                                                         LIC    LMIC    UMIC       HIC   Global
                  13 to 15 years smoke. Girls smoke at higher
                                                                                                                                                    Income Group
                  rates in high income countries than in middle or
                  low income countries. Globally, boys smoke at
                                                                                                                               almost twice the rate of girls (Fig. 1.1). Between
                                                                                                                               2000 and 2015, the prevalence of tobacco
                       Fig. 1.1. Prevalence (%) of tobacco use                                                                 smoking among children decreased in all age
                        (13-15 years) by income group, 2014                                                                    groups and this reduction is expected to
                 15                                                                                                            continue until 2025. However, not all tobacco
                                                                                                                               use involves smoke, an estimated 13.4 million
                                                                     Source: WHO, Global Health Observatory

                                                                                                                               (3.6%) of the world’s population aged 13 to 15
                 12                                                                                                            years use smokeless tobacco products with
                                                                                                                               rates almost twice as high in boys than in girls.
Prevalence (%)

                                                                                                                               Physical inactivity
                                                                                                                               Physical activity is an important protector
                  6                                                                                                            against a range of NCDs. Worldwide, 3 in 4
                                                                                                                               adolescents aged 11 to 17 years do not
                                                                                                                               currently meet the World Health Organization
                  3                                                                                                            global recommendations for physical activity
                                                                                                                               (Fig. 1.2). Physical inactivity is higher in girls
                  0                                                                                                            across all income groups but especially in low-
                       Global    HIC      UMIC        LMIC   LIC
                                       Income Group

                                                             Key Messages
•                NCDs are driven by several risk factors, but most importantly unhealthy diet and
                 obesity, physical inactivity, tobacco use and alcohol abuse.
•                Both the prevention of risk factor development (primordial prevention) and
                 modification of risk factors once they are established (primary prevention) are
•                Income disparities exist in the distribution of major preventable risk factors.

Fig. 1.3. Trends in prevalence (%) of obesity (5-19 years) by sex

Prevalence (%)



                        1975 1978 1981 1984 1987 1990 1993 1996 1999 2002 2005 2008 2011 2014
                                                                                 Years                  Source: WHO, Global Health Observatory

                    and middle-income countries with the highest                         age of 19 were overweight or obese (Fig. 1.3).
                    levels of inactivity seen in low- and upper-                         The onset of obesity during childhood can lead
                    middle income countries. Estimates suggest                           to severe health risks; obesity is a key risk
                    that physical activity may be in decline in both                     factor for orthopedic issues, diabetes and
                    sexes starting from as early as six years old.                       cardiovascular disease. A population-based
                                                                                         study estimated that 70% of obese children and
                    Unhealthy diet                                                       adolescents between the ages of 5 to 17 have
                    An unhealthy diet (including insufficient fruit,                     at least one risk factor for CVD.4
                    vegetable, legume and nut consumption and/or
                    consumption of energy dense foods) is one of                         High blood pressure
                    the major risk factors for a range of NCDs.1                         High blood pressure, or hypertension, is an
                    Malnutrition in utero and in early childhood have                    important risk factor for cardiovascular disease
                    been shown to increase a child’s vulnerability to                    in both children and adults. Increases in
                    over-nutrition later in life and into adulthood.                     childhood blood pressure have been reported
                    Unhealthy diets are associated with overweight                       by national surveys in the US and in other
                    and obesity, which rank globally as the fifth                        countries.5 These increases were observed in
                    leading cause of death. Children are especially                      all ethnicities for diastolic blood pressure and in
                    high consumers of sugar-sweetened beverages                          most ethnicities for systolic blood pressure
                    including sodas, sugary juices, and other drinks                     (including, boys, girls, and those aged 8 to 12
                    w h i c h d r i v e u p r a t e s o f o b e s i t y, a n d           years).
                    independently of type 2 diabetes.2                                        Increases in blood pressure are partially
                                                                                         driven by the rising rates of obesity in children
                    Alcohol                                                              over the last three decades (Figure 1.3).
                    From conception onwards, the human body is                           Overweight in adulthood is a known risk factor
                    susceptible to the harmful effects of alcohol and                    for cardiovascular disease, but the effect of
                    use during pregnancy can result in a range of                        overweight on hypertension in children is less
                    lifelong conditions. Globally, 155 million 15 to 19                  understood.
                    year olds consume alcohol. Alcohol use in
                    adolescents is associated with negative effects                      High levels of fat in blood
                    on the brain, gut and circulatory system as well                     Atherosclerosis has been shown to begin as
                    as increasing sexual risk-taking behavior,                           early as nine years of age. Amounts of
                    mental health disorders, and injuries and                            triglycerides, total cholesterol, low density
                    violence.3                                                           lipoprotein cholesterol, and high density
                                                                                         lipoprotein cholesterol are all more likely to be
                    Obesity                                                              abnormal in overweight children than in normal
                    The prevalence of obesity is increasing and in                       weight children. With treatment, these
                    2016 an estimated 42 million children under the

Key Figures: Risk Factors
                                                                                    Prevalence            Prevalence
                                                          Number                     Girls (%)             Boys (%)

Smoking any tobacco (13-15 years),
                                                         24 million                       8.3                  18.2
Insufficient physical activity (11-17
                                                              NA                         83.9                  77.6
years), 2010
Current alcohol drinking (15-19
                                                         155 million                            26.5 (total)
years), 2016
Obesity (5-19 years), 2014                               42 million                       5.6                   7.8

