Chronic Diseases. Women are more likely than men to have been diagnosed with a chronic disease such as diabetes (81.2 vs. 70.4 per 1,000 adults), arthritis (24.2% vs. 17.3%), and asthma (9.0% vs. 5.4%).21 Although chronic diseases can be managed during pregnancy, maternal and fetal health may still be compromised, and certain treatments may be teratogenic. Moreover, pregnancy may exacerbate chronic diseases.22 Consequences for the child can include preterm birth or low birth weight,23–29 as well as potentially diminished parental caregiving should a mother experience functional limitations related to her chronic disease. In 2008, 1 in 8 US infants (12.3%) was born preterm (<37 weeks gestation), a 20% increase since 1990.30,31 Infants born too small and too soon have higher morbidity and mortality than infants born full term, including cognitive, neurological, and developmental impairments.32,33
Health disparities are particularly apparent in this arena. The burden of chronic disease falls disproportionately on 2 overlapping subpopulations of women at increased risk for poor birth outcomes: poor women and minority women.34 Moreover, preterm births are not represented equally among racial and ethnic groups; in 2008, 11.1% of White infants were born preterm, whereas 17.5% of Black infants and 12.1% of Hispanic infants were born preterm.30
Mental Health. The mental and emotional health of the mother can have a direct impact on birth outcomes as well as healthy child development. For example, chronic maternal stress has been associated with both negative birth outcomes and suboptimal child development.35,36 Maternal depression is yet another example of the negative influence of deficits in maternal well-being on child development. Maternal depression threatens 2 core parental functions: fostering healthy relationships and carrying out the management functions of parenting—both critically important to child development, particularly as related to safety and emotional security. Approximately 12% of all women experience depression in a given year, and low-income mothers of young children and pregnant or parenting teens are at especially high risk of depression; 40% to 60% of these young women report depressive symptoms. Estimates are that 80% of low-income women who receive treatment for depression are helped.37,38
Maternal Weight. The problem of overweight among women also is of concern to child health. In 1960 to 1962, 24.5% of women were overweight and 15.7% were obese, compared with 27% and 35% in 2005 to 2006.21 Being overweight or obese increases the risk for hypertension, diabetes, heart disease, stroke, and perinatal morbidity,19,39,40 conditions that are known to affect perinatal outcomes, as noted previously. Labor and delivery problems are also correlated with maternal body mass index,41–45 and some studies suggest that overweight and obesity may limit a woman’s ability to successfully breastfeed.46–50
Breastfeeding. Breastfeeding has long-term benefits for mothers as well babies; women who breastfeed their babies have reduced risk of type 2 diabetes and breast and ovarian cancers.51 Infants who are breastfed for a period of months are at lower risk of experiencing acute otitis media, atopic dermatitis, gastrointestinal infections, and asthma, as well as diminished lifetime risk of developing obesity, diabetes (type 1 and type 2), hypertension, childhood leukemias, and Sudden Infant Death Syndrome (SIDS).51,52 However, initiation and duration of breastfeeding do not currently meet the Healthy People 2010 goals of 75% initiation, 50% duration at 6 months, and 25% duration at 12 months.
Substance Abuse. Substance abuse by pregnant women, including but not limited to alcohol, tobacco, and illicit drugs, has been linked to poor birth outcomes with consequent negative effects on the child’s health and development. Postnatal exposure to some substances can also negatively affect the child’s health and well-being.
Family Violence. Children are vulnerable to physical and emotional harm caused by family violence. There are obvious physical and emotional consequences for children who are abused by their parents or other caregivers, but exposure to any family violence has significant emotional consequences. Children who are exposed to violence between their parents or between a parent and an intimate partner fare worse than other children on a variety of mental health, behavioral and academic outcomes.67 Family violence accounted for 11% of all violence between 1998 and 2002. Nearly half of violent crimes against family members involved violence against a spouse, 11% involved victimization of a child by a parent, and 41% involved offenses against other family members.
