Although precise worldwide statistics are unavailable, the United Nations estimates that more than 8 billion children were born between 1950 and 2015. Almost a billion of them died before age 5.

Although most of those 1 billion deaths could have been prevented, far more would have died without recent public health measures. In 1950 1 young child in 5 died, but only about 1 child in 20 is projected to die in 2014 (United Nations, 2015). In earlier centuries, more than half of all newborns died in infancy. Those are official statistics; probably millions more died without being counted.

In the twenty-first century in developed nations, 99.9 percent of newborns who survive the first month live to adulthood. Even in the poorest nations, where a few decades ago infant mortality was accepted as part of the human experience, 99 percent of newborns who survive those early days live at least until age 15, although the rate of newborn death is much higher than it would be with good medical care. Some nations have seen dramatic improvement. Chile’s rate of infant mortality, for instance, was almost 4 times higher than the rate in the United States in 1970; now the two rates are even (see Figure 5.7).

The world death rate in the first five years of life has dropped about 2 percent per year since 1990, (Rajaratnam et al., 2010) with the rate in developed nations less than 1 in 1,000, and in least developed nations about 1 in 200. Public health measures (clean water, nourishing food, immunization) deserve most of the credit.

As children survive, parents focus more effort and income on each child, having fewer children overall. That advances the national economy, which allows for better schools and health care. Infant survival and maternal education are the two main reasons the world’s fertility rate in 2010 was half the 1950 rate. This is found in data from numerous nations, especially developing ones, where educated women have far fewer children than those who are uneducated (de la Croix, 2013).

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If there were enough public health professionals, the current newborn and child death rate could be cut in half again. Public health measures help parents as well as children, via better food distribution, less violence, more education, cleaner water, and more widespread immunization (Farahani et al., 2009).

Often cultural variations are noted in infant care. There are many ways to care for a baby, with all the experience-dependent versions of child care designed to raise children who are prepared for their culture. One theme of this book, as introduced in Chapter 1, it that difference is not deficit. Usually variations are simply alternative ways to meet basic infant needs for nutrition, love, and care.

Sometimes, however, one mode of infant care is much better than another, and here a cross-cultural perspective is especially useful, as evidenced in research about sudden infant death syndrome (SIDS).

Every year until the mid-1990s, tens of thousands of infants died of SIDS, called crib death in North America and cot death in England. Tiny infants smiled at their caregivers, waved their arms at rattles that their small fingers could not yet grasp, went to sleep seemingly healthy, and never woke up. As parents mourned, scientists asked why, testing hypotheses (the cat? the quilt? natural honey? homicide? spoiled milk?) to no avail. Sudden infant death was a mystery. To some extent, it still is, but one risk factor—sleeping on the stomach—is now known worldwide, thanks to the work of one scientist, as described in A Case to Study.

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Immunization primes the body’s immune system to resist a particular disease. Immunization (often via vaccination) may have had “a greater impact on human mortality reduction and population growth than any other public health intervention besides clean water” (J. P. Baker, 2000, p. 199). Within the past 50 years, immunization eliminated smallpox and dramatically reduced chickenpox, flu, measles, mumps, pneumonia, polio, rotavirus, tetanus, and whooping cough. Now scientists seek to immunize against HIV/AIDS, malaria, Ebola, and other viral diseases.

Immunization protects not only from temporary sickness but also from complications, including deafness, blindness, sterility, and meningitis. Sometimes the damage from illness is not apparent until decades later. Having mumps in childhood, for instance, can cause sterility and doubles the risk of schizophrenia in adulthood (Dalman et al., 2008).

Some people cannot be safely immunized, including the following:

Fortunately, each vaccinated child stops transmission of the disease and thus protects others, a phenomenon called herd immunity (mentioned in Chapter 1). Although specifics vary by disease, usually if 90 percent of the people in a community (a herd) are immunized, the disease does not spread. Without herd immunity, some community members die of a “childhood” disease.

