SECTION II - HEALTH GOALS
FIVE
NATIONAL GOALS

What should--and reasonably can--be our national
goals for health promotion and disease prevention?

They must be concerned with the major health
problems and the associated--~and preventable--risks
for them at each of the principal stages of life:
infancy . . childhood .°. adolescence and young
adulthood , . adulthood . . and older adulthood.

This section examines those problems and risks
and presents specific, quantified objectives for
each stage.

They are realistic objectives--based upon our
own recent mortality trends for each age group, the
rates achieved in other countries with resources
similar to our own, and the very great likelihood
that a reasonable, affordable effort can make the
goals achievable.
CHAPTER 3
HEALTHY INFANTS

 

Goal: To continue to improve infant
health, and, by 1990, to reduce
infant mortality by at least 35
percent, to fewer than nine
deaths per 1,000 live births.

 

 

 

Much has happened in recent years to make life
safer for babies. The infant mortality rate now is
only about one-eighth of what it was during the
first two decades of the century (Figure 3-A) thanks
to better nutrition and housing, and improved pre-
natal, obstetrical, and pediatric care. In 1977, a
record low of 14 infant deaths per 1,000 live births
was achieved, a seven percent decrease from the pre-
vious year.

Yet, despite the progress, the first year of
life remains the most hazardous period until age 65,
and black infants are nearly twice as likely to die
before their first birthdays as white infants. The
death rate in 1977 for black infants (24 per 1,000
live births) is about the same as that for white
infants 25 years ago.

Additional gains are clearly attainable.
Sweden, which has the lowest rate of infant deaths,
averages nine per 1,000 live births (Figure 3-B).
If present trends in the United States continue, our
rate should drop below 12 in 1982, and new preven-
tive efforts could allow us to reach the goal of
nine by 1990.

The two principal threats to infant survival and
good health are low birth weight and congenital dis-
orders including birth defects (Figure 3-C). Ac-
cordingly, the two achievements which would most
Significantly improve the health record of infants

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RATE PER 1,000 LIVE BIRTHS

100

90

80

70

60

50

40

30

20

10

 

FIGURE 3-A
INFANT MORTALITY RATES: UNITED STATES,

— ‘~ SELECTED YEARS 1915-1977

| | |

1900 1910 1920 1930 1940 1950 1960 1970

NOTE

1977 cate are provisional: data ‘cr all other years are f 1al, Selected years are 1900. 1925, 1950, 1977

Source: National Center for Health Statistics, Division of Vita! Statistics.

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J

1980
FIGURE 3-B
INFANT MORTALITY RATES: SELECTED COUNTRIES, 1975

70 --
60 F

50

30 F-

20 f-

 

RATE PER 1,000 LIVE BIRTHS

 

 

 

 

 

United Sweden Engiand Japan Chile
States and
Wales
NOTE: The most recent year of data for Chile is 1971,

Sources: United States, National Center for Health Statistics, Division of Vital Statistics:
other countries, United Nations.

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RATE PER 100,000 LIVE BIRTHS

FIGURE 3-C
MAJOR CAUSES OF INFANT MORTALITY:
UNITED STATES, 1976

 

800 -
[mite
BE 41: other
600 +
400 +
200 -
Q
tmmaturity- Birth. Congenital Sudden Infiuenza Septicemia All other
associated associated birth infant and accidents

defects deaths pneumonia

Source: Based on data from the National Center for Health Statistics, Division of Vital Statistics.

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would be a reduction in the number of low birth
weight infants and a reduction in the number born
with birth defects.

Other significant health problems include birth
injuries, accidents, and the sudden infant death
syndrome which may be the leading cause. of death of
infants older than one month.

But not all health problems are reflected in
mortality and morbidity figures. It is also impor-
tant to foster early detection of developmental
disorders during the first year of life to maximize
the benefits of care. And the first year is a sig-
nificant period for laying the foundation for sound
mental health through the promotion of loving rela-
tionships between parents and child.

Subgoal: Reducing the Number of Low Birth Weight
Infants

Low birth weight is the greatest single hazard
for infants, increasing vulnerability to develop-
mental problems--and to death.

Of all infant deaths, two-thirds occur in those
weighing less than 5.5 pounds (2500 grams) at birth.
Infants below this weight are more than 20 times as
likely to die within the first year.

Low birth weight is sometimes associated with
increased occurence of mental retardation, birth
defects, growth and development problems, blindness,
autism, cerebral palsy and epilepsy.

