Sudden Infant Death Syndrome: Every Parent's Worse Nightmare

    The Mayo Clinic defines Sudden Infant Death Syndrome (SIDS) simply as the unexplained death of a child. This definition is not specific, but that is because we do not know a lot about SIDS. Typically infants that die of SIDS are under a year old, healthy, and simply pass away in their cribs, asleep. Despite there not being a lot known about the ailment, around 2,300 babies in the United States die of SIDS each year, a rate much higher than other countries.  While SIDS is the death of a child under a year old, it is most common in an infant between one and four months. It is more common in boys than girls, and most deaths occur in the fall, winter, and early spring. 

 The specific cause of SIDS is not known. However, there are some theories as to how to explain it. According to the National Institute of Health, researchers have found problems in the brains of babies who have died from SIDS. In some cases, there was a problem in the network of nerves that control breathing, heart rate, blood pressure, temperature, and waking form sleep. Other researchers theorize that changes in the genes of an infant mat cause problem with the body functions previously mentioned. Some infants who have died from SIDS have even been found with high levels of serotonin in their blood, suggesting that this may play a role. However, despite this research, the physiological etiology of SIDS is still unknown. In addition, there is no current way to detect any of these problems the a baby is still alive. 

https://safetosleep.nichd.nih.gov/about/causes

    To help combat SIDS related deaths, researchers use the Triple Risk Model to suggest and understand how SIDS deaths may occur. This model involves infant vulnerability, the critical development period, and outside stressors.  

    Infant vulnerability could be due to low birth weight, fetal abstinence syndrome, premature birth, or other reasons not yet known. Environmental stressors that can potentially lead to SIDs include tobacco smoke, getting tangled in/suffocating in bedding, a minor illness, and breathing obstruction. 

    

    Since SIDS often occurs when infants are asleep, many SIDS prevention straggles center around safe sleeping. Avoiding co-sleeping and soft sleeping surfaces are some of the ways to prevent SIDS. Infants should sleep on their back on a firm surface. with as little loose material as possible.

    SIDS related deaths have declined in the United States since the release of the "Back to Sleep Campaign." This campaign began in 1994, named after its primary recommendation that all infants sleep on their back to reduce risk of SIDS. However, despite this and other interventions, SIDS rates in the US are still high, especially in African American and Indigenous American populations. Some of this is due to defiance against certain guidelines, particularly that regarding co-sleeping, while it can also be contributed to the systemic health decline in these communities. 

Sex Education: Does Abstinence Work?

    Sex education equips teenagers with the knowledge, skills, attitudes, and values that help to protect their health, develop respectful social and sexual relationship, make responsible choices, and protect and understand the rights of others. However, there are varying degrees of sex education, and not all of it is equal.

     "Abstinence" is defined as the practice of refraining oneself from indulging something, in this case, sexual activity. For many people, this is the only form of sex-education they received. Teen sexual health outcomes in the last decade have been mixed. Teen pregnancy and birth rates have decreased, but rates of sexually transmitted infections among teens and youth has risen. Much of these could perhaps be associated to the lack of of sex-ed. 

    24 States and DC mandate sex education for youth.

    37 States require that sex education must include abstinence, with 26 requiring that it is stressed.

    13 States require that the sex education be medically accurate.

    18 States and DC require that information on contraception be provided with sex education.

As seen above, there are two main approaches toward sex education: abstinence-only and comprehensive sex education, with each being defined as the following:

• Abstinence-Only Education - aka "Sexual Risk Avoidance," teaches that abstinence is the expected behavior of teens, typically excluding any information regarding contraception in preventing pregnancy and STIs
• Comprehensive Sex Education - provides medically accurate age-appropriate information about abstinence, as well as practices including contraception and condoms, in addition to information on healthy relationship and communication

There is also an intermediate between the two, Abstinence-"Plus"-Education, which stresses abstinence, but also includes some information on contraception and condoms. 

The American College of Pediatricians strongly endorses abstinence education, actually endorsing it over comprehensive sex education. They state that this position is based on "the public health principle of primary prevention - risk avoidance in lieu of risk reduction," and that it upholds the "human right to the highest attainable standard of health." The American College of Pediatricians supports abstinence only education due to claiming that adolescents need to be given clear directions repeatedly; they claim that emphasis on contraceptive usage undermines the authority of parents and the strength of the abstinence message. 

Guttanmacher.org

    Despite the increased funding and use, recent research shows abstinence-only programs could be harmful to young people. By the end of high school, over half of teenagers will have had sex, yet they are not learning the information about contraceptives, STIs, consent, or healthy communication. Instead, the abstinence-only programs they are learning promote judgment, fear, guild, and shame around sex. Additionally, abstinence-only programs are often heteronormative, framing LGBTQ students as deviant and not providing sexual education for them. 

    The previous argument in favor of abstinence-only education claimed that it undermined parents and confused students. However, a UNESCO quote from 2009 states the following: "Sexuality education does not hasten sexual activity but has a positive impact on safer sexual behaviors and can play sexual debut."

    The American Medical Association, the American College of Obstetricians and Gynecologists, and the Society for the Adolescent Health and Medicine oppose abstinence-only programs. In addition, the majority of parents of high school students support the instruction of broader topics outside of abstinence. 

Guttmacher.org

    

The Decline in Childhood Vaccination: A New United States Epidemic

     Over the last two decades, anti-vaccine activism has grown from a fringe subculture into a well organized, networked movement. This evolution is leading to severe public health repercussions. with the COVID-19 pandemic exacerbating this issue and magnifying the spread of vaccine misinformation. An article from the National Library of Medicine describes three noteworthy patterns in this movement.

1. Progression into right-wing identity and activism

2. Networked activism

3. Harassing and threatening health-care and public health professionals

    One of the major public health outcomes seen as a rise of this movement is the decline in childhood vaccination rates, which in turn is leading to increased occurrence in vaccine preventable diseases. The Journal of Pediatric Pharmacology and Therapeutics describes four overarching categories to describe the reasons that parents refuse, delay, or are hesitant to vaccinate their children. 

                    1. Religious reasons

                    2. Personal beliefs/Philosophical concerns

                    3. Safety concerns

                    4. A desire for more information from healthcare providers

    These concerns lead to a wide spectrum of decisions, ranging from parents delaying vaccinations so that they are more spread out, to parents completely refusing all vaccinations. Vaccinations play a vita role in preventing diseases in children. There are no federal laws regarding vaccine administration, but each state has laws dictating which vaccinations are required for children before attending school. All 50 states allow medical exceptions, such as for those who are immune compromised or those allergic to various vaccine components. There are 30 states that allow exemptions for those whose parents cite religious reasons. There are 18 states that make special accommodations for those expressing philisopical reasons. however, states with more lenient laws are shown to have increased rates of exemptions granted, leading to greater vulnerability in the population. In fact, the outcomes of these exemptions are arising. 30 states reported to the CDC that the COVID-19 pandemic resulted in a decreased rate of vaccination coverage for the 2021-22 school year. This was due to reduced access, but also due to "local or school level extensions of grade period of provisional enrollment policies." In 2021, one in five children under the age of one year did not have any vaccine doses. 

Five Reasons Childhood Immunization Is So Important

    There has also been shown to be large disparities in childhood vaccination rates by race, incomes nd geography. According to the Center for Disease Control and Prevention, from the years 2018 to 2022, children born in the United States from 2017 to 2018 who were uninsured, Black, Hispanic, and/or had family income below the federal poverty level had lower childhood vaccination coverage than those who were privately insured, white, and/or had family incomes at or above the federal poverty lines. These children were also more likely to miss routine immunizations. This was shown to be due to transportation challenges, lack of access to routine pediatric care, and greater parental vaccine hesitancy.    

CDC: Recommendations for Ages 18 and Younger, United States, 2024

    Routine childhood immunization has been shown to continuously yield considerable sustained reductions in the incidence across targeted diseases, such as influenza, measles, mumps, polio, rubella, etc. These diseases can have serious outcomes when contracted. Measles can cause brain swelling, leading to permanent brain damage or even death. Mumps can cause permanent deafness. Meningitis can also lead to permanent deafness or brain damage. Polio can cause permanent paralysis. The United States saw its first case of Polio since 1979 in July of 2022, where a man who was unvaccinated was paralyzed as a result f the infection. As of March 18, 2024, Measles cases in the Untited States have already reached last year's total of 58, with most of these cases being unvaccinated children. On average, one out of five unvaccinated people diagnosed with Measles end up needing to be hospitalized. A recent outbreak in Ohio even saw over 40% of infants and children infected with Measles in the hospital. The CDC describes Measles, stating that it "is so contagious that if one person has it, 9 out of 10 people of all ages around him or her will also become protected if they are not protected." Thus, delaying or refusing a child's vaccine proposes risk to their own health and safety, but also that of others. Those most at risk include people with weakened immune systems due to other medications or diseases, people with chronic medical conditions, newborn babies who are too young to be vaccinated against most diseases, and the elderly. 

    The decline in childhood vaccination rates can be addressed by improving access to and boosting confidence in childhood vaccinations. Some suggested interventions include:

• Bolstering resources for immunization programs through the federal Vaccines for Children (VFC) and Section 317 programs
• Expanding the vaccination workforce through policies that facilitate provider enrollment in the VFC program and support vaccinators, such as school nurses and pharmacists
• Increasing vaccine reimbursement to cover costs associated with vaccination, such as vaccine education and reducing administrative burdens
• Tightening and reenforcing school vaccine requirements that have been effective in producing high vaccination rates
• Engaging trusted community leaders, such as health care providers, school staff, and faith-based organizations, to counter vaccine disinformation with accurate and effective messaging

Importance of Books and Reading in Childhood

     According to Scientific American, as of 2023, approximately 60% of children were unable to read with proficiency, and 40% of these were essentially nonreaders. Language and literacy is one of the social determinants of health. Healthy People 2030 defines language as "the principle method of human communication, consisting of words used in a structure and conventional way and conveyed by speech, writing, or gesture." Literacy has components including oral literacy (listening and speaking skills), print literacy (writing and reading skills), numeracy (the ability to understand and work with numbers), and cultural and conceptual knowledge. Literacy is distinct from health literacy, which is the degree to which individuals understand and use health related information and searches. Research has shown that limited language and literacy skills are associated with lower educational attainment and worse health outcomes. 

    Reading to children is extremely important to early childhood development. According to the CDC, reading to young children has been shown to improve their language and literacy skills, and is linked to both better behavior and better health. It promotes healthy brain formation, while also increasing skills and vocabulary. In addition, it allows for bonding between the child and caregiver. 

    It has been shown that children who develop strong early literacy skills are more likely to succeed academically. These children exhibit higher levels of self confidence and actively engage in learning experiences. Strong health literacy early in life translates to improved health outcomes later in life. 

    Academic Pediatrics demonstrated the impact of Reach Out and Read via peer reviewed study. This program focuses on supporting healthy early parent-child relationships through shared reading. It is a national family centric program in which medical providers, typically pediatricians, share guidance to caregivers about the importance of reading aloud. They discuss with the parents how to use these books and engage with the young children in the household. The study surrounding this program, The Effect of Exposure to Reach Out and Read on Shared Reading Behaviors, showed that families who participated in this program were more likely to have books in their household and were more likely to read them to children multiple times a week. These young children displayed improved language development by three to six months. 

    The importance of this study's findings, and the importance of the program as a whole, is supported by a policy statement from the American Academy of Pediatrics (AAP), which states that positive childhood experiences, such as reading with a caregiver, can mitigate adverse childhood experiences that would otherwise lead to long-term chronic poor health and well-being. The AAP statement also advocates for a public health approach to this promotion of positive childhood experiences and sites Reach Out and Read as a model intervention. 

    Another intervention that has aimed to improve childhood literacy and family bonds is Dolly Parton's Imagination Library. Dolly Parton first launched this effort in 1995 to benefit the children of her home county in East Tennessee. It gave each child under the age of five a specially selected, high quality, age appropriate book each month, mailed directly to their home. Since 2000, more and more communities have adopted this program. As of 2004, Tennessee had state wide coverage. The program has since expanded internationally to Canada, the United Kingdom, and Australia. 

    Present day, Dolly Parton's Imagination Library sends over one million books to children each month. 1 in 7 children under the age of five in the Unite States currently receives Imagination Library books. 

Dolly Parton's Imagination Library: How it Works

The Imagination Library has been shown to improve kindergarten readiness and family literacy habits, especially for children living in high-poverty areas. In North Caroline, in which every child under the age of five now has access to the Imagination Library due to a 2017 expansion, 45% of families reported that without the program they would not have been able to purchase books. 

