Surviving in Good Health

Although precise worldwide statistics are unavailable, the United Nations estimates that more than 8 billion children were born between 1950 and 2015 and that almost a billion of them died before age 5. Far more would have died without recent public health measures.

In 1950, one young child in five died, but only about one child in twenty died in 2015 (United Nations, 2015). Infant death was worse in earlier centuries, when more than half of all children died in infancy. Those are official statistics; probably millions more died without being counted.

Better Days Ahead

Now almost all newborns who survive the first month live to adulthood. Some nations have seen dramatic improvement. Chile’s rate of infant mortality, for instance, was almost four times higher than the rate in the United States in 1970; now both nations have improved and their rates are the same (see Figure 3.5).

Figure 3.5: FIGURE 3.5 More Babies Are Surviving Improvements in public health—better nutrition, cleaner water, more widespread immunization—over the past three decades have meant millions of survivors.

As more 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).

Educated women also have healthier children, in part because they are more aware of research that emphasizes breast-feeding, immunization, and other practices that protect health. You have already read that some cultural practices may benefit infants, and others not. Practices in dispute include co-sleeping, infant massage, and constant mother-care.

In an example reported on the front page of newspapers in the United States and Denmark, a Danish woman, Annette Sorenson, left her 14-month-old daughter asleep in her carriage outside a New York City restaurant where she ate dinner. She said she could see her baby through the window, that babies need fresh air, and that in Copenhagen mothers often leave babies outside when they shop, dine, and so on.

105

Well Protected Disease and early death are common in Africa, where this photo was taken, but neither is likely for 2-year-old Salem. He is protected not only by the nutrition and antibodies in his mother’s milk but also by the large blue net that surrounds them. Treated bed nets, like this one provided by the Carter Center and the Ethiopian Health Ministry, are often large enough for families to eat, read, as well as sleep in together, without fear of malaria-infected mosquitoes.

Sorenson was arrested for child neglect, her daughter placed in foster care briefly until a judge ordered her returned (Marcano, 1997). The mother sued the city for harming her as well as her child, who was unhurt. The lawsuit was dismissed, but it is obvious that cultures have contrasting assumptions regarding infant care.

Remember, difference is not deficit. Usually variations are simply alternative ways to meet basic infant needs. However, not every cultural practice is equally good. Each practice needs to be considered carefully, especially when cultures differ.

sudden infant death (SIDS)

An infant’s unexpected, sudden death; when a seemingly healthy baby, usually between 2 and 6 months old, stops breathing and dies while asleep.

For example, every year until the mid-1990s, tens of thousands of infants died of sudden infant death syndrome (SIDS), called crib death in North America and cot death in England. In every city and village, tiny infants smiled at their caregivers, waved their arms at rattles that small fingers could not yet grasp, went to sleep, 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 who looked closely at cultural differences. See A Case to Study.

106

A CASE TO STUDY

Scientist at Work

No SIDS Allowed For centuries, Native American babies, such as this boy in Arizona, slept on their backs in cradle boards. Back-sleeping was also customary among the Navajo’s genetic ancestors, in Asia, protecting them from SIDS.

Susan Beal, a young Australian scientist with four children, studied SIDS. Often she was phoned at dawn, to be told that another baby had died. She drove to the house, sometimes arriving before the police, finding parents who were grateful that someone was trying to discover what had just killed their child.

Parents tended to blame themselves and each other; Beal reassured them that it was not their fault and that scientists shared their bewilderment. Rates were known to be lower in breast-fed babies, one reason many educated women avoided bottle-feeding. Babies were more likely to die if they were boys, 2 to 6 months old, and in winter. Beyond that, little was known.

Beal’s detailed notes on dozens of SIDS deaths revealed what didn’t matter (birth order) and what did (parental cigarette smoking). She noticed a surprising ethnic variation: Although a sizable minority of Australians are of Chinese descent, their babies almost never died of SIDS. Most experts thought this was genetic, but Beal noted something else. Almost all SIDS babies died when they were sleeping on their stomachs, contrary to the Chinese custom of placing infants on their backs to sleep.

