oPatientPlus articles are written by UK doctors and are based on research evidence, UK and European Guidelines. They are designed for health professionals to use, so you may find the language more technical than the condition leaflets.
In October 2009 the Department of Health issued the 'Healthy Child Programme'. 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 programmes.
- New focus on changed public health priorities.
The programme will be delivered by midwifery staff, health visitors and the primary care team. GPs will be responsible for some newborn and the majority of 6- to 8-week checks.
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). 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 longstanding 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 breast-feeding and authoritative parenting combined with warmth and affectionate attachment being built between the child and the primary caregiver from infancy.
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.
This programme shares much with the National Service Framework of 2004 but provides greater detail and places an increased emphasis on the review at two to two-and-a-half years. 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 one year old.
- Between two and two-and-a-half 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.
Antenatal and postnatal reviews
Antenatal screening for fetal conditions to be carried out according to National Institute for Health and Clinical Excellence (NICE) guidelines. Immediate physical external inspection after birth. Newborn Screening is covered in a separate article.
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.
First 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.
- General examination.
- Matters of concern for the parents.
This format is essentially the same for the child six-week check, which is covered in detail in a separate article Six-week Baby Check. Further examinations are provided by the health visitor at two to two-and-a-half years and by the school health service after starting in education. Vision and hearing tests are also offered during this time.
All children (and their parents) should be offered access to the routine child immunisation schedule. General practices and child health record departments maintain a register of children aged under five 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 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.
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 but nicotine replacement therapy is not licensed for use in pregnancy as nicotine is harmful to the baby. However, cigarettes contain nicotine, carbon monoxide, tar and numerous other toxic substances. 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 to promote cessation of smoking in pregnancy are supported by a Cochrane review.
Passive smoking: between 40% and 60% of children are exposed to tobacco smoke in the home. This increases the risk of sudden infant death syndrome, middle ear disease, lower respiratory tract illness,and prevalence of wheeze and cough, and exacerbates asthma.
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 difficulties. Regular attendance at antenatal care is beneficial for both mother and baby.
Breast-feeding is to be encouraged because of the numerous benefits it confers.
Getting children to eat a healthy diet is not easy. Parents are often concerned about getting the nutrition into their children whilst it is apparent from the shape of the child that calorific intake is more than adequate. 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. 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 both then and later in life.
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 level.
Parents can be remarkably 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 the new growth charts (based on World Health Organization (WHO) standards covering infants aged between two weeks and two years) which were introduced in May 2009.
The following factors will help to prevent obesity:
- An assessment at 12 weeks of pregnancy including advice on healthy weight gain during pregnancy.
- Making breast-feeding the norm for parents - evidence shows that breast-feeding reduces the risk of excess weight in later life.
- Delaying weaning until around six 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.
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 decay. Sugar should not be added to weaning foods. Where possible, all medicines given should be sugar-free.
- From six months of age, infants should be introduced to drinking from a cup; from one year of age, feeding from a bottle should be discouraged.
- Adding fluoride to the water can reduce dental caries by 40-60%, but only about 5% of the nation's water supply has been so treated. Giving children fluoride drops when small and tablets when bigger will help, but compliance over the years is arduous and general fluoridation is well overdue.
Accidents kill about 13,000 people a year and around 1,000 of those killed are children. Accidental injury, including poisoning, is the most common cause of death between the ages of 1 and 14 years. 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.
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.
Further reading & references
- UK Screening Portal Programmes; UK National Screening Committee
- NHS Newborn Bloodspot Screening Programme; Public Health England
- Child Accident Prevention Trust
- Advice for professionals, Foundation for the Study of Infant Deaths
- Healthy Child Programme: pregnancy and the first five years of life; Dept of Health (October 2009)
- Immunizations - childhood vaccination programme, Prodigy (February 2008)
- Social Exclusion Task Force (2007) Reaching Out: Think Family. Analysis and themes from the Families At Risk Review, London
- Children, National service frameworks and strategies, NHS Choices
- Antenatal care: routine care for the healthy pregnant woman; NICE Clinical Guideline (March 2008 - modified June 2010)
- Best practice statement: routine examination of the newborn, NHS Quality Improvement Scotland (2008)
- Lumley J, Oliver SS, Chamberlain C, et al; Interventions for promoting smoking cessation during pregnancy. Cochrane Database Syst Rev. 2004 Oct 18;(4):CD001055.
- Rushton L; Health impact of environmental tobacco smoke in the home. Rev Environ Health. 2004 Jul-Dec;19(3-4):291-309.
- Huizink AC, Mulder EJ; Maternal smoking, drinking or cannabis use during pregnancy and neurobehavioral and cognitive functioning in human offspring. Neurosci Biobehav Rev. 2006;30(1):24-41. Epub 2005 Aug 10.
- Bateman B, Warner JO, Hutchinson E, et al; The effects of a double blind, placebo controlled, artificial food colourings and benzoate preservative challenge on hyperactivity in a general population sample of preschool children. Arch Dis Child. 2004 Jun;89(6):506-11.
- McCann D, Barrett A, Cooper A, et al; Food additives and hyperactive behaviour in 3-year-old and 8/9-year-old children in the community: a randomised, double-blinded, placebo-controlled trial. Lancet. 2007 Sep 5;.
- Cross-Government Obesity Unit - Healthy Weight, Healthy Lives: Dept of Health/Department for Children, Schools and Families (2008); A Cross-Government Strategy for England, London
- UK-WHO growth charts; Royal College of Paediatrics and Child Health
- Harris R, Nicoll AD, Adair PM, et al; Risk factors for dental caries in young children: a systematic review of the literature. Community Dent Health. 2004 Mar;21(1 Suppl):71-85.
- Flouride; British Dental Health Foundation
Disclaimer: This article is for information only and should not be used for the diagnosis or treatment of medical conditions. EMIS has used all reasonable care in compiling the information but make no warranty as to its accuracy. Consult a doctor or other health care professional for diagnosis and treatment of medical conditions. For details see our conditions.
Dr Colin Tidy
Dr Hayley Willacy
Dr Helen Huins