Deaths due to air pollution
                                                     395 thousand                         6.4                   5.7

     Children have made significant gains in health              Article 24 of the Convention states that all
     over the past 25 years. The rates of under-5          children have the right to “the highest attainable
     mortality across the globe have decreased and         standard of health and access to facilities for
     the gaps between the richest and poorest              the treatment of illness and rehabilitation of
     countries are closing.1 Most of these gains are       health.” Since the adoption of the Convention,
     the result of focused efforts on reducing under-5     progress has been made in securing an
     mortality through the control of infectious           improved prospect for children and their future.
     diseases, reducing malnutrition and improving         However, more work must be done, and
     maternal care. However, trends in NCDs are            especially in the poorest countries, to ensure
     increasing.                                           that these gains are equally shared and
          While stunting and malnutrition rates have       accessible to all children.
     dropped by 40%, overweight in children has                  Emergent epidemics of NCDs have yet to
     increased by a third since 1990.1 These shifting      be explicitly named and, in practice, healthcare
     trends require a shifting                                                                resources are often
     response away from a                                                                     geared towards other
     focus on just the first                                                                  priorities, especially in
     five years of life toward       “Shifting trends require … a developing countries.
     a more holistic
     approach that includes         response away from a focus This                                  gap is contrary to
                                                                                              rising trends discussed
     all aspects of health.          on just the first five years of in this report and the
          In 1990, the United                                                                 high burden of some
     Nations and 194                   life toward a more holistic                            NCDs in the world.
     countries ratified the                        approach.…”                                     Children represent
     Convention on the                                                                        a vulnerable group in
     Rights of the Child,                                                                     health as they may
     enshrining the principle                                                                have a decreased ability
     that children hold fundamental economic,              to advocate for their own care, or depend on
     social, cultural, civil and political rights in which the knowledge and access to care of a parent
     they play a critical role as holders of those         or guardian. They are often the most vulnerable
     rights. It asserts that all children – without        to complex issues like violence and injuries,
     discrimination in any form – benefit from special     poverty, and a lack of education. As such,
     protection measures and assistance; have              systems must be coordinated and implemented
     access to services such as education and              to ensure the health and safety of children.
     health care; can develop their personalities,
     abilities and talents to the fullest potential; grow
     up in an environment of happiness, love and
     understanding; and are informed about and
     participate in, achieving their rights in an           Citations
     accessible and active manner.2                         1 UNICEF, For every child a fair chance: the promise of equity.
                                                            New York, November, 2015.

                                                                    2 UN General Assembly, Convention on the Rights of the Child,
                                                                    20 November 1989, United Nations, Treaty Series, vol. 1577, p. 3.

                                                Key Messages
•   Public health policy must refocus efforts towards all children and include NCDs.
•   Prevention policies and programs must begin with a preconception plan and adopt
    a whole-of-life approach.

“For many children,
                                                                                                                                 surviving the first years of
                                                                                                                              life with an NCD is a serious
THE GLOBAL                                                                                                                      challenge and many do not
                                                                                                                                     reach the age of five.”

                                                                                                                              Fig. 2.2. Deaths due to NCDs in children

  Cardiovascular disease is broad term                      Management of heart disease
  encompassing a number of conditions that                  Heart disease resulting from RHD is treatable:
  affect the heart and circulation. These can be            some children need heart surgery, but in many
  congenital or acquired. While many are highly             cases early intervention with a single procedure
  treatable, their prevention and control in                will lead to a normal or near-normal life. Basic
  children is often inadequate partly due to a lack         primary healthcare services can provide primary
  of resources or awareness for early detection             and secondary prevention of RHD, which
  and management. More than 13.9 million                    includes administration of basic medications like
  children in 2017 had some form of CVD.                    penicillin. Early identification and treatment of
                                                            the infection that can cause rheumatic fever is
  Pediatric CVD is a term used to describe                  the best form of prevention. Secondary
  several different heart conditions in children.           prevention protects children who have had
  The most common type of pediatric heart                   rheumatic fever from the recurrences that cause
  disease is congenital, which means that                   heart damage to progress.
  children are born with the defect. Globally, one
  million children a year are born with a heart             Pediatric stroke
  defect and 90% of these are born in areas                 Pediatric stroke has varying mortality rates
  where appropriate medical care is limited or              depending on the type of stroke: arterial
  unavailable.1                                             ischemic stroke (AIS) mortality ranges from 7%
                                                            to 28% and hemorrhagic stroke (HS) between
  Rheumatic Heart Disease (RHD) is the most                 6% to 54%.3 However, mortality rates for HS
  common chronic heart disease in children. RHD             are decreasing.4
  is a caused by rheumatic fever, which is brought               Pediatric arterial ischemic stroke (AIS) can
  on by common infections of the throat. RHD can            be divided into two main types: perinatal and
  result in irreversible damage to the heart valves.        childhood. Perinatal stroke occurs between 20
  Without surgery and life-long medical treatment           weeks of fetal life through the twenty-eighth
  RHD can be fatal. Better living conditions and            postnatal day. Childhood arterial ischemic
  access to antibiotics have meant that in                  stroke defines those who have pediatric AIS
  developed countries, rheumatic fever has been             beyond the first month of life. The incidence of
  nearly eradicated. Now it is almost exclusively a         perinatal AIS is considerably higher than that of
  disease of poverty RHD and is estimated to                childhood AIS; with current estimates likely to
  affect at least 15.6 million people each year.2           be an underestimate. Estimates of the
                                                            incidence of childhood AIS are variable and
                                                            highly dependent on the search strategy

