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Many health challenges and inequalities have foundations in early childhood, with the poorest families experiencing the worst health outcomes. Reducing child health inequalities, what’s the problem? reports that adverse health outcomes would be reduced by 18% to 59% if all children were as healthy as the most socially advantaged.
The first 1001 days (from conception to age 2) is widely recognised as a crucial period; evidence shows that this will have impact and influence on the rest of the life course. A healthy pregnancy is important to the health of the baby and transition to parenthood; providing nurturing environment, positive attachment and relationships are vital to build good health, emotional self-regulation and resilience through childhood and into adult life.
New information and research about neurological development and the impact of stress and anxiety in pregnancy, and further recognition of the importance of bonding and attachment, make prevention and early intervention even more important. Secure attachment and bonding will have an impact on resilience and physical, mental and socioeconomic outcomes in later life. Early attachment and good maternal mental health in early years shapes a child’s later emotional, behavioural and intellectual development.
This is a time when parents are particularly receptive to learning and making changes which improve outcomes and need information and support on:
- how to stop smoking
- avoiding alcohol during pregnancy
- nutrition in pregnancy and breastfeeding
- the importance of immunisations
- the emotional transition to parenthood
Being healthy and ready to learn at 2 is important for children and their parents. Many of the signs of developmental delay and poor health outcomes may be recognised at this age. Help should be offered early so that children do not start school already behind their peers.
The Early Intervention Foundation works with evidence based early interventions which improves outcomes for children and reduces long term health and social costs later in the course of life.
Facts about healthy beginnings
Health before and during pregnancy is vital. A healthy woman is more likely to give birth to a healthy baby. Health professionals should support women (and their partners) to adopt positive health behaviours and reduce risk factors. Pre-conceptual care includes ensuring full immunisation status, advice on vitamins, and folic acid and advice on alcohol and tobacco and on nutrition.
Between pregnancies, advice on family spacing, contraception services is important. Researchers of The prevalance of unplanned pregnancy and associated factors in Britain: findings from the third national survey of sexual attitudes and lifestyle believe that 1 in 6 (16.2%) pregnancies experienced in the UK are unplanned. Pregnancies in young, single women are most likely to be unplanned.
There are a number of factors that can increase the risk of harm to the unborn baby and many of these are influenced by health inequalities.
The Health Secretary announced his ambition to reduce stillbirth, neonatal death and maternal death by 50% by 2030.
In January 2016, Better births: a 5 year forward view for maternity care (PDF, 2MB, 126 pages) was published with recommendations for all sectors of health and social care to make to improve maternity outcomes. Achieving this requires a co-ordinated response which includes prevention focus on risk factors such as smoking, alcohol, weight and mental health, during maternity and pre-conception.
Early weeks and months of life
The earliest experiences, starting in the womb, shape a baby’s brain development. During the first 2 years of life the brain displays a remarkable capacity to absorb information and adapt to its surroundings.
At age 2, the connections that are being formed in a child’s brain are happening around twice as fast as in an adult’s brain.
Positive early experience is vital to ensure children are ready to learn, ready for school and have good life chances, these include:
- the influence of good parenting
- effects of socio-economic status
- the impact of high-quality early education and care
Parents play a critical role in children’s social and emotional wellbeing. The parent-child relationship is particularly important. Positive emotional development during infancy and early childhood is associated with school readiness and positive emotional adjustment in later life.
Evidence suggests that the use of positive discipline and supervision, and the avoidance of coercive cycles of interaction, have a key role to play in children’s emotional and behavioural adjustment.
Mental health issues can impact on a mother’s ability to bond with her baby and be sensitive and attuned to the baby’s emotions and needs. This can affect the baby’s ability to develop a secure attachment.
28% of children aged 2 to 15 were classed as either overweight or obese. Obesity is strongly related to socioeconomic status and deprivation in children; among children in reception, obesity prevalence ranges from 5.9% in the least deprived tenth of the population to 11.9% in the most deprived tenth. Early years is an important stage to promote healthy eating and activity that could be maintained through life.
Once walking, preschoolers should be physically active for at least 3 hours, spread throughout the day, to develop movement and co-ordination, improve cardiovascular and bone health and contribute to a healthy weight.
Strong speech, language and communication skills help children to develop a range of cognitive skills that are crucial for their development, including working memory and reading skills; skills associated with ‘school readiness’, and positive social and academic outcomes throughout childhood.
Many children start school without the range of skills they need. In 2014 to 2015, a third of children had not reached a good level of development by the age of 5 and children who are known to be eligible for free school meals lagged 19% points behind their peers. The Ofsted survey Unseen children: educational access and achievement 20 years on reported children from low income backgrounds in the UK are 19 months behind their better off peers. Social and emotional wellbeing: early years guidance from NICE found lags in language delay are particularly associated with behavioural problems.
