EDUCATION Cent Eur J Publ Health 2004; 12 (3): 166–170

LIFE CYCLE APPROACH TO CHILD

AND ADOLESCENT HEALTH
Kudlová E.
Charles University of Prague, First Faculty of Medicine, Institute of Hygiene and Epidemiology, Prague, Czech Republic

SUMMARY
Young people are our human capital for the future, therefore child and adolescent health has attracted considerable political and professional
attention in recent years. Health is indivisible, requirs holistic approach throughout the individual‘s life. Healthy outcome at one point in the life cycle,
provides a positive determinant for health elsewhere in the cycle. Health and development of the 0–19 age group links intimately, at both ends of
the range, with reproductive health. Health during childhood is in part determined by the health of the mother, and affected also by factors such as
the nutrition of adolescent girls and the avoidance of early pregnancy. These factors, in turn, are influenced by healthy growth and development
in childhood.
The paper presents main environmental and socio-cultural challenges for each of the stages of child and adolescent life. Main challenge described
are: unsafe abortion, malnutrition, anaemia, malformations, and infections during pregnancy; low birth weight, asphyxia, hypothermia, infection,
failure to initiate early and full breastfeeding in the neonatal period; poor nutrition, growth and development, frequent illnesses, injury, abuse and
neglect in the early childhood; poor nutrition, growth and development, injury, abuse, neglect, and helminth infections in the early school age; poor
nutrition, poor development, chronic conditions, mental disorders, injury, drug abuse, and violence in the adolescence.
Both, prevention of ill health and care for illnesses are important at all times but the balance between them shifts over time during the childhood
and adolescence. Main actions needed to meet the child and adolescent needs are presented as well.

Key words: child health, adolescent heath, life cycle, environmental risk, child development˝

Address for correspondence: E. Kudlová, Institute of Hygiene and Epidemiology, Studničkova 7, 128 00 Praha 2, Czech Republic. E-mail:
ekudl@lf1.cuni.cz

Child and adolescent health has attracted considerable political There are a number of external factors influencing outcomes
and professional attention in recent years (Table 1). Health is of the mother and child health cycle. Our health is determined to
indivisible, requiring holistic approach throughout the individu- a very considerable extent by the physical environment in which
al’s life. What happens in pregnancy and the very early stages of we live. In particular, the younger generation pays a heavy price
childhood will have a profound impact on child and adolescent for the environmental neglect. The air we breathe, the water we
development. Growth and development of young children en- drink, the food we eat and the built environment all exact their
hances the possibilities for their development during the school toll. These issues are addressed by a number of international
age period and in adolescence. This will be carried through into events (Table 1).
the adulthood and old age. Health and development of the chil- A balanced diet that provides optimum nutrition, together with
dren and adolescents links intimately, at both ends of the range, a clean water supply, are crucial to every stage of development
with reproductive health. Health during the childhood is in part from pre-conception through to later life. Poor nutrition is asso-
determined by the health of the mother, successively affected by ciated with a reduced resistance to disease, impaired physical and
factors such as the nutrition of adolescent girls and the avoidance psychological development, and infant morbidity and mortality.
of early pregnancy. Thus, a healthy outcome at one point in the An inadequate diet can lead to deficiency disorders and/or to
cycle provides a positive determinant for health elsewhere in the contribute to civilization diseases. In recognition of the food’s
cycle. An investment early on will result in a lifetime of economic, essential role in promoting and protecting health the European
social and personal benefits. Both, prevention of ill health and care states endorsed the First Action Plan for Food and Nutrition
for illnesses are important at all times but the balance between Policy (1).
them shifts over the time during the childhood and adolescence The social circumstances in which children and adolescents
in relation to risks encountered during the particular life-stage grow to maturity are also of paramount importance. Peer pressure,
(Table 2). family values, mass communication, the school environment, and

List of acronyms:
CEHAP – Children’s Environment and Health Action Plan for Europe, IMCI – Integrated Management of Childhood Illness, UNICEF – United
Nations Children’s Fund, WHO – World Health Organization.

