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. 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.

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, 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).

FIGURE 5.7
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. In some of the very least developed nations (e.g., Malawi) rates are still 1 in 100.

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).

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 together, without fear of malaria-infected mosquitoes.

a case to study

Scientist at Work

Susan Beal, a young scientist with four children, studied SIDS deaths in Australia for years, responding to phone calls, often at 5 or 6 a.m., that another baby had died. At first she felt embarrassed to question the parents, sometimes arriving before the police or the coroner. But parents were grateful to know that someone was trying to understand the puzzle that had just killed their infant. She realized that parents tended to blame themselves and each other, so she sought to get them talk to each other, as she reassured them that scientists shared their bewilderment. (Click on the video above to watch a short interview with Susan Beal.)

As a scientist, she noted dozens of circumstances at each death. Some things did not matter (such as birth order), others increased the risk (maternal smoking and lambskin blankets). A breakthrough came when Beal noticed an ethnic variation: Australian babies of Chinese descent died of SIDS far less often than did those of European descent. Genetic? Most experts thought so. But Beal noticed that almost all SIDS babies were sleeping on their stomachs, contrary to the Chinese custom of placing infants on their backs to sleep. She developed a new hypothesis: Sleeping position mattered.

FIGURE 5.8
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. SOURCES: NATIONAL VITAL STATISTICS REPORTS, FORTHCOMING; HOYERT & XU, 2012; MURPHY ET AL., 2012; KOCHANEK ET AL., 2011; MINIÑO ET AL., 2007; HOYERT ET AL., 2005; MATHEWS ET AL., 2003; HOYERT ET AL., 1999; GARDNER & HUDSON, 1996; MACDORMAN & ROSENBERG, 1993; MONTHLY VITAL STATISTICS REPORT, 1980.

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To test her hypothesis, Beal 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 gathering data, she drew a surprising conclusion: Back-sleeping protected against SIDS. Her published reports (Beal, 1988) caught the attention of doctors in the Netherlands, where pediatricians had told parents to put their babies to sleep on their stomachs. Two Dutch scientists (Engelberts & de Jonge, 1990) recommended back-sleeping; thousands of 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, that number was down to 3,050; in 2011 it was 1,910 (see Figure 5.8). Such results indicate that, in the United States alone, about 40,000 children and young adults are alive today who would be dead if they had been born before 1990. The campaign has been so successful that physical therapists report that babies now crawl later than they used to; they therefore advocate tummy time—putting awake infants on their stomachs to develop their muscles (Zachry & Kitzmann, 2011).

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 Navaho’s genetic ancestors, in Asia, protecting them from SIDS.

Stomach-sleeping is a proven, replicated risk, but it is not the only one: SIDS still occurs. Beyond sleeping position, other risks include low birthweight, being male, parents who smoke cigarettes, soft blankets or pillows, winter, bed-sharing, abnormalities in the brainstem, the heart, the mitochondria, and the microbiome (Neary & Breckenridge, 2013; Ostfeld et al., 2010). Most SIDS victims experience several risks, suggesting again a cascade of biological and social circumstances.

That does not surprise Susan Beal, who quickly realized that SIDS victims are found in many kinds of households, rich and poor, native-born and immigrant. She sifted through all the evidence and found the main risk—stomach-sleeping—but she has continued to study other factors. She praises the courage of the hundreds of parents who talked with her hours after their baby died.

Considering Culture

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

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:

  1. Embryos, who may be born blind, deaf, and brain-damaged if their pregnant mother contracts rubella (German measles)

  2. Newborns, who may die from a disease that is mild in older children

  3. People with impaired immune systems (HIV-positive, aged, or undergoing chemotherapy), who can become deathly ill

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.

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.

Problems with Immunization

Especially for Nurses and Pediatricians A mother refuses to have her baby immunized because she wants to prevent side effects. She wants your signature for a religious exemption, which in some jurisdictions allows the mother to refuse vaccination. What should you do?

It is difficult to convince people that their method of child rearing is wrong, although you should try. In this case, listen respectfully and then describe specific instances of serious illness or death from a childhood disease. Suggest that the mother ask her grandparents if they knew anyone who had polio, tuberculosis, or tetanus (they probably did). If you cannot convince this mother, do not despair: Vaccination of 95 percent of toddlers helps protect the other 5 percent. If the mother has genuine religious reasons, talk to her clergy adviser.

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

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).

Nutrition

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.

Breast Is Best

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.

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.

Do You Believe It?

This table lists so many advantages that some skepticism seems warranted. However, every item on this list arises from research that considers confounding factors, such as the mother’s health and education. It may be that breast milk is truly a miracle food.

FIGURE 5.10
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.

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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Malnutrition

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.

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.

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:

  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. 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 (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.

FIGURE 5.11
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.


Video: Malnutrition and Children in Nepal shows the plight of children in Nepal who suffer from protein energy malnutrition (PEM).

SUMMING UP   Various public health measures have saved billions of infants in the past century. Immunization protects those who are inoculated and also halts the spread of contagious diseases (via herd immunity). Smallpox has been eliminated, and many other diseases are rare except in regions of the world where public health professionals have not been able to establish best practices. In the United States, success at reducing childhood diseases have led some parents to refuse immunization completely, which may lead to an epidemic if herd immunity falls too low.

Breast milk is the ideal infant food, improving development for decades and reducing infant malnutrition and death. Fortunately, rates of breast-feeding are increasing in developing nations; most underdeveloped nations have always had high rates of breast-feeding. Malnutrition has not been eliminated, however. If a breast-feeding mother is severely malnourished, or if a toddler does not get sufficient nourishment, diseases flourish and learning diminishes. In some parts of the world, children still suffer from stunting and wasting, which are the most visible results of malnutrition.

WHAT HAVE YOU LEARNED?

  1. Question 5.17

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    Lack of access to vital immunizations contributes to low rates in some parts of these nations.
  2. Question 5.18

    imRCe0yEviRVyGJPbUuq0dqGi5AQIx21m/llXz3acMbWaR08A1RuwRmL6pV56njaUk972QyAke1uSroqX0riK32/Kzr9Lysk
    Parents' fears that immunizations can cause autism have led to a reluctance to immunize infants. Any negative effects of an immunization get reported in the media, fueling parents' concerns. However, several studies have refuted the link between immunization and autism, and the risk of a negative side effect of an immunization is minute compared to the risks associated with contracting the disease.
  3. Question 5.19

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    Breast–feeding has many benefits, including the fact that babies who are exclusively breast–fed are less often sick. 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 or heart disease. Formula feeding is preferable only in unusual cases, such as when the mother is HIV–positive or uses toxic or addictive drugs.
  4. Question 5.20

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    Chronically malnourished children have no body reserves to protect them against common diseases, and some diseases result directly from malnutrition, including marasmus during the first year and kwashiorkor after age 1.
  5. Question 5.21

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    Stunting is the failure of children to grow to a normal height for their age due to severe and chronic malnutrition. Even worse is wasting, the tendency for children to be severely underweight for their age as a result of malnutrition. Wasting can have a negative effect on brain development and often leads to disease, which is often times lethal.

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