Children's Mental Health

     

    The CDC describes children's mental health and how it contributes to children's developmental and emotional milestones. Being mentally healthy in childhood contributes to reaching these milestones and allowing children to learn healthy social skills and how to cope with problems. Being mentally healthy improves a child's quality of life and how they function at home, in school and in there community.

    Mental disorders in children are described as serious changes in how they learn, behave, and handle emotions. Amongst children aged 3 - 17 years, the most common mental health diagnoses are: 

Roseman Medical Group: Children's Mental Health - COVID-19 and Beyond

• ADHD (9.8% or approximately 6.0 million children)
• Anxiety (9.4% or approximately 5.8 million children)
• Behavior problems (8.9% or approximately 5.5 million children)
• Depression (4.4% or approximately 2.7 million children)

    Some of these conditions can occur concurrently. In 2017, it was shown that approximately 75% of children with depression los had anxiety and almost 50% had behavior problems. 

    The prevalence of mental illness in children has increased over time. Much of this has occurred in the past few years and can be sourced back to the COVID-19 pandemic. Prior to this time, CDC data found that 1 in 5 children had mental illness, with only about 20% receiving care. However, in 2020 the Lurie Children's Hospital of Chicago conducted a survey of 1,000 parents across the country and found that 71% of parents reported that the pandemic had taken a toll on their child's health. Mental health crises increased  24% for children aged 5 to and 31% for children aged 12 to 17 from 2019 to 2020. 

    The following are circumstances are reported to cause or exacerbate poor mental health in children:

Cycle of Children's Mental Health Disparities by Break the Cycle of Health Disparities inc.

• Persistent poverty
• Recurrent abuse
• Chronic neglect
• Domestic violence
• Parental mental health
• Moving homes/Changing schools
• Bullying
• Parents divorce/separation
• Death of a loved one
• Long term/Chronic illness

    There are several disparities present in children's mental health. The American Academy of Pediatrics reports that nearly one half of children in the United States do not receive care for treatable mental health conditions. Children from racial and ethnic minorities have even lower treatment rates than their white counterparts, as well as higher incidence rates of mental illness. Data from the Journal of the American Academy if Child & Adolescent Psychiatry shows that between 2010 and 2017, the rates of mental health care in black youth decreased while white and latinx youth rates increased. In some minority communities, there is a major issue in parents understanding their children's mental health. Dr. Patton-Smith of the Mid-Atlantic Permanente Medical Group explains that "There's still challenges in understanding that depression, anxiety, and mood issues are not character flaws, they're not personal weaknesses." He also notes that depression rates are highest in multiracial youth. 

    The prevalence of mental illness is also higher in children identifying as a sexual minority, with them having an almost 3 times increased odds of attempting suicide compared to their heterosexual peers. 

Conceptual Model for Child Mental Health and Mental Health Service Disparities - Margarita Algeria and Jennifer Greif Green, Ph.D.

Safe Haven Laws and Baby Boxes

     Safe Haven Baby Boxes are implemented with the goal of preventing illegal abandonment of newborn children. Not only is the Baby Box offered as a last resort option for women, maintained with complete anonymity, but the organization itself raises awareness and offers a 24 hour hotline for mothers in crisis. 

Safe Haven Baby Box

    The primary goal of Safe Haven Baby Boxes is to raise awareness of the Safe Haven Law. These laws vary across states, in areas such as maximum age at which an infant can be relinquished, whom can relinquish the infant, and where the relinquishment can occur, but overall provide safe places for parents to relinquish their newborn infants. It provides anonymity and protection against prosecution for the infant's caretakers as well as immunity of liability for providers who accept the infants. All fifty states and Puerto Rico have some variation of the Safe Haven Law. The first state to enact this type of law was Texas, who in 1999 created their "Baby Moses Law." This laws was created in a reaction to thirteen incidents of child abandonment that year, with three of the infants being discovered dead. Kentucky's version of this law is the Safe Infants Act, which allows parents to leave babies younger than 30 days old at a designated safe place, where no one will call the police or ask for your name. The baby will get medical care and be placed with a family for adoption. If the parents of the infant do not contact the Cabinet for Health and Family Services within 30 days after leaving the infant at a safe place, the Cabinet will begin the process of terminating parental rights. The World Population Review provides a breakdown for the law by each state. 