The Healthy Child Programme highlights that the preschool years represent a prime opportunity to promote the language and communication of all children.
Targeting high-risk families is important to achieve the best effects, as is good engagement with parents, early years settings and dental practices.
Enabling children to achieve their full potential and be physically and emotionally healthy provides the cornerstone for a healthy, productive adulthood.
Core principles for healthcare professionals
Healthcare professionals should:
- know the needs of families, communities and population and the services available for children and young people
- think about the resources to support healthy beginnings available in the health and wellbeing system
- understand specific activities which can prevent, protect, and promote best start in life
Healthcare professionals should be aware of the interventions at population level, which include:
- promoting the understanding of the important of the pregnancy and first 2 years of life for children’s future health and wellbeing and that the Healthy Child Programme sets out the population and individual family approach
- supporting Building Great Britons and raising awareness of this crucial time in early brain development
- supporting the Unicef UK baby friendly initiative which aims to improve breast feeding rates and the attachment and nutrition of all infants
- advising on access to programme such as Healthy Start and child care placement or offer
- using PHE’s needs assessment tool to help local commissioners and providers to plan their approach to perinatal and infant mental health in their area; the new tool provides evidence-based information on risk factors affecting perinatal and infant health
Community health professionals and providers of specialist services can have an impact by:
- being aware of the services locally
- being involved in place based activities ‘making communities healthy places for children and families
- developing integrated services between health, education providers, community and third sector organisations to ensure they are responsive to national and local needs and demonstrate improved public health outcomes
- leading and providing Healthy Child Programme and building community assists as part of health visitors 4 5 6 model (PDF, 2MB, 1 page]
- creating and raising awareness of the importance of community parenting programmes that offer social support to parents in the early years
- using available technology to improve access to support and information for parents, for example baby buddy app
- being aware of NICE guidance, health and social care commissioners, specialists in domestic violence and others who may bring them into contact with people who experience or perpetrate domestic violence and abuse
Family and individual level
Healthcare professionals can have an impact on an individual level through the actions below. There are particularly important interventions for midwives and health visitors however all healthcare professionals in contact with families can contribute to improved outcomes by:
- providing public health protective and preventive advice and interventions as part of antenatal care pathway
- supporting smoke free pregnancy: national guidance from the National Institute for Health and Care Excellence (NICE) outlines interventions to support quitting smoking in pregnancy and following childbirth
- giving advice on nutrition and physical exercise; energy needs do not change in the first 6 months of pregnancy and increase only slightly in the last 3 months, by around 200 calories per day
- giving advice on folic acid and vitamin supplements
- giving advice that when planning a pregnancy and whilst pregnant the safest approach is not to drink alcohol UK Chief Medical Officers’ alcohol guidelines review
- giving encouragement to be physically active during pregnancy
Transition to parenthood and first 2 years can be helped by healthcare professionals:
- recognising and providing evidence based interventions for post natal depression using NICE guidance on postnatal depression
- promoting PHE’s Start4Life campaign providing parents and parents-to-be with trusted NHS advice on pregnancy and early years
- leading and providing health visitors 4 5 6 model (PDF, 2MB, 1 page]
- promoting and providing newborn screening programmes and childhood immunisations programme
- supporting parents in their decision making and ensuring they have accurate information
- using active listening skills when working with parents and encouraging parents to talk about their feelings
- completing the HCP e-learning for health module on child development and attending training sessions to ensure skills and knowledge are up to date
- encouraging parents to register their child with the dentist using PHE’s oral heath toolkit (PDF, 1.5MB, 102 pages)
- using supervision as a supportive tool to address emotive issues from practice
- providing early help and access local services for children and families who may need additional support, at times when they need it most
- keeping updated on policies and procedures for working in safeguarding or child protection
- improving service access through technology and safe social media approaches which complement face to face delivery
- providing interventions in the 6 early years high impact areas which focus on the areas having the biggest impact on a child’s life
- providing integrated review at age 2 using ASQ to encourage parents to support their child development and to identify a child falling behind so that help can be given
- championing the benefits of breastfeeding and providing early support to help women address any problems
Public Health Outcomes Framework (PHOF)
There are 7 indicators linked to infants:
- low birth weight of term babies (2.01)
- breastfeeding initiation (2.02i]
- breastfeeding prevalence at 6 to 8 weeks after birth (2.02ii)
- smoking status at time of delivery (2.03)
- under 18 conceptions (2.04)
- population vaccination coverage – Hepatitis B (1 and 2 year old) (3.03i)
- infant mortality (4.01)
There are 5 indicators linked to children aged 2 years:
- population vaccination coverage - MMR for one dose (2 years old) (3.03viii)
- population vaccination coverage - Hepatitis B (2 years old) (3.03i)
- population vaccination coverage - Dtap / IPV / Hib (2 years old) (3.03iii)
- population vaccination coverage - Hib / MenC booster (2 years old) (3.03vi)
- hospital admissions caused by unintentional and deliberate injuries in children aged 0 to 4 years (2.07i)
Measuring child development at age 2 to 2.5 years explains how the ASQ-3 tool measures child development at age 2 to 2.5 years across 5 domains:
- gross motor skills
- fine motor skills
- problem-solving and personal-social
Health visitors will need to use the revised British English version of ages and stages questionnaires (ASQ-3) to generate data for the PHOF. There are plans to incorporate the ages and stages: social-emotional questionnaires at a later stage.
