Volume 64(11); November

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Clin Exp Pediatr > Volume 64(11); 2021
Choi: Changes in health status of North Korean children and emerging health challenges of North Korean refugee children


The food shortage in North Korea is a serious situation that has spanned the mid-1990s to today. North Korean refugee children, even those born in North Korea, China, or South Korea, had poor nutritional status at birth; thus, their growth and nutritional status should be continuously monitored. This review focused on the health status of North Korean children and the nutritional status of North Korean refugee children upon settling in South Korea. Immediately after entering South Korea, North Korean refugee children were shorter and lighter than South Korean children and had a serious nutritional status. Over time, their nutrition status improved, but they remained shorter and lighter than South Korean children. A new obesity problem was also observed. Therefore, it is necessary to continuously monitor their growth and nutritional status.

Graphical abstract


In the mid-1990s, the nutritional status of the North Korean (NK) population was very serious due to food shortages. The United Nations (UN) reported that the prevalence of acute malnutrition was 32.7%, while the prevalence of chronic malnutrition was as high as 74.1% [1]. These food crises caused numerous NK people to escape from China or other neighboring countries. The total number of NK refugees (NKRs) entering South Korea (SK) reached 33,752 by the end of December 2020 [2]. Among them, 4,799 (14.2%) were children and adolescents aged 0–19 years [3].
In the early 2000s, when the number of NKRs increased rapidly, the mass media released articles about the retarded growth of NKR children, but only a few studies investigated their nutritional status. Moreover, most of the studies were one-off, and the timing and number of samples differed, so a comprehensive assessment of the growth and nutritional status of NKR children is lacking. Therefore, this study summarized the studies conducted to date and assessed how the growth and nutritional status of NKR children have changed.

Health status of NK children

1. Child health

International food aid has been provided since the United Nations Food Shortage Report on NK was published in mid-19990s, and several surveys have assessed maternal and child health to verify the effectiveness of the food aid (Table 1) [4-10]. The birth rates of low birth weight infants were 6.4% in 2000 and 6.7% in 2002 but gradually decreased to 3.1% in 2017. Among children under 6 months of age, the exclusively breastfed rate increased from 69.6% in 2002 to 88.6% in 2009 and then gradually decreased to 71.4% in 2017. The vitamin A supplementation coverage rate in children aged 6–59 months was 80.2% in 2000 and gradually increased to 97.8% in 2012. The percentage of children receiving oral rehydration solutions during an episode of diarrhea was 90.9% in 2000 versus 74.1% in 2017.

2. Maternal health

The proportion of more than 4 antenatal care visits was 95% in 2004 versus 93.7% in 2017. The proportion of skilled birth attendants was 96.7% in 2000 versus 99.5% in 2017. The proportion of childbirths that occurred at the health facility was 94.7% in 2009 versus 92.2% in 2017.

3. Nutrition

Among children under the age of 5 years, the underweight rate was 60.6% in 1998 and then gradually decreased to 18.8% in 2009 and 9.3% in 2017. Similarly, the rates of wasting and stunting decreased from 15.6% and 62.3% in 1998 to 2.5% and 19.1% in 2017, respectively.

4. Immunization

Fig. 1 shows the immunization rates of NK children from 1998 to 2019 [11]. The Bacillus Calmette-Guérin vaccine immunization coverage rate was 69% in 1998 versus 96% in 2002. It decreased to 88% in 2003 and then continued to fluctuate gradually, reaching 96% in 2019. The DTP3 (third dose of diphtheria and tetanus toxoids and pertussis-containing vaccine) immunization coverage rate was as low as 43% in 1998 but has continued to increase since then, reaching 97% in 2019. The Pol3 (third dose of polio vaccine) immunization coverage rate was 82% in 1998, increased to 99% in 2002, and was 98% in 2019.
The MCV1 (first dose of measles-containing vaccine) immunization coverage rate was 49% in 1998 and increased rapidly to 98% in 2002, and then gradually fluctuated, reaching 98% in 2019. The coverage rate of the HepB3 (three-dose hepatitis B vaccine) was very low at 27% in 2003, increased sharply to 98% in 2004, and remained at 97% in 2019.

5. Leading cause of death in NK children

The changes in the leading cause of death in children with NK between 2000 and 2019 using data from the Institute for Health Metrics and Evaluation [12] are shown in Fig. 2. Among children under 5 years of age, protein-energy malnutrition was the most common cause of death in 2000 but sharply decreased in 2019, while the rates of measles and whooping cough decreased similarly in 2019. However, the rates of lower respiratory infections and diarrheal diseases were higher in 2019. In addition, the rates of injuries, such as drowning, foreign bodies, and road injuries, increased in 2019 compared to 2000.
In children aged 5–14 years, the most common cause of death in 2000 was protein-energy malnutrition, which decreased sharply in 2019, similar to what was noted in children under 5 years of age. The same infectious diseases, measles and meningitis, also declined in 2019, whereas lower respiratory infections maintained a similar ranking in 2019. The rates of injuries (drowning, road injury, interpersonal violence, and falls) and noncommunicable diseases (leukemia, congenital defects, brain cancer, and other malignant neoplasms) increased in 2019.

Health challenges of NKR children

1. Background of NKR children

The backgrounds of NKR children can be divided into several categories [13]: those who were born in NK but have moved to SK; those who were born in a third country such as China after one of their parents left NK and subsequently entered SK; and those who were born in SK after a parent settled in SK. The Ministry of Unification data includes only children born in NK. In fact, it is estimated that there are more NKR children living in South Korea than reported. These children are highly likely to have poor nutritional status at birth and have a low socioeconomic status (SES), even after settling in SK [14]; therefore, their nutritional status must be regularly monitored.

2. Growth status between NK and SK children

After the NK famine of the mid-1990s, researchers have aimed to determine the growth and nutritional status of NK children using UN survey data (Table 2). In a study comparing the height and weight, NK children were 6–7 cm shorter and about 3 kg lighter than SK children [15]. In another study, NK children were up to 13 cm shorter and up to 7 kg lighter than SK children (Table 3) [16].

3. Growth and nutrition status after defecting from NK

As the food shortage persisted and many NK citizens began escaping the country, investigators became concerned about the growth and nutritional status of NKR children (Table 4). NKRs generally stay in third countries (mainly China) for months to years before entering SK. One study assessed the growth status of NKR children residing in China [17]. The heights and weights of 436 NKRs aged 4–19 years old were measured, and their growth statuses were only 70%–90% of those of SK children.

4. Growth and nutrition status immediately after SK entry

Immediately after entering SK, NKRs undergo a medical examination at Hanawon. Some studies have evaluated the growth status of NKR children using Hanawon health data (Table 4). Of them, 30.2% were shorter than the 3rd percentile of the SK standard, while 27.9% weighed less than the 3rd percentile of the SK standard [18]. Similarly, another study