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Table 1. Overview of important events addressing child and adolescent health (9)

• 1991: World Summit for Children: leaders from across the globe issued an urgent appeal to give every child a better future.
• 1999: WHO Regional Office for Europe published HEALTH21: health for all in the 21st century, which laid out a vision to improve the health
of the 870 million people living the European Region.
• 1999: The Third Ministerial Conference on Environment and Health placed children‘s health at the top of the political agenda.
• 2000: The United Nations Millennium Summit of world leaders highlighted development as being at the heart of the global agenda and
formulated eight Millennium Development Goals.
• 2002: Global Consultation on Child and Adolescent Health and Development in Stockholm confirmed the need for more investment in those
interventions known to have the greatest impact.
• 2002: The Johannesburg Declaration on Sustainable Development underlined the need to eradicate poverty and engage in sustainable
development in the context of the need to create a better future for all children.
• 2003: The Children‘s Environment and Health Action Plan for Europe (CEHAPE) set out steps for various sectors that are designed to
decrease exposure to a number of environmental hazards.
• 2003: World Health Assembly adopted Strategic Directions for Improving the Health and Development of Children and Adolescents.
• 2003: WHO Regional Committee for Europe in Vienna supported resolution calling for the development of the comprehensive regional
strategy on the health of children and adolescents.
• 2004: Fourth Ministerial Conference on Environment and Health: "The future for our children“ accepts the CEHAP as the key platform.

Table 2. Main risks of pregnancy, childhood and adolescence

Pregnancy Neonatal period Early childhood Early school age Adolescence

Unsafe abortion Low birth weight Poor nutrition, growth Poor nutrition, growth Poor nutrition
Malnutrition Asphyxia and development and development Poor development
Anaemia Hypothermia Frequent illnesses Injury Chronic conditions
Malformations Infection Injury Abuse and neglect Mental disorders
Infections Failure to initiate early Abuse and neglect Helminth infections Injury, drug abuse,
and full breastfeeding violence

social and gender norms all exert a considerable influence on PREGNANCY

lifestyle. Over the past decade, many countries in the European
region have experienced rapid socio-political change, econo- The starting point in the life-course of health and development is
mic hardship, increased insecurity, conflict and even war. The that every baby should be a wanted baby. Unwanted pregnancies
health-related behaviour of adolescents is a function of all these may lead to unsafe abortions, child neglect, malnutrition, disease,
pressures. Differences in the health experience of boys and girls and social problems. This implies effective contraceptive advice
are apparent in all countries. Some of these are associated with and availability as young people approach puberty and during
the lower socio-economic status of women; some are related to their reproductive years.
differences in biology. Social behaviours and gender norms are A healthy start to life is essential. A woman‘s health directly
also important influences. influences the health and development of her child. Access to
Poverty is a major determinant of health. Inequities related to timely and responsive health services, including skilled birth
economic situation affect both physical and mental health. Poor attendants at the time of delivery, is essential.
children grow up in less healthy environments and are more likely Maternal mortality varies enormously across the European
to suffer the effects of pollution. Overcrowded housing is invari- region, ranging from 6 per 100,000 live births in Switzerland to
ably associated with a lack of safe areas for play. Accidents and 41 per 100,000 in some Eastern European countries (3).
crime are more prevalent; a poor diet and lack of physical activity Inadequate nutrition in the very early stages of development
are more likely. Poverty places maternal and newborn health at can have an impact throughout an individual‘s life. In many
risk and has a deleterious impact on mental health. Relative po- European countries, micronutrient deficiency diseases co-exist
verty within countries may be even more important than absolute with disorders of energy excess that result from a lack of fruit and
poverty. Relative poverty is growing at a more rapid rate in Europe vegetable intake. Malnutrition and anaemia, in pregnant women in
and central Asia than anywhere in the world. According to the low-income countries are a significant threat, as they can severely
European Anti-Poverty Network, in some European countries as impact a foetus‘ growth and development and result in long-term
many as 26% of children live in relative poverty (2). consequences. It has been estimated that eliminating malnutrition

