Child Health PDF

Children's Rights rights may be positive or negative and may be defined by special relationships, e.g. parent–child positive rights: welfare, institutional and legal rights established by social contract change as our society changes e.g. rights to information and best available health car...

Children's Rights rights may be positive or negative and may be defined by special relationships, e.g. parent–child positive rights: welfare, institutional and legal rights established by social contract change as our society changes e.g. rights to information and best available health care negative rights: natural or liberty rights require action by others entail an obligation not to infringe constant take precedence over positive rights e.g. freedom of movement, speech, religious beliefs The UN Convention of Rights of the Child: Key Principles any decision or action concerning children as individuals or a group must have their best interests as a primary consideratio n a child who is capable of forming his or her views has a right to express them freely a child’s view should be given due weight in accordance with that child’s age and maturity Child Health Page 1 Prevention in the Early Years The goal of most public health interventions is to prevent disease and maximise health. Interventions aimed at pregnant women, babies, and young children have the potential to influence health and wellbeing throughout life. However, working with these groups presents some particular challenges, not least because the outcomes are often realised only decades later. Evaluation of preventive actions The evaluation of any public health intervention may be complicated by various factors. Evidence base Studies that investigate the impact of early interventions on children and families may be considered under five principal headings, namely, 1. Education 2. Health and nutrition 3. Socio-economic benefits 4. Emotional and social support 5. Combined programmes Education of the child and parents Preschool education can improve children's social and intellectual development, as well as their long-term outcomes. Education for parents can include parenting skills and ensuring that young parents have access to adult education programmes. Example: The Effective Provision of Pre-School Education (EPPE) project A cohort study of 3000 children across Europe considered the effects at age 6-7 of preschool education and the home learning environment on children's Literacy Numeracy Social development (e.g. anxiety, antisocial behaviour and positive social behaviours) Child Health Page 2  Social development (e.g. anxiety, antisocial behaviour and positive social behaviours) Social inequalities The key findings included 1. Children who attended preschool showed higher educational and social attainment, even after adjusting for home and social circumstances. 2. The quality of preschool education influenced the educational levels achieved. 3. Although the home environment was important, parents' socio-economic status did not affect children's benefit from preschool education. 4. The report concluded that 'what parents do is more important than who they are.... Children whose parents read to them, taught them letters and numbers, songs and nursery rhymes, and took them to the library had better outcomes at 6 and 7 years". Health and nutrition Low birthweight Health promotion in the early years starts before birth with interventions designed to reduce the risk of LBW babies. LBW is associated with higher infant mortality and long-term effects, such as a higher risk of chronic conditions in adult life (e.g. diabetes, heart disease). LBW is more common in lower socio-economic groups. An evidence review identified two major modifiable factors that influence LBW, which are as follows: 1. Poor maternal nutrition at conception and during pregnancy can lead to LBW babies. While there is evidence that calcium supplements and folate can be effective in mitigating risk, there is little evidence about the effective- ness of any other supplements. 2. Smoking during pregnancy doubles the risk of having a LBW baby. Formal smoking cessation programmes with nicotine replacement therapy help some pregnant women to give up smoking. However, other factors (e.g. partner's smoking status and the mother's socio-economic group) affect the success of such programmes. Breastfeeding Research suggests that breastfeeding can improve the health and wellbeing of infants and mothers as follows: Reduced risk of infections through passive immunity (antibodies in the colostrum) and other mechanisms Lower rates of SIDS Reduced rates of obesity in the child and possible reductions in the rates of diabetes Lower rates of atopy Greater mother-baby bonding (mediated through hormone release) Reduced rates of breast and ovarian cancer in the mother Breastfeeding is less common in lower socio- economic groups and rates are falling in certain minority ethnic groups that traditionally breast-fed their babies. Prenatal support and education for mothers have been shown to improve breast-feeding rates. In the early years, interventions to promote maternal and child nutrition include: Education (e.g. improved diet, cooking skills) Subsidies (e.g. free school meals, free fruit in schools) Supplements (e.g. fluoridation of water supplies, nutritional supplements in staple foods, such as bread) Example of early years nutritional intervention: The Healthy Start scheme (UK) The Healthy Start programme is a government scheme to provide food and vitamin vouchers for disadvantaged pregnant women and young children. The vouchers can be spent at local retailers on certain food items, including milk, formula milk, fruit, and vegetables. Coupons are also provided to women for 'healthy start vitamins' in pregnancy (folic acid, vitamin C, and vitamin D) and early childhood (vitamin A, vitamin C, and vitamin D). An evaluation commissioned by the DH found that the scheme was working well -misuse is rare, retailers accept the vouchers, and beneficiaries use vouchers for the correct products. Interventions to prevent childhood injuries Numerous interventions exist to reduce the risk of injury in childhood; these include: Education campaigns (e.g. focusing on burns, poisonings, and falls) Playground renovation Increased supervision Seat belts Cycle helmets Child Health Page 3 While there is strong evidence for specific interventions such as seat belts or cycle helmets, other multi-agency mixed programmes are often difficult to evaluate. Socio-economic benefits In the UK, the Acheson Report concluded that families with young children were at increased risk of poverty. Many of these families found themselves in a 