In the United States in 1976, about seven per-
cent of all newborns weighed less than 5.5 pounds,
In Sweden, however, the figure was four percent.
The difference probably explains Sweden's more fa-
vorable infant mortality experience. Because sub-
Stantial reductions in infant mortality and child-
hood illness could be expected to follow any signi-
ficant reductions in the number of infants of low
birth weight in this country, that should be a major
public health goal.

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Many maternal factors are associated with low
infant birth weight: lack of prenatal care, poor
nutrition, smoking, alcohol and drug abuse, age
(especially youth of the mother), social and eco-
nomic background, and marital status.

Given no prenatal care, an expectant mother is
three times as likely to have a low birth weight
child.

And many women least likely to receive adequate
prenatal care are those most likely to have other
risk factors working against them.

Women from certain minority groups are half as
likely as white women to receive the minimum of pre-
natal care recommended by the American College of
Obstetrics and Gynecology. About 70 percent of ex-
pectant mothers under age 15 receive no care during
the first months of pregnancy, the period most im-
portant to fetal development; 25 percent of their
babies are premature, a rate three times that for
older mothers.

The lower risk with regular prenatal care may
result from the benefits of medical and obstetrical
services--and from accompanying social and family
support services.

Infants born to women experiencing complications
of pregnancy such as toxemia* and infections of the
uterus have a four to five times higher mortality
rate than others. For mothers with such medical
conditions as diabetes, hypertension, or kidney and
heart disease, there is a higher risk of bearing
babies who will not survive their first year--a risk
which competent early medical care can reduce.

*® Toxemia--present in two percent of pregnancies--
js characterized by high blood pressure, tissue
swelling, headaches, and protein in the urine. It
can provoke convulsions and coma in the mother,
death for the fetus.

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Maternal nutrition is a critical factor for
infant health. Pregnant women lacking proper nutri-
tion have a greater chance of bearing either a low
birth weight infant or a stillborn. Diet supplemen-
tation programs--especially those providing suitable
proteins and calories--materially increase the like-
lihood of a normal delivery and a healthy child, and
attention to sound nutrition for the mother jis a
very important aspect of early, continuing prenatal
care.

Also hazardous for the child are maternal ciga-
rette smoking and alcohol consumption. Smoking
Slows fetal growth, doubles the chance of low birth
weight, and increases the risk of stillbirth. Re-
cent studies suggest that smoking may be a signifi-
cant contributing factor in 20 to 40 percent of Tow
weight infants born in the United States and Canada.
Studies also indicate that infants of mothers regu-
larly consuming large amounts of alcohol may suffer
from low birth weight, birth defects, and/or mental
retardation. Clearly, both previously developed
habits need careful attention during pregnancy.

Maternal age is another determinant of infant
health. Infants of mothers aged 35 and older have
greater risk of birth defects. Those of teenage
mothers are twice as likely as others to be of low
birth weight. And subsequent pregnancies during
adolescence are at even higher risk for complica-
tions. Family planning services, therefore, are
important--and, for pregnant adolescents, good pre-
natal care, which can improve the outcome, is
receiving increased emphasis in many communities.

Racial and socioeconomic groups show great dis-
parity in low birth weight frequency. Not only is
infant mortality nearly twice as high for blacks as
for whites, prematurity and low birth weight are
also twice as common for blacks and some other
minorities.

Evidence indicates that the racial differential
is associated with corresponding socioeconomic
differences. Analyses of birth weight distribution
according to socioeconomic status among homogeneous

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ethnic populations reveal a clear relationship
between birth weight and social class; the birth
weight of black infants of higher socioeconomic
status is comparable to that of whites.

Marital status is another important factor. In
1975, the risk of having a low birth weight infant
was twice as great for unmarried as for married
women--at least partly because the unmarried are
less likely to receive adequate prenatal care.

Although further research can help define more
precisely the relationship between all these factors
and low birth weight and infant mortality, we have
clear indications of measures which can be taken now
to reduce the risks. Chapter 8 is devoted to those
measures.

Subgoal: Reducing the Number of Birth Defects

Birth defects include congenital physical anom-
alies, mental retardation, and genetic diseases.
Many present immediate serious hazards to infants.
Many others, if not diagnosed and treated immedi-
ately after birth or during the first year of life,
can affect health and well-being in later years.