Everywhere parents can refuse to vaccinate their children for medical reasons, but in 19 states of the United States, parents are able to opt out of vaccination because of “personal belief” (Blad, 2014). In Colorado, for instance, 15 percent of all kindergartners have never been immunized against measles, mumps, rubella, diphtheria, tetanus, or whooping cough. That is below herd immunity, and an epidemic could occur—with infants most likely to suffer.

Infants may react to immunization by being irritable or even feverish for a day or so, to the distress of their parents. However, parents do not notice if their child does not get polio, measles, or so on. Before the varicella (chicken pox) vaccine, more than 100 people in the United States died each year from that disease, and 1 million were itchy and feverish for a week. Now almost no one dies of varicella, and far fewer get chicken pox.

Many parents are concerned about the potential side effects of vaccines. Whenever something seems to go amiss with vaccination, the media broadcast it, which frightens parents. This has occurred particularly as rates of autism have risen. (Developmental Link: The link between fear of immunization and increased rates of autism is discussed in A View from Science in Chapter 1.) As a result, the rate of missed vaccinations in the United States has been rising over the past decade. This horrifies public health workers, who, taking a longitudinal and society-wide perspective, realize that the risks of the diseases are far greater than the risks from immunization. The 2014 spike in measles cases was the highest since 1994, one result of increasing numbers of parents objecting to vaccination.

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Concerns about safety are greatest for newer vaccines, including the annual flu shot. Pregnant women and young children are particularly likely to be seriously affected by flu, which has led the United States Centers for Disease Control to recommend vaccination. However, most pregnant women and about 30 percent of parents do not follow that recommendation (MMWR, March 7, 2014).

In 2012, two states, Connecticut and New Jersey, required flu vaccination for all 6- to 59-month-olds in licensed day-care centers. Flu immunization rates of young Connecticut children rose from 68 to 84 percent. In the 2012–2013 winter, far fewer young children in Connecticut were hospitalized for flu than in previous years, although rates rose everywhere else. Since most Connecticut children are not in day care, apparently herd immunity, added to the perception of parents that flu vaccination was safe, was protective. Meanwhile, Colorado had the highest rate of flu hospitalizations, an increase from previous years (MMWR, March 7, 2014).

As already explained, infant mortality worldwide has plummeted in recent years for several reasons: fewer sudden infant deaths, advances in prenatal and newborn care, and, as you just read, immunization. One more measure is making a huge difference: better nutrition.

Ideally, nutrition starts with colostrum, a thick, high-calorie fluid secreted by the mother’s breasts at birth. After about three days, the breasts begin to produce milk.

Compared with formula based on cow’s milk, human milk is sterile, always at body temperature, and rich in many essential nutrients for brain and body (Wambach & Riordan, 2014; Drover et al., 2009). Babies who are exclusively breast-fed are less often sick, partly because breast milk provides antibodies and decreases allergies and asthma. Disease protection continues lifelong: Babies who are exclusively breast-fed in the early months become obese less often (Huh et al., 2011) and thus have lower rates of diabetes and heart disease.

Breast-feeding is especially protective for preterm babies; if a tiny baby’s mother cannot provide breast milk, physicians recommend milk from another woman (Schanler, 2011). (Once a woman has given birth, her breasts can continue to produce milk for decades.)

The specific fats and sugars in breast milk make it more digestible and better for the brain than any substitute (Drover et al., 2009; Wambach & Riordan, 2014). The composition of breast milk adjusts to the age of the baby, with milk for premature babies distinct from that for older infants. Quantity increases to meet the demand: Twins and even triplets can be exclusively breast-fed for months.

Formula is preferable only in unusual cases, such as when the mother is HIV-positive or uses toxic or addictive drugs. Even then, however, breast milk without supplementation may be advised, depending on the alternatives. For example, in some African nations, HIV-positive women are encouraged to breast-feed because infants’ risk of catching HIV from their mothers is lower than the risk of dying from infections, diarrhea, or malnutrition as a result of bottle-feeding (Cohen, 2007; Kuhn et al., 2009). The worst option in that circumstance is a mixture of breast- and formula-feeding.