'benefit-dependent poverty trap' where they were unable to seek work because affordable childcare was unavailable. The report recommended reducing poverty in young families by Providing accessible and affordable childcare Increasing benefits and the uptake of bene- fits offered to pregnant women and to families with young children Emotional/social support Family support programmes can be based at the community level (e.g. addressing poverty, social isolation, and lack of community resources) or at the small group or individual level (e.g. home visiting during pregnancy and after birth). The aims of such support are to Improve parental wellbeing (e.g. provide par- ents with respite, problem-solving skills, and decrease incidence of postnatal depression) Improve children's physical, emotional, and cognitive development Prevent child abuse Few studies have evaluated the long-term outcomes of family support. However, in 2005, the European Early Promotion Project (a cohort study of approximately 1000 families across Europe) identified that training healthcare workers to support early parent-infant relationships led to fewer psychosocial problems in young children. Combined programmes Combined programmes include elements from more than one of the four types of intervention described earlier. They are often run by multi-agency teams. An example in England from the 1990s was the Sure Start programme, which has now developed into children's centres. This programme provides childcare, early education, health, and family support in disadvantaged areas. An ongoing evaluation (the National Evaluation of Sure Start) has produced regular reports on the success of Sure Start. A similar programme - Head Start - has been running over a longer period in the United States. Evaluation of Sure Start An initial evaluation of Sure Start in 2005 found little benefit for children living in Sure Start Local Programme (SSLP) areas and in some cases found that educational achievements in SSLP areas were worse than in control areas. However, a later evaluation in 2008 found a number of benefits associated with living in a SSLP area by the time children reached 3 years of age. These improvements included better social development, improved parenting, more positive social behaviour, greater rates of immunisation, and lower rates of accidental injuries. More recently, a 2012 report found that by the age of 7, children in Sure Start areas had greater improvements in home learning environments, greater decreases in harsh punishment by parents, and greater improvements in life satisfaction of parents. USA Head Start: Long-term effects of comprehensive child development in the early years The Head Start programme is a preschool education scheme run for disadvantaged families and children in the United States to reduce social, educational, and health inequalities between children from disadvantaged backgrounds and their more affluent peers. As well as preschool education, Head Start provides a range of other services, including Facilitating use of medical care for children (e.g. immunisations and dental health) Provision of healthy food and snacks Encouragement of parents' involvement in their children's education Because Head Start was established in the 1960s, it has been now possible to evaluate its long-term outcomes. A large-scale survey of social, health, and economic behaviours (the Panel Survey of Income Dynamics) has been conducted in a cohort of 8000 families since 1968. In 1995, adults aged 18-30 were asked as part of the survey whether they participated in Head Start or another preschool as a child. The survey found that adults who had attended Head Start were more likely to complete high school and attend college than their siblings who attended other preschools. The effects of the Head Start programme are not restricted to educational achievement but also encompass crime and economic benefits. For example, Head Start graduates of African-American origin were less likely to have been charged or convicted of a crime than their siblings who attended other preschool programmes. Also, white graduates in their 20s who had attended Head Start earned higher incomes than comparator groups. Family nurse partnership RCT: evidence for a preventive intervention in the early years Child Health Page 4 Family nurse partnership RCT: evidence for a preventive intervention in the early years The Family Nurse Partnership (FNP) is a preventive programme for vulnerable young first-time mothers. It offers intensive and structured home visiting, delivered by specially trained nurses, from early pregnancy until age two. The programme uses in- depth methods to work with young parents on attachment, relationships, and psychological preparation for parenthood. Family nurses build supportive relationships with families and guide first-time teenage parents so that they adopt healthier lifestyles (for themselves and their babies), provide good care for their babies, and plan their futures. The FNP is based on the Nurse Family Partnership, a similar programme that has been delivered and tested extensively in the United States over the last 30 years. Evidence from three RCTs of the FNP showed significant benefits for vulnerable young families in the short, medium and long term across a wide range of health and social outcomes, including Improvements in antenatal health Reductions in children's injuries, neglect, and abuse Improved parenting practices and behaviour Improved early language development, school readiness, and academic achievement Fewer subsequent pregnancies and greater intervals between births Increased maternal employment and reduced welfare use Overall, the cost savings in the US ranged from $17,000 to $34,000 per child by the time they reached 15 years, with a $3-5 return for every $1 invested. In England, FNP was tested in a 3-year formative evaluation beginning in 2007. Subsequently, a large- scale RCT was established, whose preliminary findings are due in 2014. Child Health Page 5 Reducing Health Inequalities through Early Child Development Learning Outcomes Understand and discuss how early child development acts as a determinant of health and influences a child’s chance of achieving her / his potential. Understand the importance of nutrition during first 1000 days of a Child’s life. Appreciate how early childhood development can be measured. Appreciate the type of interventions required to address the social gradient in early childhood development and reduce health inequalities in later life. Early Child Development (ECD) as a Determinant of Health Early childhood is defined as the period from conception to eight years of age. Increasingly this period of human growth