                                                              Key Figures: Cardiovascular disease
           Key Messages                                 Measure                                           Rate
• Deaths due to CVD are highest in                      (
Fig. 2.3. Deaths due to CVD in children
management. Painful blockages in blood flow
known as vasco-occlusive crises are common
in SCD. These are responsible for most of the
major complications as many organs of the
body can be affected. In childhood, infection,
stroke and acute chest syndrome (ACS)
dominate as causes of morbidity and death. In
adolescence, bacteraemias, dactylitis, ACS,
and stroke decrease in frequency, and
gallstones, episodes of severe pain, and leg
ulceration increase in frequency. Those with the
disease face the physical limitations and the
psychological impact of a serious chronic
condition. In adulthood, complications
associated with pregnancy, the eyes, and
chronic organ damage become increasingly

Policy frameworks
For the prevention and management of adult
CVD, the WHO has developed the Global
HEARTS Initiative, however, there is no                  Citations
pediatric equivalent, partly due to the fact that        1 NCD Alliance. A Focus on Children and NCDs: Remembering
                                                         our future at the UN Summit on NCDs, September 2011.
pediatric CVD has a broad etiology.12 In 2011,
the US National Heart, Lung and Blood Institute          2 Carapetis JR, Steer AC, Mulholland EK, Weber M, The global
                                                         burden of group A streptococcal diseases. The Lancet Infectious
released its Integrated Guidelines for                   Diseases. 2005;5(11):685-694
Cardiovascular Health and Risk Reduction in
                                                         3 Blom I, De Schryver EL, Kappelle LJ, Rinkel GJ, Jennekens-
Children and Adolescents. The guidelines’                Schinkel A, Peters AC.Prognosis of haemorrhagic stroke in
recommendations were controversial and not               childhood: a long-term follow-up study.Dev Med Child Neurol.
                                                         2003; 45:233–239.
universally embraced, but they did suggested
potential avenues for key research. In the same          4 Fullerton HJ, Chetkovich DM, Wu YW, Smith WS, Johnston
                                                         SC.Deaths from stroke in US children, 1979 to 1998.Neurology.
year, the WHO released the Global Atlas on               2002; 59:34–39.
Disease Prevention and Control. Although the
                                                         5 Felling, Sun, Maxwell et al Cardiovascular disease risk in
document does not specifically address the               healthy children and its association with body mass index:
issues of CVD in children, it does address               systematic review and meta-analysis Blood Cells, Molecules and
                                                         Diseases 67 (2017) 23–3.
several contributing factors, such as obesity,
rheumatic fever and Chagas disease.                      6 Greenham M, Gordon A, Anderson V, Mackay MT. Outcome in
                                                         Childhood Stroke. Stroke 2016;47:1159–1164.

                                                         7 Lo WD, Hajek C, Pappa C, Wang W, Zumberge N.Outcomes in
                                                         children with hemorrhagic stroke.JAMA Neurol. 2013; 70:66–71

                                                         8 Monagle, P, Chan A.K.,Goldenberg al, American College
                                                         of Chest P, Antithrombotic therapy in neonates and children:
                                                         antithrombotic therapy and prevention of thrombosis, 9th ed:
                                                         American College of Chest Physicians Evidence-Based Clinical
                                                         Practice Guidelines, Chest 141 (2 Suppl) (2012) e737S–e801S,

                                                         9 Roach, ES, Golomb, MR. Adams R,et al, American Heart
                                                         Association Stroke C, Council on Cardiovascular Disease in the
                                                         Y. Management of stroke in infants and children: a scientific
                                                         statement from a Special Writing Group of the American Heart
                                                         Association Stroke Council and the Council on Cardiovascular
                                                         Disease in the Young, Stroke 39 (9) (2008) 2644–2691.

                                                         10 Weatherall DJ, Clegg JB. Inherited haemoglobin disorders: an
                                                         increasing global health problem. Bull World Health Organisation
                                                         2001; 79(8):704-712.

                                                         11 World Health Organization. Joint WHO/TIF Meeting on the
                                                         Control of Haemoglobinopathies. Report of the VIIth Meeting of
                                                         the WHO Working Group on the Control of Hereditary Anaemias,
                                                         Nicosia, Cyprus, 3-4 April, 1994. (unpublished document WHO/
                                                         HDP/TIF/HA/93.1). 1994. Geneva, WHO.

                                                         12 Global Atlas on Cardiovascular Disease Prevention and
                                                         Control. Mendis S, Puska P, NorrvingB editors. World Health
                                                         Organization, Geneva 2011.


