Although most of the nation’s children are healthy and succeed in school, many are not enjoying optimal health and well-being and are not reaching their full potential as contributing members of society. Despite improvements, the mortality and morbidity rates for U.S. children in all age groups are unacceptably high. Consider:

The health of a child has long-term implications. The health habits adopted by children and youth will profoundly influence their potential to lead healthy, productive lives. The physical and emotional health experienced by a child plays a pivotal role in his or her overall development and the well-being of the entire family. Children who go to school sick or hungry, who cannot see the chalkboard or hear the teacher, who have learning disabilities, who are troubled by abusive parents or disruptive living circumstances, or who fear for their safety at home or in school often do not perform on the level of their counterparts who are healthy, well nourished, well cared for at home, and safe and secure in their world. From fetal life onward, the health and well-being of individuals has a substantial impact on their futures.

In 2007, there were about 73.9 million children in the United States under age 18 years, forming about 25% of the country’s population. The number of children is expected to increase to 80 million by the year 2020, but the proportion of children as compared with adults has been decreasing since the mid-1960’s baby boom (Federal Interagency Forum on Child and Family Statistics, 2008). The demographic composition of the nation is important to planners and policy makers because it influences how resources will be allocated. For example, a growing child population necessitates more resources for schools, child care, and health care.

The ethnic and racial composition of the United States’ child and adolescent population is also changing. The percentage of children living in the United States with at least one foreign-born parent rose from 15% in 1994 to 22% in 2007. About 20% of school-age children speak a language other than English at home.

In 2007, 57% of children living in the United States were white, non-Hispanic; 21% were Hispanic; 15% were black; 4% were Asian; and 4% were of all other races (Figure 16-1). The percentage of children who are Hispanic has increased faster than that of any other racial or ethnic group, growing from 9% of the child population in 1980 to 21% in 2007. By 2020, it is projected that nearly one in four children in the United States will be of Hispanic origin (Federal Interagency Forum on Child and Family Statistics, 2008).

Children are a dependent population and rely primarily on parents or other adults to protect and promote their health and well-being. Community health nurses can learn more about this important population group and the positive and negative factors that influence their health. Nurses can use this information to help improve the chances that children will grow up to be healthy, both physically and emotionally.

This chapter focuses on the health status of children and adolescents and the medical, socioeconomic, environmental, educational, safety, and public health factors that community health nurses must address to improve child and adolescent health. This chapter also discusses indicators of child and adolescent health status, the individual and societal costs of poor child health, public programs targeted to children’s health, and strategies to improve child and adolescent health at the individual, family, and community levels.

Infant mortality, the death of an infant during the first year of life, is a critical gauge of children’s health status. It is an important marker because it is related to several factors, including maternal health, medical care quality and access, socioeconomic conditions, and public health practices. Infant mortality reflects the health and welfare of an entire community and is used as a broad indicator of health care and health status. Box 16-1 lists some terms and definitions associated with infant health and mortality.

Surprisingly, the United States ranks a dismal twenty-ninth in infant mortality behind most other industrialized nations, including Japan, Sweden, Spain, Hong Kong, Italy, France, and Canada (Table 16-1). Fifty years ago, the United States ranked twelfth. The gap in infant mortality between the United States and other nations has occurred despite the United States’ comparatively high per capita spending on health care and technological advancements.

Despite a poor ranking among other nations in the world, in the past century, the infant mortality rate in the United States declined substantially (Figure 16-2). The 2006 infant death rate of 6.71 deaths per 1000 live births (MacDorman and Mathews, 2008) was the lowest infant mortality rate ever recorded in this country. The incidence of infant mortality has decreased largely because of public health measures and improved standard of living (e.g., improved sanitation, a clean milk supply, immunizations against deadly childhood diseases, the increased availability of nutritious food, and enhanced access to maternal health care). Technological advances in neonatal care, for example, the introduction of synthetic lung surfactant, have also contributed to reductions in infant mortality. However, declines in infant mortality have stagnated during the past decade.

The three leading causes of infant death in the United States are congenital malformations, deformities, and chromosomal abnormalities; disorders relating to short gestation and low birth weight; and sudden infant death syndrome (SIDS) (Kung et al., 2007) (Box 16-2). Prematurity is a key risk factor for infant death. Socioeconomic factors also play an important role in infant mortality. Out-of-wedlock births pose greater risks for infant mortality, for example. In 2007, 40% of all babies were born to unmarried women, a rapidly increasing trend, particularly among Latino women (Martin et al., 2009). Infant mortality rates are also higher for children whose mothers receive late or no prenatal care, who are adolescents, who did not complete high school, who are unmarried, or who smoke during pregnancy.