is understood to be critical to a child developing to her / his full potential in terms of social, educational, earning, participation, health outcomes and is a focus of attention for the WHO, UNICEF and the World Food Programme (WFP) of the United Nations (UN), as well as many other international and domestic organisations. The WHO recognises Early Child Development as a health determinant. Addressing early child development means creating the conditions for children, from prenatal to eight years, to thrive equally in their physical, social/emotional, and language/cognitive development (WHO, 2014). Childhood Development Child development is dynamic (rapidly changing) and multifaceted (encompassing physical, social, emotional and intellectual ability). The American National Research Council and Institute of Medicine define child health as: “The extent to which individual children or groups of children are able or enabled to: 1. Develop and realize their potential, 2. Satisfy their needs, 3. Develop the capacities that allow them to interact successfully with their biological, physical, and social environments.” Why is Early Childhood Development a Public Health Concern? The early years environment, stimulation and relationships all have a direct impact on early development. Early childhood development strongly influences life-long health. Major public health problems such as obesity, heart-disease and mental ill-health have roots in early childhood. There is a social gradient in early childhood development. Worldwide it is estimated that 200 million children do not achieve their full developmental potential. Early childhood development differs from adult health in the extent and manner in which it is influenced by the environment. The social gradient is very evident with children from poorer backgrounds doing less well in school and entering into an intergenerational cycle of reduced employment opportunities, higher fertility and health inequalities. Worldwide, 10 million children under the age of five die annually and a further 200 million children do not achieve their full developmental potential. In low and middle-income countries this is most pronounced. Yet even in high income countries, despite unprecedented economic growth and technological development in the past 50 years, many children and young people have unacceptably poor health and social outcomes. Child Health Page 6 The Early Years and Brain Development Children are born ready to learn (once there hasn’t been significant pre-natal deprivation or toxicity). The neuro-system is pre-programmed to develop various skills and neuro-pathways, depending on the experience it receives. Initially, healthy brain development is facilitated by consistent and responsive care given by primary carers, to whom the baby becomes attached; good nutrition; appropriate stimulation and adequate sleep. At later stages different types of stimulation become important for example play, being told or read stories, and socialising with others; the child also learns to recognise her/ himself as separate from primary care givers. Nutrition in First 1000 days of Child’s life UNICEF, the World Food Programme (WFP) and many other organisations put great emphasis on the importance of Nutrition in the first 1000 days of a child’s life. The 1000 days between conception and a child’s 2nd birthday offer a unique window of opportunity to shape healthier and more prosperous futures. The right nutrition during this 1000 day window can have a profound impact on a child’s ability to grow, learn, and rise out of poverty. It can also shape a society’s long-term health, stability and prosperity. The first 1000 days include the following stages: Pregnancy Mothers need proper nutrition such as healthy protein foods, fruit, vegetables, iron, vitamins and minerals to grow and nourish a healthy baby in the womb. This greatly reduces the risk of stunting and low birth weights. Mothers should avoid smoking tobacco and consuming alcohol during pregnancy and breastfeeding. Breastfeeding It is recommended that babies are exclusively breastfed for the first six months of life and continue to be breastfed for an additional two years or more along with correct weaning practices to ensure the child meets its essential nutrient intakes. Weaning After six months a baby can be gradually weaned onto solid foods. A variety of foods including different flavours and textures and plenty of fruit and vegetables, should be gradually introduced. Toddler nutrition Every toddler needs adequate fruit and vegetable, Iron, Vitamin D and protein to enhance brain development and growth. 1000 Days: Fighting Hunger & Malnutrition Child Health Page 7 1000 Days: Fighting Hunger & Malnutrition One child dies every 12 seconds from problems related to malnutrition. By improving nutrition in the 1,000 days between pregnancy and a child's second birthday, families, communities and countries can be helped to break the cycle of poverty (Concern, 2014). Early Childhood Theory and Ecology Birth cohort studies have made a major contribution to our understanding of the impact of early childhood development throughout life. Three key pathways or mechanisms by which this influence takes place have been identified: Latent There are sensitive periods of brain development which, if missed cannot be easily altered in later life. If circumstances i n early effects life are not conducive to particular aspects of human development taking place, this has lifelong effects regardless of intermediate life events. Pathway Events in early life are not discrete but have a knock-on effect on subsequent life experiences leading to a pathway or series of effects events. Therefore early adverse events lead to on-going problems which in turn lead to poorer outcomes and conditions. Cumulative adverse outcomes are not the result of a discreet event but due to an accumulation of on -going circumstances which, if taken effects individually are not that exceptional but it is the extent and depth of the experience of early deprivation that has a graded effect on later outcomes. If circumstances in early life are not conducive to particular aspects of human development taking place, this has lifelong effects regardless of intermediate life events. If circumstances in early life are not conducive to particular a spects of human development taking place, this has lifelong effects regardless of intermediate life events. Bronfenbrenner’s Ecological Theory Can be used to explore the impact of context on child development and outlines the complex interconnectedness between the child’s intimate environments, social relations and the broader social, economic and cultural