    The term “childhood cancer” is most commonly                                      Although many studies have tried to identify
    used to designate cancers that arise before the                            the causes of childhood cancers, the vast
    age of 15. The most common categories of                                   majority have no known cause, with a minimal
    childhood cancers include leukemias, brain                                 number of cancers in children being due to
    cancers, lymphomas and solid tumors (Table                                 environmental or lifestyle factors. Only 10% of
    2.1). Acute lymphoblastic leukemia is the most                             all children with cancer are attributable to
    common type of cancer, except in sub-Saharan                               genetic factors.
    Africa, where children are more prone to                                          Some infections are risk factors for
    develop non-Hodgkin’s lymphomas and                                        childhood cancer, while others increase the risk
    Kaposi’s sarcoma (related to HIV infection).                               of developing cancer as an adult. As a result of
         Cancer in childhood represents between                                the limited understanding of the causes of
    0.5% and 4.6% of the total number of cancer                                c h i l d h o o d c a n c e r s , t h e Wo r l d H e a l t h
    cases in the world. Overall, annual incidence                              Organization (WHO) suggests that cancer
    rates vary between 9 and 22 per 100,000 in                                 prevention in children should aim to promote
    children and around 14 per 100,000 in                                      behaviors that will prevent the child from
    adolescents (Fig. 2.4). The youngest age group,                            developing preventable cancer as an adult. In
    1 to 4 years, has the highest incidence relative                           LMICs, efforts should include vaccination,
    to other groups, possibly due to genetically                               screening and early diagnosis of chronic
    linked diseases, with girls having a higher                                infections that lead to cancer.
    prevalence of cancer in each age group than
    boys (Fig. 2.5).
                                                                                      Fig. 2.4. Incidence of cancer in children
         Cancer is a leading cause of death for                                           (
Fig. 2.5. Prevalence of cancer in children (
Table 2.1. Top cancers in children (
    In children, chronic respiratory disorders                                 barriers to optimal treatment. These barriers
    (CRDs) contribute to disability and                                        range from reduced availability of medications
    hospitalization in children (Fig 2.6). Some of                             to more societal factors such as poverty and
    these respiratory disorders are preventable                                literacy. In LMICs, this reduced access to
    including asthma and respiratory allergies.                                treatment is compounded by the lack of
    Preventable CRDs affect millions, especially the                           resources to enable diagnosis of CRDs.
    young and elderly, with more than 500 million of                                Allergic rhinitis (AR) and asthma are the
    these people living in low- and middle-income                              most common preventable CRDs in children.
    countries (LMICs). The most common                                         AR is characterized by one or more symptoms,
    preventable CRDs are: chronic obstructive                                  such as sneezing, itching, nasal congestion and
    respiratory disease (COPD), sleep apnea,                                   runny nose. If treatment is not adequate,
    allergic rhinitis, and asthma. Of these, the last                          children can experience chronic inflammation
    two greatly affect child health.                                           which can induce a range medical
         There are many risk factors for preventable                           complications, learning and behavioral issues,
    CRDs but the most significant fall into three                              as well as aggravate conditions such as
    categories:                                                                sinusitis and asthma.
       • indoor (pollution, pets, and insects),                                     Children and adolescents are the most
       • outdoor (pollution, pollens and molds),                               commonly affected by AR with a prevalence up
       • and occupational agents (platinum salts,                              to 40% of the population.2 AR is a multifactorial
           flour and latex) that more common for                               disease with genetic as well as environmental
           working adults.
        In LMICs, solid fuels are a major source of                                   Fig. 2.7 Deaths due to CRD in children
    indoor pollution with children under 5 and                                           (
factors influencing disease development.                 variability in the prevalence and severity of
                              Sensitization to allergens at an early age along         asthma between regions and countries as well
                              with a range of maternal and in utero factors            as within countries.4
                              contribute to the risk of developing AR. Not                  Asthma is rarely a cause of death in
                              surprisingly, outdoor allergens appear to                children, but it can be an important source of
                              constitute a greater risk for seasonal rhinitis          disability and hospitalization. Childhood asthma
                              while indoor allergens pose a greater risk for           can result in many lost school days and may
                              perennial rhinitis.                                      deprive the affected children of both academic
                                                                                       achievement and social interaction.
                              Asthma                                                        There are genetic and non-genetic factors
                              Another common cause of CRDs in children,                contributing to asthma with the disease often
                              asthma is described as a heterogeneous                   running in families. Although a number of
                              disease usually characterized by chronic airway          factors that can cause exacerbations in
                              inflammation. Symptoms include wheeze,                   symptoms have been identified, there is no
                              shortness of breath, chest tightness, cough and          recognized cause. Environmental factors,
                              expiratory airflow limitation that vary over time        particularly indoor allergens (including smoking
                              and in intensity.3                                       in the household) are more likely to be
                                   The prevalence of asthma in children is             responsible for a large portion of the numbers
                              rising and is highest among children under 9             of people with asthma. In addition to this focus
                              years. The International Study of Asthma and             on environmental factors, it is now understood
                              Allergies in Childhood highlighted the wide              that allergic mechanisms are only responsible

