Surviving in Good Health

Although precise worldwide statistics are unavailable, at least 9 billion children were born between 1950 and 2010. More than 1 billion of them died before age 5. Although 1 billion is far too many, twice that many would have died without recent public health measures. One young child in 5 died in 1950, as did 1 child in 17 in 2010 (United Nations, 2012). Those are official statistics; probably millions more died in the poorest nations without being counted. In earlier centuries more than half of all newborns died in infancy.

Better Days Ahead

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, now about 93 percent live (see Figure 5.6a). Some nations have seen dramatic improvement. For instance, Chile’s rate of infant mortality was almost 4 times higher than the rate in the United States in 1970; now the two rates are even (see Figure 5.6b).

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.

Source: United Nations, Department of Economic and Social Affairs, Population Division, 2013.

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.

© LOUISE GUBB/CORBIS

The world death rate in the first five years of life has dropped about 2 percent per year since 1990 (Rajaratnam et al., 2010). Public health measures (clean water, nourishing food, immunization) deserve most of the credit. Further, as more children survive, parents focus more effort on each child.

For example, when parents expect every newborn to live, they have fewer babies. That advances the national economy, which can provide better schools and health care. Infant survival and maternal education are the two main reasons the world’s 2010 fertility rate is half what the rate was in 1950 (Bloom, 2011; Lutz & K. C., 2011).

If public health professionals were more available, the current infant death rate would be cut in half again, because public health includes measures to help parents as well as children, via better food distribution, less violence, more education, cleaner water, and more widespread immunization (Farahani et al., 2009).

Immunization

Immunization primes the body’s immune system to resist a particular disease. Immunization (often via vaccination) is said to 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). Immunization has been developed for measles, mumps, whooping cough, smallpox, pneumonia, polio, and rotavirus, which no longer kill hundreds of thousands of children each year.

It used to be that the only way to become immune to these diseases was to catch them, sicken, and recover. The immune system would then produce antibodies to prevent recurrence. Beginning with smallpox in the nineteenth century, doctors discovered that giving a small dose of the virus to healthy people who have not had the disease stimulates the same antibodies. (Immunization schedules, with U.S. recommendations, appear in Appendix A. Most of the vaccines listed reduce the risk of child death in every nation. However, specifics vary; caregivers need to heed local health authorities.)

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.

SCOTT EELLS/REDUX

Stunning successes in immunization include the following:

• Smallpox, the most lethal disease for children in the past, was eradicated worldwide as of 1980. Vaccination against smallpox is no longer needed.
• Polio, a crippling and sometimes fatal disease, is rare. Widespread vaccination, begun in 1955, eliminated polio in the Americas. Only 784 cases were reported anywhere in the world in 2003. In the same year, however, rumors halted immunization in northern Nigeria. Polio reappeared, sickening 1,948 people in 2005, almost all of them in West Africa. Then public health workers and community leaders campaigned to increase immunization, and Nigeria’s polio rate fell again to 21 in 2010. However, poverty and wars in South Asia prevented immunization: Worldwide, 650 cases were reported in 2011, primarily in Afghanistan, India, Nigeria, and Pakistan (De Cock, 2011; World Health Organization, 2012; Roberts, 2013). (See Figure 5.7.)
• Measles (rubeola, not rubella) is disappearing, thanks to a vaccine developed in 1963. Prior to that time, 3 to 4 million cases occurred each year in the United States alone (Centers for Disease Control and Prevention, 2007). In 2010 in the United States, only 61 people had measles, most of them born in nations without widespread immunization (MMWR, January 7, 2011). The number of reported cases rose again in 2011, when 222 were reported to have measles, 17 of which were brought into the United States from other countries, including countries in Europe and Asia. The other 215 occurred because too many children are unvaccinated (MMWR, April 20, 2012).