3. Children’s health and safety are strongly influenced by the community environment. Chronic and acute conditions such as obesity, asthma, lead poisoning, and injuries are associated with risk factors within a child’s built environment.17
Both injuries and chronic conditions have an impact on a children’s ability to learn and succeed in school as well as their health as an adult. Almost 5% of children missed 11 or more days of school over the past year because of illness or injury.68 Unintentional injuries are the leading cause of death for children 1 to 24 years old. A substantial proportion of these injuries are related to motor vehicles.69 Lack of seatbelt use is a major contributor to this problem; the 2007 Youth Risk Behavior Survey found that 11% of students had rarely or never worn a seat belt. Substantially more, 66%, rarely or never wore a helmet when riding a motorcycle.70 Pedestrian road safety is also a major concern in this regard and can be ameliorated with changes in roadway construction and traffic patterns. Work-related injuries also contribute to the burden of injuries among children and adolescents.71
In recent years, chronic illnesses have emerged as serious problems for children. Of particular concern are asthma and obesity. In 2008, more than 10 million US children (14%) had been diagnosed with asthma at some point in their lives, and almost 7 million (10%) were still affected.68 Children in poor families were more likely to have been diagnosed or to still have asthma (18% and 12%) than children in families who were not poor (13% and 9%).68 Although it can be difficult to determine the actual cause of asthma, some triggers can cause more frequent and severe attacks. These include environmental tobacco smoke, mold, dust mites, air pollution, and pet hair. Children living in substandard housing or in neighborhoods near freeways or heavy industry are more likely to be exposed to these triggers.
Over the past 30 years, the prevalence of childhood obesity has increased in all age groups. Data from NHANES surveys (1976–1980 and 2003–2006) show that the prevalence of obesity increased from 5% to 12.4% for the very young (2–6 years), from 6.5% to 17% for children (6–12 years), and from 5% to 17.6% for adolescents (11–20 years). Children of color are more likely to be affected by obesity. The prevalence is highest among non-Hispanic Black and Mexican American children.72 The physical and psychosocial consequences of childhood obesity include orthopedic complications, type 2 diabetes, poor immune functions, increased blood pressure and hypertension, low self-esteem, discrimination, and depression.73
Community and neighborhood design can either promote or hinder physical activity for children.17 Safe places to play (parks, bicycle paths, recreational facilities), regular opportunities for physical activity during the school day, and formal physical education programs all promote physical activity in children. For many low-income children, these opportunities are lacking: schools are discontinuing formal physical education programs and even recess and parks and neighborhoods are unsafe for children to play outside. For children with disabilities, attention to community and neighborhood design is especially important to ensure accessible environments for physical activity and play.
Community and neighborhood design must also consider food access. Access to healthy foods is a problem for low-income children. Not only can healthy food options be more expensive but also many low-income neighborhoods do not have food markets or grocery stores that offer adequate options of healthy food, such as fresh fruits and vegetables.
4. All children, families and communities have assets and strengths—people, relationships, and community structures—that should be recognized in building a fabric of social support. Children develop assets from constant exposure to interlocking systems of support that provide empowerment, boundaries and expectations, and structure.74
Building on the existing strengths of people, families, and communities is a critical component to preventing risky behaviors and promoting health. Educational attainment is a critical determinant of health, both for children and their families. Health status has consistently been strongly linked to educational achievement. In 2007, 87% of 25 to 29 year olds had received a high school diploma or an equivalency certificate. There continues to be a gap between the completion rates for Blacks and Hispanics compared with White students.75 Limited educational attainment has been linked to a wide range of health outcomes, including increased mortality, increased rates of chronic diseases, and decreased functioning.76
The family plays a crucial role in the healthy development of the child. In the United States, there is great diversity in what constitutes a family. It is important to recognize the diversity within families, including acknowledging various gender roles, the extended family, and racial/ethnic cultural variations, to support a range of healthy family structures whereby children can thrive. For example, the American Academy of Pediatrics has called for the enhanced role of fathers in children’s care and development, and regular engagement by fathers has predicted a range of positive outcomes for children.7,76
Children and adolescents are vulnerable to adopting risky behaviors when they do not have the protection of sufficient personal, family, and community assets, and many children lack these assets. The 2007 Youth Risk Behavioral Survey indicated that 50% of students had tried cigarette smoking and 20% smoked cigarettes on at least 1 day in the previous month. Three-quarters of youth surveyed had tried alcohol (at least 1 drink), and 44% reported drinking in the past month. Nearly half (47%) of the surveyed youth had ever had sexual intercourse, and 15% had 4 or more sexual partners during their lifetime.70 The age of onset of risky behaviors also is of concern, as children are adopting these behaviors at early ages. Before the age of 13, 14% of students had smoked a cigarette, 24% drank alcohol, and 7% had sexual intercourse.70 Research suggests that increasing protective factors on multiple levels—community, families, and children—may result in reducing risk-taking behaviors.78