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Doctors worldwide recommend breast-feeding with no other foods—not even juice—for the first months of a newborn’s life. (Table 5.1 lists some of the benefits of breast-feeding.) Some pediatricians suggest adding foods (rice cereal and bananas) at 4 months; others want mothers to wait until 6 months (Fewtrell et al., 2011). For breast milk to meet the baby’s nutritional needs, the mother must be well fed and hydrated (especially important in hot climates), and avoid alcohol, cigarettes, and other drugs.

Breast-feeding was once universal, but by the mid-twentieth century many mothers thought formula was better. Fortunately, that has changed again. In the United States, 77 percent of infants are breast-fed at birth, 48 percent at 6 months (most with other food as well), and 25 percent at a year (virtually all with other food and drink) (U.S. Department of Health and Human Services, 2011) (see Figure 5.10). Worldwide, about half of all 2-year-olds are still nursing, usually at night.

Encouragement of breast-feeding and help from family members, especially new fathers, are crucial. Ideally, nurses visit new mothers weekly at home; such visits (routine in some nations, rare in others) increase the likelihood that breast-feeding will continue. It is also true that, as with many aspects of child care, “there may be little net benefit to breast-feeding if it results in distressed mothers or marital or family discord” (Brody, 2012). In other words, “breast is best” when compared to formula, but exclusive breast-feeding is not always best when a family’s entire life together is considered. In developed nations, sterile formula has nourished millions of infants, who have become happy and healthy children.

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Protein-calorie malnutrition occurs when a person does not consume enough food to sustain normal growth. This form of malnutrition affects roughly one-fourth of the world’s children in developing nations: They suffer from stunting, being short for their age because chronic malnutrition kept them from growing. Stunting is most common in the poorest nations (see Figure 5.11).

Even worse is wasting, when children are severely underweight for their age and height (2 or more standard deviations below average). Many nations, especially in East Asia, Latin America, and central Europe, have seen improvement in child nutrition in the past decades, with an accompanying decrease in wasting and stunting.

In some other nations, however, primarily in Africa, wasting has increased. And in several nations in South Asia, about one-third of young children are stunted (World Health Organization, 2014). In some nations, the traditional diet for young children or their mothers does not provide sufficient vitamins, fat, and protein for robust health (Martorell & Young, 2012). As a result, the infant’s energy is reduced and normal curiosity is absent (Osorio, 2011). Young children naturally want to do whatever they can: A child with no energy is a child who is not learning.

Chronically malnourished infants and children suffer in three additional ways:

Prevention, more than treatment, is needed. Sadly, some children hospitalized for marasmus or kwashiorkor die even after feeding because their digestive systems are already failing (M. Smith et al., 2013). Ideally, prenatal nutrition, then breast-feeding, and then supplemental iron and vitamin A stop malnutrition before it starts. Once malnutrition is apparent, highly nutritious formula (usually fortified peanut butter) often restores weight—but not always.

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Some severely malnourished children still die. Researchers believe that for them, a combination of factors—genetic susceptibility, poor nutrition, infection, and abnormal bacteria in the digestive system (the microbiome)—is fatal (M. Smith et al., 2013). Giving severely ill children an antibiotic to stop infection saves lives—but always, prevention is best (Gough et al., 2014).

A study of two very poor African nations (Niger and Gambia) found several specific factors that reduced the likelihood of wasting and stunting: breast-feeding, both parents at home, water piped to the house, a tile (not dirt) floor, a toilet, electricity, immunization, a radio, and the mother’s secondary education (Oyekale & Oyekale, 2009). Overall, “a mother’s education is key in determining whether her children will survive their first five years of life” (United Nations, 2011, p. 26).

Several items on this list are taken for granted by readers of this book. However, two themes apply to everyone at any age: (1) Prevention is better than treatment, and (2) people with some knowledge tend to protect their health and that of their family. The next chapters continue these themes.

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