Healthy child programme

In October 2009 the Department of Health issued the 'Healthy Child Programme'¹ . This gives comprehensive advice on health and social care throughout a child's life. It differs from the previous schedule of child health surveillance in several key ways:

• Greater focus on antenatal care.

• A major emphasis on support for both parents.

• Early identification of at-risk families.

• New vaccination programmes² .

• New focus on changed public health priorities.

The programme is delivered by health visitors, midwifery staff, Sure Start children's centres³ , GPs and the primary health care team.

The 'Healthy Child Programme' aims to⁴ :

• Help parents develop a strong bond with children.

• Encourage care that keeps children healthy and safe.

• Protect children from serious diseases, through screening and immunisation.

• Reduce childhood obesity by promoting healthy eating and physical activity.

• Encourage mothers to breastfeed.

• Identify problems in children's health and development (for example, learning difficulties) and safety (for example, parental neglect), so that they can get help with their problems as early as possible.

• Make sure children are prepared for school.

• Identify and help children with problems that might affect their chances later in life.

The document includes a detailed schedule for care during pregnancy, and at each stage in a child's life. It contains core universal recommendations, along with additional preventative elements for children with risk factors.

At-risk families

There is a clear relationship between the number of parent-based disadvantages and a range of adverse outcomes for children (Social Exclusion Task Force, 2007)⁵ . It is estimated that around 2% of families in Britain experience five or more of the following disadvantages:

• Both parents are unemployed.

• The family lives in poor-quality or overcrowded housing.

• Neither parent has any educational qualifications.

• Either parent has mental health problems.

• At least one parent has a long-standing limiting illness, disability or infirmity.

• The family has a low income.

• The family cannot afford a number of food and clothing items.

Protective factors should also be assessed - eg, breastfeeding and authoritative parenting combined with warmth and affectionate attachment being built between the child and the primary caregiver from infancy.

The 'Healthy Child Programme' encourages early identification of families who might have factors which could put child health and well-being at risk, and specifies extra supportive measures on top of the universal approach at each stage.

Health and development reviews

The core purpose of health and development reviews is to:

• Assess family strengths, needs and risks.

• Give mothers and fathers the opportunity to discuss their concerns and aspirations.

• Assess growth and development.

• Detect abnormalities.

The following are the most appropriate opportunities for screening tests and developmental surveillance, for assessing growth, for discussing social and emotional development with parents and children, and for linking children to early years services:

• By the 12th week of pregnancy.

• The neonatal examination.

• The new baby review (around 14 days old).

• The baby's 6- to 8-week examination.

• By the time the child is 1 year old.

• Between 2 and 2½ years old.

The majority of children will be fine but others may need more support and guidance, and a small minority will need intensive preventative input. Reviews can provide an opportunity to plan a package of support using local services (such as those provided in a Sure Start children's centre) or for referral to specialist services. The Common Assessment Framework should be used where there are issues that might require support to be provided by more than one agency.

Health and developmental reviews require covering a comprehensive range of topics to assess risk and protective factors, and establish where further support is required. These start in pregnancy, and continue with the child and the family after birth. Topics to cover are listed in the 'Healthy Child Programme' document, and include:

• In pregnancy:

  • Physical health, mental health, general well-being of both parents.

  • Smoking.

  • Folic acid.

  • Breastfeeding.

  • Attitudes and concerns.

  • Assessment of risks and protective factors.

• In the child:

  • Physical health, growth and development (physical, social and emotional).

  • Speech and language.

  • Vision.

  • Hearing.

  • Development of self-care skills and independence.

  • Assessment of parental attachment.

  • Immunisations.

• In the family:

  • Parenting skills.

  • Contraceptive advice.

  • Financial advice.

  • Housing and employment issues.

  • Safety and dietary issues.

  • Family relationships.

  • Family health issues.

  • Assessment of risk factors within the family.

Support for the family can be provided by encouraging a discussion that involves:

• Exploring the mother's and father's feelings, attitudes and expectations in relation to the pregnancy, the birth and the growing relationship with the baby.