Birth defects are responsible for one-sixth of
all infant deaths. They are the second leading
cause of death for children one to four years old,
and the third leading cause for those five to 14
years old.

Nearly one-third of all hospitalized children
are admitted because of genetically determined or
influenced disorders which often result in long-term
economic and social strains for affected families.

Approximately two to three percent of infants
have a serious birth defect identified within the
first weeks of life--and five to 10 percent of these
are fatal. Those most likely to be lethal include
malformations of brain and spine, congenital heart
defects, and combinations of several malformations.

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In about one-fourth of birth defects, the cause
is thought to be purely genetic; in one-tenth,
purely environmental. In the remaining two-thirds,
the cause is unknown. Interaction between genetic
and environmental factors is an important concept
guiding substantial research in this area.

Given current knowledge, many birth defects
cannot be prevented. But many can be. Identifiable
environmental hazards can be reduced. Carrier iden-
tification, amniocentesis, and neonatal screening
procedures (Chapter 8) can aid in detecting some ge-
netic disorders before, during, and after pregnancy.

Inherited Factors

Although some 2,000 genetic disorders are known,
fewer than 20 are responsible for most genetic di-
sease in this country.

Five types cause most of the illness and death:

Down syndrome. One of the best known genetic
disorders, Down syndrome is associated with the
presence of an extra chromosome, and occurs in about
one of every 1,000 births. It causes physical de-
fects which require lifelong care, and is respon-
sible for 15 to 30 percent of the severe mental
retardation in children living to age 10.

The risk of having a Down syndrome child in-
creases with maternal age, especially after 35; at
least one-fourth of the 3,000 infants with the syn-
drome born each year are those of women 35 or older.
Recent research has shown that the father, rather
than mother, contributes the extra chromosome in
about one-fourth of all cases.

Down syndrome can be detected by sampling intra-
uterine fluid through amniocentesis but the proce-
dure currently is being performed for only about 10
percent of the 150,000 women aged 35 and older who
become pregnant in any one year. The advisability
of having amniocentesis depends upon individual cir-
cumstances and should be discussed with a physician.

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Severe brain and spinal cord (neural tube)
defects. Neural tube defects not only occur more
frequently than Down syndrome but also result in
more deaths within the first month of life.

 

Characterized by lack of development of parts of
the central nervous system or its skeletal protec-
tion, neural tube defects include spina bifida (a
vertebral column defect) and anencephaly (very smal]
head and brain). The defects occur in about two of
every 1,000 infants, half of whom die in the newborn
period. In addition to amniocentesis, a maternal
blood screening test for a substance called alpha-
fetoprotein can detect pregnancies at risk for
neural tube defects.

Risk for neural tube defects is 2.5 times great-
er for whites than other racial groups. At greatest
risk are families with previous history of the de-
fects or with an affected child; genetic counseling
is recommended for them.

Defects related to particular ethnic groups.
These include Tay-Sachs disease, Sickle cell anemia,
and cystic fibrosis.

Tay-Sachs disease is 100 times more frequent
among Jewish families of Ashkenazi (Eastern
European) descent than in the general population.
Although children with the disease appear normal at
birth, they die by age five as a result of severe
mental retardation and progressive neurologic de-
terjoration. The disease is caused by accumulation
of a fatty substance in the brain. Because the
responsible gene is recessive, Tay-Sachs disease
occurs only when both parents carry the gene. Each
prospective child then has a 25 percent chance of
developing the disease. Fortunately, a carrier de-
tection screening test is available to identify an
at-risk couple before pregnancy.

Sickle cell anemia is the most common ser i0us

genetic disease among blacks. About 1,000 infants
each year are born with sickle cell disease in which

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red blood cells are damaged because of altered sta-
bility of their hemoglobin content. Although no
mental retardation jis associated with sickle cell
disease, it is a serious condition leading to years
of pain, discomfort, and even death from complica-
tions. Specific treatment has yet to be found.

Cystic fibrosis occurs primarily among whites in
about one of every 2,000 births, affecting 1,500
infants a year. In the disease, abnormal production
of mucus leads to chronic Tung obstruction and dis-
ability during childhood and early adult life. The
disease can also affect the pancreas, liver, and
intestines. In 1976, it caused the death of twice
as many infants as tetanus, whooping cough, syphilis
and rubella combined. Although there is no specific
cure, there have been many advances in caring for
patients so that, if they survive through infancy,
many now reach adult life.