Many parents work outside the home, and high-quality, accessible community resources for families with young children are necessary to ensure that children are obtaining developmentally appropriate child care. In 2005, 60% of children under 6 years old required at least 1 child care arrangement.79 High-quality early education and child care for young children improves their health and promotes their development and learning. Research on high-quality, intensive early childhood education programs for low-income children confirms lasting positive effects such as greater school success, higher graduation rates, lower juvenile crime, decreased rates for special education services later, and lower adolescent pregnancy rates. Public funding for high-quality child care is inadequate. In many states, the cost of early education and child care programs is approximately twice as expensive as paying for 1 year of tuition at a 4-year public college.80
Coordinated school health programs (CHSPs) are an excellent example of interlocking support networks. CHSPs provide both support to children and families within the school system and linkages to resources in the community. Research suggests that CHSPs have positive impacts on educational achievement of children and have supported the positive effects of individual program components.81
5. Children should have access to developmentally appropriate, integrated health care (physical, mental, developmental, oral and vision) that is accessible, continuous, comprehensive, family centered, coordinated, compassionate, and culturally effective.61
Medical care is necessary for good health. Particularly for children, regular, periodic health screenings are needed to identify emerging medical, emotional, vision, and dental conditions and developmental delays and to provide preventive care such as immunizations; these are fundamental to their health. It is well established that children who do not have access to a regular source of care are more likely to not receive care in a timely manner. In particular, the American Academy of Pediatrics continues to endorse the use of a medical home and Bright Futures standards to better ensure optimal health, development, and quality of life for children.65,66,71,82 Health insurance coverage is critical to receiving care; children without coverage are 4 times more likely not to have seen a health professional in the past year.68 More than 7.3 million children (9.9%) in the United States did not have health insurance in 2008,14 and children living in poor households were more likely to lack coverage.
Health care is not limited to medical care. Poor oral health is increasingly recognized as a serious public health problem because of its effects on other aspects of health and its relationship to several chronic diseases in adulthood.83,84 More than 4 million children between the ages of 2 and 17 had unmet dental needs because their families could not afford dental care.68 Thirty-four percent of uninsured children had no dental care for more than 2 years.68 Children with dental disease can experience pain and have difficulty concentrating, miss school, have impaired speech development, among other consequences.85 In addition, more than 7 million children, or 83% of families with incomes at or below 400% federal poverty level, have an unmet vision care needs because their families could not afford vision care.71
6. Some children are more vulnerable (children with special health care needs or disabilities, children of immigrants or refugees, children in foster care or in the juvenile justice system) and special policies may be necessary to ensure that these children thrive. Service systems should address the special needs of these children while promoting the inclusion of these children and their families in all aspects of community life.
Children with special health care needs (CSHCN) make up 14% of the population of children in the United States.86 Although most CSHCN receive the services they need, the National Survey of Children with Special Health Care Needs found that 16% of CSHCN did not receive at least 1 needed health care service, and 6% did not receive more than 1 needed service. Preventive dental care was the most frequently lacking, followed by mental health services.86 CSHCN often are served by multiple systems of care (e.g., education, health, early intervention, social services, child welfare, juvenile justice, mental health). Currently, these systems lack integration, and families of CSHCN must navigate and coordinate a complex array of services.
In 2007, 783,000 children, the vast majority of whom had been abused or neglected, were served by the foster care system in the United States.87 Children in the foster care system have been found to fall below national levels on nearly every measure of cognitive and social development and tend to suffer from physical health problems.88 Similar to CSHCN, children in the foster care system have multiple needs and are most often served by multiple systems of care, which lack integration and are difficult for families to navigate.
7. Ensuring that all children are healthy requires a broad-based national commitment to child health. This commitment includes an infrastructure that supports public participation and education, research, professional education and training, and systems to ensure equity in health care delivery.