                                 Fig. 2.7 Prevalence of asthma in children (
for no more than 50% of asthma cases.                               3. Encouraging the implementation of health
However, the non-allergic mechanisms are not                           promotion and CRD prevention policies;
fully understood.                                                   4. Developing simple and affordable strategies
                                                                       for the control of CRDs.
Management and care
The most common diagnostic tests for AR are                         In addition to these objectives, GARD also has
the percutaneous skin test and allergen specific                    6 areas of focus, one of which is pediatric
IgE antibody test. Treatment of AR includes the                     asthma.
avoidance of allergens, use of antihistamine
tablets or nasal sprays and in some cases                           In 2017, the Forum of International Respiratory
desensitization.                                                    Societies (FIRS) called for eight essential
     Asthma treatment comprises                                     actions to reduce the burden of respiratory
“relievers” (bronchodilators that reverse airway                    disease. These actions supported the WHO
narrowing) and “controllers” (inhaled                               strategy goals and included improved early
corticosteroids) that reduce the underlying                         diagnosis of respiratory diseases, ultimate
airway inflammation. Diagnosis and treatment                        elimination of tobacco products and increased
for CRDs are more widely available in high                          education of health professionals.5 Their first
income countries. With rising air pollution in                      essential action specifically mentioned children:
many developing countries, rates of asthma
and AR are expected to rise in the coming                               “Increase public and policy makers’
decades.                                                                awareness that respiratory health is
                                                                        essential to global health and that
                                                                        childhood respiratory disease may have
Policy frameworks
                                                                        long-term negative consequences on
In 2002, the WHO launched its strategy on
                                                                        adult health by advocating at world
CRDs; the strategy has three key objectives:
                                                                        health meetings and through
   •   Improved surveillance to enable mapping                          publications and media postings.”
       of the magnitude of CRDs and analyze
       their determinants;                                          Formed in 2001 FIRS comprises the leading
   •   Reductions in the level of exposure of                       international respiratory societies with the goal
       individuals and populations to common                        of promoting worldwide respiratory health.
       risk factors, particularly tobacco, poor
       nutrition, frequent lower respiratory
       infections during childhood, and
       environmental air pollution (primary
   •   Secondary and tertiary prevention to
       strengthen health care for people with
       CRDs by identifying cost-effective
       interventions, upgrading standards and
       accessibility of care at different levels of
       the health care system.3
This was followed by the launch of the Global
Alliance Against Respiratory Diseases (GARD)                        Citations
which in 2006 brought together a range of                           1 Bousquet J, Khaltaev N. Global surveillance, prevention and
                                                                    control of Chronic Respiratory Diseases. A comprehensive
international and national organizations with the                   approach. (2007), WHO, Geneva, Switzerland
aim of improving the lives of those affected by
                                                                    2 Mims JW. Epidemiology of allergic rhinitis. Int Forum Allergy
respiratory diseases. It initiated the                              Rhinol 2014;4 Suppl 2:S18-20
i m p l e m e n t a t i o n o f t h e C R D s t r a t e g y.
                                                                    3 Global Initiative for Asthma (GINA), Global strategy for asthma
Consequently, the main objective of GARD is to                      management and prevention. 2018. Available from http://
apply a comprehensive approach to combat                  
CRDs by:                                                            4 Mallol J, Crane J, von Mutius E, Odhiambod J, Keile U, Stewart
                                                                    A, et al. The International Study of Asthma and Allergies in
1. Developing standardized methods for                              Childhood (ISAAC) Phase Three: A global synthesis. Allergol
   surveillance of the burden of chronic                            Immunopathol (Madr). 2013; 41: 73–85

   respiratory diseases and their risk factors;                     5 Forum of International Respiratory Societies. The Global Impact
                                                                    of Respiratory Disease – Second Edition. Sheffield, European
2. Advocating for action on chronic respiratory                     Respiratory Society, 2017.


    More than 8 million children in 2017 were                                     leading to a life threatening condition called
    affected by diabetes. There are three main                                    diabetic ketoacidosis (DKA). While DKA is also
    types of diabetes which affect children. Type 1                               found in type 2 diabetes, it is more common and
    diabetes, representing up to 25% of cases of                                  more severe in people with type 1 diabetes and
    diabetes, is characterized by an inability to                                 is often the first sign of the disease.
    produce the hormone insulin due to inactive                                        Type 1 diabetes is more common in high
    beta cells in the pancreas, leading to an                                     income countries which is largely due to high
    uncontrolled rise in blood glucose. People with                               mortality rates in developing countries. Still, the
    type 2 diabetes produce insulin, but their cells                              incidence of type 1 diabetes is increasing
    and tissues become insensitive to the hormone,                                globally for reasons that are not clear (Fig. 2.9).
    leading to high blood glucose. The prevalence                                 Mortality rates in developing countries, where
    for both types of diabetes is highest in                                      access to insulin is limited are higher, leading to
    adolescents (Fig. 2.8). A third kind of diabetes,                             fewer children overall living with the disease.
    gestational diabetes, arises during pregnancy                                 Indeed, many deaths due to diabetes occur in
    and can pose risks to both mother and child.                                  children under 14 often at the point of diagnosis
    More detail is given on gestational diabetes in                               (Fig. 2.10).1
    the chapter discussing early life development.
        Type 1 and type 2 diabetes require lifelong                                    Fig. 2.8. Prevalence of diabetes in children
    careful self-management and care. People with                                            (
Fig. 2.9 Deaths due to diabetes in                                           Fig. 2.10. Trends in incidence of type 1
                 children (

    Mental health disorders are the most prevalent
    NCD in children under 20 years affecting more
    than 231 million children. They encompass a                                              Fig. 2.11. Deaths due to self-harm in
                                                                                           children (
Fig. 2.13. Trends in substance abuse disorders in children
not just on children with mental health disorders
but also in preventing new cases from
developing.5 They have also shown great
promise in resource-limited settings both with
low income communities and in low- and
middle-income countries.6,7

Policy frameworks
Healthcare providers and caregivers must be
made aware of the warning signs and risk
factors of mental health disorders and risky
behavior. The WHO, respecting the United
Nations Convention on the Rights of the Child,
recommends targeting multiple mental health
problems at diagnosis, using supervised staff
trained in managing adolescents’ specific
needs, engaging and empowering caregivers,
guided self-help methods, and cautions against
the overuse of psychotropic medication as only            “Treatment of mental health
appropriate for those with moderate-severe
mental health conditions.
                                                           disorders is still hampered
    Nevertheless, developing countries and                     by stigma and a lack of
low-resource areas struggle to provide                   awareness of the prevalence
adequate mental health support and
adolescents may remain in a precarious                          of these conditions in
position if their needs are not met.                                          children.”