Beal convinced a large group of non-Chinese parents to put their babies to sleep on their backs, contrary to the advice of most pediatricians, including Dr. Benjamin Spock (author of Baby and Child Care, purchased more often than any other book except the Bible). Almost no back-sleeping Australian babies died. Beal concluded that back-sleeping protected against SIDS.

Beal’s published report in the Medical Journal of Australia (Beal, 1988) caught the attention of doctors in the Netherlands. Two Dutch scientists (Engelberts & de Jonge, 1990) recommended back-sleeping. The Netherlands has one of the highest rates of educated women in the world; thousands of new mothers read the recommendation and followed it. SIDS was reduced in Holland by 40 percent in one year—a stunning replication.

Australian Women: Shaping a Nation

Figure 3.6: FIGURE 3.6 Alive Today As more parents learn that a baby should be on his or her “back to sleep,” the SIDS rate continues to decrease. Other factors are also responsible for the decline—fewer parents smoke cigarettes in the baby’s room.

Worldwide, putting babies “Back to Sleep” has now cut the SIDS rate dramatically (Mitchell & Krous, 2015). In 1984 SIDS killed 5,245 babies in the United States; in 1996, 3,050; in 2010, about 1,700 (see Figure 3.6). In the United States alone, 100,000 children and young adults are alive today who would be dead if they had been born before 1990.

Stomach-sleeping is not the only risk. Beyond sleeping position, other risks include low birthweight, exposure to cigarette smoke, soft blankets or pillows, bed-sharing, and abnormalities in the brain stem, heart, mitochondria, or microbiome (Neary & Breckenridge, 2013; Ostfeld et al., 2010). Most SIDS victims experience several risks, a cascade of biological and social circumstances. But thanks to cross-cultural research, one major risk need not occur.

107

Immunization

immunization

A process that stimulates the body’s immune system to defend against attack by a particular contagious disease. Immunization may be accomplished either naturally (by having the disease) or through vaccination (often by having an injection). (Also called vaccination.)

Immunization primes the body’s immune system to resist a particular disease. Within the past 50 years, immunization eliminated smallpox and dramatically reduced chicken pox, flu, measles, mumps, pneumonia, polio, rotavirus, tetanus, and whooping cough. Now scientists seek to immunize against HIV/AIDS, malaria, Ebola, and other viral diseases.

Stunning successes include the following:

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 years later. Having mumps in childhood, for instance, can cause male sterility and doubles the risk of schizophrenia in adulthood (Dalman et al., 2008). Measles weakens the immune system, making later death more likely (Mina et al., 2015).

PROBLEMS WITH IMMUNIZATION Immunization is not safe for newborns or people with impaired immune systems (HIV-positive, aged, or undergoing chemotherapy). To catch the actual disease is much worse for them; they could die of a disease that is quite mild in childhood. Fortunately, each vaccinated child stops transmission of the disease and thus protects others who are vulnerable, a phenomenon called herd immunity. For that reason, proof of immunization is required before children enter school or college.

True Dedication This young Buddhist monk lives in a remote region of Nepal, where, until recently, measles was a fatal disease. Fortunately, a UNICEF porter carried the vaccine over mountain trails for two days so that this boy—and his whole community—could be immunized.

108

Some parents refuse to vaccinate their children for medical reasons; every state in the United States allows such exemptions. However, in 19 states, parents can refuse 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.

Globally, about 20 million cases of measles occur each year, almost all in nations with inadequate public health. If a traveler brings measles back to the United States, unimmunized children and adults may catch the disease. That happened in 2014, when the number of U.S. measles cases was 554, ten times the rate only two years before (MMWR, January 2, 2015).

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 only a few get chicken pox.

Many parents worry about the possible side effects of vaccines. This horrifies public health workers, who, taking a longitudinal and society-wide perspective, believe 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.