Children grow up in an environment of relationships and structures that have enormous influence on their health outcomes. Public policies shape many aspects of this environment, from the foods served in schools to the health providers children see. A lack of public understanding about these critical aspects of child health and development has resulted in insufficient political and public will to make children a national priority. Therefore, a broader, more inclusive national commitment to child health is necessary.
Research suggests that current professional education and training will lead to a shortage of providers involved with child health. By the year 2020, the United States will need 57,900 pediatricians and 47,200 obstetricians/gynecologists. Estimates based on current medical school enrollment, age of current practicing physicians, and other factors, suggest that in 2020 there will be 54,560 pediatricians and 44,630 obstetricians/gynecologists in clinical practice.89 Of particular additional concern to maternal and child health practitioners is the great difficulty experienced in local and state child health programs in recruiting nurses with public health training and experience and advanced degrees.90 Moreover, a national survey of state maternal and child health and Children and Youth with Special Health Care Needs Programs conducted in 2008 documented a critical shortage of staff. These public health programs have a broad scope of responsibilities; many states oversee as many as 15 to 20 program areas spanning chronic illness, medically fragile children, adolescent health, infant mortality reduction, newborn screening and follow-up, injury prevention, oral health, family planning, and others. Yet they operate with staff levels as few as 7, and with average staffing vacancy rates nationally of 13% of all positions.90 Recent substantial declines in federal funding for public health infrastructure for maternal and child health in the states has left these programs greatly challenged to keep pace with needs for prevention programs and services, surveying population needs and vulnerabilities, and ensuring supportive and specialized services and systems of care for high-risk groups of children, mothers, and families.
Additional attention to research will ensure that we have cutting-edge scientific knowledge to inform policy and practice. Recent reviews of child health and health promotion point to several major gaps in scientific knowledge, particularly with respect to understanding the mechanisms of genetic–environment interactions that shape lifelong health, and intervention research.91,92 The National Children’s Study, funded by a consortium of federal agencies, is a longitudinal study that will examine the effects of environment on the health and development of 100,000 children across the country, following them from before birth until age 21. Ultimately, this study will be one of the richest research efforts focused on children and will have the potential to inform policy and practice.93
Public health infrastructure plays a critical role in the delivery of services to children and families. The first White House Conference on Children was convened in 1909 by President Theodore Roosevelt and resulted in creation of the Children’s Bureau and subsequent significant efforts to build an infrastructure for public maternal and child health services. Over the next 70 years, a conference specifically devoted to improving the lives of children and youth was convened at least once a decade by the president of the United States. President Reagan was the first president not to convene a conference dedicated to children. Only 1, convened by President Clinton with a focus on early childhood development and learning, has been held since.94 In 2008, legislation calling for a White House Conference on Children and Youth in 2010 was filed in both the House and Senate.
Uses and limitations
This policy statement is intended to provide a framework and a broad overview for decisionmaking. Although the document includes narrative to provide context and support for each principle, topical areas discussed should not be construed to reflect the complete list of child health issues; rather, the evidentiary information provided illustrates the breadth of the many specific, more narrowly focused issues affecting children. We anticipate that as specific new political, policy, science, or social/cultural concerns emerge and development of formal targeted policy is not yet possible for APHA, this broad framework will remain relevant and can be considered to encompass the newly emerging concern. Because the framework of key principles is so broad, it should be useful as relevant context as new policy issues are addressed by the association with a targeted approach or policy statement.
- Urges federal and state governments to appropriate adequate funding for public health programs and interventions that focus on building environments that support health and thriving families and communities, including those that address food security, livable wage, affordable and safe housing, healthful and safe workplaces, health disparities, and high-quality of out-of-home care and early childhood education.6–11
- Urges federal and state governments to consider the impact on children when making environmental policy, legislation, and regulation.10
- Encourages collaboration among health professionals, government, foundations, advocacy organizations, faith- and community-based organizations, and businesses to support efforts that improve personal health throughout the lifespan by—
- Promoting health care and healthy behaviors among women of child-bearing age, both before and during pregnancy
- Promoting awareness of the impact of maternal depression and supporting policies that promote screening and services
- Supporting breastfeeding, especially for poor women and their children, including employer policies and community structures that facilitate the choice to breastfeed
- Supporting the development of coordinated school health programs that include linkages, as appropriate, with public health and promotion of health education11
- Supporting programs that develop assets in children and prevent risk-taking behaviors
- Encourages Congress to pass legislation that will enhance and expand insurance coverage for all that includes physical, mental, vision, and oral health benefits and that promotes prevention as well as access to specialized medical care where needed.12
- Supports that a uniform set of core preventive and support services for children and their families be established in policy at the national, state, and local levels.