                                                         1 World Health Organization (2019). Adolescent mental health.
                                                         [online] Available at:
                                                         fact-sheets/detail/adolescent-mental-health [Accessed 8 May

                                                         2 O’Donnell KJ, Meaney MJ. Fetal origins of mental health: the
                                                         developmental origins of health and disease hypothesis. Am J
                                                         Psychiatry. 2017 Apr 1; 174(4):319-328.

                                                         3 Hawkes, N. (2018). Barriers for mental health services for
                                                         children and adolescents are too high, finds regulator. BMJ,
                                                         k1093. doi:10.1136/bmj.k1093

                                                         4 MacDonald, K., Fainman-Adelman, N., Anderson, K. K., & Iyer,
                                                         S. N. (2018). Pathways to mental health services for young
                                                         people: a systematic review. Social psychiatry and psychiatric
                                                         epidemiology, 53(10), 1005–1038.

                                                         5 Christensen, H., Pallister, E., Smale, S. et al. J Primary Prevent
                                                         (2010) 31: 139.

                                                         6 Farahmand, F. K., Grant, K. E., Polo, A. J. and Duffy, S. N.
                                                         (2011), School‐Based Mental Health and Behavioral Programs for
                                                         Low‐Income, Urban Youth: A Systematic and Meta‐Analytic
                                                         Review. Clinical Psychology: Science and Practice, 18: 372-390.

                                                         7 Barry M.M., Clarke A.M., Jenkins, R. and Patel, V. (2013) A
                                                         systematic review of the effectiveness of mental health promotion
                                                         interventions for young people in low and middle income
                                                         countries. BMC Public Health, 13: 835.


     In 2017, injury was responsible for more than            violence including: economic development,
     707,000 deaths in children and young people              status, age, sex and gender. The rate of
     under 20 years. Injury can be divided into two           intentional injury in children is higher in upper-
     categories: intentional (including sexual                middle income countries (2,086 per 100,000)
     violence, homicide, and suicide) or                      than the global average (1,512 per 100,000).
     unintentional (including drowning, falls,                     The GBD Study estimates that in 2017,
     poisoning and road traffic accidents).1                  27.1 million girls and 8.6 million boys
          Intentional injury to self or by others             experienced sexual violence. The majority of
     (violence) against children occurs regardless of         this sexual violence is committed by family
     geography, race, class, religion and culture.            members or other people staying or visiting a
     Perpetrators can be from inside or outside the           child’s family home. A review of epidemiological
     family and it occurs in a range of settings. Of          surveys from 21 countries, mainly high- and
     these child victims, most were between 15 and            middle-income countries, found that at least 7 to
     19 years of age; 75% of these deaths occurred            36% of females and 3 to 29% of males reported
     in boys (Table 2.2).2                                    sexual victimization during their childhood.3
          For infants the risk of death is about three
     times greater for children under one year old            Unintentional injuries
     than for those aged 1 to 4. The younger the              Unintentional injuries (Table 2.3) account for
     child, the more likely their death will be caused        almost 90% of all injuries and they are the
     by a close family member. There are many                 leading cause of death for children aged 10 to
     factors associated with the risk of lethal               19 years. These include falls, the most common

              Table 2.2. Top prevalence per 100,000 of causes of intentional injuries for children
Table 2.3. Prevalence and deaths due to unintentional injuries in children (
“At each stage, the
environment a child is
exposed to will influence
his or her chances of                                         CROSS-CUTTING
developing an NCD.”

     The health of a child and the future risk for
     developing disease is influenced by more than
     just biology. The environment the child lives in,
     the care available to him or her and interactions
     with peers and society all have a powerful
     influence on health. That environment starts in
     the earliest development in the womb, through
     early life through to young childhood and
     adolescents. At each stage the environment a
     child is exposed to will influence his or her
     chances of developing an NCD. Factors such
     as air pollution, nutrition, social norms around
     physical activity and other behaviors, the
     influence of peers, exposure to violence,
     access to education, and household income all
     play a role.

     The requirements for care for children then
     become important to be tailored not just to the
     individual, but to the circumstances of the
     community in which the child lives and the
     stage of development. This chapter examines
     the social determinants of health that have a
     strong influence on the development and
     management of NCDs, the influence of the
     earliest life experience on the future risk of
     NCDs, and how treatment and care can
     respond for the prevention and control of NCDs.
     It discusses the earliest ages of development
     through to the impact of communities,
     environment, health care, and government

                                        Key Messages
 • The health of a child is determined not only by biological factors, but also by their
   social and economic realities.
 • A lifetime risk for NCDs can start in the womb.
 • Managing NCDs in children requires a tailored approach with training and education
   for the workforce and community engagement