Sex-linked defects. These congenital disorders
affect the sons of mothers who carry an abnormal X
chromosome. Hemophilia and muscular dystrophy are

two prominent examples. The bleeding disorder,
hemophilia, is due to deficiencies in the clotting
mechanism of the bload. In muscular dystrophy,

muscle is replaced by fat, leading to gradual
muscular weakness and wasting.

Metabolic disorders. The most widely known of
this group--and the one for which infants are most
frequently tested--is PKU (phenylketonuria). It
involves a genetic liver enzyme deficiency which
allows an amino acid to accumulate abnormally,
impairing brain function and leading to increasingly
severe mental retardation later in childhood. PKU,
which occurs in one of every 15,000 births, can be
treated with special diet that compensates for the
enzyme deficiency.

Cogenital hypothyroidism (cretinism) jis a more
common metabolic disorder capable of causing mental
retardation. Some cases result from genetic pre-
disposition but others may be the result of circum-
stances (e.g. maternal iodine deficiency) occurring
during fetal development. About 600 infants a
year--one per 5,000 births--are affected, but early
detection and prompt treatment with thyroid medi-
cation in the first weeks of life can prevent the
retardation.

The availability of specific tests for both PKU
and congenital hypothyroidism has prompted States to
consider requiring both for each newborn. Even
though the number of affected babies detected will
be small, the benefits of early diagnosis and treat-
ment for the affected babies can be profound.

External Factors

Birth defects can result from exposure of the
fetus to infectious or toxic agents during preg-
nancy, especially during the first three months
(first trimester).

Infections. Rubella (German measles), when it
affects a mother during the first trimester, can
lead to congenital malformations as well as still-
birth and miscarriage.

The greatest risk occurs when most women may not
even be aware of being pregnant. The likelihood of
rubella-induced malformations is approximately 25
percent during the first three months, after which
it begins to decline substantially. The most seri-
ous problems for the fetus include blood disorders,
heart defects, cataracts or other eye defects, deaf -
ness, and mild to profound mental retardation.

For prospective mothers who have not been ex-
posed to rubella, vaccination prior to pregnancy can
help prevent all of the problems for the fetus.

Radiation and chemicals in the workplace. These
environmental factors have their greatest potential
for harm during the early weeks of fetal develop-
ment--again, often before a woman realizes that she
is pregnant. And they remain hazards throughout
pregnancy. High doses of jonizing radiation in

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utero not only can increase risk of fetal malforma-
tion; there is suggestive evidence of increased risk
of subsequent leukemia and other childhood cancers.
To reduce risks, protective measures should be taken
to help pregnant women avoid unnecessary exposure.

Drugs. A broad range of medications, including
some seemingly innocuous over-the-counter prepara-
tions, may harm the fetus.

A now-classic example of drug hazard is the epi-
demic several years ago of birth defects caused by
maternal use of thalidomide. Taken as a mild seda-
tive and sleeping aid, thalidomide led to devel-
opmental defects, particularly of the limbs, in
approximately 35 percent of infants of mothers using
it. Throughout the world, an estimated 10,000 de-
formed infants were born. Thalidomide was on the
European market approximately five years before the
problem was identified and the product removed, but
it was never approved for use in the United States.

Other drugs known to cause birth defects include
some hormones such as DES (diethylstilbestrol), as
well as certain anti-cancer and anticonvulsant
agents. DES taken by mothers during pregnancy has
been linked to vaginal cancer development in daugh-
ters during adolescence and early adulthood.

Among drugs currently under Study for possible
birth defect potential are warfarin, diphenylhy-
dantoin, trimethadione, and lithium. Some women
need these drugs for serious problems such as post-
rheumatic heart disease, seizures, and severe mental
disturbances. Also under investigation are some
drugs used during childbirth which may have detri-
mental effects on the child's central nervous system.

It must be emphasized to the public--and perhaps
to some physicians--that exposure to any drug should
be avoided at any time during pregnancy, but espe-
cially during the first trimester, unless there are
overriding medical considerations to use a drug for
the mother's health.

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Alcohol. The incidence of alcohol-induced birth
defects 1s now estimated to be one for every 100
women consuming more than one ounce of alcohol daily
in early pregnancy. The fetal alcohol syndrome
therefore accounts for the occurrence of approxi-
mately one birth defect in every 5,000 births in the
United States.

Affected infants are often of low birth weight,
mentally retarded, and may have behavioral, facial,
limb, genital, cardiac and neurological
abnormalities.