setting. Micro-systems are the immediate environments that the child experiences first-hand. They include the physical, social and emotional circumstances that support or impede the child in developing their full potential. In the early years, the care-giver/child relationship is a crucial aspect of this environment. Nurturing relationships with family, school and peer-groups all play a role. The Mesosystems are the links between the various elements of the Microsystem. Of particular relevance are the links between the home and school or childcare environments. The Exosystems are links and interactions between Microsystems and outside settings which are not directly related to the child but nonetheless impact on their development e.g. the parents’ place of work. Macrosystems refer to the overarching socio-cultural systems in which the micro-, meso-, and exosystems are located and which provide the norms and values that inform each of the systems. Chronosystems refer to an additional dimension – the passage of time. This does not just refer to the child’s age but also to the time- sensitive effects across all of the other systems and the effects of changes and events in the environment in which the child lives. Child Health Page 8 Population Health Approach to ECD A population health strategy aims to reduce the burden of risk within a society by addressing factors which, though of little immediate benefit to the individual, positively shift the distribution of the health outcome. This can lead to a combination of target strategies which address groups with particularly high risk and universal strategies which seek to reduce risk across the entire population. Early childhood development is a key public health issue that needs to be supported through a comprehensive programme of targeted and universal approaches. Measuring Early Development Offord Centre for Child Studies, Ontario, Canada in the late 90s designed an Early Development Instrument (EDI) as a population level measure of early childhood development at school entry age. Across five domains it measures the level of maturity a child has attained in relation to her / his ability to engage in school activities. This approach reflects a broad concept of developmental health. It is of note that the EDI, and its Australian adaptation the AEDI, are the only population level measures of child development across five domains. Child Health Page 9 Australian adaptation the AEDI, are the only population level measures of child development across five domains. Worldwide EDI Implementations The EDI has been implemented in 24 countries worldwide with full population coverage in Australia and almost full population coverage in Canada. In a further 10 countries it has been used as a population-level measure with regional coverage. In recent years it has been used in Ireland on a pilot basis in the Cork area by Dr Margaret Curtin and the following slides describe this EDI based study. You can also find further information in the published study at this link. Study Design and Methodology Irish Example: Observational study conducted in 47 schools in Cork Ireland. The Early Development Instrument included a teacher-completed questionnaire on children in first year of formal education (Junior Infants class). The children were not present and there was no individual identifier. EDI consists of five domains (104 questions, Internationally used) 1. Physical health and well-being, 2. Social competence, 3. Emotional maturity Language 4. Cognitive development 5. Communication skills & General knowledge. Children in the lowest 10% of the population in any domain were deemed ‘vulnerable’. An additional anonymous parental questionnaire was completed which linked to a child questionnaire by a form number. This examined: Child’s health Early years care and pre-school Parental interaction Family economic and social circumstances Neighbourhood Child Health Page 10 Findings - Who is Not Ready for School? Vulnerable in at Least 1 domain This table presents some of the headline findings of the study identifying 34% of boys were not ‘school – ready’ in at least one domain. A very high level of children from the Traveller community (an ethnic minority group in Ireland), children whose mother tongue was not English and children who had not received pre-school education, were also found to be vulnerable in at least 1 domain. Child Health Page 11 Vulnerability All Participants This Pie chart illustrates the percentage of children who are not vulnerable in any domain or vulnerable in 1, 2, 3, 4 or 5 domains. Age Related Vulnerability Mother’s Education and Vulnerability Irish Example of mothers education level and its relationship with a child’s vulnerability Vulnerability Associated with Television, Video Games and Computer Use. Child Health Page 12 Vulnerability and Read to\told Stories in the Past Seven Days Logistic Regression Predicting Likelihood of vulnerability on EDI Scores Factors associated with increased risk of vulnerability at the child level were being male, a younger child, having English as a second language and low birth weight. Key factors at the family level were mother’s education and reading stories. In the logistic regression model, the strongest predictor of vulnerability on EDI scores was storytelling. Children who were never told stories in the past week were over five times as likely to be vulnerable compared with children who were told stories every day. Children With Special Educational Needs are at a Greater Risk of not being Ready to Engage in Formal Education This graph illustrates that children who have special educational needs are at a greater risk of not being ready to engage in formal education. However, the majority have access to support services. Of concern are the children in the study who were deemed by their teacher to be in need of further assessment. These children showed an equivalent level of vulnerability across all domains of development to the children with Child Health Page 13 need of further assessment. These children showed an equivalent level of vulnerability across all domains of development to the children with special needs but because they do not have a designated special need they do not have access to the same level of support. Logistic Regression Predicting Likelihood on EDI Scores. A separate logistic regression, controlled for individual level factors and examined area and school level associations. Children attending schools with the greatest level of disadvantage were almost twice as likely to be vulnerable as those attending non-disadvantaged schools. As the study is concerned with developmental health at school entry, the results are indicative of the