Catherine Radwan

With government focus on reducing federal safety net benefits for low-income populations comes news that the Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) reduces infant mortality by one-third during the first year of life and lowers the risk of preterm birth for expectant mothers who participate.

, analyzed the live birth certificates of babies born to more than 11 million women between January 1, 2011, and December 31, 2017, from the National Center for Health Statistics, which had recorded insurance coverage and receipt of WIC benefits on the birth certificates, for outcomes of gestational age at birth and death within the first year of life. Of these mothers, about 8 million (73%) had received WIC benefits during pregnancy.   

The odds of infant mortality in the first year after birth were lower for babies of mothers who had received WIC benefits during pregnancy (adjusted OR, 0.84; 95% CI, 0.83-0.86). The infant mortality rate was 5.2 deaths per 1000 live births among those who had received WIC benefits during pregnancy and 8.2 deaths per 1000 live births among those who did not (a 36.6% relative risk reduction).

The odds of preterm birth compared with normal term birth were lower among expectant mothers covered by Medicaid who had received WIC benefits than for mothers who did not receive WIC benefits (adjusted proportional odds ratio [OR], 0.87; 95% confidence interval [CI], 0.86-0.87). For extremely premature birth, the prevalence was 0.7% among women who received WIC benefits during pregnancy and 1.2% among those who did not 

<.001); for very premature birth, 1.3% among those who received WIC benefits during pregnancy versus 1.7% for those who did not receive WIC benefits (

<.001); for moderate-to-late premature birth, 10.5% among those who received WIC benefits during pregnancy and 11.2% among those who did not (

The study also found that the odds of preterm birth compared with normal gestational age birth were lower for non-Hispanic white, non-Hispanic black, and Hispanic expectant mothers covered by Medicaid who had received WIC benefits during their pregnancies compared with expectant mothers in these groups who had not received WIC benefits. Likewise, the researchers found that odds of infant mortality were lower for these groups of expectant mothers when they had received WIC benefits during their pregnancies than for those mothers who had not participated in the WIC program.

The researchers note that participation in WIC enables higher overall and protein-specific caloric intake in pregnant women that improve fetal growth and increase infant birth weight. In addition, WIC increases vitamin D intake that may lower the risk of pregnancy-induced hypertension and preeclampsia, major risk factors for fetal mortality, as well as greater maternal iron intake that may increase birth weight for gestational age. Finally, WIC encourages breastfeeding by providing new mothers with guidance and breast pumps. Breastfeeding can reduce the risk of postnatal death between 28 days and 1 year after birth.

The researchers note that one drawback of their study was that it focused on live births and not those pregnancies resulting in miscarriage or stillbirth. They say that participation in the WIC program may reduce the incidence of these outcomes among high-risk pregnancies through better nutrition and prenatal visits.

Also, they call for public health campaigns and increased federal funding so that all expectant mothers who are low income or at risk for poor nutrition can receive WIC benefits during their pregnancies. Currently, about 40% of expectant mothers in the United States participate in the WIC program.

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 Low-income pregnant women who receive Women, Infants, and Children (WIC) federal nutrition assistance reduce their offspring’s risk for infant mortality and premature birth.   

WIC program cuts infants’ risk for early death and preterm birth

States that allow exemptions to vaccinations for children based upon personal or religious beliefs of the parents report a significant rise in kindergartners with religious exemptions during the 2017-2018 school year compared with the 2011-2012 school year, and a new study has determined that the elimination of personal belief exemptions may be responsible for the increase.

 analyzed data on exemptions for children starting kindergarten from 2011 to 2018 from the Centers for Disease Control and Prevention. Researchers performed a cross-sectional, retrospective, state-level analysis of state estimates of the proportion of children with medical and religious/personal belief exemptions as well as the proportion of kindergartners who were up-to-date on recommended vaccines (measles/mumps/rubella, diphtheria/ tetanus/ acellular pertussis, and varicella) and calculated the proportion of kindergartners with religious vaccine exemptions for each state year, adjusting for the strength of each state’s exemption policies.

In unadjusted analyses, states with religious and personal belief exemptions had a significantly lower mean proportion of kindergartners with religious exemptions (0.41%; 95% confidence interval [CI], 0.28%-0.53%) compared with states with religious exemptions only (1.63%; 95% CI, 1.30%-1.97%). In adjusted analyses, states with religious and personal belief exemptions were one-fourth as likely to have kindergartners with religious exemptions compared with states with religious exemptions only (risk ratio 0.25%; 95% CI, 0.16-0.38).

Using the 2011-2012 reference year, states were more likely to have kindergartners with religious exemptions during the 2017-2018 school year (

=.04). This finding held for states with easy, medium, or difficult exemption policies.

The researchers say their study demonstrates how vaccine exemption policies influence state-reported vaccine exemption data. “State-level religious exemption rates appear to be a function of personal belief exemption availability, decreasing significantly when states offer a personal belief exemption alternative,” they write.

However, the study authors note that the increase in exemptions based on religious beliefs is curious because it is accompanied by a simultaneous decrease in Americans’ declarations of religious affiliations. All major religions support vaccination, they write, and fewer Americans say they are religious, yet exemptions based on religious belief have increased as of the 2017-2018 school year.

They suggest that researchers and policymakers work together to reconsider the nature and purpose of religious exemption laws “to determine how best to balance a respect for religious liberty with the need to protect public health.” 

As state policies regarding vaccination for children entering kindergarten eliminate exemptions for personal beliefs, parents turn to claiming exemptions on religious grounds.

