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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.
An effective universal service is central to the success of the Healthy Child Programme; Marmot’s review of health inequalities concluded that,
Focusing solely on the most disadvantaged will not reduce health inequalities sufficiently. To reduce the steepness of the social gradient in health, actions must be universal, but with a scale and intensity that is proportionate to the level of disadvantage. Marmot (2010)
All Our Health takes an ecological approach to improve outcomes for children by addressing the child as an individual within the context of his/ her family, community and the wider system in which children and families live.
The first 1001 days (from conception to age 2) are recognised as a crucial period during which the foundations for future health and wellbeing are built. Positive experiences and good quality parent-infant relationships during this time are associated with the formation of a secure attachment which contributes to good physical and mental health, emotional self-regulation, resilience and wider social and economic advantages throughout the life course.
A healthy pregnancy is important to the health of the developing baby and transition to parenthood. A growing body of information and research on neurological development, epigenetics and the impact of stress, anxiety and adverse experiences in pregnancy and the first years of life make prevention, support for parents and early intervention even more important.
Pregnancy and the early years provide an ideal opportunity for public health practitioners and other professional groups who have contact with families during this time to support parents to:
- quit smoking
- avoid alcohol during pregnancy
- establish or maintain healthy eating habits
- benefit from the full maternal and child immunisation programme provided by the NHS
- make a positive emotional transition to parenthood and access targeted and specialist interventions and support if needed
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 prevalence of unplanned pregnancy and associated factors in Britain: findings from the third national survey of sexual attitudes and lifestyle identified that 45% of pregnancies in the UK are unplanned or associated with feelings of ambivalence. 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 coordinated 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
Emotional health and wellbeing
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.
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.
Early language has been recognised as a significant indicator of child wellbeing which impacts on many areas of child development; it contributes to children’s ability to manage emotions and communicate feelings, to establish and maintain relationships, to think symbolically, and to learn to read and write.
Almost all children learn to communicate through language, yet there are strong and persistent differences in their ability to do so. Difficulties in language development arise for a variety of complex reasons, including delays in a child’s ability to understand and use vocabulary, grammatical rules and meaning. In some cases, speech, language and communication needs are associated with more general learning disabilities or sensorineural losses; however, these do not explain the differences that also occur across different social groups giving a pronounced social gradient in early language acquisition.
The rate at which children develop language is sensitive to the amount of input they receive from the adults around them; however, the quality of linguistic input that children receive is likely to be more important than the quantity.
Between 5% and 8% of all children have early language difficulties; however children from low income households are two times more likely to experience these difficulties. In areas of higher deprivation, up to 50% of children may start school with delayed speech, language and communication skills.
Early speech, language and communication needs are associated with a range of poor outcomes including:
- Emotional and behavioural difficulties: increased risk of behavioural problems, ADHD, anxiety disorders in adolescence and adult mental health problems;
- educational disadvantage: Children with speech-language and communication needs fall behind their peers in academic achievement at every stage of education;
- economic disadvantage
- over representation in the criminal justice and prison system
Prevention and Early intervention
Babies are born ready to communicate; midwifery, health visiting and Early Years services are well placed to promote parental attunement during pregnancy and the first few years of life to support parents to recognise and respond to their baby’s individual cues and gestures which provide the foundation for future language.
The Healthy Child Programme highlights that the preschool years represent a prime opportunity to promote the language and communication of all children and identify those children who are not developing as expected and require targeted and specialist intervention to improve their outcomes.
Ready to learn at age 2; Ready for school at age 5
Being healthy and ready to learn at age 2 and ready for school at age 5 is important to give every child the best start in life. From about 18 months the gap between those children who are developing as expected and those who are not begins to widen. The mandated reviews provide an ideal opportunity to promote good development and identify those children who would benefit from additional support or targeted early intervention. Many of the signs of developmental delay and poor health outcomes can 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 work with Public Health England (PHE), government departments and leading academics to evaluate early interventions and support the embedding of this evidence in practice. Full details on evaluated programmes can be found in The Foundations for Life Report, The Rapid Review of the Healthy Child Programme and the EIF Guidebook with evidence-based early interventions which improve outcomes for children and reduce long term health and social costs later in the course of life.
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.
Promoting physical activity
Once walking, preschoolers should be physically active for at least 3 hours, spread throughout the day, to develop movement and coordination, improve cardiovascular and bone health and contribute to a healthy weight. CMO Physical Activity for Early Years
Reducing Unintentional Injuries
Reducing unintentional injuries in childhood remains a key priority. Public Health England (PHE) has published a number of key documents to support this work: Reducing unintentional injuries in and around the home among children under five years (PHE, 2014) and Preventing unintentional injuries A guide for all staff working with children under five years. (PHE, 2017) Local data to support these PHE publications is available on the PHE Fingertips site.
Unintentional injuries in and around the home are a leading cause of preventable death for children under five years and are a major cause of ill health and serious disability. The majority of unintentional injuries are preventable and they disproportionately affect children living in socioeconomic disadvantage.