intake and not school performance. Children who had not attended pre-school were four times more likely to be developmentally vulnerable than those who had. Residence in an area in the most deprived tertile (based on being in the most deprived third of Electoral Districts in the whole country) did not emerge as a factor strongly predicting the likelihood of vulnerability. The lack of a clear area-level gradient is consistent with studies in other countries which found that area-level variation in child development is influenced by factors other than standard indicators of material wealth. Community-level processes and implementation of support programmes can result in some neighbourhoods showing better developmental outcomes than would have been predicted based solely on socio-economic indicators. The opposite effect has also been observed in some seemingly affluent neighbourhoods. This results in a complex picture which can only be captured by collecting population-level child development data. The Gradient in ECD There is a social gradient in health – the lower a person’s social position, the worse his or her health. The same gradient exists in childhood vulnerability. It is very important to note that this is a GRADIENT. It is not true that ALL children in low SES (Socio- Economic Status) neighbourhoods are vulnerable. Child Health Page 14 What Does it Take to Reduce Inequality? Our focus needs to be on shifting the gradient in childhood vulnerability Targeted Programmes How can this be done? Are targeted programmes the answer? In the field of ECD, traditionally, there has been a tendency to deliver highly targeted programs in high risk neighbourhoods – in the absence of any universal platform (program) which provides to all neighbourhoods. BUT research shows up that the effect of this is simply to shift the gradient in health at one end. It does not address vulnerability in the vast majority of other neighbourhoods. Further, it is relatively expensive strategy (per capita). Universal Programmes Are universal programmes the answer? It is also important to understand that the creation of a universal ECD platform (program), though critical, will not alone address vulnerability Child Health Page 15 It is also important to understand that the creation of a universal ECD platform (program), though critical, will not alone address vulnerability In fact, if we simply provide a universal platform, without addressing barriers to access, research suggests that we can steepen the gradient Proportionate Universality What needs to be done – Proportionate Universal Programmes. Achieving a real shift in the gradient of childhood vulnerability requires that we move from a singular strategy to one that builds a universal platform for ECD, but which also identifies and addresses the specific needs of high risk neighbourhoods and families within this. It requires a focus on the broader social determinants of health. Summary Early Childhood Development is a determinant of health. Healthy development in early childhood facilitates a child to fulfil her / his potential Adverse events, including poor nutrition, in early childhood lead to a social gradient in health and health inequalities. The social gradient in Early Child Development is best addressed by proportionate universal programs which take account of the social determinants of health. Child Health Page 16 Global Child Health Child Health Page 17 Child Health Page 18 Child Mortality 5.2 million children or adolescents died in 2018 (one every 5 seconds), mostly preventable and mostly in LMIC 85% of deaths occur in the first 5 years of life, 40% occur in the first month, largely due to treatable causes such as infectious diseases progress has been made in every age group and in every region, but progress has been uneven and largely based on country wealth in Sub-Saharan Africa, 1 in 13 children die before their fifth birthday, in high income countries it is 1 in 199 age breakdown 2.4m (47%) in the first 28 days 1.5m (28%) from 1-12 months 1.3m (25%) from 1-5 years an additional 2.2m occurred among children and young people from 5-24 years distribution over half of child deaths (2.8 million) occur in Sub-Saharan Africa one third of deaths (1.5 million) occur in central & southern Asia Child Health Page 19 improvement over time there has been huge success in reducing child deaths, particularly in recent decades Child Health Page 20 causes of child mortality almost half of child deaths are in the neonatal period (first 28 days) pneumonia and diarrhoea are the biggest killers after the first month the first 1000 days is a critical time for improving outcomes for children malnutrition is not included as a direct cause of death, but is thought to be implicated in 45% of under-5 deaths Stolen Childhoods - Save the Children End of Childhood Report 2017 identified 8 major risks to healthy childhood & adolescence under-5 mortality malnutrition lack of school child homicide early marriage child labour adolescent births Child Health Page 21  adolescent births displacement by conflict Child Health Page 22 Consent in Childhood informed consent should be obtained freely and given by a person who has the capacity to understand the issues involved even where children do not have legal capacity to consent, they still have the right to receive information given in a form and at a pace that they can comprehend if a child’s views are to be overridden they should receive an explanation as to why this will happen there is no legal requirement for written consent; it can equally be verbal or by acquiescence however, a written document forms objective evidence that consent has been taken and records details of information given if consent is verbal, circumstances, topics discussed and outcomes should be recorded in the clinical notes there is a legal presumption that young people 16-18 have capacity to consent, and routine testing is not indicated however, if there is doubt about capacity, this should be assessed according to the criteria used for any adult refusal of therapy, particularly if the treatment is for life-threatening disease, is more difficult, and legal advice should be sought despite wishing to uphold the autonomy of competent children, courts effectively prohibit children from refusing treatment that will save them from death or serious permanent harm parental consent the law only requires doctors to have consent from one person with parental responsibility for a procedure or treatment unmarried fathers cannot consent for the child unless their name is on the birth certificate (UK law) where parents disagree, the clinician should decide whether to proceed with treatment despite the disagreement