An Update on Child Health Promotion

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An Update on Child Health Promotion

• Dr Stuart Murray
• Consultant Community Paediatrician,
• Child Health Department,
• Bath

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Aims of Child Health Promotion Programme - 1

• To ensure that all parents and children have
  access to, and understanding of, all relevant
  health care messages that are evidence based and
  shown to be beneficial.
• To arrange and deliver immunisations.

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Aims of Child Health Promotion Programme - 2

• To enable parents with worries about their
  children to locate the help they need promptly
  and efficiently.
• To support the local community in creating an
  environment at home and at school in which the
  child can be safe, grow and thrive physically
  and emotionally.

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Aims of Child Health Promotion Programme - 3

• To identify vulnerable children and families who
  may benefit from additional support or services
  beyond the core programme and negotiate whatever
  is needed.
• To ensure that as far as possible children who
  have or may have special educational needs are
  identified and referred to the education services
  and to the appropriate voluntary agency.

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Primary Prevention

• Prevention of SIDS
• Prevention of unintentional injury (aka
  accidents)
• Prevention of infectious diseases

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Child Health Promotion and Primary Prevention - 2

• Promotion of good parenting
• Promotion of good nutrition
• Promotion of dental health
• Promotion of optimum child development
• Promotion of mental health

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Language and cognition (promotion, prevention
andprotection)

• Effects 20 of population
• Language and cognition
• Early Talk
• Book start
• Singing
• Mobile libraries
• TV limiting
• Iron
• Bottle to cup schemes
• Early identification of high risk neonates,
  hearing loss etc.
• Early identification of parental concerns and
  prompt referral

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Child mental health (promotion, prevention and
protection)

• PERINATAL
• Parenting preparation, post birth debriefing,
  skin to skin bonding, infant massage, early
  identification of parental mental health
  disorders, parenting promotion competencies in
  staff, early identification and treatment of
  common behavioural issues
• INFANCY
• Increasing maternity leave
• PRESCHOOL
• Quality child care
• Improved nutrition (decrease in iron deficiency)
• SCHOOL
• Negotiation skills in school
• SOCIETY
• Reduce levels of physical violence

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Child Health Promotion Programme

• Major emphasis on parenting support
• Application of new information about neurological
  development and child development
• Use of new technologies and scientific
  developments
• Internet information, NHS Early Years Life
  Check
• Inclusion of changed public health priorities
• Increase breast feeding
• Early identification and prevention of obesity
• Promoting the social and emotional development
• Encouraging play and physical activity,
  minimising risk of injury

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Child Health Promotion Programme

• Emphasis on integrated services
• CHPP team across primary care and Sure Start
  Centres
• Led by Health Visitor, delivered by range of
  practitioners
• Health practitioners supporting early years staff
  in their role to promote health of children
• An increased focus on vulnerable children
  underpinned by a model of progressive universalism

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Progressive universalism

• A universal service is offered to all families
  with additional services for those with specific
  needs and risks
• Service should offer a range of preventive and
  early intervention services for different levels
  of risk, need and protective factors

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Vulnerable children

• Those disadvantaged children who would benefit
  from extra help from public agencies in order to
  make the best of their life chances
• 4 million children live in families with less
  than half the average household income

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Summary of screening recommendations

• Universal neonatal hearing screen
• Physical examination in first 3 days
• Neonatal blood spot at 5-8 days
• 6-8 week physical examination
• Orthoptic-led vision screening at 4-5 years
• Height, weight and hearing at school entry
• Vision screening in school ISQ, except 7 years
  to cease

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Summary of child health promotion programme -
Pregnancy
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Summary of child health promotion programme
first few weeks
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Summary of child health promotion programme 6
weeks to 1 year
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Summary of child health promotion programme
One to three years
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Summary of child health promotion programme
Three to five years
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Summary of child health promotion programme
School age
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Newborn and infant physical examination Standards
and competencies March 2008
http//nipe.screening.nhs.uk
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Bath Child Health Surveillance Manual

• On BANES intranet
• nww.banes-pct.nhs.uk/Departments/Child Health

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http//www.nipetoolbox.screening.nhs.uk/
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Umbilical GranulomaTreatment with salt

• 1. Apply a very small pinch of table/cooking salt
  over the umbilical granuloma
• 2. Cover the area with a gauze dressing and hold
  it in place for 10-30 mins.
• 3. Clean the site using a clean gauze soaked in
  warm water
• 4. Repeat the procedure twice a day for at least
  3 days
• 5. Granuloma should be reviewed at one week by a
  health professional.
• Further information and parent leaflet will be
  available on intranet

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Tongue tie10 of babies born with some degree of
tongue tie