- Urges the federal government to support a strong infrastructure for children, youth, and families that includes—
- A locus of accountability for the health and well-being of children within health reform
- Particular attention to the most vulnerable children (those with special health care needs or disabilities, children of immigrants or refugees, children in foster care or in the juvenile justice system)
- Increased investment in basic and intervention research in child health and development
- A public health and clinical workforce that is sufficient and proficient in caring for children and families10
- Urges federal, state, and local governments to develop policies to improve the integration of services and information for children and their families.
- Urges the president of the United States to convene a White House conference on children and youth that includes a multidisciplinary focus on all aspects of children’s protection, health, and healthy development.
- Urges the development of a national plan for children’s health and development that is comprehensive; based on research in the neurobiological, behavioral, and social sciences such as the National Children’s Study92,93; includes a core set of preventive and support services; and addresses the needs of all children while paying particular attention to concerns related to health disparities.
- Urges the development of a public education campaign that explains critical issues affecting child health and connects them to society’s long-term interests in healthy outcomes for children.
- American Public Health Association. APHA policy statement 49-02: Child health services. Washington, DC: American Public Health Association; 1949. Available at: http://www.apha.org/advocacy/policy/policysearch/default.htm?id=308. Accessed January 14, 2011.
- American Public Health Association. APHA policy statement 66-04: A national dental health program for children. Washington, DC: American Public Health Association; 1966. Available at: http://www.apha.org/advocacy/policy/policysearch/default.htm?id=562. Accessed January 14, 2011.
- American Public Health Association. APHA policy statement 69-13: National health program for children. Washington, DC: American Public Health Association; 1969. Available at: http://www.apha.org/advocacy/policy/policysearch/default.htm?id=626. Accessed January 14, 2011.
- American Public Health Association. APHA policy statement 72-27(PP): Child health and public policy background. Washington, DC: American Public Health Association; 1972. Available at: http://www.apha.org/advocacy/policy/policysearch/default.htm?id=716. Accessed January 14, 2011.
- American Public Health Association. APHA policy statement 74-08: Health insurance for infants, children, and youth. Washington, DC: American Public Health Association; 1974. Available at: http://www.apha.org/advocacy/policy/policysearch/default.htm?id=750. Accessed January 14, 2011.
- American Public Health Association. APHA policy statement 2007-2: Addressing obesity and health disparities through federal nutrition and agricultural policy; 2007. Available at: http://www.apha.org/advocacy/policy/policysearch/default.htm?id=1347. Accessed January 15, 2011.
- American Public Health Association. APHA policy statement 2003-19: Support for WIC and child nutrition programs; 2003. Available at: http://www.apha.org/advocacy/policy/policysearch/default.htm?id=1257. Accessed January 15, 2011.
- American Public Health Association. APHA policy statement 2007-12: Toward a healthy, sustainable food system; 2007. Available at: http://www.apha.org/advocacy/policy/policysearch/default.htm?id=1361. Accessed January 15, 2011.
- American Public Health Association. APHA policy statement 2006-18: Reducing nutrition-related disparities in America through food stamp nutrition education and the reauthorization of the farm bill; 2006. Available at: http://www.apha.org/advocacy/policy/policysearch/default.htm?id=1342. Accessed January 15, 2011.
- American Public Health Association. APHA policy statement 1995-11: The environment and children’s health; 1995. Available at: http://www.apha.org/advocacy/policy/policysearch/default.htm?id=106. Accessed January 15, 2011.
- American Public Health Association. APHA policy statement 2004-09: Promoting public health and education goals through coordinated school health programs; 2004. Available at: http://www.apha.org/advocacy/policy/policysearch/default.htm?id=1292. Accessed January 15, 2011.
- American Public Health Association. APHA policy statement 2000-07: Support for a new campaign for universal health care; 2000. Available at: http://www.apha.org/advocacy/policy/policysearch/default.htm?id=212. Accessed January 15, 2011.
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