The risk and degree of abnormality increases
with increased alcohol] consumption. According to a
Boston City Hospital study of infants born to heavy
drinkers (average 10 drinks a day), 29 percent had
congenital defects compared to 14 percent for
moderate drinkers and only eight percent among non-
drinkers. Furthermore, 71 percent of infants born
to women who consumed more than 10 drinks daily had
detectable physical and developmental abnormalities.

Safe alcohol consumption levels during pregnancy
have yet to be determined. But, in view of the as-
sociation between high levels and fetal abnormali-
ties, women who are pregnant or think they might be
should be encouraged to use caution. And women
alcoholics, until treated effectively for their
addiction, should be encouraged by public informa-
tion programs and by direct counseling to avoid
conception.

Other Important Problems

 

Several other problems with major impact on
infant health are noted in Figure 3-C.

Injuries at Birth
Birth injuries, difficult labor, and other con-
ditions causing lack of adequate oxygen for the

infant are among the leading reasons for newborn
deaths.

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Although most pregnant women experience normal
childbirth, complications may occur during labor and
delivery. Some--such as small pelvic cavity--can be
detected in advance, during prenatal care.

Others unidentifiable beforehand require prompt
management. They include hemorrhaging from the site
of attachment of the placenta (afterbirth); abnormal
placental location; abnormal fetal position; pre-
mature membrane rupture; multiple births; sudden
appearance or exacerbation of toxemia; and sudden
intensification of a known medical problem such as
heart disease or diabetes.

Sudden Infant Death

Certain babies, without apparent cause or warn-
ing, suddenly stop breathing and die, even after
apparently uncomplicated pregnancy and birth.

This unexplained event, called the sudden infant
death syndrome, is believed by some authorities to
be the leading cause of death for babies older than
one month.

Recently evidence has been accumulating that ab-
normal sleep patterns with increased risk of breath-
ing interruptions (apnea) may be associated with the
unexpected deaths. A variety of factors, such as
prematurity and maternal smoking, are emerging as
possible contributors to increased risk for sudden
infant death, but there is a need to learn more.

Extensive research now under way should refine
our ability to identify high risk infants and effec-
tively prevent their deaths.

Accidents

More than 1,100 infants died in accidents in
1977. The principal causes were suffocation from
inhalation and ingestion of food or other objects,
motor vehicle accidents, and fires. Many deaths
reflect failure to anticipate and protect against
Situations hazardous for developing infants. Child
abuse may also account for some deaths.

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Inadequate Diets and Parental Inadequacy

Although they are not major causes of death,
problems related to infant care have significant
impact on infant health.

Even in a society of considerable affluence,
many infants are not receiving appropriate diets and
suffer from deficiencies of nutrients needed for
development. Frequently, it jis overnutrition rather
than undernutrition which is the problem setting the
stage for obesity later in life.

Recognition of the extent to which parental
attitudes are important to a child's development--
and, with it, the need to bring parents and babies
together psychologically--is receiving increasing
attention.

Even when an infant must be kept in the hospital
because of low birth weight, early contact between
parents and child may be helpful to a good start in
life and sound emotional development. Breast feed-
ing is to be encouraged not only for its nutritional
benefits but also for the contribution it can make
to psychological development.

The fact is that growth of a "sense of trust"
has been identified as a significant aspect of
healthy infancy. Intimate, enjoyable care for
babies fosters that growth and the building of sound
emotional and mental health.

Moreover, recently, there has been growing
recognition that certain disorders occur when there
is neglect or inappropriate care for an infant. One
is "failure to thrive" or developmental attrition--
with the child losing ability to progress normally
to more complex activities such as standing, walk-
ing, talking, and learning. Other disorders linked
to neglect or inappropriate care include abnor-
malities in eating and digestive functions, sleep
disorders, and disturbances in other activities.

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All of these problems underscore the need for
regular medical care during the prenatal period and
early months of infancy. Such care should be sensi-
tively designed to enhance the relationship between
parents and child as well as to ensure sound nutri-
tion, appropriate immunizations, and early detection
and treatment of any developmental problems.

As programs have expanded to provide better
services to pregnant women and newborn babies, the
health of American infants has steadily improved.
These recent gains to infant health are indeed
heartening.

Moreover, more can be done to a greater extent
than ever before, we have a clearer understanding of
the factors important to ensuring healthy infants.

Section III discusses in greater detail the
actions we can take.

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