• Babies may present with a range of problems
  including-
• Difficulty or inability to latch on
• Constantly slipping off the breast
• Excessive weight loss
• Slow or no weight gain
• Constant or very frequent feeding
• Unsettled baby

• Mothers often complain of-
• Sore nipples
• Pain during feeds
• Engorgement or mastitis
• Poor milk supply

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Tongue tie - Management

• Conservative
• Breast feeding advice and counselling - Skilled
  breast feeding support is an integral part of the
  management of breast feeding difficulties. Breast
  feeding is a complex interaction between mother
  and infant and many factors can affect ability to
  feed.
• Division of tongue tie
• Limited evidence suggests that this procedure can
  improve breast feeding (NICE).
• This should only be performed by registered
  health professionals who are properly trained
  (NICE).

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Division of tongue tie

• performed in early infancy
• usually performed without anaesthesia
• baby is swaddled and supported at the shoulders
  to stabilise the head and sharp, blunt-ended
  scissors are used to divide the lingual frenulum
• little or no blood loss
• feeding may be resumed immediately.

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• One randomised controlled trial compared division
  of tongue-tie with 48 hours of intensive support
  from a lactation consultant.
• 95 (19/20) of babies had improved breastfeeding
  48 hours after tongue-tie division,
• compared with 5 (1/20) of babies in the control
  group (p lt 0.001).

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Division of tongue tie - referral

• Suggest discuss urgently with Midwife/HV re
  assessment of feeding and, if indicated, best
  referral route
• Oral Surgery Mr Mike Lutterloch
• Trained midwives (2) will be available when
  service commissioned
• Lactation Consultant involves payment

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Plagiocephaly

• Deformational plagiocephaly - asymmetrical
  flattening of the cranium in the absence of
  synostosis (premature or abnormal closure of
  skull bones),
• caused by uneven external pressures exerted on
  the cranium
• most commonly manifests as unilateral flattening
  of the parieto-occipital area
• often associated with prominence of the
  ipsilateral frontal region

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Deformational plagiocephaly

• Incidence and prevalence in the UK is unknown
• Prevalence estimates of 10 to 15 for
  mild/moderate and 1.5 for severe for infants
  under the age of six months in the USA
• In New Zealand prevalence decreases from 19.7 at
  4 months of age to 9.2 at 8 months and 3.3 at
  24 months
• rise in the incidence in recent years.
  ?associated with the back to sleep campaign
• Other contributory factors
• a greater awareness of the condition
• an increase in the use of child carriers and car
  seats.

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• Prenatal
• foetal compression
• intrauterine constraint
• extrauterine compression
• Postnatal
• sleeping position
• torticollis
• nervous system disorders or cervical spine
  defects.

• Risk factors
• multiple births
• firstborn child
• premature birth
• Males
• supine sleeping first 6 weeks without head
  repositioning
• positional preference when sleeping
• bottle feeding
• limited prone time and low activity levels

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Deformational plagiocephaly

• Natural history not well documented
• prevalence decreases as untreated infants grow
  older implying that many cases resolve
  spontaneously
• Not associated with any long-term complications
  such as effects on brain function
• effects appear to be purely cosmetic

• There is no standard treatment for deformational
  plagiocephaly
• counterpositional therapy (actively repositioning
  the infants head, encouraging the infant to move
  its head using stimulating objects and supervised
  time lying on the stomach)
• stretching exercises through physiotherapy
  particularly if torticollis is present
• cranial orthoses lack of evidence to support
  use
• education and reassurance of parents, and surgery
  in severe cases

main reason for specialist referral to
differentiate the condition from
craniosynostosis
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Craniosynostosis
Lambdoid synostosis
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Care Pathway

• Prevention
• Promote tummy time for play through awareness
  raising for parents using leaflets to all new
  parents (see leaflet from Scotland and FSID
  leaflet) and advice at Health Visitor primary
  visit.
• Awareness raising for health professionals
  paediatricians, GPs, HVs, physios, midwives, NICU
  nurses.

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• Primary care advice
• Tummy time for play always supervise, never let
  baby fall asleep on their tummy
• Change babys head position when they are asleep
• Limit time in car chairs / bouncy seats
• Regular position changes throughout the day
• Alter sleeping pattern move cot, position of
  toys and mobiles to encourage change in head
  position
• Give parents leaflet about plagiocephaly
• (see GOS and Scottish leaflets)

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• When to refer to Paediatrician
• If significant asymmetry or concerns about rapid
  progression
• Concerns about possible craniostenosis
• Severe plagiocephaly present at birth
• If associated with torticollis / restricted neck
  movements refer paediatric physiotherapist