Even when local authorities have child injury rates that are similar to those for England, this may mask significant inequalities between smaller geographical areas (districts, wards) within local authorities which need addressing. Local authorities should consider not only the overall child injury rate but also the extent of inequalities in child injury rates across smaller geographical areas when deciding what child injury prevention actions are required.
Our analysis shows that the emergency hospital admission rate for unintentional injuries among the under-fives is 42% higher for children from the most deprived areas compared with children from the least deprived, and for some injury types this inequality may be much larger. These inequalities support the targeting of preventative interventions to children and young people living in the most deprived areas.
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 the 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 breastfeeding rates and the attachment and nutrition of all infants
- advising on access to programmes 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
- 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:
- leading the delivery of the Healthy Child Programme and health visitors 4 5 6 model
- providing interventions in the Six Early Years High Impact Areas which focus on the areas having the biggest impact on a child’s life
- working in partnership with parents to develop a shared understanding of the things that matter most to the family; using active listening skills and a non-judgmental, asset-based approach when working with parents and encouraging parents to talk about their feelings and develop their own goals and plans to improve their health and wellbeing
- supporting parents in their decision making and ensuring they have accurate information
- early identification of perinatal mental health problems; providing evidence-based interventions and signposting to specialist support where needed 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
- promoting and providing newborn screening programmes and childhood immunisations programme
- completing the HCP e-learning for health module on child development and attending training sessions to ensure skills and knowledge are up to date
- working with parents and early years settings to provide an integrated review at age 2 for all children using ASQ-BE and ASQ-SE as part of a holistic assessment of health, growth and development; to identify children who are not developing as expected and to work with families to promote development and targeted interventions as indicated
- championing the benefits of breastfeeding and providing early support to help women address any problems
- encouraging parents to register their child with the dentist and receive their first dental health check by one year using PHE’s oral health toolkit
- using supervision as a supportive tool to address emotive issues from practice and promote resilience
- providing early help and access to local services for children and families who may need additional support, at times when they need it most
- recognising signs of maltreatment and responding to safeguarding concerns in accordance with Working together to safeguard children (2015) to receive sufficient training and supervision to ensure that they are up to date with local 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
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.
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-BE 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 healthcare 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, the healthy child programme (0 to 5 years) rapid review and Best Start in Life and Beyond (PHE 2016) documents describe the transformed 4-5-6 health visiting universal preventative model which focuses on giving every child the best start in life. The documents provide a framework to support collaborative working and integrated services to improve health outcomes in response to local need. The programme provides families with screening, immunisation, health and development reviews, prevention, and early intervention.
Health visitors lead the delivery of the programme in collaboration with other health and early years professionals to support families to give their children the best start in life. 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.
Mandated 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
The universal service facilitates the early identification of children and families who are at risk of poor outcomes and in need of additional support, through effective assessment of need using an ecological approach. Using an asset-based approach and the health-promoting principles of Making Every Contact Count (MECC), and NICE Public Health guidance, health visitors promote healthy lifestyles and the value of ‘health’ as a foundation for future wellbeing at all universal contacts.
Health visitors build parental confidence in making positive changes to protective factors like healthy eating, physical activity, accident prevention, dental health, and responsive parenting.The programme can ensure families receive early help and support upstream before problems develop further and reduce demand on downstream, higher cost specialist services.
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 MBRRACE Report ‘Saving Lives, Improving Mothers’ Care’ includes data on surveillance of maternal deaths between 2012 and 2014. It also includes Confidential Enquiries for women who died between 2009 and 2014 focusing on lessons about cardiovascular disease, caring for women with hypertensive disorders of pregnancy, and messages for early pregnancy and critical care.
The Marmot Review Fair Society Healthy Lives proposed the most effective evidence-based strategies for reducing health inequalities in England from 2010. It includes two 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: the priority areas identified by the Local Government Association and Department of Health
1) transition to parenthood and the early weeks 2) maternal mental health (perinatal depression) 3) breastfeeding (initiation and duration) 4) healthy weight, healthy nutrition, and physical activity 5) management of minor illness, accident prevention, and reducing hospital attendance and admission 6) health, well-being, and development of the child aged 2
PHE has developed a range of data analysis tools to help local commissioners and providers plan their services and identify local priorities. 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.
Local authorities, health visiting services and early years providers are expected to work together to ensure that children receive an integrated review at 2 to 2.5 years. The National Children’s Bureau (NCB) has produced materials to support this 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
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 recommendations for those planning a pregnancy or who have an infant under 12 months.
Preventing unintentional injuries
PHE has published a number of key documents to support this work:
Reducing unintentional injuries in and around the home among children under five years (PHE, 2014) Preventing unintentional injuries A guide for all staff working with children under five years (PHE, 2017) Local data to support these PHE publications is available on the PHE Fingertips website.
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 on the 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 is 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.