• Listening to mothers and fathers carefully, encouraging them as necessary to find solutions for themselves.

• Empowering parents to develop effective strategies that build resilience, facilitate infant development and enable them to adapt to their parenting role.

• Enabling parents to recognise and use their own strengths and those of their informal networks, as well as formal services if appropriate.

Screening

Antenatal and postnatal screening protocols across the UK differ slightly and can be found on the UK screening portal⁶ .

Antenatal screening

Prenatal screening for fetal conditions should be carried out according to National Institute for Health and Care Excellence (NICE) guidelines⁷ . This includes:

• The fetal anomaly scan.

• Screening for Down's syndrome.

• Sickle cell and thalassaemia screening.

• Screening for infectious diseases (rubella, syphilis, hepatitis B and HIV).

Newborn screening

This involves:

• Immediate physical external inspection of the newborn after birth.

• Newborn hearing screening test.

• Newborn blood spot. This screens for:

  • Cystic fibrosis.

  • Phenylketonuria (PKU).

  • Sickle cell disease.

  • Congenital hypothyroidism.

  • Medium-chain acyl-CoA dehydrogenase deficiency (MCADD).

• Physical examination of the newborn. Ideally given by 72 hours and should include:

  • Cardiac examination.

  • All babies should have a clinical examination for developmental dysplasia of the hips. Those with an abnormality of the hips on examination or a risk factor should also have an ultrasound examination.

  • Eyes.

  • Testes.

  • General examination.

  • Matters of concern for the parents.

Six- to eight-week baby check

This is covered in detail in a separate article Six-week Baby Check. It essentially repeats the same checks done at the newborn physical examination.

Further checks

These include:

• A review at 2-2½ years by the health visitor.

• A review by the school health service after starting in education. This includes height, weight, vision and hearing.

Immunisations

All children should be offered access to the routine child immunisation schedule. General practices and child health record departments maintain a register of children aged under 5 years, invite families for immunisations and maintain a record of any adverse reactions, on the GP record. At every contact, members of the team should identify the immunisation status of the child.

The parents or carers should be provided with good-quality, evidence-based information and advice on immunisations, including the benefits and possible adverse reactions. Every contact should be used to promote immunisation.

Health promotion

Health promotion and primary prevention activities for young children are mainly directed at parents, as they are responsible for small children. It is still possible for information to be aimed directly at children, by parents or others. Attitudes are often formed at an early age and even degenerative disease like atheroma starts early in life. Parents are strongly motivated to do the best for their children and so are receptive to education from well before the child is born.

Smoking

Pregnancy tends to be a time of high motivation and it is often a time when women stop smoking. They must be given all possible help and support with stopping smoking. The British National Formulary (BNF) states: "The use of nicotine replacement therapy in pregnancy is preferable to the continuation of smoking, but should be used only if smoking cessation without nicotine replacement fails. Intermittent therapy is preferable to patches but avoid liquorice-flavoured nicotine products. Patches are useful, however, if the patient is experiencing pregnancy-related nausea and vomiting. If patches are used, they should be removed before bed"⁸ . It is also a good time to get the father to stop. If couples can quit together they are mutually supportive. They need to have a smoke-free home for the child and the money saved will be most welcome. Interventions, including psychosocial interventions, to promote cessation of smoking in pregnancy are supported by Cochrane reviews⁹ .

Passive smoking
In the UK, around two million children are estimated to be exposed to tobacco smoke in the home¹⁰ . 6.5-20% are estimated to be exposed to tobacco smoke in cars. This increases the risk of sudden infant death syndrome, middle ear disease, lower respiratory tract illness and asthma. It increases prevalence of wheeze and cough and also exacerbates asthma¹¹ .

Alcohol/drugs

Alcohol consumption should be kept to a minimum, with avoidance of binge drinking and there is much to commend complete abstention. Fetal alcohol syndrome is well recognised in children of mothers who drank heavily in pregnancy but fetal alcohol effects represent a milder form of the condition and it is uncertain if there is any safe level of consumption.

There is also some evidence that use of drugs like cannabis may have an adverse effect on neuro-behavioural and cognitive outcomes with an increased risk of attention deficit hyperactivity disorder (ADHD) and learning difficulties¹² . It may be this is confounded by the presence of other factors. Regular attendance at antenatal care is beneficial for both mother and baby.

Nutrition

Breastfeeding is to be encouraged because of the numerous benefits it confers.

Getting children to eat a healthy diet is not easy. Processed food tends to contain too much salt and sugar and the need for colouring is dubious. Not all E numbers are harmful and some, like vitamin C and citric acid, are totally innocuous. Some, like tartrazine, can cause temporary hyperactivity in susceptible small children^{13 14} . The link between excessive salt consumption and hypertension is well established. It may not be manifest until later in life but the baroreceptors can be set early. The separate article Hypertension in Childhood examines risk factors in childhood for hypertension.

In recent decades obesity in children has moved from an uncommon observation to a national epidemic. The Government's obesity strategy sets out a comprehensive action plan to tackle the rise in obesity at every level¹⁵ .

Parents may be oblivious to the fact that their child is overweight and centile charts can be invaluable. Body mass index (BMI) is only applicable to adults. Where parents or health professionals have concerns, the child's growth should be measured and plotted on standard growth charts, based on World Health Organization (WHO) standards covering children aged between 0-4 years and UK-based growth charts covering ages 2-18 years¹⁶ . The following factors will help to prevent obesity:

• An assessment at 12 weeks of pregnancy, including advice on healthy weight gain during pregnancy.

• Making breastfeeding the norm for parents - evidence shows that breastfeeding reduces the risk of excess weight in later life.

• Delaying weaning until around 6 months of age, introducing children to healthy foods and controlling portion size.

• Identifying early those children and families who are most at risk (eg, where either the mother or the father is overweight or obese, or where there is rapid weight gain in the child).

• Encouraging an active lifestyle.

• For some families, skilled professional guidance and support will be necessary.

Dental health

As soon as teeth erupt, parents should brush them twice daily. Parents should be advised to use only a smear of toothpaste. Children should be taught to clean their teeth from an early age but, when small, they will need help and supervision:

• A good diet, low in sugar, and dental hygiene will reduce dental decay¹⁷ . Sugar should not be added to weaning foods. Where possible, all medicines given should be sugar-free.

• From 6 months of age, infants should be introduced to drinking from a cup; from 1 year of age, feeding from a bottle should be discouraged.

• Drinks containing sugar, including juice, should be limited, and where consumed be limited to mealtimes.

• Adding fluoride to the water can reduce dental caries by 40-60%. However, only some of the nation's water supply has been treated. Toothpaste containing fluoride should be used, and dentists can advise further.

Hazards

There is more detail in the separate article Accidents and their Prevention but some additional features are worthy of mention:

• Vehicle safety: ascertain that children are adequately restrained in cars with correct size restraints.

• Burns and scalds: have smoke alarms. Do not hold hot drinks when holding a baby. When a small child is mobile, use fireguards, a gate across the kitchen doorway, and cordless kettles, and keep pan handles away from the front of the cooker.

• Choking: avoid toys with small parts.

• Falls: do not place babies on tables, beds, etc. Baby walkers should be discouraged. Use playpens instead.

• Suffocation: avoid pillows when they are very small. Do not use dummies on a cord around the neck. Keep plastic bags away from children.

• Poisoning: keep medicines, cleaning agents, etc, out of reach. Child-resistant caps help.

• Cuts: keep knives out of reach; use safety glass in doors.

• Drowning: do not leave a young child unsupervised in a bath or near any water.

Attitudes

These are formed early and, when even quite young children can be led by word and example to see drug taking, smoking and binge drinking as stupid and undesirable, rather than as adult and sophisticated, they may be more resistant to pressures in later life.