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among pregnant women would reduce disabilities among their of these deaths are due to just five preventable and treatable con-
infants by almost one third (4). ditions: pneumonia, diarrhoea, malaria, measles, and malnutrition,
Mothers can also be the vectors for transmitting communicable and often to a combination of these conditions (10). There are
diseases to their babies. Although the absolute numbers remain many biological environmental factors associated with this high
relatively small, mother-to-child transmission of HIV has increa- toll, among them the lack of clean water and sanitation, as well
sed dramatically in Eastern Europe. In the Ukraine, for example, as environmental-related diseases such as malaria and dengue
infection rates in pregnant women rose from 0.005 per 10,000 in fever. Throughout Europe, the incidence of food-borne diseases
1996 to 17 per 10,000 only four years later (3). continues to increase, with the main burden falling on children
For the child, infection is the major killer during pregnancy and under 10 years. Infants aged between 6 to 12 months are at greatest
after birth, as well as low birth weight due to intrauterine growth risk as the protection from breast-milk declines and the potential
retardation and/or pre-term birth. Congenital abnormalities are hazards from weaning foods increase (9).
the second leading cause of death in high-income countries (5). Many of the childhood communicable illnesses can be
In the United States, these anomalies, along with sudden infant avoided through the efficient organization and management of
death syndrome and premature birth, account for more than 50 immunization programmes. World Health Organization (WHO)
per cent of all infant deaths (6). Approximately 3–10% of these and UNICEF addressed the care for illnesses in young children
cases have been attributed to exogenous and environmental by developing a strategy „Integrated Management of Childhood
agents (6). Scientific studies reveal that exposure during the Illness“ (IMCI). IMCI is an integrated approach to child health
early months of pregnancy can lead to an increased likelihood of that focuses on the well being of the whole child. It aims to reduce
mental retardation and development disabilities (7). The scope for death, illness and disability, and to promote improved growth and
reducing unnecessary disability and ill health is also considerable, development among children under 5 years of age (10).
through the application of interventions that are already known Young children are particularly susceptible to environmental
to be effective such as vaccination against rubella (which causes threats because of the rapid development of their immune, respi-
birth defects in 90% of children if contracted early in pregnancy). ratory and nervous systems. The metabolic functions of young
Avoiding alcohol and stopping smoking have beneficial effects on children are in a dynamic state of development. Any irritants,
the unborn child. One measure of success will be a decrease in the such as air and water pollutants, encountered during these early
number of low birth weight babies (below 2,500 grams) (8). stages of growth may permanently impair the development of
these vital organs. Children breathe more air, drink more water
and eat more food than adults do per unit of body weight, and this
NEONATAL PERIOD higher rate of intake results in greater exposure to pathogens and
pollutants (11). Brain development is much more vulnerable to
The first 28 days, the neonatal period, are critical. It is also during environmental influence than was previously suspected, and the
this time that the child is at highest risk for death. Of the approxi- influence of early environmental quality on brain development
mately 7 million infants, who die each year, about two-thirds die in is long lasting (17). Small children are also curious and learn by
the neonatal period. Improving newborn survival will dramatically exploring their world, for instance, by putting their hands and
reduce infant mortality worldwide. Ninety-eight percent of all objects in their mouths, they also crawl and play on the ground
neonatal deaths occur in developing countries. Perinatal condi- and are at risk from pathogens and pollutants on these surfaces.
tions, many of which are significantly influenced by environmental Close parental care and supervision is, therefore, crucial to the
conditions, account for 20 per cent of the under-five mortality safe and healthy development of young children.
rate worldwide (4). Asphyxia can kill the baby if it is not given Inappropriate nutrition is a major cause of poor health outcomes.
adequate basic treatment. Hypothermia, often interacting with low WHO has estimated that globally 27% of children under 5 years are
birth weight or infection is a major risk. Failure to initiate early underweight (12) and there are wide variations also between the
and full breastfeeding contributes to this set of events. European countries (13). Appropriate feeding practices stimulate
Neonatal health is largely a product of socio-economic cir- psycho-social development, lead to improved nutrition and physi-
cumstances, access to appropriate services at the time of delivery cal growth, reduced susceptibility to common childhood infections
as well as during the antenatal period, and parental education. and better resistance to cope with them. Improved health outcomes
Success in reducing neonatal mortality requires many compo- in young children have long-lasting health effects throughout the
nents: caring families, availability of adequate healthcare, ability life span. Much has already been done in recent decade to promote
to recognize when a sick child needs professional care, good nu- breastfeeding. As a result, increasing breastfeeding prevalence
trition, and support from communities. It is during this time that rates are reported from a number of countries (14, 15). However,
the fundamental health and feeding practices are established. a continuing great concern led WHO to develop a global strategy
for infant and young child feeding (16).
It is essential also to provide a stimulating environment for
EARLY CHILDHOOD psychosocial development. Medical and educational research
has shown that the development of intelligence, personality and
Over 40% of the global burden of disease is attributed to envi- social behaviour occurs most rapidly in humans during their first
ronmental risks that affect children under five, although this age three to four years (4). Parents are the children’s earliest teachers,
group only accounts for 10% of the world‘s population (9). Each Therefore, strengthening the ability of the mother and all family
year more than 10 million children in low-and middle-income members to care for and stimulate their children and encourage
countries die before they reach their fifth birthday. Seven in ten them to learn can set the stage for adult success.