Troubling disparities in infant mortality persist between racial and ethnic populations. For example, black infants continue to die at more than twice the rate of white infants (Figure 16-3) (MacDorman and Mathews, 2008). Identifying and remedying the causes of higher infant mortality rates among certain population subgroups remains a vexing societal problem (Box 16-3).

Birth weight and length of gestation are the most important predictors of infant health. One reason infant mortality has declined so slowly in recent years is that the preterm rate (birth before 37 completed weeks of gestation) has risen so quickly over the past two decades. About 13% of babies in the United States are born prematurely. A portion of this increase is due to increases in multiple births, but prematurity among single births has also risen (Martin et al., 2007). The greatest rise in preterm births has occurred in babies who are born between 34 and 36 6/7 completed weeks of gestation (late preterm). Indeed, 70% of babies born prematurely are born late preterm (Hamilton et al., 2009).

Infants born preterm or at a low birth weight have a far greater risk of death and physical and mental disabilities such as blindness, deafness, cerebral palsy, learning disabilities, and mental retardation than infants born at term with normal weight. Even babies born late preterm carry a risk for developmental delay that is 36% higher than for babies born at term (Morse et al., 2009).

Prematurity and low birth weight overlap. About half of preterm infants are born at low birth weight, but only two thirds of low-birth-weight babies are born prematurely. Babies born at term but at low birth weight are considered “growth restricted.” Non-Hispanic black infants are disproportionately affected by preterm birth and low birth weight; indeed, they are nearly twice as likely as white infants to be born at low birth weight (Hamilton et al., 2009). Factors associated with preterm birth and low birth weight include the following:

The development of advanced life-support technologies for small infants has significantly improved the survival rate of low-birth-weight babies. Success stories of tiny survivors are sensationalized in the news, but the long-term consequences of babies born even a few weeks early are not well publicized. Medical management of high-risk pregnancy and increasing numbers of labor inductions and elective cesarean births have helped to push the rate of late preterm birth upward. Consequences of late preterm birth can be long lasting and costly (Petrini et al., 2009; Morse et al., 2009; Bettegowda et al., 2008; Adams-Chapman, 2006; Institute of Medicine, Section IV, 2006). Because late preterm births account for the majority of preterm births, it is imperative that all possible measures are taken to decrease elective births before 39 weeks of gestation (Oshiro et al., 2009).

Preventing the occurrence of prematurity and low birth weight is a high priority for clinical and public health research and policy. Nurses can play important roles in preventing prematurity, through the provision of evidence-based primary care, research, screening, counseling, education, advocacy, referral, and implementation of interventions to reduce risk among target population groups.

The good health of a woman before becoming pregnant is imperative to the health of her baby. Adapting healthy lifestyles and obtaining regular medical care before becoming pregnant can help to ensure a healthy pregnancy. Tiny developing fetal organ systems are highly vulnerable to the effects of maternal nutrition, drugs, alcohol, tobacco, chronic maternal diseases, environmental toxins, and other exposures. The fetus can suffer damage very early in pregnancy, even before a woman knows she is pregnant. This is important because approximately half of the pregnancies in the United States are unintended (Finer and Henshaw, 2006). Because of the likelihood that a woman may become pregnant, all women of childbearing age should adapt healthy lifestyles. Measures known to help ensure fetal health such as consuming 0.4 mg of the B vitamin folic acid every day, even before conception, will decrease the likelihood of defects of the brain and spine, known as neural tube defects (Wolff et al., 2009). The Centers for Disease Control and Prevention (CDC) estimates that 50% to 70% of neural tube defects could be prevented if this recommendation were followed before and during early pregnancy, yet fewer than one third of women get the recommended amount of folic acid (CDC, 2008). For women planning to become pregnant, preconceptional counseling is a prevention strategy that helps to identify potential risks to a fetus before pregnancy. Preconception assessment encourages health and lifestyle modifications that can lead to healthier babies.

Obtaining early and regular prenatal care greatly enhances a woman’s chance of delivering a healthy, term baby. Prenatal care includes client education, risk identification, and monitoring and treatment of symptoms. It also includes referral to health, nutrition, and social service programs that can help a woman optimize her chances for a healthy pregnancy. In the past two decades, the Medicaid program was expanded to cover health care for increasing numbers of low-income pregnant women and infants. Still, fewer than 70% of women receive prenatal care beginning in the first trimester. Large disparities by race persist in the receipt of prenatal care. Non-Hispanic black and Hispanic women are more than twice as likely as non-Hispanic white women to receive late or no care (Martin et al., 2009). Examples of population groups that are less likely to receive early prenatal care include the following: