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Healthy Infants and Toddlers COMMUNITY HEALTH ASSESSMENT

Prepared by: HealtheConnectionsHealthPlanning November 2013 CHA Infants and Toddlers Ages 0-3 |

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Overarching Goal Statement Healthy People in Every Stage of Life: All people, and especially those at greater risk of health disparities, can achieve their optimal lifespan if they have the best possible quality of health in every stage of life.

Strategic Goal Statement Start Strong: Infants and Toddlers (aged 0–3): Increase the number of infants and toddlers that have a strong start for healthy and safe lives.

Healthy Infants and Toddlers TABLE OF CONTENTS Introduction ....................................................................................................................... 1 Key Findings....................................................................................................................... 2 Demographics and Social Determinants ....................................................................... 3 Morbidity and Mortality....................................................................................................4 Economic Stability.............................................................................................................5 Insurance Coverage ........................................................................................................5 Educational Attainment & Marital Status of Mothers ................................................6 Child Abuse/Maltreatment .............................................................................................7 Healthy Care ..................................................................................................................... 8 Prenatal Care ....................................................................................................................8 Healthy Birth Weight .........................................................................................................9 Preventing Substance Abuse & Excessive Alcohol Abuse ......................................10 Healthy Childhood ..........................................................................................................11 Injury Free Living ..............................................................................................................12 Infection Free Living ........................................................................................................13 Childhood Development ..............................................................................................13 Lead Free Living ..............................................................................................................15 Healthy Behavior ............................................................................................................. 16 Healthy Pregnancy/Healthy Birth.................................................................................16 Healthy Eating .................................................................................................................19 Healthy Weight ................................................................................................................20 Healthy Teeth ...................................................................................................................21 Data Tables ...................................................................................................................... 22 References ....................................................................................................................... 25

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Today’s children will become tomorrow’s citizens, workers, and parents. When we fail to provide children with what they need to build a strong foundation for healthy and productive lives, we put our future prosperity and security at risk. – “The Science of Early Childhood Development,” National Scientific Council on the

INTRODUCTION

Developing Child

Every child deserves a healthy start in life. The risk of pregnancy-related complications, such as maternal and infant disability and death, can be reduced by improving access to quality care before, during, and after pregnancy. Many women suffer pregnancy complications, ranging from depression to the need for a cesarean delivery. Preconception and between pregnancy care provides an opportunity to identify existing health risks and to prevent future health problems for women and their children. The foundation of the population’s health, well-being, and productivity throughout life is established before and during pregnancy as well as in early childhood. Research shows that biological, social, and environmental exposures in the early stages of life determine long-term health and developmental status. The brain and the body’s core systems are established during pregnancy and the early years. Good health and nutrition can optimize cognitive and physical development. Infants and toddlers reared in safe and nurturing families and neighborhoods are much more likely to grow up as physically, intellectually, socially, and emotionally healthy teens and adults. Despite major advances in medical care, critical threats to maternal, infant, and child health still exist. Among the most pressing challenges are reducing the rate of preterm births, low birth weight infants and the infant death rate. In addition to increasing the infant’s risk of death in its first few days of life, preterm birth and low birth weight can lead to devastating and lifelong disabilities. Primary among these are visual and hearing impairments, developmental delays, and behavioral and emotional problems that range from mild to severe. Healthy birth outcomes and early identification and treatment of health conditions among infants can prevent death or disability and enable children to reach their full potential. CHA Infants and Toddlers Ages 0-3 |

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KEY FINDINGS Healthy Care The percent of births with adequate prenatal care in Madison County has decreased from 78.8%, between 2004-2006, to 66.0%, between 2008-2010; whereas New York State had an increase from 63.0% to 80.1% during the same time periods. The percentage of pregnant women in WIC of low socioeconomic status with first trimester prenatal care increased in Madison County from 80.0% to 86.9% from 2004-2006 to 2008-2010, which is a greater increase than New York State as a whole (84.0% to 85.6% during the same timeframe). The percentage of women delivering live births that received no prenatal care increased from 4.5% to 5.9% between 2004-2006 and 2008-2010 whereas New York State had a slight decrease from 5.0% to 4.7% during the same timeframe. The hospitalization rate for asthma in children 0-4 years of age decreased from 30.3 per 10,000 to 25.7 per 10,000 from 2004-2006 to 2008-2010, and the County rate is considerably lower than New York State as a whole (61.7 per 10,000 in 2004-2006 to 58.8 per 10,000 in 2008-2010). The percentage of children who have had at least one lead screening by age 36 months has increased in Madison County from 80.8% (2004) to 86.8% (2008-2010), which has exceeded New York State as a whole (82.8% to 85.3% during the same time period). The percent of caesarian sections in Madison County is less than New York State as a whole but has increased slightly in both Madison County and New York State from 2004-2006 to 2008-2010 (29.5% to 31.0% vs. 31.5% to 34.4%, respectively).

Healthy Behaviors Teen pregnancy for all ages cohorts is less in Madison County than New York State as a whole. There has been an increase in the newborn drug related discharge rate in Madison County from 59.4 per 10,000 (2004-2006) to 98.0 per 10,000 (2008-2010). This is greater than the increase for New York State as a whole (57.9 per 10,000 to 64.0 per 10,000 during the same timeframe. The percent of births with a 5 minute APGAR score of less than 6 increased from 0.4 (2004-2006) to 0.8 (2008-2010) which is similar to the trend in New York State (0.5 to 0.7 during the same timeframe). The percent of infants exclusively breastfed in the hospital is greater in Madison County than New York State (62.2% vs. 43.7%) whereas the percent of infants fed any breast milk in the hospital is similar (75.1% vs. 78.3%, respectively). The percent of infants in WIC who were breastfeeding at 6 months remained constant from 2004-2006 to 2008-2010 (21.9% to 20.8%) and remains lower than New York State percentages (38.6% to 38.8%). The percentage of obese children in WIC ages 2-4 (BMI > 95th percentile) in Madison County increased between 20042006 and 2008-2010 from 13.9% to 16.4% while NYS as a whole decreased during the same timeframe (15.2% to 13.1%).

Key Indicates a favorable status compared to New York State and/or when compared to Madison County’s previous data. Indicates an unfavorable but similar status compared to New York State and/or when compared to Madison County’s previous data (difference within 10%). Indicates an unfavorable and worse status compared to New York State and/or when compared to Madison County’s previous data (difference greater than 10%).

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DEMOGRAPHICS AND SOCIAL DETERMINANTS OF HEALTH Children ages birth to 3 years represent 4.2% of the population in Madison County. Over the past 10 years, there has been a 5% decrease in the number of children ages 0-3 years in Madison County. The greatest change is seen in children 12-24 months.

2000

2010

Total 3,259

Percent of Population 4.7%

Total 3,095

Percent of Population 4.2%

Percent Change -5.0%

Under 1 year

759

1.1%

696

0.9%

-8.3%

1 year

840

1.2%

749

1.0%

-10.8%

2 years

829

1.2%

839

1.1%

1.2%

3 years

831

1.2%

811

1.1%

-2.4%

TABLE 1 Ages 0-3 years

Source: US Census, 2010

Figure 1 Madison County Population for ages 0-4 years

6,000

4,494

4,923

4,104

3,903

2000

2010

4,000

2,000

0 1980

1990

Year Source: U.S. Census Bureau, 1980, 1990, 2000, 2010.

Figure 2

Source: U.S. Census Bureau, 2000, 2010.

NOTE: Data for ages 0-3 was unavailable for 1980 and 1990 so the age cohort was expanded to include 4 year olds to demonstrate the trend.

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Morbidity and Mortality Infant, neonatal, and post neonatal mortality are among the most widely used indicators of the health and welfare of a population because they reflect the general state of maternal health and the effectiveness of primary health care systems. Infant, neonatal, and post neonatal mortality rates have declined steadily since the 1970s, primarily due to advances in neonatal care.7 Healthy People 2020 objectives call for a national reduction in the infant mortality rate to no more than 6.0 per 1,000 live births. The objectives also call for a national reduction in the neonatal, and post neonatal mortality rate to no more than 4.1 and 2.0, respectively, per 1,000 live births. The NYS Prevention Agenda target is 4.5 per 1,000 live births.

Figure 3

Source: Vital Statistics Data, NYSDOH, http://www.health.ny.gov/statistics/chac/indicators/mih.htm.

Infant mortality decreased in Madison County between 2004-2006 and 2008-2010 from 4.6 per 1,000 live births to 3.6 per 1,000 live births which is below the rates for NYS as a whole (5.8 to 5.1 during the same timeframe).

Figure 4

The neonatal mortality rate in the first 28 days of life has remained constant from 2004-2006 to 20082010 (3.2 per 1,000 live births to 3.1 per 1,000 live births) which is lower than New York State (4.0 per 1,000 live births to 3.6 per 1,000 live births) during the same time period. The perinatal morality rate from 20 weeks gestation to 28 days of life decreased from 7.8 to 5.4 between 2004-2006 and 2008-2010, which is below rates of New York State as a whole (10.9 to 10.4 during the same timeframe).

Source: Vital Statistics Data, NYSDOH, http://www.health.ny.gov/ statistics/chac/indicators/mih.htm.

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Economic Stability Poverty affects many aspects of a child’s life, including living conditions, nutrition, and access to health care. Single-parent families are particularly vulnerable to poverty. Developmental science consistently shows a strong association between poverty and compromised child development. A child’s earliest years are a period of tremendous brain development influenced predominantly by the family context, suggesting that the family’s economic condition in early childhood may be far more important in shaping children’s ability, behavior, and achievement than conditions later in childhood. Exposure to poverty during this period of rapid brain development can lead to significant short and long-term consequences for the healthy development of infants and toddlers.

Figure 5

Source: 2009-2011 American Community Survey 3-Year Estimates, Madison County

Insurance Coverage Figure 6

Source: US Census, 2010

Health insurance is key to assuring children’s access to appropriate and necessary health care and preventive services. Research shows that uninsured children are more likely to lack a consistent source of care, to go without needed care, and to experience worse health outcomes than insured children.5 The Healthy People 2020 target is that 100 % of children acquire health insurance.

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Educational Attainment & Marital Status of Mothers Women with less educational attainment are more likely to have unintended pregnancies.2 Unplanned pregnancies are associated with delayed prenatal care, smoking during pregnancy, not breastfeeding, poorer health during childhood, and poorer outcomes for the mother and the mother-child relationship.3 Non-marital births are at higher risk of having adverse birth outcomes such as low birth weight, preterm birth, and infant mortality, and are more likely to live in poverty than babies born to married women. 4

Figure 7

Source: Data and Statistics, New York State Department of Health, http:// www.health.ny.gov/statistics/chac/indicators/ses.htm. Accessed: May 19, 2013.

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Child Abuse/Maltreatment Children may suffer from child abuse and maltreatment regardless of their socioeconomic status, race or ethnic backgrounds. There are short-term and long-term negative consequences related to child abuse and maltreatment, including adverse health effects, lower educational attainment, and delayed social and behavioral development. Persistent stress resulting from child maltreatment for young children can disrupt early brain development and impair development of the nervous and immune response systems. Incidents of abuse and maltreatment most frequently occur in the victims' own home and are perpetrated by someone they know. In addition to the immediate trauma of abuse and neglect on children, some of the long-term consequences for the children, families, and society, include: Physical: Chronic health problems, broken bones, brain trauma or even death. Psychological: Emotional effects including fear, inability to trust, depression, anxiety, and difficulties in forming relationships. Behavioral: Increased risk of delinquency, teen pregnancy, low academic achievement, substance abuse, to be arrested as a juvenile and involved in adult or violent crime, and to eventually victimize their own children. Societal: The direct costs (e.g. law enforcement, child welfare system and healthcare costs) and indirect costs (e.g. juvenile and adult criminal activity) were estimated at more than $94 billion per year for the United States and more than $2.4 billion per year for New York State.

The number of indicated reports of child abuse and maltreatment is an important measure of its incidence. However, it should be noted that the rate of indicated reports is affected by a number of factors other than the actual incidence of abuse and maltreatment. Therefore, some caution is required in drawing conclusions. The percent of child abuse/maltreatment indicated on reports of child abuse / maltreatment decreased from 25.2% in 2005 to 20.0% in 2011 whereas NYS as a whole was 16.9% for 2011.

Figure 8

Source: Council on Children and Families, Kids’ Wellbeing Indicators Clearinghouse (KWIC), www.nyskwic.org

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HEALTHY CARE Prenatal Care Early, high-quality prenatal care can help to prevent poor birth outcomes by enabling early identification and, where possible, treatment of health problems. Such care can also provide an opportunity to educate or counsel pregnant women about the adverse effects of behaviors such as alcohol, tobacco, or other drug use that increase their risk of poor outcomes for their baby. Such preventive measures as nutrition counseling and HIV testing can have important long-term effects on the health and well-being of the baby. Receiving late or no prenatal care during a pregnancy can result in negative health outcomes for both mother and child. Women who receive late or no prenatal care are at a significantly higher risk of bearing children who are of low birth weight, stillborn, or die within the first year of life. Teenagers are especially at risk.6 Healthy People 2020 objectives seek to increase the proportion of all pregnant women who receive prenatal care in the first trimester of pregnancy to at least 78%. The percent of births with adequate prenatal care in Madison County has decreased from 78.8% between 2004-2006 to 66.0% between 2008-2010 whereas New York State had an increase from 63.0% to 80.1% during the same timeframe. The percentage of pregnant women in WIC, of low socioeconomic status, with first trimester prenatal care increased in Madison County from 80.0% in 2004-2006 to 86.9% in 2008-2010 which is a greater increase than New York State as a whole (84.0% to 85.6% ) during the same timeframe. The percentage of women delivering live births that received no prenatal care increased from 4.5% in 2004-2006 to 5.9% in 2008-2010 whereas New York State had a slight decrease from 5.0% to 4.7% during the same timeframe.

Figure 9

Source: Vital Statistics Data, New York State Department of Health, http://www.health.ny.gov/statistics/chac/indicators/mih.htm.

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Healthy Birth Weight Low birth weight (LBW) is the most important predictor of infant mortality. LBW infants, especially infants born to teen mothers, are at risk for health problems such as blindness, deafness, mental retardation, mental illness, and cerebral palsy. As the birth weight decreases, children have a greater likelihood of these outcomes. Ten percent of all health care costs for children can be attributed to LBW.7 Healthy People 2020 objectives call for a national reduction in the incidence of low birth weight to no more than 7.8 % of live births. The New York State Public Health Council set an objective to reduce low birth weight births to no more than 5.0%. The percentage of low birth weight (<2500 grams) singleton births decreased in Madison County between 2004-2006 and 2008-2010 from 5.3% to 5.0% which is below the rates for NYS as a whole (6.1% to 6.2% during the same timeframe). The percentage of very low birth weight (<1500 grams) singleton births increased in Madison County between 2004-2006 and 2008-2010 from 0.6% to 0.8%, which is below the rates for NYS as a whole, which remained unchanged during the same timeframe (1.1%). The percentage of births that are low birth weight (< 2500 grams) decreased in Madison County between 2004-2006 and 2008-2010 from 7.0% to 6.3% which is below the rates for NYS as a whole (8.3% to 8.2% during the same timeframe. The percentage of births delineated as very low birth weight increased slightly in Madison County between 2004-2006 and 2008-2010 from 1.0% to 1.1%; however, Madison rates remained below NYS as a whole during the same timeframe (1.6% to 1.5%).

Figure 10

Source: Vital Statistics Data, NYSDOH, http://www.health.ny.gov/statistics/chac/indicators/mih.htm.

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Preventing Substance Abuse & Excessive Alcohol Use

Figure 11

The national epidemic of prescription drug abuse is reflected locally in Central New York maternity wards where a growing number of babies are being born addicted to narcotics. There has been an increase in the newborn drug related discharge rate in Madison County from 59.4 per 10,000 (2004-2006) to 98.0 per 10,000 (2008-2010). This is greater than the increase for New York State as a whole (57.9 per 10,000 to 64.0 per 10,000) during the same timeframe.

Source: Vital Statistics Data, NYSDOH, http://www.health.ny.gov/statistics/ chac/indicators/cah.htm. Accessed: May 16, 2013.

A study published in The Journal of the American Medical Association in 2012 estimated 13,500 U.S. babies are born annually — or one every hour — with symptoms of withdrawal from opioid drugs. Opioids are prescription painkillers such as oxycodone and hydrocodone. Any baby whose mother takes narcotics during pregnancy is at risk. Not all newborns go through withdrawal. The type of drugs the mother used during pregnancy, the frequency of use, timing and amount of last maternal use, and maternal and infant metabolism can determine if a baby will experience withdrawal. Approximately 50 – 75% of babies born to mothers on prescription painkillers go through some degree of withdrawal.

A baby in withdrawal, who is not treated, can suffer seizures and brain damage. Research is unclear whether babies exposed to prescription painkillers during pregnancy will experience long-term problems. Caring for drug addicted newborns is labor intensive and costly. A typical infant goes home from the hospital after two or three days. Drugdependent newborns stay in the NICU an average of 29 days. The cost of caring for one of these infants is about $52,200. By comparison, the cost of caring for a typical newborn is about $2,100.8

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Healthy Childhood

Figure 12

The top five leading causes of death for ages 1 to 9 in Upstate New York are unintentional injury, malignant neoplasms, congenital anomalies, homicide and diseases of the heart. Nationally, unintentional injury continued to be the leading cause of death among children 1 to 4 year olds, and congenital anomalies (or birth defects) were the second most common cause of death. In Madison County, between 2009-2012 all deaths that occurred in this age group (1-4) were the result of unintentional injuries (MCDOH 2013). Healthy People 2020 objectives call for a national reduction in the child mortality rate to no more than 25.7 per 100,000 live births for the age. Recent data indicates that while Madison County (22.1) surpasses the Healthy People target for child mortality, the county has a higher child mortality rate than NYS as a whole (19.9).

Source: Vital Statistics Data, NYSDOH, http://www.health.ny.gov/statistics/chac/ indicators/cah.htm.

The hospitalization rate for otitis media in children 0-4 years of age increased from 0.9 per 10,000 to 1.8 per 10,000 from 2004-2006 to 2008-2010, and the rate is less than New York State as a whole (4.0 per 10,000 in 2004 -2006 to 3.3 per 10,000 in 2008-2010). The hospitalization rate for gastroenteritis in children 0-4 years of age decreased from 20.2 per 10,000 to 5.3 per 10,000 from 20042006 to 2008-2010, and the rate is much less than New York State as a whole (32.5 per 10,000 in 2004-2006 to 15.7 per 10,000 in 2008-2010).

Figure 13

The hospitalization rate for asthma in children 0-4 years of age decreased from 30.3 per 10,000 to 25.7 per 10,000 from 20042006 to 2008-2010, and the rate is much less than New York State as a whole (61.7 per 10,000 in 2004-2006 to 58.8 per 10,000 in 2008-2010). The hospitalization rate for pneumonia in children 0-4 years of age decreased from 62.5 per 10,000 to 36.3 per 10,000 from 2004-2006 to 2008-2010, and the rate is less than New York State as a whole (44.8 per 10,000 in 2004-2006 to 44.6 per 10,000 in 2008-2010). Source: Vital Statistics Data, NYSDOH, http://www.health.ny.gov/ statistics/chac/indicators/cah.htm.

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Injury Free Living

ED Utilization that Involved Injuries, 0-4 years, Madison County, 2009

Most (99%) Madison County children 0 to 4 years seen in the Emergency Department for injuries are treated and released. More than half (57%) of which are superficial injuries and open head wounds.

Number

Rate per 1,000

Total

538

137.8

Treat and Release

532

136.3

Superficial injury; contusion

184

47.1

Open wounds of head; neck; and trunk

TABLE 2

122

31.3

Other injuries and conditions

53

13.6

Open wounds of extremities

39

10.0

Fracture of upper limb

25

6.4

Joint disorders and dislocations; trauma-related

19

4.9

Sprains and strains

16

4.1

Burns

14

3.6

Fracture of lower limb

13

3.3

Other

47

12.0

6

1.5

Other injuries and conditions

2

0.5

Superficial injury; contusion

1

0.3

Skin and subcutaneous tissue infections

1

0.3

Fracture of lower limb

1

0.3

Other

1

0.3

Hospitalized

Source: SPARCS, 2009

Leading Causes of Death, Ages 1-4, New York State, 2011

TABLE 3 Unintentional Injury Birth Defects Cancer Homicide and Legal Intervention Heart Disease

Number of Deaths 33 31 18 13 5

Crude Death Rate per 100,000 4 3 2* 1* Less than 1*

Source: Vital Statistics Data as of March, 2013. New York State Department of Health Bureau of Biometrics and Health Statistics. http://www.health.ny.gov/statistics/leadingcauses_death/gender/nys_age2_by_year.htm. Accessed: November 2, 2013. *Rates based on fewer than 20 events in the numerator are unstable.

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Infection Free Living

Figure 14

Vaccine-preventable disease levels are at or near record lows. Even though most infants and toddlers have received all recommended vaccines by age 2, many under-immunized children remain, leaving the potential for outbreaks of disease. If you look at the history of any vaccine-preventable disease, you will virtually always see that the number of cases of disease starts to drop when a vaccine is licensed. 9 Madison County’s percentage of children ages 19-35 months with 4:3:1:3:3:1:4 immunization series is comparable to NYS as a whole. Source: Vital Statistics Data, NYSDOH, http://www.health.ny.gov/statistics/chac/ indicators/cah.htm. Accessed: November 2, 2013

Childhood Development How a child plays, learns, speaks, and acts offers important clues about their development. Developmental milestones are things most children can do by a certain age. The early years of a child’s life are very important for his or her health and development. Healthy development means that children of all abilities, including those with special health care needs, are able to grow up where their social, emotional and educational needs are met. Having a safe and loving home and spending time with family―playing, singing, reading, and talking―are very important. Proper nutrition, exercise, and rest also can make a big difference in the health of a young child. In Madison County, the Department of Health’s Early Intervention (EI) Program provides services to children under 3 years of age with a confirmed disability or established developmental delay. A disability or developmental delay as defined by the State impacts one or more of the following areas of development: physical, cognitive, communication, social-emotional, and/or adaptive. The number of children served through the EI program has remained steady between 2008-2011 with an average of 192 children served each year. However, there was a decrease (25%) in 2012 with a total of 145 served. Between 2008-2012, the top three services provided by the program for children ages 0-3 were speech therapy (77%), physical therapy (53%), and/or occupational therapy (37%). In 2012, Madison County provided services to 10.75% of children ages 0-5 in the county with identified developmental delays.

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Developmental Milestones One Year Sits without support Knows five or six words Pulls self to standing and cruises-walks Two Years Says names of toys Uses two to three word sentences Imitates adults Three Years Uses three to five word sentences Catches a large ball with two hands Names at least one color correctly Developmental delays are significant lags in one or more areas of emotional, mental, or physical growth. If a child experiences a delay, early treatment is the best way to help him or her make progress or even to catch up. There are many different types of developmental delays in infants and young children. They include problems with: language or speech, vision, motor skills, social and emotional skills, and cognitive skills. Language and speech problems are the most common type of developmental delay. A variety of problems may cause language and speech delays, including: exposure to more than one language (which can cause mild delays in toddlers but not delays by the time they reach school age); a learning disability; a problem with the muscles controlling speech; hearing loss; and autism spectrum disorders.

walking, or fine motor skills, such as using fingers to grasp a spoon. A child may need physical therapy or occupational therapy for gross and fine motor delays. Children with social and/or emotional developmental delays experience problems interacting with adults or other children. Usually these problems show up before a child begins school. Treatment may include special types of behavioral and skill-oriented therapy, and medication if therapies do not work. Depending upon the diagnosis, treatment may also include play therapy or steps to aid attachment between parent and child. Cognitive delays may occur due to genetic defects, significant medical problems soon after birth, exposure to harmful environmental toxins such as lead, or neglect during infancy or early childhood. As with most types of developmental delays, early treatment can make a big difference in the progress a child makes. Educational intervention can help a child develop specific cognitive skills.14

Researchers from the CDC and Health Resources and Services Administration (HRSA), published a study that showed that developmental disabilities (DDs) are common: about 14% of children in the U.S. had a DD in 2006â&#x20AC;&#x201C;2008. These data also showed that prevalence of parent-reported DDs has increased 17% from 1997 to 2008.15 Data is needed to know more about the incidence and It is typical for a newborn's vision is normally prevalence of developmental delays in Madison blurry until six months of age but improves as the County. child begins to coordinate sight in both eyes. However, sometimes this does not happen or other vision problems show up. Vision delays may be caused by nearsightedness, farsightedness, lazy eye, poor vision in one eye, infantile cataracts, or another inherited problem, retinopathy of prematurity (an eye disease that sometimes affects premature infants), and strabismus (cross eyed). Depending on the eye problem a child may need glasses or contacts, special glasses, surgery, and an eye patch. Developmental delays may be related to problems with gross motor skills, such as crawling or

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Lead Free Living Lead is a highly toxic metal that was used for many years in products found in and around our homes. Most children who have elevated levels of lead in the blood do not have any symptoms. When symptoms, such as stomach ache, poor appetite, and irritability appear they are often confused with other childhood illnesses. The long-term effects of elevated blood lead levels in children may include slow development, reduced IQ scores, learning disabilities, hearing loss, reduced height and hyperactivity.15 Exposure to elevated levels of lead affects all socioeconomic levels, but children living in poverty are at the greatest risk. Lower income families are more likely to live in an older housing that are most likely to have lead paint and hazards. Homes built before 1950 are most likely to contain lead-based paint. Nearly 40% of homes in Madison County were built before 1950 and 60% before 1970 . The percentage of children that have had at least one lead screening by age 36 months has increased in Madison County from 80.8% (2004) to 86.8% (2008-2010) which has exceeded New York State as a whole (82.8% to 85.3% during the same time period). Incidence of children less than 6 years old with confirmed blood lead levels greater or equal to 10 decreased from 10.5 per 1,000 to 8.4 per 1,000 in Madison County whereas NYS decreased from 13.3 per 1,000 to 5.3 per 1,000.

Figure 15

Source: Vital Statistics Data, NYSDOH, http://www.health.ny.gov/statistics/chac/indicators/cah.htm.

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HEALTHY BEHAVIORS Healthy Pregnancy/Healthy Birth Preterm delivery underlies most LBW births. While the etiology of preterm birth remains unknown, several factors are associated with preterm and LBW births. Lifestyle behaviors such as cigarette smoking, insufficient weight gain or nutritional intake during pregnancy and use of alcohol and drugs are known risk factors. Other known risk factors include late or no prenatal care, domestic violence, lack of social support, stress, long working hours, exposure to environmental pollutants, infections, poor oral health, high blood pressure, diabetes, and short spacing between pregnancies. Having a preterm birth is the greatest predictor of a subsequent preterm birth. Babies born prematurely or at LBW are more likely to have or develop significant health problems.7

The percentage of births before 32 weeks increased in Madison County between 20042006 and 2008-2010 from 1.3% to 1.5% which is below the rates for NYS as a whole during the same timeframe (2.1% to 2.0%). The percentage of births between 32 and 37 weeks decreased in Madison County between 2004-2006 and 2008-2010 from 10.2% to 9.1% which is a greater change than for NYS as a whole (10.2% to 9.9% during the same timeframe). The percentage of births less than 37 weeks decreased in Madison County between 20042006 and 2008-2010 from 11.5% to 10.6% which is below the rates for NYS as a whole during the same timeframe (12.3% to 12.0%).

Figure 16

Source: Vital Statistics Data, NYSDOH, http://www.health.ny.gov/statistics/chac/indicators/mih.htm.

Multiple births and short birth spacing are associated with increased risk of preterm births and LBW infants. Nearly half of all twins are born before 37 weeks; and the risk increases with higher-order multiples.

Figure 17 The percent of multiple births increased in Madison County between 2004-2006 and 2008-2010 from 3.3% to 3.9%, whereas NYS as a whole decreased during the same timeframe (3.8% to 3.3%). The percent of births within 24 months of previous pregnancy increased in Madison County between 2004-2006 and 20082010 from 22.2% to 23.0% which is higher than for NYS as a whole during the same timeframe (16.5% to 18.9%). Source: NYS Pregnancy Nutrition Surveillance System, NYSDOH, http://www.health.ny.gov/statistics/chac/indicators/mih.htm.

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Figure 18 During pregnancy, obesity is associated with gestational diabetes, hypertension, preeclampsia, and complications at delivery including increased number of Cesarean deliveries. Obesity can also have a serious impact on the health and development of infants including congenital abnormalities, LBW, fetal overgrowth, preterm birth and neonatal mortality.10

Source: Vital Statistics Data, NYSDOH, http://www.health.ny.gov/ statistics/chac/indicators/mih.htm.

Recovery from a Cesarean section takes longer than does recovery from a vaginal birth. And like other types of major surgery, Cesarean sections also carry a higher risk of complications. Babies born by C-section are more likely to develop breathing problem during the first few days after birth. C-sections done before 39 weeks of pregnancy or without proof of the baby's lung maturity might increase the risk of other breathing problems, including respiratory distress syndrome. 11 The percent of births delivered by C-section increased in Madison County between 20042006 and 2008-2010 from 29.5% to 31.0%, which is lower than NYS as a whole during the same timeframe (31.5% to 34.4%).

The percentage of pregnant women in WIC who were obese (BMI 30 or greater) in Madison County decreased between 2004-2006 and 2008-2010 from 33.1% to 30.5% which is a greater change than for NYS as a whole during the same timeframe (26.1% to 23.4%), but Madisonâ&#x20AC;&#x2122;s proportion remains notably higher than NYS. The percentage of pregnant women in WIC who were overweight (BMI 26-29) increased in Madison County between 2004-2006 and 2008-2010 from 14.1% to 23.3% which is less than for NYS as a whole (15.4% to 26.6% during the same timeframe). The percent of births with a five minute APGAR score of less than 6 increased in Madison County between 2004-2006 and 20082010 from 0.4% to 0.8% which is less than NYS as a whole during the same timeframe (0.5% to 0.7%).

Figure 19 Research has shown that obesity during pregnancy is associated with increased use of health care and physician services, and longer hospital stays for delivery. Anemia may leave women feeling tired and weak. Chronic poorly-controlled hypertension is associated with an increased risk for preeclampsia, placental abruption, and gestational diabetes. These women also face a higher risk for poor birth outcomes such as preterm delivery, having an infant small for his/her gestational age, and infant death. Poorly controlled Gestational Diabetes Mellitus increases the risk of preeclampsia, early delivery, cesarean birth, having a big baby, having a baby born with low blood sugar, breathing problems, and jaundice.10 Source: Vital Statistics Data, NYSDOH, http://www.health.ny.gov/statistics/ chac/indicators/mih.htm.

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Figure 20

Source: NYS Pregnancy Nutrition Surveillance System, NYSDOH, http://www.health.ny.gov/statistics/chac/indicators/mih.htm. Accessed: February 4, 2013

Advanced maternal age (women 35 years and older) is associated with poorer infant outcomes but may be ameliorated by social advantages. Young maternal age is associated with LBW infants and preterm births, which can result in neonatal mortality.11 The percentage of births to women over the age of 35 in Madison County decreased between 2004 -2006 and 2008-2010 from 16.0% to 13.7%, which is less than for NYS as a whole during the same timeframe (20.1% to 19.4%).

Figure 21

The percentage of births to women 15-17 in Madison County decreased between 2004-2006 and 2008-2010 from 1.8% to 1.6% while NYS as a whole increased during the same timeframe (1.9% to 2.1%). The teen pregnancy rate per 1,000 is lower in Madison County for all age cohorts than for NYS as a whole.

Source: Vital Statistics Data, NYSDOH, http://www.health.ny.gov/ statistics/chac/indicators/mih.htm.

Teen Pregnancy Rates per 1,000, 2008-2010

TABLE 4 Madison

NYS

Pregnancy rate (ages 10-14)

0.5

1.4

Pregnancy rate (ages 15-17)

7.5

12.1

Pregnancy rate (ages 15-19)

15.8

24.0

Pregnancy rate (ages 18-19)

21.5

40.0

Source: Vital Statistics Data, NYSDOH, http:// www.health.ny.gov/statistics/chac/indicators/mih.htm.

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Folic acid is a B vitamin. If a woman has enough folic acid in her body before and during pregnancy, it can help prevent major birth defects of the babyâ&#x20AC;&#x2122;s brain and spine. Women need 400 micrograms of folic acid every day.13 The percentage of women with knowledge of folic acid intake has decreased in Upstate NY from 72% in 2000 to 52% in 2011. No county-specific data is available.

Figure 22

Source: Pregnancy Risk Assessment Monitoring System (PRAMS) Report. http://www.health.ny.gov/ statistics/prams/reports/plots/plot_fa_knw.htm. Accessed November 27, 2013.

Healthy Eating The nation benefits overall when mothers breastfeed. Recent research shows that if 90% of familiesâ&#x20AC;&#x2122; breastfed exclusively for 6 months, nearly 1,000 deaths among infants could be prevented. The United States would also save $13 billion per year as medical care costs are lower for fully breastfed infants than never-breastfed infants. Breastfed infants typically need fewer sick care visits, prescriptions, and hospitalizations. Breastfeeding also contributes to a more productive workforce since mothers miss less work to care for sick infants and employer medical costs are also lower. 12 The percentage of WIC mothers who were breastfeeding at 6 months in Madison County decreased between 2004-2006 and 2008-2010 from 21.9% to 20.8% which is less than for NYS as a whole during the same timeframe (38.6% to 38.8%). The New York State Public Health Council set an objective to increase the percent of infants exclusively breastfed in the hospital to 48.1% and increase the percent of WIC mothers breastfeeding at 6 months to 50.0%. Between 2008 and 2010, 62.2% of Madison County infants were exclusively breastfed in a hospital compared to 43.7% for NYS.

Figure 23

Source: Vital Statistics Data, NYSDOH, http://www.health.ny.gov/statistics/chac/indicators/mih.htm.

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Healthy Weight

Figure 24

According to the Office of Womenâ&#x20AC;&#x2122;s Health, breastfeeding may help prevent babies from growing up to be overweight children. The immediate health effects of childhood obesity are high cholesterol or high blood pressure; pre-diabetes; bone and joint problems, sleep apnea, and social and psychological problems such as stigmatization and poor self-esteem. Long-term health effects: obese as adults and are therefore more at risk for heart disease, type 2 diabetes, stroke, several types of cancer, and osteoarthritis.13 The percentage of obese children in WIC ages 2-4 (BMI > 95th percentile) in Madison County increased between 2004-2006 and 20082010 from 13.9% to 16.4% while NYS as a whole decreased during the same timeframe (15.2% to 13.1%).

Figure 25

Source: Vital Statistics Data, NYSDOH, http://www.health.ny.gov/statistics/ chac/indicators/mih.htm.

Good evidence suggests that TV screen viewing before age 2 has lasting negative effects on childrenâ&#x20AC;&#x2122;s language development, reading skills, and short-term memory. It also contributes to problems with sleep and attention. Toddlers who watch more TV are more likely to have problems paying attention at age 7.14 Reducing sedentary activity such as watching television and videotapes, and playing computer games is also an important strategy for preventing obesity. The percentage of children in WIC ages 0-4 years viewing TV more than 2 hours per day in Madison County drastically decreased between 2004-2006 and 2008-2010 from 67.0% to 27.2% as did NYS as a whole during the same timeframe from 76.0% to 21.4%.

Source: Vital Statistics Data, NYSDOH, http://www.health.ny.gov/statistics/chac/indicators/mih.htm.

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Healthy Teeth Dental caries is a common childhood disease: as many as 19 percent of children aged 2 to 5 years have experienced dental caries. Minority and economically disadvantaged children have a higher prevalence and severity of caries compared with other groups. Untreated caries in primary teeth may lead to caries in permanent teeth and a possible loss of arch space. Although a first dental visit is recommended when a child is approximately 1 year old, only 36 percent of 2- to 4-year-olds have had a dental visit in the past year.21 Madison County has a higher rate of visits to the emergency department for dental caries per 10,000 for 3 to 5 year olds than NYS as a whole.

Figure 25

Source: SPARCS 2009

Exposure to Second Hand Smoke According to the 2011 Adult Tobacco Survey, most (73%) households in New York State do not allow smoking anywhere in the home. This is even greater in households with children younger than five years old (85%). No county-specific data is available.

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DATA TABLES Year

Madison

NYS

Year

Madison

NYS

Percentage of births with adequate prenatal care

2004-2006

78.8

63.0

2008-2010

66.0

80.1

Percentage of Pregnant Women in WIC with Early (1st Trimester) Prenatal Care, Low SES

2004-2006

80.0

84.0

2008-2010

86.9

85.6

Percentage of women delivering live births receiving early prenatal care

2004-2006

79.4

74.9

2008-2010

72.8

80.6

Percentage of women delivering live births receiving no or late prenatal care

2004-2006

4.5

5.0

2008-2010

5.9

4.7

Percentage of births within 24 months of previous pregnancy

2004-2006

22.2

16.5

2008-2010

23.0

18.9

2005

62.7

56.8

2010

55.3

54.4

2005

8.1

10.4

2010

8.5

11.7

Early childhood mortality rate (1-4 years)

2004-2006

22.9

21.5

2008-2010

22.1

19.9

Infant mortality rate per 1,000 live births

2004-2006

4.6

5.8

2008-2010

3.6

5.1

Maternal mortality rate per 100,000 live births Neonatal mortality rate (first 28 days) per 1,000 live births Perinatal mortality rate (20 weeks gest-28 days of life) Perinatal mortality rate (28 weeks gestation -7 days of life)

2004-2006

46.0

18.3

0.0

23.3

2004-2006

3.2

4

2008-2010

3.1

3.6

2004-2006

7.8

10.9

2008-2010

5.4

10.4

2004-2006

5.5

6

2008-2010

4.9

5.7

Postnatal mortality rate per 1,000 live births

2004-2006

1.4

1.8

2008-2010

0.5

1.7

Spontaneous fetal deaths 20+ weeks

2004-2006

4.1

6.9

2008-2010

2.5

6.9

Percentage of Caesarian Section

2004-2006

29.5

31.5

2008-2010

31.0

34.4

Percentage of Anemic Children in WIC, 6mo-4 years, Low SES

2005-2007

9.7

11.4

2008-2010

1.5

2

Percentage of births before 32 weeks gestation Percentage of births between 32 and 37 weeks gestation Percentage of births less than 37 week gestation

2004-2006

1.3

2.1

2008-2010

10.6

12

2004-2006

10.2

10.2

2008-2010

9.1

9.9

2004-2006

11.5

12.3

12.1

12.0

Percentage of births that were multiple births Percentage of births with 5 minute APGAR less than 6

2004-2006

3.3

3.8

2008-2010

3.9

3.3

2004-2006

0.4

0.5

2008-2010

0.8

0.7

Percentage of first births

2004-2006

41.6

42.9

2008-2010

43.5

40.4

Gestational weight gain greater than ideal

2008-2010

52.1

41.8

Hypertension during pregnancy

2008-2010

9.7

7.2

Gestational diabetes

2008-2010

6.4

5.5

Status

Primary & Preventive Care

Prenatal Care - Births to Women 10-19 Years Receiving Early (1st Trimester) Prenatal Care, percent live births for ages 10-19 years Receiving Late (3rd Trimester) or No Prenatal Care, percent live births for ages 10-19 years Healthy Birth

2008-2010

2008-2010

~

Sources: Family Planning/Natality Indicators - Madison County http://www.health.ny.gov/statistics/chac/chai/docs/fp_25.htm. Maternal and Infant Health Indicators - Madison County http://www.health.ny.gov/statistics/chac/chai/docs/mih_25.htm

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Healthy Behavior Data

Year

Madison

NYS

Year

Madison

NYS

Abortion ratio all ages

2004-2006

12.8

48.4

2008-2010

16.0

46.6

Abortion ratio (15-19 years)

2004-2006

41.8

123.7

2008-2010

44.0

116.3

2008-2010

1.6

1.9

Births to teens (ages 15 to 17) Age specific birth rates for teenagers (15-19 years) per 1,000 females of the same age group

2004-2006

1.8

2.1

2008-2010

8.3

6.6

Fertility rate per 1,000 (all births to population 15-44)

2004-2006

47.5

60.7

2008-2010

46.2

60.9

Pregnancy rate (ages 10-14)

2008-2010

0.5

1.4

Pregnancy rate (ages 15-17)

2008-2010

7.5

12.1

Pregnancy rate (ages 15-19)

2008-2010

15.8

24.0

Pregnancy rate (ages 18-19)

2008-2010

21.5

40.0

Status

~ ~ ~

Healthy Eating & Healthy Weight Percent of low birth weight singleton births

2004-2006

5.3

6.1

2008-2010

5.0

6.2

Percentage of very low birth weight singleton births

2004-2006

0.6

1.1

2008-2010

0.8

1.1

Percentage of Overweight Children in WIC, 2-4 years, Low SES

2004-2006

13.9

15.2

2008-2010

16.4

13.1

Percentage of Pregnant Women in WIC Who Were Prepregnancy overweight (BMI 26-29), Low SES

2004-2006

14.1

15.4

2008-2010

23.3

26.6

Percentage of Pregnant Women in WIC Who Were Prepregnancy Underweight (BMI Under 19.8), Low SES

2004-2006

10.2

11.3

2008-2010

4.5

4.6

Percentage of Pregnant Women in WIC Who Were Prepregnancy Very Overweight (BMI Over 29), Low SES

2004-2006

33.1

26.1

2008-2010

30.5

23.4

Percentage of births that are low birth weight (< 2500 grams)

2004-2006

7.0

8.3

2008-2010

6.3

8.2

Percentage of births that are very low birth weight (<1500 grams)

2004-2006

1.0

1.6

2008-2010

1.1

1.5

Percentage of Infants in WIC Who Were Breastfeeding at 6 Months, Low SES

2004-2006

21.9

38.6

2008-2010

20.8

38.8

Percentage of Pregnant Women in WIC with Anemia, Low SES

2004-2006

13.2

11.4

2008-2010

34.0

37.3

% of infants exclusively breastfed in hospital

2008-2010

62.2

43.7

% of infants fed any breast milk in delivery hospital

2008-2010

75.1

78.3

Active Living Percentage of Children in WIC Viewing TV <=2 Hours per Day 0-4 years

2005-2007

67.0

76.0

2008-2010

27.2

21.4

2004-2006

59.4

57.9

2008-2010

98.0

64.0

Pneumonia rates 0-4

2004-2006

62.5

44.8

2008-2010

36.3

44.6

Gastroenteritis rates 0-4

2004-2006

20.2

32.5

2008-2010

5.3

15.7

Otitis media rates (0-4 years)

2004-2006

0.9

4.0

2008-2010

1.8

3.3

Preventing Substance Abuse & Excessive Alcohol Use Newborn Drug related discharge rate per 10,000 Infection Free Living

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Healthy Environment Data

Year

Madison

NYS

Year

Madison

NYS

Percentage of births to women 25+ years without HS education

2004-2006

0.7

7.6

2008-2010

14.8

6.2

Percentage of births to women 35 plus years

2004-2006

16

20.1

2008-2010

13.7

19.4

Percentage of out of wedlock births

2004-2006

39.3

39.2

2008-2010

42.3

41.4

2004

80.8

82.8

2008-2010

86.8

85.3

2003-2005

1.1

1.3

2008-2010

25.3

15.8

2008-2010

0.6

6.8

2008-2010

43.7

52.9

2008-2010

75.5

69.5

Status

Social Determinants

Exposure to Lead Percentage of children that had at least one lead screening by age 36 months Incidence of children < 72 months with confirmed blood lead level >= 10 (per 100 tested), per 1,000 % of children born in 2007 with lead screening by 9 months % of children born in 2007 with at least 2 led screenings by 36 months % of children born in 2007 with a lead screening by 18 months

Key Indicates a favorable status compared to New York State and/or when compared to Madison County’s previous data. Indicates an unfavorable but similar status compared to New York State and/or when compared to Madison County’s previous data (difference within 10%). Indicates an unfavorable and worse status compared to New York State and/or when compared to Madison County’s previous data (difference greater than 10%).

~

Neither favorable nor unfavorable; comparison unavailable

Sources: Family Planning/Natality Indicators - Madison County http://www.health.ny.gov/statistics/chac/chai/docs/fp_25.htm. Maternal and Infant Health Indicators - Madison County http://www.health.ny.gov/statistics/chac/chai/docs/mih_25.htm.

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REFERENCES [1] Addy, S, Engelhardt, W, and Skinner C. Basic Facts about Low-Income Children: Children Under 3 Years, 2011. National Center for Children in Poverty. January 2013. [2] CDC- Family Planning. http://www.healthypeople.gov/2020/topicsobjectives2020/overview.aspx? topicid=13. June 5, 2013. [3] Mosher WD, Jones J, Abma JC. Intended and unintended births in the United States: 1982–2010. National health statistics reports; no 55. Hyattsville, MD: National Center for Health Statistics. http://www.cdc.gov/ nchs/data/nhsr/nhsr055.pdf. 2012. [4] Ventura SJ. Changing patterns of nonmarital childbearing in the United States. NCHS data brief, no 18. Hyattsville, MD: National Center for Health Statistics. http://www.cdc.gov/nchs/data/databriefs/db18.htm. 2009. [5] Kossen, J and Rosman, E. Leading the Way to a Strong Beginning: Ensuring Good Physical Health of Our Infants and Toddlers. 2012. [6] U.S. Department of Health and Human Services. Prenatal Care: Frequently Asked Questions. 2009. [7] National Center for Health Statistics. National Vital Statistics Reports (NVSR). 2012;61(6). Found at: http:// www.cdc.gov/reproductivehealth/MaternalInfantHealth/InfantMortality.htm [8] Patrick SW, Schumacher RE, Benneyworth BD, Krans EE, McAllister JM, Davis MM. Neonatal Abstinence Syndrome and Associated Health Care Expenditures : United States, 2000-2009. JAMA. 2012; 307(18):1934-1940. [9] CDC. More About Vaccines – Part 3. http://www.cdc.gov/vaccines/pubs/parents-guide/downloads/parents -guide-part3.pdf. Accessed: November 2, 2013. [10] American Academy of Pediatrics, Committee on Fetus and Newborn, American College of Obstetricians and Gynecologists and Committee on Obstetric Practice. The Apgar Score. Pediatrics 2006;117;1444. http:// pediatrics.aappublications.org/content/117/4/1444.full.html. Accessed: November 27, 2013. [11] Mayo Clinic. http://www.mayoclinic.com/health/c-section/MY00214/DSECTION=risks. Accessed 11/10/2013 [12] CDC – Reproductive Health, Preterm Birth. http://www.cdc.gov/reproductivehealth/ MaternalInfantHealth/PretermBirth.htm. Accessed: May 2, 2013. [13] http://www.cdc.gov/ncbddd/folicacid/index.html. Accessed November 27, 2013. [144] Recognizing Developmental Delays in Children. http://www.webmd.com/parenting/baby/recognizing-developmental-delays-birth-age-2. Accessed: November 27, 2013 [15] CDC. http://www.cdc.gov/features/dsdev_disabilities/. Accessed: November 27, 2013. [16] CDC. Reproductive Health, Pregnancy Complications. http://www.cdc.gov/reproductivehealth/ MaternalInfantHealth/PregComplications.htm. Accessed: June 3, 2013. [17] Pittard WB 3rd, Laditka JN, Laditka SB. Associations between maternal age and infant health outcomes among Medicaid-insured infants in South Carolina: mediating effects of socioeconomic factors. Pediatrics. Jul 2008; 122(1):e100-6.

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[18] Bartick M, Reinhold A. The Burden of Suboptimal Breastfeeding in the United States: A Pediatric Cost Analysis. Pediatrics. May 2010; 125(5). [19] CDC - Childhood Obesity Facts. http://www.cdc.gov/healthyyouth/obesity/facts.htm. Accessed: May 2, 2013. [20] Hill DL. Why to Avoid TV Before Age 2. http://www.healthychildren.org/English/family-life/Media/pages/ Why-to-Avoid-TV-Before-Age-2.aspx?nfstatus=401&nftoken=00000000-0000-0000-0000000000000000&nfstatusdescription=ERROR%3a+No+local+token. Accessed: May 2, 2013. [21] U.S. Preventive Services Task Force. Prevention of Dental Caries in Preschool Children: Recommendations and Rationale. April 2004. http://www.uspreventiveservicestaskforce.org/3rduspstf/dentalchild/dentchrs.htm. Accessed: November 27, 2013. [22] CDC â&#x20AC;&#x201C; Lead: What Do Parents Need to Know to Protect Their Children? http://www.cdc.gov/nceh/lead/ ACCLPP/blood_lead_levels.htm. Accessed: May 2, 2013. [23] U.S. Census Bureau, 2010-2012 American Community Survey. http://factfinder2.census.gov/faces/ tableservices/jsf/pages/productview.xhtml?pid=ACS_12_3YR_DP04&prodType=table. Accessed: May 2, 2013. [24] https://www.childwelfare.gov/pubs/factsheets/domestic_violence/impact.cfm. Accessed: November 27, 2013.

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For Report Information please contact: Madison County Department of Health www.healthymadisoncounty.org © 2013 For Report Information please contact: Madison County Department of Health www.healthymadisoncounty.org © 2013 Madison County Department of Health Madison Department of13163 Health PO BoxCounty 605 • Wampsville, NY PO 315‐366‐2361 Box 605 • Wampsville, NY 13163 Tel: • Fax: 315‐366‐2697 Tel:health@madisoncounty.ny.gov 315‐366‐2361 • Fax: 315‐366‐2697 health@madisoncounty.ny.gov

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2 - CHA Healthy Infants and Toddlers  

Appendix 2 - Madison County 2013 Community Health Assessment Healthy Infants and Toddlers

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