exceptions to this rule are controversial elective procedures (e.g. male circumcision) where both parents must agree Gillick competence a child who has yet to reach 16 years is presumed by law to be incapable of providing consent some children may be able to demonstrate competence and if they can, provide consent independently of their parents it is rare for parental involvement to be inappropriate however, unless confidentiality is an issue a child under 16 can be deemed to have capacity to consent for treatment if they: understand that a choice exists understand the purpose and nature of the proposed treatment understand the risks, benefits and alternatives understand the consequences of not undergoing the treatment can remember the information for long enough to make a considered decision are free from undue pressure the ability of the child to pass this ‘test’ is entirely dependent on both the proposed procedure and the child’s experience the Gillick test sets a high threshold for capacity that would probably be unattainable by many adults as with 16-17 year olds, the ability of Gillick-competent children to provide valid consent does not extend to a right to refuse confidentiality in general, personal information should not be disclosed without the consent of the patient (or those with parental responsibility) exceptions notification of certain specified infectious diseases notification of births and deaths specific requests from the courts risk of significant harm to a third party detection or prevention of serious crime including child abuse doctors may ethically disclose information to parents of children younger than 18 years, even with the child’s refusal, if they genuinely believe that it is in the young person’s best interests to do so consent in an emergency doctors may treat without consent in an emergency to save life or prevent serious harm however, the views of the parents and the child (if known), the likelihood of improvement with treatment and the need to avoid restricting future treatment options where possible must all be considered in this situation consenting to underage sex Child Health Page 23 Child Health Page 24 Accident Prevention epidemiology after infancy, accidental injury is the main cause of death in children in Europe injury is also the most common cause of physical disability in young adults about half of accidents in children under the age of 5 years occur in the home boys are more likely to have accidents than girls absolute rates of death from injury have fallen over the last few decades falls are the leading cause of accidental injury in children; road traffic accidents are the leading cause of accidental deat h in children injury prevention is by the 3 E's: education, engineering and enforcement socioeconomic inequalities the children of parents who have never worked are 13 times more likely to die from unintentional injury and 37 times more lik ely to die from exposure to smoke, fire or flames context locations of injuries leading to emergency hospital admissions in the UK 28% home 14% transport 8% school 6% sports or athletics grounds 1% farm 35% unspecified mortality and morbidity rates may be reduced by: use of cycle helmets and car restraints (reduce severity of injury in road traffic accidents) urban safety measures (e.g. crossing patrols, traffic redistribution schemes, improving safety on individual roads) use of home safety devices (e.g. smoke detectors, stairgates, thermostat control of hot water) studies have established that educational programmes alone are not successful in preventing accidents to reduce accidents the educational material must be accompanied by: targeting the families most at risk of accidents home visits free distribution of devices such as smoke alarms Child Health Page 25 Non-Accidental Injury incidence unknown but most estimates almost certainly underdiagnose the problem 30% of childhood fractures are thought to be inflicted - before the age of 1 year, the figure is 75%, esp. when considering rib fractures risk factors in child abuse parent child environment abused as children (perpetuation) unwanted or difficult pregnancy poor housing unreasonable expectations of child peak incidence 5 months unemployment aggressive and impulsive prematurity or low birth weight refugees rigid or authoritarian in SCBU isolation and lack of family support psychiatric illness and addiction hyperactive/crying excessively single or separated parent young, immature, lonely, isolated disappointing because of defect or wrong sex family history of violence learning difficulties chronic illness or disability step-parent or co-habitee present poor interparental relationship different < 18 months between the births of children mental illness, drug or alcohol addiction difficult behaviour mother < 21 years old at the time of birth separated from mother for > 24 hours post- indifference / intolerance / overanxiety delivery history taking ask detailed questions re any mechanism of injury, e.g. how did child fall, how far, on to which surface, who witnessed, etc. ask about previous incidents consider speaking to the child directly even without the consent of the carer consider collateral from siblings gain information from multiple sources, e.g. school, GP, health visitor, other hospitals ensure all notes are comprehensive and contemporaneous (include content of all telephone calls, handovers, etc.) record any difference of medical opinion indicate on notes what the father said and what the mother said (may reveal contradictions) red flags injuries in an infant vague, unwitnessed, inconsistent, discrepant history time delay in presentation (30%) baby presents shocked, possibly apnoeic, following apparent sudden spontaneous collapse at home unconcerned or aggressive carers inappropriate response in chid (e.g. didn’t cry, felt no pain) multiple injuries bruising in infants - "children that don't cruise rarely bruise" child or family known to social services, child protection plan in place previous history of unusual injury repeated presentations examination look for physical injuries Child Health Page 26 look for physical injuries assess growth and development the child should be fully undressed and examined in a warm, secure environment carefully photograph and chart injuries using body maps examine fontanelles and measure head circumference in head injury certain injuries are ‘typical’ in abuse, as follows types of injury burns/scalds common in children most are accidental e.g. hot drinks, heaters, fires, cookers, fireworks, candles, sunburn however, they may involve cases of inadequate abuse or neglect red flags dorsum of hands only small circular burns (cigarettes) burns to