As you will see later, the fear that infant immunization leads to autism is unfounded; children who are not immunized are no less likely to have an autism spectrum disorder, but much more likely to become sick. It is easy to understand why parents of such a child would seek to blame something other than genes or teratogens, but in this case a cultural fear is destructive.

Nutrition

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

Video: Nutritional Needs of Infants and Children: Breast-Feeding Promotion shows UNICEF’s efforts to educate women on the benefits of breast-feeding.

BREAST MILK The World Health Organization now recommends exclusive breast-feeding for the first six months of life. That stunning endorsement of breast milk is based on extensive research from all nations of the world. 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).

Breast-feeding mothers should be well nourished and hydrated; then their bodies will make the perfect food for their babies. 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 best.

The more research is done, the better breast milk seems. For instance, 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. Each generation of scientists, and consequently each generation of mothers, knows more about breast milk and formula, as the following explains.

109

Same Situation, Far Apart: Breast-Feeding Breast-feeding is universal. None of us would exist if our fore-mothers had not successfully breast-fed their babies for millennia. Currently, breast-feeding is practiced worldwide, but it is no longer the only way to feed infants, and each culture has particular practices.

A VIEW FROM SCIENCE

From Breast to Formula and Back

Scientific discovery does not always proceed smoothly in one direction. Research on breast milk shows that. Four generations of women in my family heeded the best evidence known at the time when we fed our children.

A hundred years ago, my grandmother, an immigrant who spoke accented English, breast-fed her 14 children. If women of her generation could not provide adequate breast milk (for instance, if they were sick or seriously malnourished), the alternatives were milk from another woman (called a wet nurse), from a cow, or from a goat. Those alternatives increased the risk of infant malnutrition and death.

Two of Grandma’s babies died in infancy. Did insufficient nutrition play a role?

By the middle of the twentieth century, scientists had analyzed breast milk and created formula, designed to be far better than cow’s milk. Formula solves the problems of breast-feeding, such as insufficient milk and the exhaustion that breast-feeding mothers often experienced. Bottle-fed babies gained more weight than breast-fed ones; in many nations only poor or immigrant women breast-fed.

That is why my mother formula-fed me. She explained that she wanted me to have the best that modern medicine could provide. She recounted an incident meant to convey that my father was less conscientious than she was. He had volunteered to give me my 2 A.M. feeding (babies were fed on a rigid four-hour schedule). But the next morning, she noticed the full bottle in the refrigerator. She asked what happened. He said I was sound asleep, so he decided I was “fat enough already.” I never told her that Dad was right.

Companies that sold formula promoted it in Africa and Latin America as well as North America. They paid local women in developing nations to convince mothers to buy formula.

Then public health workers compiled statistics on infant mortality: In developing nations formula-fed babies were more likely to die. The reason was said to be lack of clean water and proper sterilization. Formula increased the rate of diarrhea (a leading killer of children in poor nations) by a factor of ten (León-Cava et al., 2002). The World Health Organization (WHO) recommended a return to breast-feeding in developing nations.

In sympathy for those dying babies, I was among the thousands of North Americans who boycotted products from the offending manufacturers. I breast-fed my children, to my mother’s surprise. But I gladly took my pediatrician’s advice to feed my 2-month-olds occasional bottles of formula (carefully sterilized), juice, water, and spoons of baby cereal and bananas.

110

Longitudinal research continues. The data led to a new conclusion: Even with good sterilization, in every nation breast-fed babies are healthier than other babies, benefiting throughout childhood (see Table 3.1) (Wambach & Riordan, 2014; Drover et al., 2009). The World Health Organization recommends exclusive breast-feeding for four to six months, no juice or baby food until that half-year mark.

