Health Promotion for Young Children

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.¹

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, prevalence of wheeze and cough, and exacerbates asthma.²

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 is 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 neurobehavioural and cognitive outcomes with an increased risk of ADHD and learning difficulties.³ 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. Human milk is the most complete food for human babies and it contains the lipids necessary for development of the brain. Formula milk is an inferior substitute. A child of 18 months has the highest brain to body ratio in the animal kingdom.
In addition there is benefit from improved immunity⁴ and this includes protection against atopy.⁵
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 are totally innocuous like vitamin C and citric acid. Some, like tartrazine, can cause temporary hyperactivity in susceptible small children.^6,7 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 article on 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 cause is probably multifactorial:

• Fast food and junk food are often blamed. They do tend to be high in fat and fast sugars.
• Television and computer games, as well as a reluctance to let children play as they used to for fear of physical risks, may also be a factor.
• The second car for a busy working mother may reduce the amount of walking.
• Mothers who are out to work may choose convenience food and there may be an urge to give the child more food to demonstrate the love of an absent parent.

Children who are overweight are tall for their age but they perform poorly physically, they get teased or shunned and they are storing up great physical problems for later life. Amongst the problems that may arise is type 2 diabetes but now we are seeing cases of maturity onset diabetes in the young (MODY). This is when obesity, in a genetically susceptible individual, has led to type 2 diabetes well before the usual age of onset. Childhood obesity predisposes to hypertension and coronary heart disease in later life.
Parents can be remarkably oblivious to the fact that their child is overweight and centile charts can be invaluable. Overweight children are usually tall but a child who is on the 75th centile for height and over the 95th centile for weight is obese. BMI is only applicable to adults.

Immunisation is a highly effective way to control or eradicate diseases that were common in childhood, producing unpleasant illness and causing significant child mortality.
No vaccine is 100% effective and so a high level of uptake is required to produce herd immunity so that the disease is not endemic and the vulnerable are protected. Public reaction to ill-informed comment about risk of such procedures can undermine an effective campaign causing unnecessary illness, long term sequelae and death.
In the 1980s there as concern about the pertussis vaccine but that has settled with a newer, purer vaccine. A paper in the Lancet in 1998⁸ has since been retracted by all its authors except one,⁹ but it continues to do enormous damage and in many areas uptake of the MMR vaccine has fallen below 80% and there is a real danger of these diseases becoming endemic again. There is no new evidence to support the original allegation, but there is plenty to refute it.
Children should follow the routine schedule for immunisations but where there are specific risks extra measures may be needed.

• If there is tuberculosis in the family or in communities with a high prevalence, BCG vaccination is offered to infants. It probably has about a 75% efficacy.
• Hepatitis B prevention requires all pregnant women to be screened for hepatitis B and if positive the infant is immunised with an accelerated schedule.
  • This may also be used in communities with a high prevalence.
  • Chronic infection with Hepatitis B can lead to cirrhosis and hepatocellular carcinoma and immunisation may be seen as the first anti-cancer vaccine.

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.¹⁰
• More detail is available in some dental and periodontal problems.
• Adding fluoride to the water can reduce dental caries by 40 to 60%,¹¹ 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 them are children. Accidental injury, including poisoning is the commonest cause of death between 1 and 14 years. There is more detail in Accidents and Their Prevention but some additional features are worthy of mention.
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 kitchen doorway, cordless kettles and keep pan handles away from front of 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.

Preventing SIDS

The incidence of SIDS has fallen from about 1.8 per 1000 births in the 1980's to about 0.45 per 1000, probably because of the widespread uptake of the advice to parents published by The Foundation for the Study of Infant Deaths which includes:

• Place the baby on the back to sleep. There is an 8 fold increase in risk with sleeping prone, and 2 fold increase in sleeping on side.
• Avoid smoking in pregnancy and in the home, especially in the same room as the baby.
• Place the baby in the 'feet to foot' position - with their feet touching the foot of the cot and their head uncovered. This should stop them wriggling down under the covers.
• Do not let a baby sleep on a pillow, cushion, bean bag, or waterbed.
• Use a firm mattress. The theory that some mattresses may give off 'toxic gases' and cause SIDS is unsubstantiated.
• Use a sheet and layers of blankets appropriate for the temperature rather than a duvet.
• Do not let the baby get too hot or cold. Do not let the baby sleep in direct sunlight or next to a radiator.
• Do not sleep in the same bed as a baby if you smoke, have taken alcohol or drugs, or are very tired.
• Do not sleep with a baby on the sofa.

These are formed early, and if 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.