Viral TikTok Shows How Safe Haven Baby Boxes Work

   

    According to the National Library of Medicine, more than 100 infants are abandoned each year, with approximately one-third of these infants being found dead. However, since the implementation of the Safe Haven Baby Box, the hotline has received 9,000 calls, the organization has referred over 500 women to crisis pregnancy centers and assisted in 9 adoption referrals, and over 150 infants were safely surrendered. Since the implementation of the first Safe Haven Law in 1999 in Texas, more than 3,500 newborns have been successfully surrendered. 

Newborn baby safely surrendered to the Safe Haven Box at the Beech Grove, Indiana Fire Department

    Despite their benefit towards preventing infant abandonment, scholars have offered critiques of safe haven laws, stating they do not address the root problem of infant abandonment and mortality. They argue that these laws make citizens feel like the crime is being prevented while ignoring racial, cultural, and socioeconomic issues impacting infant relinquishment. These scholars argue for more research to be done on infant abandonment so that evidence based interventions can be implemented to decrease the issue in the first place. 

The Opioid Crisis and Maternal and Child Health

     The Opioid Crisis is a rising epidemic across America. According to the CDC, the number of people who died from drug overdose in 2021 was over 6 times the amount in 1999. This number increased by 16% from 2020 to 2021 alone, with 75% of drug overdose related deaths in 2021 involving opioids. 

Center for Disease Control and Prevention: Three Waves of Opioid Overdose Deaths

    The chart above describes the rise of the opioid epidemic over time. The CDC describes this in three waves.

1. The first wave began in the 1990s, with physicians increasing the amount of opioids prescribed. The majority of these deaths involved prescription opioid overdoses (natural and semi-synthetic opioids and methadones).
2. The second wave began in approximately 2010, with overdose deaths rapidly increasing with the involvement of heroin.
3. The third wave began not long after, in 2013, with significant increases in overdose deaths involving synthetic and illegally manufactured opioids, particularly fentanyl 

    This epidemic has had major affects on maternal and child health, with opioid use disorder causing negative health outcomes for both mothers and infants. The CDC also addressed this issue, describing the following health outcomes associated with opioid use during pregnancy: 

• Pre-term birth
• Low birthweight
• Breathing problems 
• Feeding problems
• Maternal mortality

   Babies exposed in vitro to drugs can often be born with neonatal abstinence syndrome, in which the are dependent on the substance at birth and face withdrawal symptoms as the drug is cleared from their system. 

    In addition to physiological morbidities, this crisis is causing more and more families to be separated, whether by social services or by the loss of a parent. 

    The National Network of Perinatal Quality Collaboratives, which is funded by the CDC, has the focus of improving the health outcomes of those affected by the opioid crisis. They have the goal of improving three potential encounters at three early stages of motherhood, via public health interventions.

1. Prenatal opportunities: Screening and intervention

This intervention focuses on screening for opioid use disorder as early as the mother's first prenatal visit. The provider can measure the mother's addiction severity and can then offer information on the risks of continued drug abuse, advise on the next steps throughout the pregnancy, connect the mother with available support system (Medication Assisted Treatment providers, psychiatric care, social workers, etc.).

    2.  Opportunities post-delivery: Empowering caregivers

 After birth, opioid exposed newborns are typically taken in for critical and intense care to try to alleviate their negative health outcomes. This can often leave mothers feeling alienated from both their baby and their baby's care. An attending neonatologist explained that, "Rather than inspire change, this approach risks telling a mother that she's not capable of caring for her child." Thus, care teams must empower mothers and teach them how to console their babies. This is shown to improve long-term outcomes for families and to help babies recover at a faster rate. Mothers must be informed of what to expect and be prepared to talk to social services. 

    3. Postpartum opportunities: Supporting the dyad

When mothers first return home, they are often still battling addiction, now with the additional stress of a newborn. During the first year of life for a newborn, relapse rates spike for mothers, causing accidental overdose to be one of the leading causes of death in first year mothers. Thus, it is recommended for a two-generational approach at pediatric visits. These can allow for discussing addiction treatment and directing mothers to additional community support systems.