Health and Social Care Information Centre (HSCIC)
The HSCIC features (use the search box to find the relevant indicators):
- 6 indicators for infants
- 68 indicators for children
The Early Years Profile has been developed by NHS England and the Child and Maternal Health Intelligence Network as a health profile of public health outcomes relating to early years (children aged 0 to 5 years). Using the profiles, you can see at a glance how your local area performs against important indicators and use the information to design and commission services to meet local needs.
Ages and stages questionnaires
ASQ-3 measures development across 5 domains: communication, gross motor skills, fine motor skills, problem-solving and personal-social.
ASQ:SE-2 contains parent-completed questionnaires focused solely on social and emotional development in young children.
The Everyday Interactions Measuring Impact Toolkit provides a quick, straightforward and easy way for health care professionals (HCPs) to record and measure their public health impact in a uniform and comparable way.
The healthy beginnings impact pathway is recommended for healthcare professionals to record and measure actions undertaken as part of routine care which impact on adult obesity.
Examples of good practice
The Healthy Child Programme
The Healthy Child Programme is essential for public health service for children and families. The healthy child programme (0 to 5 years) rapid review brings together the evidence on delivering good health, wellbeing and resilience for every child. It sets out the schedule for services covering care from 28 weeks of pregnancy through to age 5. This is delivered as a universal service with additional services for families needing extra support, whether short-term intervention or ongoing help for complex longer-term problems.
The programme provides a range of services to families:
- immunisation during pregnancy and childhood immunisations
- health and development reviews
- advice and support to help children’s physical and emotional development
The programme can ensure families receive early help and support upstream before problems develop further and reduce demand on downstream, higher cost specialist services. This programme is led by health visitors in collaboration with other health professionals.
Universal health and development reviews are an important feature of the Healthy Child Programme and take place at:
- 28 weeks of pregnancy
- within 14 days of birth
- 6 to 8 weeks
- 9 to 12 months
- 2 to 2.5 years
Healthy Start is a UK-wide government scheme, embedded within the Healthy Child Programme, to improve the health of low-income pregnant women and families on benefits and tax credits.
Healthy Start provides a great opportunity for health professionals and others working with pregnant women and families to offer encouragement, information and advice on issues such as healthy eating, breastfeeding and vitamins. Vouchers can be used to help families on a low-income buy some basic foods such as milk and fresh or frozen fruit.
The Early Intervention Foundation Guidebook is an online resource of evidence-based interventions of ‘what works’ in the early years.
The UK Baby Friendly Initiative is based on a global accreditation programme of Unicef and the World Health Organisation and includes baby friendly standards. It is designed to support breastfeeding and parent infant relationships by working with public services to improve standards of care.
The Centre for Maternal and Child Enquiries published the eighth report into a review of maternal deaths during 2006 to 2008: Saving Mothers’ Lives. It lists the top 10 recommendations to reduce avoidable maternal deaths, highlights important points of good perinatal care and also covers public health issues that contribute to inequality of maternal outcomes between different socioeconomic groups.
The Marmot Review Fair Society Healthy Lives proposed the most effective evidence-based strategies for reducing health inequalities in England from 2010. It includes 2 specific policy areas for children:
- Give every child the best start in life.
- Enable all children, young people and adults to maximise their capabilities and have control over their lives.
The 6 Early Years High Impact Areas have been developed to support the transition of commissioning of the health visiting and integrated children’s early years services to Local Authorities from 1 October 2015 and to articulate the contribution of health visitors to the 0 to 5 agenda.
Baby Steps is a perinatal educational programme which means it’s for parents in the run up to the birth of their baby and afterwards. It’s designed to help prepare people for becoming parents, not just for the birth itself.
The Healthy Child Programme rapid review contains the latest evidence of public health interventions for improving the health and wellbeing of children. It features mentalisation based programmes which include encouraging the use of reflective functioning and video feedback.
Every child a talker: guidance for early language lead practitioners (ECaT) is a national programme designed to:
- raise children’s achievement in early language
- improve practitioners’ skills and knowledge
- increase parental understanding and involvement in children’s language development
The triple P, positive parenting program is an effective evidence-based parenting programme that gives parents simple and practical strategies to help them confidently manage their children’s behaviour, prevent problems developing and build strong, healthy relationships.
The Incredible Years is a series of interlocking, evidence-based programmes to prevent and treat young children’s behaviour problems and promote their social, emotional and academic competence.
PHE has developed an interactive tool to help local commissioners and providers to plan their approach to perinatal and infant mental health in their area. The new needs assessment tool provides evidence-based information on risk factors affecting perinatal and infant health.
Early intervention: the next steps is a report about interventions in children’s earliest years that can eliminate or reduce costly and damaging social problems.
From September 2015, local authorities, health visiting services and early years providers will be expected to undertake an integrated review at 2 to 2.5 years. The National Children’s Bureau (NCB) has produced materials to support the new approach.
Case studies, evidence summaries and information on the Family Nurse Partnership (targeted service for first time mums under 19).
Educational outreach interventions aimed at reducing antibiotic use in children:
- Reducing antibiotic use in children: a randomised trial in 12 practices on enrolled children under 6
- An evidence based approach to reducing antibiotic use in children with acute otitis media: controlled before and after study
Examples of good practice in the transformed health visitor programme, divided into the 6 high impact areas:
- transition to parenthood and the early weeks
- maternal mental health
- healthy weight, healthy nutrition
- managing minor illness and preventing accidents
- health, wellbeing and development of child age 2 and support to be ready for school ##Guidance
Behaviour change: general approaches (PH6) is aimed at those responsible for helping people to change their behaviour to improve their health.
Behaviour change: individual approaches (PH49) also makes recommendations on individual-level interventions aimed at health-damaging behaviour in over 16s.
Pregnancy and complex social factors: a model for service provision for pregnant women with complex social factors (CG110) describes how access to care can be improved for pregnant women with complex social factors.
Weight management and nutrition
Maternal and child nutrition (PH11) relates to pregnant women (and those who are planning to become pregnant), mothers and other carers of children aged under 5 and their children. It is particularly aimed at those on a low income or from a disadvantaged group.
In addition, Weight management before, during and after pregnancy: guidance (PH27) provides evidence-based recommendations to help all pregnant women eat healthily and keep physically active.
Vitamin D: increasing supplement use among at-risk groups (PH56) aims to increase supplement use to prevent vitamin D deficiency among at-risk groups.
Promoting physical activity for children and young people (PH17) also provides guidance for all those who are involved in promoting physical activity among children and young people, including parents and carers.
Obesity: guidance on the prevention, identification, assessment and management of overweight and obesity in adults and children (CG43) is the first national guidance on the prevention of overweight and obesity in adults and children in England and Wales.
Social and emotional wellbeing
Social and emotional wellbeing: early years (PH40) aims to define how the social and emotional wellbeing of vulnerable children under 5 years can be supported.
Antenatal and postnatal mental health (CG192) offers evidence-based advice on the care and treatment of mental health problems during pregnancy and postnatal, and in women planning pregnancy.
NICE has produced guidance on antenatal and postnatal mental health which can help health professionals recognise the signs of mental health problems and to select the appropriate treatment.
Smoking: brief interventions and referrals (PH1) provides guidance on smoking cessation for GPs and other professionals working in local health services.
Smoking: stopping in pregnancy and after childbirth (PH26) includes recommendation for those planning a pregnancy or who have an infant under 12 months.
Preventing unintentional injuries
Unintentional injuries: prevention strategies for under 15s (PH29) gives advice and guidance on preventing unintentional injuries in the home, on the road and during outdoor play and leisure.
Unintentional injuries ont he road: interventions for under 15s (PH31) gives advice on how healthcare professionals and local highways authorities can make the roads safer.
Unintentional injuries in the home: interventions for under 15s (PH30) aims to prevent unintentional injuries among all children and young people but in particular, those living in disadvantaged circumstances, as they are at increased risk compared to the general population.
Postnatal care (CG37) offers evidence-based advice on the care of women and babies in the 6 to 8 weeks after birth.
Atopic eczema in under 12s: diagnosis and management (CG57) covers the management of atopic eczema in children from birth up to the age of 12 years.
Division of ankyloglossia (tongue-tie) for breastfeeding (IPG149) is guidance and resources on the procedure of the division of tongue-tie.
There are a range of additional NICE guidance documents which are relevant to Early Years High Impact Area 6 - Health, Wellbeing and Development of the Child Age 2.
Child maltreatment: when to suspect maltreatment in under 18s (CG89) covers the alerting features in children and young people.
Immunisations: reducing differences in uptake of under 19s (PH21) aims to increase immunisations uptake among under 19s from groups where uptake is low.
Approaches for local authorities and their partners to improve the oral health of their communities (PH55) makes recommendations on undertaking oral health assessments, local strategies and community-based interventions.