both feet or buttocks (immersion injury) clearly demarcated burns (hot object has been applied to skin) "glove and stocking" distribution (consistent with a child being immersed into hot water) bruises uncommon in children under 1 year, especially if not mobile bruises of different ages or finger-shaped bruises, bruises around wrists and ankles (swinging), inside and behind pinna (blow with hand) and ring of bruises (bite mark) should all raise concerns accidental bruises are uncommon in all ages on the buttocks, neck, hands, trunk and lower jaw in contrast bruises to the front of the body and over bony prominences are more likely to be accidental two black eyes may indicate blood tracking down after a significant injury to the forehead differentials: bleeding disorder, meningococcal sepsis, Henoch-Schönlein purpura, mongolian blue spots estimating ages of bruises and fractures cannot be accurately done and should not be relied on poisoning presents as unusual, unexplained illness features: drowsiness, loss of consciousness, biochemical chaos, metabolic disturbance intracranial injury most common in infants < 6 months direct trauma: multiple fractures, cerebral oedema shake injury: subdural haematoma, retinal haemorrhage rates of mortality and long-term sequelae are high visceral injury mesenteric tears, perforation of small intestine, tears of liver & spleen fractured ribs very suspicious unless major trauma or underlying bone disease; may be caused by shaking skull fractures whether accidental or not, these require significant force linear parietal fractures are the most common accidental or non-accidental fracture features of particular concern include occipital fractures, depressed fracture, growing fracture, wide fracture, fracture crossing suture line, history of fall less than 3 feet other fractures femur, humerus, metaphyseal torn epiphyses may indicate swinging torn frenulum may indicate direct blow to mouth or forced feeding perforated eardrum can be caused by slap or blow to side of head other injuries strap / lash marks, nail injuries, strangulation marks, belt/buckle marks, ligature marks, pinch marks, bites Child Health Page 27 belt marks skull fractures and intracranial bleed suspicious fractures fractures may be categorised as being of high, moderate or low risk of being related to non-accidental injury: high metaphyseal fractures, posterior rib fractures moderate multiple fractures, fractures of different ages, complex skull fractures Child Health Page 28 moderate multiple fractures, fractures of different ages, complex skull fractures low clavicular fractures, long bone shaft fractures, linear skull fractures intentional upper airway obstruction it may be impossible to distinguish intentional airway obstruction from other causes of sudden and unexplained death in infancy (SUDI) there are often no clinical signs evident externally and for those who survive the sequelae may be significant presentations sudden death acute life-threatening event (ALTE) apnoea / transient respiratory difficulty cyanotic spells recurrent seizures unexplained collapse / illness bleeding from nose or mouth petechiae on neck conjunctival haemorrhage NAI differentials accidental injury & fractures spontaneous intracranial bleeds osteopenia e.g. due to prematurity or chronic illness osteogenesis imperfecta pathological fractures bleeding diatheses e.g. idiopathic thrombocytopenic purpura, haemophilia iatrogenic e.g. post-interosseous insertion, or after holding neonates for blood sampling malignancy infection deficiencies e.g. vitamin A, vitamin C, vitamin D (rickets), copper spontaneous retinal / subdural haemorrhage occurring after birth (resolve within the neonatal period) other causes of SDH: glutaric aciduria type 1, post-op, hypernatremic dehydration, rare congenital malformations investigations bloods FBC, coag profile, ca2+, po4-, alk phos, vit D, copper ophthalmic exam look for retinal haemorrhages in shaken baby syndrome - age of haemorrhages is important skeletal survey every bone in the body is x-rayed must be performed and reported by specialist paediatric radiologist look for fractures, dislocations and periosteal reactions from rotation injury if clear, repeat 10-14 days later bone scan particularly if bony injury suspected but not confirmed on initial skeletal survey DEXA scan may reveal osteopenia cranial imaging CT brain / ultrasound / MRI as clinically indicated look for acute / chronic intracranial haemorrhage, diffuse axonal injury, acute encephalitis or cerebral oedema CT brain recommended for all infants < 1 year in suspected NAI shaken baby syndrome most common in babies aged 5-10mths baby cries, carer shakes baby, baby become somnolent and stops crying, this reinforces the response high risk of physical damage as babies have big heads & weak neck muscles acceleration-deceleration forces cause brain trauma (like whiplash) classic triad 1. intracranial haemorrhage: usually subdural haematoma, due to tearing of small bridging veins b/w dura & arachnoid 2. cerebral oedema: from shearing forces, diffuse axonal damage, secondary oedema, infarction 3. retinal haemorrhages (highly specific finding): in all quadrants of eye & all retinal layers (subretinal, intraretinal, preretinal) ○ retinoschisis = splitting in retinal layers (very suspicious for abuse) prognosis 20% die outright 50% have long-term sequelae e.g. blindness, paralysis, behavioural changes, intellectual impairment Child Health Page 29  50% have long-term sequelae e.g. blindness, paralysis, behavioural changes, intellectual impairment 30% have good prognosis w/ no long-term complications fabricated or induced illness (FII) formerly termed Munchausen syndrome by proxy when a parent injures their child or feigns disease for attention/sympathy/reassurance/hospitalization the perpetrator often has some medical knowledge it is more commonly the mother presentation spectrum of presentation is wide and includes suffocation, non-accidental poisoning and sudden infant death child presents with persistent or recurring illness that cannot be explained discrepancy between clinical findings and history symptoms & signs do not make clinical sense features suggest a multisystem and rare disorder attempts at treatment unsuccessful management accurate history taking and reconciliation from all professionals involved often requires hospital admission/ investigation early referral to police, social workers and mental health teams if you suspect a child abuse case put the interests of the child first alert your superiors adhere to local protocols don't give the parents any impression of your suspicion until you get the facts right early liaison / referral to social services