Table 3.3: Table 3.1 The Benefits of Breast-Feeding

For the Baby

Balance of nutrition (fat, protein, etc.) adjusts to age of baby

Breast milk has micronutrients not found in formula

Less infant illness, including allergies, ear infections, stomach upsets

Less childhood asthma

Better childhood vision

Less adult illness, including diabetes, cancer, heart disease

Protection against many childhood diseases, since breast milk contains antibodies from the mother

Stronger jaws, fewer cavities, advanced breathing reflexes (less SIDS)

Higher IQ, less likely to drop out of school, more likely to attend college

Later puberty, fewer teenage pregnancies

Less likely to become obese or hypertensive by age 12

For the Mother

Easier bonding with baby

Reduced risk of breast cancer and osteoporosis

Natural contraception (with exclusive breast-feeding, for several months)

Pleasure of breast stimulation

Satisfaction of meeting infant’s basic need

No formula to prepare; no sterilization

Easier travel with the baby

For the Family

Increased survival of other children (because of spacing of births)

Increased family income (because formula and medical care are expensive)

Less stress on father, especially at night

International research continues. In Africa, an infant’s risk of catching HIV from a breast-feeding, HIV-positive mother is lower than the risk of dying from infections, diarrhea, or malnutrition as a result of bottle-feeding. Fears that medication prescribed for HIV-positive mothers affects the child’s later learning are unfounded (Ngoma et al., 2014).

In China, a study of more than a thousand babies in eight cities compared three groups of babies: those exclusively breast-fed (by their own mothers or wet nurses), those fed no breast milk, and those fed a combination of foods, formula, and breast milk. Based on all the data, the researchers suggest that the WHO recommendation for exclusive breast-feeding for the first six months “should be reinforced in China,” although some vitamin supplements might be warranted (see Figure 3.7) (Ma et al., 2014, p. 290).

Question 3.14

OBSERVATION QUIZ

In what one way might exclusive breast-feeding be worse than a combination of breast milk and other foods?

Combination feeding might provide some protection against the common cold. The advantage is not much (a difference of 5 percent) and may be because exclusively breast-fed infants are fed wherever their mothers are—and that may include outdoors, in polluted air.

Figure 3.7: FIGURE 3.7 Reducing Risk, No Guarantee Breast milk does not prevent all problems. Almost a third of the breast-fed babies had had a stuffed nose (respiratory disease). But the overall results of this study, which looked at dozens of variables, confirm that “breast is best.”

The research has caused a dramatic cohort change in the United States. Currently most (about 80 percent) mothers breast-feed in the beginning (unlike my mother) and 19 percent breast-feed exclusively until 6 months (unlike me). My daughters gave their babies nothing but breast-milk for the first six months of their lives.

Virtually all scientists and pediatricians have reached a conclusion opposite to the one their predecessors held 50 years ago: Infants should be nourished only by breast milk until they are 4 to 6 months old.

THINK CRITICALLY: For new mothers in your community, why do some use formula and others breast-feed exclusively for six months?

As of 2015 about 200 hospitals in the United States and hundreds more worldwide have been designated as “Baby-Friendly,” a UNICEF designation that includes putting every baby to the breast within half an hour of birth, and giving newborns nothing but breast milk except in unusual circumstances (such as a very small, fragile baby being tube-fed). My daughters breast-fed in the delivery room; I was not allowed to touch my newborns until 24 hours after birth.

Our knowledge advances with each generation. I wonder what the future will bring when my grandchildren become parents.

protein-calorie malnutrition

A condition in which a person does not consume sufficient food of any kind. This deprivation can result in illness, severe weight loss, and even death.

stunting

The failure of children to grow to a normal height for their age due to severe and chronic malnutrition.

MALNUTRITION Protein-calorie malnutrition occurs when a person does not consume enough food to sustain normal growth. This form of malnutrition affects roughly one-third 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 3.8).

Figure 3.8: FIGURE 3.8 Genetic? The data show that basic nutrition is still unavailable for many children in the developing world. Some critics contend that Asian children are genetically small and therefore that Western norms make it appear as if India and Africa have more stunted children than they really do. However, children of Asian and African descent born and nurtured in North America are as tall as those of European descent. Thus, malnutrition, not genes, accounts for most stunting worldwide.

wasting

The tendency for children to be severely underweight for their age as a result of malnutrition.