Not Yet Zero Many public health advocates hope polio will be the next infectious disease to be eliminated worldwide, as is the case in almost all of North America. The number of cases has fallen dramatically worldwide (a). However, there was a discouraging increase in polio rates from 2003 to 2005 (b).

Source: Earth Policy Institute, 2011; CDC, 2013.

Immunization protects not only from temporary sickness or death 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:

• Embryos, who may be born blind, deaf, and brain-damaged if their pregnant mother contracts rubella (German measles)
• Newborns, who may die from a disease that is mild in older children
• People with impaired immune systems (HIV-positive, aged, or undergoing chemotherapy), who can become deathly ill

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

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 broadcasts it, which frightens parents. 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. A hypothesis that the MMR (measles-mumps-rubella) vaccine causes autism has been repeatedly disproved (Shattuck, 2006; Mrozek-Budzyn et al., 2010; MMWR, 2013). [Lifespan Link: The major discussion of autism appears in Chapter 11.]

Doctors agree that vaccines “are one of the most cost-effective, successful interventions in the history of public health” and lament that that success has made parents, physicians, and governments less vigilant (Hannan et al., 2009, p. S571). For example, lack of immunization is blamed for a spike in infant whooping cough deaths in 2010 in California, which declared a whooping cough epidemic (McKinley, 2010).

Nutrition

Infant mortality worldwide has plummeted in recent years. Several reasons have already been mentioned. One more measure has made 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 (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; Riordan, 2005). 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 grow strong while being exclusively breast-fed for months.

Formula-feeding 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 risks and the alternatives. For example, in some African nations, HIV-positive women are encouraged to breast-feed because their 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).

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.

BARTOSZ HADYNIAK/GETTY IMAGES
SELECTSTOCK/GETTY IMAGES.

For all these reasons, doctors worldwide recommend breast-feeding with no other foods—not even juice. (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 (which is especially important in hot climates) and should avoid alcohol, cigarettes, and other drugs.

Breast-feeding was once universal, but by the middle of the twentieth century many mothers thought formula was better because it was more modern. 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) (see Figure 5.8) (U.S. Department of Health and Human Services, 2011). Worldwide, about half of all 2-year-olds are still nursing, usually at night.

A Smart Choice In 1970, educated women were taught that formula was the smart, modern way to provide nutrition—but no longer. Today, more education for women correlates with more breast milk for babies. About half of U.S. women with college degrees now manage three months of exclusive breast-feeding—no juice, no water, and certainly no cereal.

Source: Centers for Disease Control and Prevention, 2012 and previous years.

Since formula-feeding may seem easier for the mother, particularly in the early weeks, 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.

Protein-calorie malnutrition occurs when a person does not consume enough food to sustain normal growth. That 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 (World Bank, 2010). Stunting is most common in the poorest nations (see Figure 5.9).

Genetic? The data show that basic nutrition is still unavailable to 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.

Source: UNICEF, 2012.

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.

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.

AP PHOTO/SCHALK VAN ZUYDAM
© DANG NGO/ZUMAPRESS.COM

In some other nations, however, primarily in Africa, wasting has increased. And in several nations in South Asia, about half the children over age 5 are stunted and half of them are also wasted, at least for a year (World Bank, 2010). In some nations, the traditional diet for young children does not provide sufficient vitamins, fat, and protein for robust health. As a result, energy is reduced and normal curiosity is absent (Osorio, 2011). Young children naturally want to understand whatever they can: A child with no energy is also a child who is not learning.

Chronically malnourished infants and children suffer in three additional ways (World Bank, 2010):

1. Their brains may not develop normally. If malnutrition has continued long enough to affect height, it may also have affected the brain.
2. Malnourished children have no body reserves to protect them against common diseases. About half of all childhood deaths occur because malnutrition makes a childhood disease lethal.

3. 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 deficiency makes the child more vulnerable to other diseases, such as measles, diarrhea, and influenza.

   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).

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 (Smith et al., 2013). Ideally, prenatal nutrition, then breast-feeding, and then supplemental iron and vitamin A stop malnutrition before it starts.