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 Child abuse and neglect manifest themselves during the first increasingly influential in establishing the child’s values, attitudes
years of life in every country. For instance 60% of children in and behaviour patterns. School is an important place for bringing
Europe and central Asia say they face violent or aggressive be- about behavioural changes, promoting better health for students,
haviour at home (9). The health consequences can be physical, and teaching about caring for the community environment.
sexual and reproductive, psychological and behavioural, or lead For this age group, both prevention and the appropriate care
to long-term, chronic disease. of illness are essential. As a child moves through the school-age
Accidents and unintentional injuries also become more prevalent years and into adolescence, prevention of behaviours that can
as the child increasingly starts to explore his or her environment, lead to health risks takes on a greater importance.
often without the necessary coordination or awareness of hazards.
Drowning, falls, fires, accidental poisoning and traffic accidents ac-
count for some of the disability and deaths in this age group (3). ADOLESCENCE
Both, prevention and care for illnesses are very important for
young children, and both focus primarily on the mother and other One in every five people in the world is an adolescent – defined
caretakers. Prevention that contributes to the healthy development by WHO as a person between 10 and 19 years of age. Out of
of the young child includes important issues such as breastfeeding 1.2 billion adolescents worldwide, about 85% live in developing
and the appropriate introduction of complementary foods, hygiene countries. Every year, an estimated 1.7 million persons between
practices, immunization and caring behaviours. ages of 10 and 19 lose their lives (20). There are relatively few
deaths due to illnesses. Many adolescents die prematurely due to
other causes such as accidents and risky behaviour. Many habits
EARLY SCHOOL AGE and lifestyle choices that start during these critical years contri-
bute greatly to the overall health of an adult. The WHO estimates
Globally, most deaths among older children are due to diseases that that 70% of premature deaths among adults are largely due to
can be prevented, but that can also be treated easily. An appropriate behaviour initiated during adolescence (20).
and timely health care is essential. Vaccines protect a child against Physical and emotional development accelerates with the
the childhood diseases, other diseases, such as diarrhoea and hep- arrival of puberty, and the young adolescent becomes ever more
atitis A can be prevented by good hygiene and sanitary practices. subject to cultural influences, perceived social norms and pressu-
Childhood cancers are a major concern in developed countries. In re from friends although the family support continues to be of
the United States, cancer is the second biggest killer of children significance. It is a normal part of adolescent development to take
after accidents, with the median age of child victims of cancer on new responsibilities and roles which can incur risks, to renego-
being six years old (18). Acute leukaemia is the most common type tiate relations with adults in the family and community and with
of cancer found in children, and its incidence appears to be rising peers, to experiment with things symbolic of adult life. Growing
in some developed countries. Among the environmental factors independence is associated with increased risk-taking. Accidents,
that may play a role are tobacco smoke, radon, asbestos, ultraviolet violence, and suicide are among the three most common causes of
light radiation, hazardous waste and some pesticides (18). death in adolescence (4). Adolescence is also a period of experi-
Helminth diseases, which are caused by intestinal worms found mentation and rebellion against authority. This is the age when the
in soils and vegetables, are one of the common health problems use of tobacco, alcohol and drugs can become established habits.
among school age children in developing countries. These chil- Their use is a major contributing factor to accidents, suicides,
dren commonly carry large loads of helminths, which can cause violence, unwanted pregnancies and sexually transmitted diseases
anaemia and other debilitating conditions. These illnesses can among young people in many countries. There is an urgent need to
result in impaired learning, poor school performance and more create safer and more supportive environments within which young
absences from school (19). people can develop. Adult role models, positive peer influence
Poor nutrition remains globally a major contributor to child- and initiatives such as Health Promoting Schools (9) all have an
hood diseases and deaths. In countries with plentiful food provisi- important part to play in healthy adolescent development.
on, the cheapest form of food energy comes regrettably from fats, Sound nutrition remains a foundation stone for good health as the
oils and sugar. Consumption of these energy-dense foods, together child progresses towards adulthood. However, in many countries,
with lack of physical activity, results in increasing prevalence of overweight and obesity in children and adolescents is increasing,
obesity among children (9). often co-existing with micronutrient deficiencies (9). Type II dia-
New health challenges emerge as children become increasingly betes, previously a disease of middle age, is now increasingly being
exposed to the wider physical and social environment. Injuries, reported among young people in European countries (3).
usually road traffic injuries, falls and drowning, are now the number- Pre-existing mental health issues may worsen as the adolescent
-one killer of children aged five to 14 years in developed countries undergoes this demanding phase of emotional and physical matura-
(5). Additional factors such as exposed cooking set-ups, dangerous tion. Impaired mental health is a precursor or consequence of many
tools and equipment, open sewers, construction or electrical sites above-mentioned health-risky behaviours. Adolescence is also a
and hazardous chemicals pose threats in developing countries. peak age of onset for serious mental illness. In the European region,
Parental lifestyle increases its impact as the child develops. the incidence of psychological ill health and mortality increases as
Attitudes to health-related behaviours such as smoking and a consequence of the breakdown of traditional social and family
physical activity are formed, and eating patterns become esta- structures, particularly in those communities experiencing signifi-
blished. As social interaction beyond the family develops, the cant societal, political and economic change. About 10% to 20% of
school environment, peer pressure and the mass media become children have one or more mental or behavioural problem (9).

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