    In 2003, the World Health Organization                          Within countries, those at lower
    recognized that health is influenced by the                socioeconomic levels are more likely to be
    conditions in which people are “born, grow,                obese, have an increase risk of NCDs, and less
    work, live, and age, and the wider set of forces           likely to have access to care. 2 These
    and systems shaping the conditions of daily                inequalities extend to several NCDS. Mental
    life.”1 These forces are influenced by policy,             health issues, in particular, tend to be higher in
    economics, development, social norms and                   children of lower socioeconomic status because
    political systems, all of which play a role in the         of complex drivers such as more exposure to
    health and development of a child. Together                violence and bullying, less family support, and
    these elements are known as the “social                    discrimination.1
    determinants of health” and are often used to
    discover and understand inequalities in health             Gender and ethnicity
    among and between groups. Identifying                      Gender and ethnicity can also play a role in
    inequalities can help to target aid and treatment          driving inequalities. For example, girls are more
    to specific groups who may be more vulnerable              likely than boys to be physically inactive which
    to disease or its effects. In general, children are        can have effects on obesity, cardiovascular
    considered a vulnerable group when compared                health, mental health, and other risk factors for
    to adults because they are less able to                    NCDs.3 Girls are also at risk of early pregnancy
    advocate for themselves, are socially and                  and NCD-related complications such as
    economically dependent on others and often                 preeclampsia and maternal mortality. On the
    suffer the worst effects from inequalities.                other hand, boys are more likely to engage in
                                                               risky behaviors leading to injuries and violence,
    Socioeconomic status                                       more likely to smoke, and more likely to
    The socioeconomic status of a household can                consume harmful amounts of alcohol.3
    have a profound influence on health. The most                   Some ethnic groups are more likely to
    obvious way in which this may happen is the                develop NCDs. Diabetes is high among Pacific
    ability to purchase food, access healthcare, or            Islanders, Southeast Asians, and native
    provide for the basic needs of survival.                   populations around the world and gestational
    However, social factors may also play a role. As           diabetes in these populations means that
    countries and economies have developed,                    children born of mothers with high blood
    issues related to poverty such as malnutrition             glucose during pregnancy carry a greater risk
    have decreased. However, access to cheap                   for type 2 diabetes later in life.4 Sickle cell
    and unhealthy foods is on the rise and                     disease, a condition where hemoglobin is
    especially in developing countries, leading to an          produced abnormally in red blood cells, is more
    increase in prevalence of obesity in children              prevalent in people of African descent and can
    (Fig 3.1).                                                 lead to lifelong risks for pain, infection, organ

                                      Key Messages
• Several factors can contribute to the health and development of a child including:
  gender, access to education, household income, ethnicity, and socioeconomic status.
• With economic development, NCDs in children has also increased.
• Adequate care and resources for health are lacking in developing countries,
  contributing to a higher mortality for children there with NCDs.

Fig. 3.1. Trends in prevalence of obesity (%) in children (

    A person’s lifelong risk for NCDs can start as         experience extreme stress or trauma during
    early as development in the womb, where the            pregnancy can lead to a uterine environment for
    intrauterine environment can play a significant        a developing fetus that will affect their genetic
    role in the later development of NCDs and              propensity to develop mental health problems
    obesity. For example, mothers with untreated           later in life.5 Even after birth, the life experience
    high blood glucose during pregnancy can                of children in their earliest years can have a
    experience greater risks of complications              great impact on their risk for developing MHDs.
    including macrosomia, obstructed labor, and            Left untreated or unmanaged, this pattern can
    other immediate issues but also will have              set up a cycle of MHDs generations.5
    babies who have a higher lifelong risk of
    developing type 2 diabetes.1 As the epidemic of        Infant feeding and early life experience
    type 2 diabetes increases, and more women of           After birth, what mother and child eat and the
    reproductive age experience high blood                 environment in which they live can also have a
    glucose, more babies will be born with an              profound impact on a child’s future risk for
    added future risk for obesity and type 2               NCDs. The World Health Organization
    diabetes (Fig 3.2).2                                   recommends an early introduction to
         These increases are expected especially in        breastfeeding - within the first hour after birth -
    developing countries where the rate of new             and exclusive breastfeeding for at least 6
    cases of type 2 diabetes is highest.3 The              months. A child who follows these
    mechanisms for these changes are being                 recommendations is less likely to develop
    described in research which indicates that the         obesity and type 2 diabetes later in life and
    nutrition and health status of the mother can          more likely to have greater educational
    have permanent effects on the growth and               achievement.6 The benefits of breastfeeding
    structure of the child in a phenomenon known           have shown to reduce a mother’s risk of ovarian
    as ‘fetal programming.’4 Growing evidence              and breast cancer, type 2 diabetes, and
    suggests that the presence of NCDs or obesity,         cardiovascular disease and hypertension.7-9
    in particular, can have a detrimental effect on
    the development of the child leading to the            Early pregnancy and NCDs
    development of metabolic and other problems            Adolescent pregnancy carries a number of risks
    later in life.4 These changes can lead to a            related to NCDs for mother and child. An
    generational transmission of NCDs from mother          adolescent pregnancy is more likely to
    to child, especially in the absence of adequate        experience complications such as low birth
    treatment and prevention.                              weight, preeclampsia (high blood pressure
                                                           during pregnancy), anemia, and preterm
    Mental health disorders and early life                 delivery and is a leading cause of death for
    One of the most prevalent NCDs in children, the        girls.9 While some of these are related to
    risk for mental health disorders (MHDs) can            biological factors, there is evidence that
    develop as early as in the womb. Mothers who           pregnant adolescents do not access antenatal

                                    Key Messages
• Risk for NCDs can be established as early as the womb.
• Early life experiences and exposures can strongly affect a child’s risk for NCDs and
  their outcomes.
• Mothers experiencing NCDs or their risk factors during pregnancy are at future risk
  for illness.

