Chapter 4: Health and Safety

FACTORS AFFECTING CHILDREN'S HEALTH
DISEASES OF CHILDHOOD
MENTAL HEALTH ISSUES IN YOUNG PEOPLE
CHILDHOOD DEATHS

FACTORS AFFECTING CHILDREN'S HEALTH

A variety of factors affect children's health. These range from prenatal influences; access to and quality of health care; poverty, homelessness, and hunger; childhood diseases; and diet and exercise. This chapter discusses these factors and looks at the leading causes of death among infants, children, and adolescents.

Birth Defects

In “Birth Defects: Frequently Asked Questions” (December 12, 2006, http://www.cdc.gov/ncbddd/bd/faq1.htm), the Centers for Disease Control and Prevention (CDC) indicates that birth defects affect one out of every 33 babies born. Birth defects are the leading cause of infant deaths. In addition, these babies have a greater chance of illness and disability than do babies without birth defects. Two major birth defects, neural tube defects and fetal alcohol syndrome, are in large part preventable.

NEURAL TUBE DEFECTS. Major defects of the brain and spine are called neural tube defects. Each year, as many as 3,000 infants are born in the United States with neural tube defects caused by the incomplete closing of the spine and skull. Another estimated 1,500 pregnancies are either stillborn or terminated because of these defects. The occurrence of these defects can be greatly reduced by adequate folic acid consumption before and during early pregnancy.

FETAL ALCOHOL SYNDROME. Alcohol consumption by pregnant women can cause fetal alcohol syndrome (FAS), a birth defect characterized by a low birth weight, facial abnormalities such as small eye openings, growth retardation, and central nervous system deficits, including learning and developmental disabilities. The condition is a lifelong, disabling condition that puts these affected children at risk for secondary conditions, such as mental health problems, criminal behavior, alcohol and drug abuse, and inappropriate sexual behavior. Not all children affected by prenatal alcohol use are born with the full syndrome, but they may have selected abnormalities.

According to the CDC, in “Tracking Fetal Alcohol Syndrome” (December 5, 2006, http://www.cdc.gov/ncbddd/fas/fassurv.htm), estimates of the prevalence of FAS vary from 0.2 to 1.5 per 1,000 births in different areas of the United States. Other alcohol-related birth defects are thought to occur three times as often as FAS. In “Alcohol Consumption among Women Who Are Pregnant or Who Might Become Pregnant—United States, 2002” (Morbidity and Mortality Weekly Report, vol. 53, no. 50, December 2004), the CDC finds that in 2002, 10.1% of pregnant women drank alcohol, putting their babies at risk for FAS. As many as one out of 50 (1.9%) pregnant women frequently drank alcohol. According to James Tsai et al., in “Patterns and Average Volume of Alcohol Use among Women of Child-bearing Age” (Maternal and Child Health Journal, vol. 11, no. 5, September 2007), 2% of pregnant women and 13% of nonpregnant women of childbearing age are estimated to engage in binge drinking, and 21.5% reported drinking at least 45 drinks per month.

Health Care

IMMUNIZATIONS. In America's Children in Brief: Key National Indicators of Well-Being, 2008 (2008, http://www.childstats.gov/americaschildren/index.asp), the Federal Interagency Forum on Child and Family Statistics explains that the proportion of preschool-age children immunized against communicable and potentially dangerous childhood diseases—including diphtheria, tetanus, and pertussis (whooping cough), known collectively as DTP, polio, and measles—dropped during the 1980s but rose significantly during the 1990s. By 2006, 85.2% of all children had received four doses of DTP, 92.8% had received three doses of poliovirus vaccine, 93.4% had received haemophilus influenzae type b vaccine, 93.3% had received three doses of hepatitis B vaccine, 92.3% had received measles

vaccines, and 89.2% had received varicella (chickenpox) vaccine. (See Table 4.1.) More than four out of five of these children received the vaccinations in combined series. Children living below the poverty line and African-American children were slightly less likely than the general child population to be immunized.

In 1994 the U.S. Department of Health and Human Services (HHS) implemented the Vaccines for Children (VFC) program, which provides free or low-cost vaccines to children at participating private and public health care provider sites. Eligible children, including children on Medicaid, children without insurance or whose insurance does not cover vaccinations, and Native American or Alaskan Native children can receive the vaccinations through their primary care physician. Children not covered under the program but whose parents cannot afford vaccinations can receive free vaccines at public clinics under local programs. The HHS states in Budget in Brief, Fiscal Year 2009 (2008, http://www.hhs.gov/budget/09budget/2009BudgetInBrief.pdf) that the VFC program and Section 317 (the supporting vaccine infrastructure) had a budget of $3.2 billion for fiscal year 2009. Vaccines provided through the program represented about 40% of all childhood vaccines purchased in the country.

The World Health Organization (WHO) and the United Nations Children's Fund report in Global Immunization Vision and Strategy, 2006–2015 (October 2005, http://www.who.int/vaccines-documents/DocsPDF05/GIVS_Final_EN.pdf) that developed nations, including the United States, generally have among the highest immunization rates in the world. The global immunization rate for DTP in 2003 was 78%, up from only 20% in 1980. Immunization rates for the developed world for the same time period were 10 to 20 percentage points higher than the global average, reflecting the low immunization rates in many developing nations. The WHO notes in “Global Immunization Data” (January 2008, http://www.who.int/immunization/newsroom/Global_Immunization_Data.pdf) that in 2006 immunization coverage exceeded 90% in Europe and the Americas, 92% in the western Pacific, and 86% in the eastern Mediterranean.

PHYSICIAN VISITS. Children's health depends on access to and usage of medical care. Based on household interviews of a sample of the civilian noninstitutionalized population, the National Center for Health Statistics (NCHS) finds that in 2006, 57.2% of children under the age of 18 visited the doctor between one and three times, 24.6% saw the doctor between four and nine times, and 7.3% saw the

doctor 10 or more times. (See Table 4.2.) However, 10.9% of children did not see a doctor at all. Poor children have less access to health care than nonpoor children.

HEALTH INSURANCE. One reason some children do not have access to medical care is their lack of health insurance. According to the U.S. Census Bureau, 11% (8.1 million) of American children had no health insurance coverage in 2007. (See Figure 4.1.) Factors affecting children's access to coverage included their age, race, and ethnicity, and their family's economic status. Children between the ages of 12 and 17 were more likely to be uninsured (12%) than six- to 11-year-olds (10.3%) and children under the age of six (10.5%). Poor children were proportionately more likely to be uninsured than all children (17.6% versus 11%), and those of Hispanic origin were the least likely racial or ethnic group to receive health insurance coverage—one out of five (20%) Hispanic children were uninsured, compared to 12.2% of African-American children, 11.7% of Asian-American children, and 7.3% of non-Hispanic white children.

Child health insurance coverage increased slightly among all age groups, races, and ethnicities from 2000 to 2004, but then declined from 2004 to 2006. Overall, the percent of children covered by private health insurance declined from 70.2% in 2000 to 64.7% in 2006. (See Table 4.3.) In the press release “HHS Issues New Report Showing More American Children Received Health Insurance in Early 2002” (December 31, 2002, http://www.hhs.gov/news/press/2002pres/20021231.html), the NCHS states that Tommy G. Thompson, the HHS secretary, attributed ongoing increases to a push to provide more government coverage, particularly under the State Children's Health Insurance Program. This trend, however, leveled off in 2005 and 2006.

According to Carmen DeNavas-Walt, Bernadette D. Proctor, and Cheryl Hill Lee of the Census Bureau, in Income, Poverty, and Health Insurance Coverage in the United States: 2005 (August 2006, http://www.census.gov/prod/2006pubs/p60-231.pdf), in 2005 government programs, such as Medicare, Medicaid, and military insurance, covered a greater proportion of African-American and Hispanic children than other children. Almost half (44.9%) of African-American children and 39.3% of Hispanic

children had government insurance, compared to only 18% of non-Hispanic white children and 15.9% of Asian-American children.

To remain in the Medicaid program, families must have their eligibility reassessed at least every six months. If the family income or other circumstances change even

slightly, the family can lose its eligibility for the Medic-aid program, disrupting health care coverage.

From the late 1980s through the mid-1990s the numbers of uninsured American children rose as coverage rates for employer-sponsored health insurance declined, even though the proportion of children covered by Medicaid also rose. In 1997, as part of the Balanced Budget Act, Congress created the State Children's Health Insurance Program (SCHIP) to expand health insurance to children whose families earned too much money to be eligible for Medicaid but not enough money to pay for private insurance. SCHIP provides funding to states to insure children, offering three alternatives: states may use SCHIP funds to establish separate coverage programs, expand their Medicaid coverage, or use a combination of both. By September 1999 all 50 states had SCHIP plans in place. By September 4, 2003, the program had been expanded to enroll even more children at higher income levels. According to the Centers for Medicare and Medicaid Services, in “FY 2008 Number of Children Ever Enrolled Year—SCHIP by Program Type” (January 20, 2009, http://www.cms.hhs.gov/NationalSCHIPPolicy/downloads/FY2008StateTotalTable012309FINAL.pdf), in fiscal year 2008, 7.4 million children were enrolled in SCHIP, up from 7.1 million the year before.

Homelessness

Under the McKinney-Vento Homeless Assistance Act, the U.S. Department of Education is required to file a report on homeless children served by the act. The Department of Education obtains the data from school districts, which use

different methods of estimation. In Report to the President and Congress on the Implementation of the Education for Homeless Children and Youth Program under the McKinney-Vento Homeless Assistance Act (2006, http://www.ed.gov/programs/homeless/rpt2006.doc), the Department of Education states that 602,568 children who experienced homeless-ness at some point during the year were enrolled in school during the 2003–04 school year. Of these children, half (50.3%) lived doubled-up with relatives or friends, a quarter (25.3%) lived in shelters, 9.9% lived in hotels or motels, and 2.6% were unsheltered—in other words, sleeping outside, in vehicles, or in abandoned buildings. This number is almost certainly much lower than the number of children who actually experienced homelessness during this period, as the homeless status of children does not always come to the attention of school officials and many homeless children are not enrolled in school.

The U.S. Conference of Mayors find in Hunger and Homelessness Survey: A Status Report on Hunger and Homelessness in America's Cities, a 23-City Survey (December 2007, http://www.usmayors.org/HHSurvey2007/hhsurvey07.pdf) that 23% of homeless people were in families with children, 76% were single men or women, and 1% were unaccompanied youth—usually runaways. According to the Conference of Mayors, between 1994 and 2007 the proportion of families among the homeless generally declined, as did the proportion of unaccompanied youth among the homeless population. Data from this survey show city-by-city estimates of children as a percent of homeless family members. In Mayors Examine Causes of Hunger, Homelessness: The U.S. Conference of Mayors Release 2008 Hunger and Homelessness Survey Results (December 12, 2008, http://www.usmayors.org/pressreleases/documents/hungerhomelessness_121208.pdf), the Conference of Mayors announces that the homeless rate among cities, in general, grew about 12% from 2007 to 2008, and 16 cities cited an increase in homeless families.

Nearly nine out of 10 (87%) mayors surveyed in the 2007 report said the lack of affordable housing was a principal cause of homelessness among families with children, and 57% cited poverty. Another major cause of family homelessness was domestic violence: 39% of mayors cited such violence as a principal cause of homelessness among families with children. In contrast, 65% of mayors said mental illness and 61% said substance abuse were the principal causes of homelessness among single people and

unaccompanied youth. In Mayors Examine Causes of Hunger, Homelessness: The U.S. Conference of Mayors Release 2008 Hunger and Homelessness Survey Results “twelve cities (63 percent) reported an increase in homelessness because of the foreclosure crisis.”

The poverty and lack of stability that homelessness brings have a very negative impact on children. An example of the poor educational achievement of homeless youths is shown in Homeless Census and Homeless Youth/Foster Teen Study (2002, http://www.appliedsurveyresearch.org/www/products/MC_Homeless02_report.pdf), a study of unaccompanied homeless youths conducted in Monterey County, California. According to the survey's findings, 21% of 16-year-olds, 22% of 17-year-olds, 33% of 18-year-olds, 51% of 19-year-olds, 59% of 20-year-olds, and 70% of 21-year-olds were below grade level. Only 13% of the homeless youths in the study had a high school diploma or general equivalency diploma. The remaining 87% were performing below grade level.

Homelessness also has a negative impact on children's health. Catherine Karr of the National Health Care for the Homeless Council argues in Homeless Children: What Every Health Care Provider Should Know (December 29, 2003, http://www.nhchc.org/Children/index.htm) that these children suffer from frequent health problems. They are seen in emergency rooms and are hospitalized more often than other poor children. The often crowded and unsanitary conditions they live in lead to a higher rate of infectious diseases, such as upper respiratory infections, diarrhea, and scabies. Homeless children live in less structured and often unsafe environments, leaving them more vulnerable to accidents and injury. They tend not to have access to nutritious food, and are often malnourished or obese. Homeless children tend to lag behind their housed peers developmentally, and school-age homeless children often have academic problems. The greater likelihood that homeless children come from families plagued by mental illness, drug use, and domestic violence negatively affects their own mental health. Homelessness results in serious negative consequences for the children's health.

Hunger

Food insecurity is defined as the lack of access to enough food to meet basic needs. Mark Nord, Margaret Andrews, and Steven Carlson of the U.S. Department of Agriculture report in Household Food Security in the United States, 2006 (November 2007, http://www.ers.usda.gov/Publications/ERR49/ERR49.pdf) that in 2006, 89.1% of U.S. households were food secure, which remained essentially unchanged from the year before. However, the remaining 10.9% (12.6 million) of U.S. households experienced food insecurity at some time during the year. Most of these households used a variety of coping strategies to obtain adequate food, such as eating less varied diets, participating in food assistance programs, or getting food from community food pantries or soup kitchens. Regardless, 4% (4.6 million) of all households experienced very low food security—in other words, some household members reduced or otherwise altered their normal food intake because of a lack of money.

Nord, Andrews, and Carlson find that a higher percentage of children than adults were food insecure—17.2% of children were food insecure, and 15.6% of households with children were insecure. Households experiencing food insecurity tend to go through a sequence of steps as food insecurity increases: first, families begin to worry about having enough food, then they begin to decrease other necessities, then they reduce the quality and quantity of all household members” diets, then they decrease the frequency of meals and quantity of adult members” food, and finally they decrease the frequency of meals and the quantity of children's food. Even though children are usually protected from being hungry, an estimated one out of every 200 children (0.6%) experienced very low food security on one or more days during the year. Households with incomes below the poverty line,

households with children headed by a single woman, and African-American and Hispanic households were the most likely to experience food insecurity.

EMERGENCY FOOD ASSISTANCE . Feeding America (formerly America's Second Harvest), the nation's largest charitable hunger-relief organization, reports in Hunger Study, 2006 (2006, http://www.hungerinamerica.org/key_findings/) that in 2005, 25.3 million Americans sought emergency food assistance. In Hunger and Homelessness Survey, the Conference of Mayors states that 80% of mayors reported that requests for emergency food assistance had increased in 2007, and that the total number of emergency food assistance requests increased by 12% during that year. The Conference of Mayors note, “Overall, it appears that the need for emergency food assistance programs is continuing to increase and that cities are facing many challenges in responding to the demand for assistance.” The most frequent reasons for hunger cited by city officials were poverty (90% of mayors), high housing costs (57% of mayors), and unemployment (52% of mayors). Other causes included high medical, utility, and transportation costs, substance abuse, and a lack of education. In the 2008 report Mayors Examine Causes of Hunger, Homelessness, the Conference of Mayors observes that requests for emergency food assistance had continued to increase in most cities. The organization states that “an estimated 59 percent of requests for food assistance were coming from families—many for the first-time.”

Exposure to Toxins

Another threat to children's health is exposure to environmental toxins. Two toxins that children are most frequently exposed to are lead and second-hand smoke.

LEAD POISONING. Because they have smaller bodies and are growing, children suffer the effects of lead exposure more acutely than adults do. Lead poisoning causes nervous system disorders, reduction in intelligence, fatigue, inhibited infant growth, and hearing loss. Toxic levels of lead in a parent can also affect unborn children.

In “Toys and Childhood Lead Exposure” (August 31, 2007, http://www.cdc.gov/nceh/lead/faq/toys.htm), the CDC indicates that children are primarily exposed to lead in paint and plastics. Leaded paint was banned in the United States in 1978, although children may be exposed to leaded paint in older homes. Even though leaded paint is not used on toys manufactured in the United States, it is still widely used on toys manufactured in other countries. Therefore, children may be exposed to lead when playing with imported toys. In addition, the use of lead in plastic, which makes it more flexible and able to return to its original shape, has not been banned. The CDC explains that “when the plastic is exposed to substances such as sunlight, air, and detergents the chemical bond between the lead and plastics breaks down and forms a dust.”

David Barboza reports in “Why Lead in Toy Paint? It's Cheaper” (New York Times, September 11, 2007) that in 2007 nearly two dozen toys were recalled because they contained toxic levels of lead paint. Dozens of children's jewelry products, most of them made in China, had also been recalled in 2006 and 2007. In September 2007 Mattel, the world's largest toy maker, announced its third recall in six weeks, asking people to return certain toys made in China that contained high levels of lead paint. Lead paint is sometimes used in manufacturing products for children because it is less expensive than nonleaded paint. Ashland University randomly tested plastic toys and children's jewelry and found high lead levels in many of them, most of which had not been recalled. According to the article “China Bans Lead Paint in Toys Exported to U.S.” (Associated Press, September 11, 2007), China signed an agreement on September 11, 2007, to prohibit the use of lead paint on toys for export to the United States. However, Barboza states that “enforcement of the regulations in China is lax.”

In “CDC Surveillance Data, 1997–2006” (November 29, 2007, http://www.cdc.gov/nceh/lead/surv/stats.htm), the CDC states that in 2006, 39,526 children in the United States aged five and under had confirmed blood lead levels greater than the CDC's recommended level of 10 micrograms per deciliter of blood. This was 1.2% of all children tested. According to the Commission for Environmental Cooperation, in Children's Health and the Environment in North America: A First Report on Available Indicators and Measures (January 2006, http://www.cec.org/files/PDF/POLLUTANTS/CEH-Indicators-fin_en.pdf), this number had dropped substantially since the early 1970s, due largely to the phasing out of lead in gasoline between 1973 and 1995. Even though children from all social and economic levels can be affected by lead poisoning, children in families with low incomes who live in older, deteriorated housing are at higher risk. Paint produced before 1978 frequently contained lead, so federal legislation now requires owners to disclose any information they may have about lead-based paint before renting or selling a home built earlier than 1978. Lead is also found in lead plumbing and is emitted by factory smokestacks.

SECONDHAND SMOKE AND CHILDREN. Environmental tobacco smoke is a major hazard for children, whose respiratory, immune, and other systems are not as well developed as those of adults. According to the CDC, in “Disparities in Secondhand Smoke Exposure—United States, 1988–1994 and 1999–2004” (Morbidity and Mortality Weekly Report, vol. 57, no. 27, July 11, 2008), secondhand or passive smoke (smoke produced by other people's cigarettes) increases the number of attacks and severity of symptoms in children with asthma and can even cause asthma in preschool-age children. It also causes lower respiratory tract infections, middle-ear disease, and a reduction in lung function in children, and it increases the risk of sudden infant death syndrome. The CDC

finds the percentage of children aged four to 11 who were regularly exposed to secondhand smoke in their homes decreased from 38.2% in the 1988–94 period to 23.8% in the 1999–2004 period, a reduction of 37.7%. The percentage of children aged 12 to 19 exposed to secondhand smoke decreased from 35.4% in the 1988–94 period to 19.5% in the 1999–2004 period, for an even larger decline of 44.9%.

DISEASES OF CHILDHOOD

Overweight and Obese Children

The number of overweight and obese Americans has reached epidemic proportions and has become a national concern. The percentage of overweight children and adolescents has grown significantly since the 1970s. Between 1976 and 1980, 6.7% of boys and 6.4% of girls aged six to 11 years were overweight. (See Table 4.4.) For boys, this percentage hit a high of 19.9%, or one in five boys, in the 2003–04 period, before dropping to a still high of 16.2% in 2005–06. Girls also hit a high of 17.6% in 2003–04, before it dropped to 14.1% in 2005–06.

An upward trend was also seen in the rates of overweight adolescents; 4.5% of boys and 5.4% of girls aged 12 to 17 were overweight in the period from 1976 to 1980, but 18.1% of adolescent boys and 17.5% of adolescent girls were overweight in the 2005–06 period—and these figures had not dropped from the previous two-year period. (See Table 4.4.) The proportion of overweight children overall between the ages of six and 17 tripled (from 5.7% to 16.5%) between 1976 and 2006.

The percentages of overweight children (in the 85th percentile or above for body mass index) and obese children (in the 95th percentile or above for body mass index) vary by race and ethnicity. In 2007 African-American adolescents were more likely to be overweight (19%) or obese (18.3%) than non-Hispanic white adolescents (14.3% were overweight and 10.8% were obese) or Hispanic adolescents (18.1% were overweight and 16.6% were obese). (See Table 4.5.) Younger students were more likely than older students to be either overweight or obese.

Medical professionals are concerned about this trend, because overweight children have an increased risk for premature death in adulthood as well as for many chronic diseases, including coronary heart disease, hypertension, diabetes mellitus (type 2), gallbladder disease, respiratory disease, some cancers, and arthritis. Type 2 diabetes, previously considered an adult disease, has increased dramatically in children and adolescents. Being overweight or obese can also lead to poor self-esteem and depression in children.

Weight problems in children are thought to be caused by a lack of physical activity, unhealthy eating habits, or a combination of these factors, with genetics and lifestyle playing important roles in determining a child's weight. Watching television and playing computer and video games contribute to the inactive lifestyles of some children. According to Danice K. Eaton et al. of the CDC, in “Youth Risk Behavior Surveillance—United States, 2007” (Morbidity and Mortality Weekly Report, vol. 57, no. SS-4, June 6, 2008), a quarter (24.9%) of high school students spent three or more hours per school day on the computer and more than a third (35.4%) spent three or more hours per school day watching television, often not getting a sufficient amount of physical exercise as a consequence.

Physical activity patterns established during youth may extend into adulthood and may affect the risk of illnesses such as coronary heart disease, diabetes, and cancer. Mental health experts correlate increased physical activity with improved mental health and overall improvement in life satisfaction. Eaton et al. report that only 43.7% of high school boys and 25.6% of high school girls met recommended levels of physical activity. (See Table 4.6.) White students were somewhat more likely to meet recommended levels of physical activity (37%) than African-American (31.1%) or Hispanic (30.2%) students. Only about half (53.6%) of high school students attended physical education classes, 56.3% played on a sports team, and only

30.3% attended physical education classes daily. (See Table 4.7.) Rigorous activity among high school students also generally declined with age.

Asthma

Another serious disease affecting children is asthma, a chronic respiratory disease that causes attacks of difficulty breathing. In The State of Childhood Asthma, United States, 1980–2005 (December 12, 2006, http://www.cdc.gov/nchs/data/ad/ad381.pdf), Lara J. Akinbami of the CDC indicates that millions of children in the United States have asthma. In 2005, 8.9% (6.5 million) of children were currently suffering from asthma, and 12.7% (9 million) of children had suffered with it at some point in their lifetime. Childhood asthma

caused 27 hospitalizations per 10,000 children in 2004, and caused 12.8 million missed days of school in 2003. The American Lung Association estimates that up to a million asthmatic children are exposed to secondhand smoke, worsening their condition.

According to Akinbami, African-American children suffer from asthma at a rate 60% higher than that of non-Hispanic white children, and Puerto Rican children suffer from asthma at a rate 140% higher than non-Hispanic white children. In addition, she finds that African-American children's asthma is apparently much less well controlled than that of non-Hispanic white children. African-American children have a 250% higher hospitalization rate, a 260% higher emergency department visit rate, and a 500% higher death rate from asthma. Akinbami speculates that this is due to the lower level and quality of health care received by African-American children.

HIV/AIDS

Acquired immune deficiency syndrome (AIDS) was identified as a new disease in 1981, and, according to the CDC, in HIV/AIDS SurveillanceReport: Cases of HIV Infection and AIDS in the United States and Dependent Areas, 2006 (2008, http://www.cdc.gov/hiv/topics/surveillance/resources/reports/2006report/pdf/2006SurveillanceReport.pdf), an estimated one million cases had been diagnosed in the United States through 2006. AIDS is caused by the human immunodeficiency virus (HIV), which weakens the victim's immune system, making it vulnerable to other opportunistic infections. Young children with AIDS usually have the virus transmitted to them either by an infected parent or through contaminated transfusions of blood or blood products. Adolescents who are sexually active or experimenting with drugs are also vulnerable to HIV infection, which can be spread through sexual intercourse without the use of a condom or through shared hypodermic needles.

In adults the most common opportunistic infections of AIDS are Kaposi's sarcoma (a rare skin cancer) and pneumocystis carinii pneumonia. In infants and children, a failure to thrive and unusually severe bacterial infections characterize the disease. Except for pneumocystis carinii pneumonia, children with symptomatic HIV infection seldom develop opportunistic infections as adults do. More often, they are plagued by recurrent bacterial infections, persistent oral thrush (a common fungal infection of the mouth or throat), and chronic and recurrent diarrhea. They may also suffer from enlarged lymph nodes, chronic pneumonia, developmental delays, and neurological abnormalities.

HOW MANY ARE INFECTED? According to the CDC, in HIV/AIDS Surveillance Report, by the end of 2006 there were a cumulative total of 9,144 AIDS cases in children under the age of 13 since record-keeping began in 1981. (See Table 4.8.) African-American children made up the overwhelming majority of these cases (5,654 cases), followed by Hispanic children (1,748 cases), non-Hispanic white children (1,599 cases), Asians or Pacific Islanders (54 cases), and Native Americans or Alaskan Natives (31 cases). By the end of 2006, 5,165 children aged 14 and under had died from the disease.