A study of two of the poorest 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). This conclusion has been found in other research as well: Apparently mothers worldwide try to nurture their children well, but sometimes they do not know how to do it and some cultural practices—as you already saw with avoidance of immunization—harm children’s health.

But we should not close this chapter by blaming the mothers or the cultures. Sometimes culture helps, as you will now see.

Sudden Infant Death Syndrome

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. Tiny infants smiled at their caregivers, waved their arms at rattles that their small fingers could not yet grab, went to sleep, and never woke up. As parents mourned, scientists tested hypotheses (the cat? the quilt? natural honey? homicide? spoiled milk?) to no avail: Sudden infant death was a mystery.

One scientist named Susan Beal studied every SIDS death in South Australia for years, noting dozens of circumstances, seeking factors that increased the risk. Some things did not matter (such as birth order), and others increased the risk (such as maternal smoking and lambskin blankets).

Protective Sleeping It matters little what infants sleep in—bassinet, cradle, crib, or Billum bag made from local plants in Papua New Guinea, as shown here. In fact, this kind of bag is very useful since babies can easily be carried in it. It can also be used for carrying food, tools, and much else. What does matter is the infant’s sleeping position—always on the back, like this healthy infant.

PETER SOLNESS/GETTY IMAGES

Beal discovered an ethnic variation: Australian babies of Chinese descent died of SIDS far less often than did Australian babies of European descent. Genetic? Most experts thought so. But Beal’s scientific observation led her to note that Chinese babies slept on their backs, contrary to the European or American custom of stomach-sleeping. The Chinese mothers, many of whom had no formal education, said that back-sleeping is what their mothers and grandmothers advised.

Beal thought of a new hypothesis: that sleeping position mattered. To test that hypothesis, she convinced a large group of non-Chinese parents to put their newborns to sleep on their backs. Almost none of them died suddenly. After several years of data, comparing them with a control group who put babies to sleep on their stomachs, Beal reached a surprising conclusion: Back-sleeping protected against SIDS.

Her published reports (Beal, 1988) caught the attention of doctors in the Netherlands, one of the many Western nations where babies almost always slept on their stomachs. Two Dutch scientists (Engelberts & de Jong, 1990) recommended back-sleeping, and parents took heed. SIDS was reduced in Holland by 40 percent in one year, a stunning replication.

Replication and application spread. By 1994, a “Back to Sleep” campaign in nation after nation cut the SIDS rate dramatically (Kinney & Thach, 2009; Mitchell, 2009). In the United States, in 1984, SIDS killed 5,245 babies; in 1996 it was down to 3,050; and since 2000, about 2,000 a year (see Figure 5.10). The campaign has been so successful that physical therapists report that babies crawl later than they used to, and so they advocate tummy time—putting awake infants on their stomachs to develop their muscles (Zachry & Kitzmann, 2011).

We close with the saga of SIDS because it is a dramatic example of many themes of this chapter. First, infant care is complex, with many factors interacting to produce each accomplishment. Stomach-sleeping is a proven, replicated risk, but it is not the only one: SIDS still occurs. Researchers are discovering other risks: low birthweight, a brain-stem abnormality that produces too little serotonin, cigarette smoking in the household, soft blankets or pillows, and bed-sharing (Duncan et al., 2010; Ostfeld et al., 2010).

Before and After Detailed U.S. data on SIDS are available only for the past 25 years, but as best we know, the rate was steady at about 1 baby in every 700 throughout most of the twentieth century and has been even lower after 2008, at about 1 baby in every 2000.

Sources: Anderson et al., 1997; Murphy et al., 2012; National Center for Health Statistics (1998–2010).

The success in reducing SIDS underscores several themes first described in Chapter 1. Because of developmental science, with a multidisciplinary and multicultural perspective, in the United States alone about 40,000 children and young adults are alive today because they were born after 1990 and thus escaped sudden infant death.