Fig. 3.2. Pregnancies affected by high blood glucose, by age, 2013
                        9M                                                                            Number of pregnancies                         60%
                                                                                                      Prevalence (%)
Number of pregnancies


                                                                                                                                                          Prevalence (%)
                        5M                                                                                                                          30%


                        0M                                                                                                                          0%
                                20 to 24       25 to 29        30 to 34          35 to 39            40 to 44               45 to 49
                                                                     Age (years)                            Source: Adapted from Guariguata et al2

                        care at the same rates as older women putting            and management of women with high blood
                        themselves and their babies at risk.10                   glucose in pregnancy.14 In addition, guidelines
                             Other factors, such as poor dietary habits,         on breastfeeding also reinforce the links to
                        tend to be higher in adolescents and can affect          obesity and NCD risk reduction for children and
                        both mother and child.11 In many parts of the            mother.15
                        world, adolescent pregnancy can result from a
                        lack of agency for girls, early marriage                 Citations
                        influenced by social and family pressures, lack          1 International Diabetes Federation, IDF Diabetes Atlas 6th
                                                                                 Edition. Brussels, Belgium. 2013.
                        of awareness on sexual education, and sexual
                        violence.12 Girls who become pregnant earlier            2 Guariguata L, Linnenkamp U, Beagley J, Whiting DR, Cho NH.
                                                                                 Global estimates of the prevalence of hyperglycaemia in
                        are also less likely to achieve education goals,         pregnancy. Diabetes Res Clin Pract. 2014 Feb;103(2):176-85.
                        thus setting them up for a higher risk of poverty
                                                                                 3 Institute of Health Metrics and Evaluation, University of
                        and lower socioeconomic status which is                  Washington. Global Burden of Disease (GBD) Study 2017.
                        increasingly linked to obesity (see chapter on           Seattle, WA, 2017.
                        Social Determinants of Health).                          4 Fall C. H. (2012). Fetal programming and the risk of
                             Early screening for NCDs in pregnancy,              noncommunicable disease. Indian journal of pediatrics, 80 Suppl
                                                                                 1(0 1), S13–S20.
                        comprehensive antenatal care, and family
                        planning can all help improve outcomes for               5 McGowan PO, Syzf M. The epigenetics of social adversity in
                                                                                 early life: implications for mental health outcomes. Neurbiol Dis.
                        mothers and children - preventing future cases           2010 Jul;39(1):66-72.
                        of NCDs. Special attention and care should be
                                                                                 6 Lutter C, Lutter R. Fetal and Early Childhood Undernutrition,
                        given to delaying pregnancy in girls and                 Mortality, and Lifelong Health. Science, 337 (6101): 1495-1499.
                        promoting their education achievement. The
                                                                                 7 Danforth, D.N. et al. Breastfeeding and risk of ovarian cancer in
                        early life experience of the child can also have         two prospective cohorts. Cancer Causes Control. 2007. 18 (5):
                        a great impact on future NCD risks thus making           517-23.
                        it important for mothers to receive care and             8 Martin, R.M. et al. Breastfeeding and cancer: the Boyd Orr
                        support for nutrition and breastfeeding, even            cohort and a systematic review with meta-analysis. J Natl Cancer
                                                                                 Inst. 97 (19): 1446-57 (2005)
                        after the birth of a child.
                                                                                 9 Conde-Agudelo, A., Belizán, J. M., & Lammers, C. (2005).
                                                                                 Maternal-perinatal morbidity and mortality associated with
                        Policy frameworks                                        adolescent pregnancy in Latin America: Cross-sectional study.
                        The World Health Organization has produced a             American Journal of Obstetrics and Gynecology, 192(2), 342-349.
                        comprehensive guide for essential practice in            10 Loto, O., Ezechi, O., Kalu, B., Loto, A. B., Ezechi, L. O., &
                        pregnancy, childbirth, postpartum and newborn            Ogunniyi, S. (2004). Poor obstetric performance of teenagers: is it
                                                                                 age- or quality of care-related? Journal of Obstetrics and
                        care.13 The guideline stresses the importance of         Gynaecology, 24(4), 395-398.
                        antenatal care, an attended birth, and continued
                                                                                 11 Gutierrez, Y., & King, J. C. (1993). Nutrition During Teenage
                        monitoring in the first few weeks and months of          Pregnancy. Pediatric Annals, 22(2), 99-99.
                        life for both mother child. These guidelines have
                                                                                 12 Plan International. (n.d.). Teenage pregnancy. Retrieved from
                        contributed greatly to the overall global      
                        reduction in maternal and child mortality. They
                                                                                 13 World Health Organization. Pregnancy, childbirth, postpartum
                        also include recommendations on tobacco use              and newborn care: a guide for essential practice - 3rd ed.
                        and postpartum depression but do not address             Geneva, Switzerland. 2015.
                        NCDs during pregnancy in any specific way.               14 World Health Organization. Diagnostic criteria and
                              But awareness is growing. In 2013, the             classification of hyperglycaemia first detected in pregnancy.
                                                                                 Geneva, Switzerland. 2013.
                        WHO produced guidelines on the screening
                                                                                 15 World Health Organization. Global strategy for the infant and
                                                                                 young child feeding. Geneva, Switzerland. 2003.

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