Religious exemptions to vaccination rise amid stricter state policies

With the joyful music of the Andrews Junior Jazz Band, American Academy of Pediatrics (AAP) President Kyle E. Yasuda, MD, FAAP, welcomed attendees, including 2000 visiting pediatricians from 58 countries, to New Orleans for the AAP 2019 National Conference and Exhibition, and in his President’s Address called on the “best minds in Pediatrics” to celebrate the joy of their profession and the differences they have made in the lives of children.

Yasuda pointed out that 2019 was a year of notable achievements in children’s health. The AAP helped pass legislation to protect Medicaid; convinced lawmakers to change policies harmful to immigrant children; met with national groups to address prior authorization, value-based payment, and use of telemedicine; helped to ban reclining infant sleepers from the market; published guidelines for attention-deficit/hyperactivity disorder, sugar in children’s diets, and the harmful effects of racism on child health; worked with a major toy company to launch toys that promote the power of play; and worked to reduce the administrative burden for clinicians.

However, there are new challenges, he said, most troubling: the return of measles as a threat to public health; emergence of lung illness related to vaping; decreasing numbers of children with healthcare coverage; increasing numbers of child deaths from firearms; and the diminished trust in government and venerable institutions that undermines years of advances made in public health.

“The good news is that people do trust the American Academy of Pediatrics, and they trust their pediatricians,” he said to loud applause.

Yasuda outlined the AAP’s agenda to counteract harmful cultural and political misinformation going forward into 2020.

First on the AAP’s agenda is fighting the battle of misinformation among parents who get their medical information from online sources. To counteract this trend, the AAP is partnering with Google, Facebook, and Pinterest to keep vaccine misinformation off their platforms so that when one searches the site for vaccines or immunizations, the first search result is the AAP.

Additionally, the AAP will focus on gun safety and gun violence prevention, and working with the Centers for Disease Control and Prevention and the National Institutes of Health to support a House bill to study gun violence prevention.

Also in the AAP’s agenda is the epidemic of e-cigarette use among young persons and the outbreak of lung disease associated with e-cigarettes, all of which is setting back years of antismoking success. The AAP is working with policymakers to ban flavored vaping products that appeal to children and adolescents and to raise the legal age to purchase these products to 21 years.

Yasuda also said the AAP will address the media portrayal of pediatricians as “vigilantes” who separate children from their parents in suspected cases of child abuse, especially for head trauma, further undermining the trusted relationship between pediatrician and patient.

Lastly, he said the AAP will advocate for action to counter the negative effects of climate change on children’s health.

Yasuda called climate change “the most defining issue of our time” because 88% of its health consequences will be felt by children. Recently, the AAP and 70 media and public health organizations put forth a climate agenda for policymakers and government officials. The AAP also joined the American Heart Association in filing an amicus brief on behalf of Juliana v United States, the “climate kids” lawsuit that is suing the federal government for creating a climate system that violates children’s rights to an environment that sustains life.

Finally, Yasuda announced that the AAP has formed a nature subcommittee of the Council on Community Pediatrics to explore the beneficial impact of the natural world on children’s health and well-being. That subcommittee held its first meeting at the 2019 National Conference.

In closing his address, Yasuda emphasized that the AAP always puts the best interests of children first, and that this mission makes the organization the leading national voice for children. Its 60,000 members represent different countries, ethnic backgrounds, religious beliefs, and political views, and those members may often disagree with each other, but through its members united in its common cause, the AAP will always be the leading advocate for child health.

“This is our calling,” he said. “Let us keep leading the way forward."

The American Academy of Pediatrics (AAP) reminds its members not to be content with 2019’s achievements in children’s health, but to stand up against new challenges that threaten to undo what already has been won.

AAP challenges members to speak up for children’s health in 2020

Tiffani Johnson, MD, MSC, FAAP, enthralled a packed room at the American Academy of Pediatrics 2019 National Conference & Exhibition Friday afternoon when she led session attendees to admit that they harbor many hidden biases and discriminatory attitudes toward patients and families that can unconsciously determine how they treat patients, parents, and even office staff.

In Johnson’s interactive session “Blind side: Implicit bias we hide, abide, and push aside,” she first guided her audience through the online Implicit Association Test (IAT) to set a private baseline for individual’s attitudes related to topics such as race, sex, ethnicity, nationality, language, socioeconomic factors, and more. Then the participants paired randomly to discuss what they had discovered about their attitudes toward persons different from themselves.

Johnson defined bias as the tendency to believe that some people or ideas are better than others, which leads to treating certain persons differently based on these beliefs. Implicit bias lies below the surface and may not be recognized by the physician as such, but it may influence a physician’s behavior toward particular patients or their families.

She explained that implicit bias is automatic, activated without one’s control or intent, and pervasive because everyone has some sort of hidden bias.

However, bias is malleable, Johnson said, and can be changed by 1) first being aware, 2) becoming concerned about the consequences and being motived to change, and 3) forming strategies to replace a biased response with attitudes that are more consistent with one’s true beliefs and goals.

Johnson put the attendees in the room through several more group exercises designed to open their minds to the problems caused by such biased attitudes and change their own behaviors. Group discussions produced many “aha” moments that the audience said had opened their eyes and would be introduced into their practices at home.

The take-home message: Be mindful of bias in all its forms; avoid labeling; put yourself in the other person’s place to find empathy, tolerance and understanding; focus on the common identities you share with those you perceive as different; and practice individuation to see the many differences among all persons and accept them.

The session lasted well past its allotted time and continued informally as many attendees gathered around Johnson for more one-on-one discussions.

Catherine Radwan

Articles

WIC program cuts infants’ risk for early death and preterm birth

Religious exemptions to vaccination rise amid stricter state policies

AAP challenges members to speak up for children’s health in 2020

Discover the hidden biases that drive your practice