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 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). Because of head-sparing, some stunted children may not suffer intellectually. However, adults who were wasted in the first year of life have lower IQs throughout life, even if they are well fed after infancy (Waber et al., 2014).

Some of this is directly related to brain growth, but in addition, the severely malnourished infant has less energy and reduced curiosity. Young children naturally want to do whatever they can: A child with no energy is a child who is not learning.

An added problem is disease. Malnourished children have no body reserves to protect them against common diseases. A decade ago, scientists reported in the leading medical journal in England that half of all childhood deaths occur because malnutrition makes a childhood disease lethal (Black et al., 2003).

Video: Malnutrition and Children in Nepal shows the plight of children in Nepal who suffer from protein calorie malnutrition.

111

Same Situation, Far Apart: Children Still Malnourished Infant malnutrition is common in refugees (like this baby now living in Thailand, right) or in countries with conflict or crop failure (like Niger, at left). Relief programs reach only some of the children in need around the world. The children in these photographs are among the lucky ones who are being fed.

112

marasmus

A disease of severe protein-calorie malnutrition during early infancy, in which growth stops, body tissues waste away, and the infant eventually dies.

kwashiorkor

A disease of chronic malnutrition during childhood, in which a protein-calorie deficiency makes the child more vulnerable to other diseases, such as measles, diarrhea, and influenza.

Finally, some diseases result directly from malnutrition—both marasmus during the first year, when body tissues waste away, and kwashiorkor after age 1, when growth slows down, hair becomes thin, skin becomes splotchy, and the face, legs, and abdomen swell with fluid (edema). Digestive patterns may be impaired lifelong. Giving severely ill children an antibiotic to stop infection saves lives—but always, prevention is best (Gough et al., 2014).

WHAT HAVE YOU LEARNED?

Question 3.15

1. Why do public health doctors wish that all infants worldwide would get immunized?

Immunization primes the body’s immune system to resist a particular disease. Within the past 50 years, immunization eliminated smallpox and dramatically reduced chicken pox, flu, measles, mumps, pneumonia, polio, rotavirus, tetanus, and whooping cough. Now, scientists seek to immunize against HIV/AIDS, malaria, Ebola, and other viral diseases.

Question 3.16

2. Why would a parent blame immunization for autism spectrum disorder?

Parents of children with autism spectrum disorder may be angry or confused about how their child developed ASD. They may seek to blame something other than genes or teratogens, but the fear that infant immunization leads to ASD is unfounded. Children who are not immunized are no less likely to have autism spectrum disorder but are much more likely to become sick.

Question 3.17

3. What is herd immunity?

When children are vaccinated and stop transmission of a disease, thus protecting others who are vulnerable, a phenomenon called herd immunity occurs. Public health doctors worry when too many parents avoid immunization, because herd immunity decreases as a result.

Question 3.18

4. What are the reasons for exclusive breast-feeding for the first six months?

In infancy, breast milk provides antibodies against any disease to which the mother is immune and decreases allergies and asthma. Babies who are exclusively breast-fed for six months are less likely to become obese and thus less likely to develop diabetes and heart disease.

Question 3.19

5. What is the relationship between malnutrition and disease?

Malnourished children have no body reserves to protect them against common diseases.

Question 3.20

6. What diseases are caused directly by malnutrition?

During the first year, malnutrition can cause marasmus, which causes body tissues to waste away. After age 1, kwashiorkor can occur; with this disease, growth slows down, hair becomes thin, skin becomes splotchy, and the face, legs, and abdomen swell with fluid (edema).

Question 3.21

7. What is the difference between stunting and wasting?

Stunting is failure of children to grow to a normal height for their age due to severe and chronic malnutrition. Wasting happens when children are severely underweight for their age as a result of malnutrition.

Question 3.22

8. In what ways does malnutrition affect cognition?

Adults who suffered from wasting in their first year of life have lower IQs throughout life, even if they are well fed after infancy. Some of this is directly related to brain growth. In addition, a severely malnourished infant has less energy and reduced curiosity and therefore is not learning.