if suspected abuse (in most cases parents / carers should be told that referral is taking place) in severe cases admit the child to hospital "for monitoring" for a temporary safe place remember you're not on your own - you're always working as part of a team if NAI is discovered, need to take steps to protect siblings also Child Health Page 30 if NAI is discovered, need to take steps to protect siblings also arrange strategy meeting involving parties with an legitimate interest in the child's health, including social care services and police Child Health Page 31 Adoption & Fostering adoption adoption is about meeting the needs of a child and not those of the prospective parents full parental rights are taken on by the adopting parents and the child has all the rights of a natural child of those parent s adoption of newborn babies is increasingly uncommon the legal complexities of bringing infants and children from overseas for adoption are immense steps include consent from the natural parents (may not be required if parents are deemed incapable of decision-making) meticulous assessment of prospective adoptive parents – carried out by social services application for adoption order adoption hearing – an Adoption Panel considers the needs of both the child and the prospective parents pre-adoption medicals – health of both natural parents, pregnancy, delivery, neonatal problems, development, etc. there are no medical conditions in the child that absolutely contraindicate adoption fostering foster care offers a child care in a family setting but does not provide legal permanency parental rights remain with the natural parents, local authority or courts, depending on the legal circumstances different types of foster care include the following: care of babies awaiting adoption young children in whom return to parents is anticipated short break fostering remand fostering for some children with strong natural family ties long-term fostering is appropriate foster parents are selected by a foster panel and, as with adoption, their health and that of the children awaiting fostering is considered foster carers receive a financial allowance Child Health Page 32 Emotional Abuse & Neglect emotional abuse the persistent emotional ill treatment of a child such as to cause severe and persistent adverse effects on their emotional development passive leaving child unattended for long periods lack of affection lack of encouragement/stimulation active repeated threats and intimidation inappropriate restriction undermining of self esteem restriction of normal peer relationships Cinderellas complications babies feeding difficulties failure to thrive crying excessively being excessively quiet and non-demanding toddlers symptoms range from being quiet and clingy to being overactive with a bad temper older children poor school performance antisocial or difficult behaviour wetting or soiling developmental delay or regression faltering growth (suboptimal growth hormone production may be noted) attachment disorder ADHD enuresis neglect the persistent failure to meet a child’s basic physical and/or psychological needs to an extent that is likely to result in serious impairment of the child’s health or development e.g. inadequate provision of food, shelter or clothing, failure to protect from physical harm or danger it also includes failure to ensure adequate care takers and failure to ensure appropriate access to medical care or treatment, as well as unresponsiveness to a child’s basic emotional needs it is the most common form of child abuse all symptoms improve when the child's environment has changed presentations multiple A& E attendances with injuries non-concordance with treatment plans or missed appointments for medical intervention failure to take up routine immunisations failure to thrive behavioural changes ranging from craving attention from adults to being shy and withdrawn difficult/challenging behaviour and school failure inadequate hygiene including nappy rash poor emotional attachment to the care givers developmental and speech delay Child Health Page 33 Female Genital Mutilation FGM is a violation of the human rights of girls and women involves the partial or total removal of external female genitalia or other injury to the female genital organs for non-medical reasons the practice has no health benefits for girls and women it can cause severe bleeding and problems urinating, and later cysts, infections and complications in childbirth it is associated with increased risk of newborn deaths WHO is opposed to all forms of FGM, and is opposed to health care providers performing FGM (medicalization of FGM) treatment of health complications of FGM in 27 high prevalence countries costs $1.4 billion per year epidemiology more than 200 million girls and women alive today have been cut in 30 countries in Africa, the Middle East and Asia it is mostly carried out on young girls between infancy and age 15 Child Health Page 34 types risk factors Child Health Page 35 poverty education when and how is it done? Child Health Page 36 opinions Child Health Page 37 consequences legislation 24 of the 29 countries where FGM/C is concentrated have enacted decrees or legislation related to FGM/C Child Health Page 38 WHO guidelines Child Health Page 39 Immunization immunization is the artificial induction of immunity the objective is to produce without harm to the recipient, a degree of resistance sufficient to prevent a clinical attack of natural infection key stats immunization is probably the best thing a parent or a GP can do for a child's health it is the most cost effective health intervention bar none diphtheria was the most successful vaccination programme ever in 1940, 500 Irish children died every year from vaccine preventable disease the average Irish child now receives 14 individual immunizations BCG is the vaccine most likely to cause a minor local reaction the HPV vaccine costs about as much as all the others in the Irish immunization schedule combined (approx. 500 euro per dose) it takes 10 years from conception of a vaccine to its first delivery in some US states, vaccination is semi-compulsory ("no shots, no school") mechanism of action vaccines are biological preparations that improve immunity to a particular disease causing agent first used by Edward Jenner in 1776 when he inoculated humans with cowpox to protect against smallpox they contain either dead or attenuated viruses, or purified products derived from them can be mono/univalent (immunizing against a single antigen) or poly/multivalent (immunizing against 2 or more strains of the same pathogen) they act as antigens and stimulate protective antibody production they can also activate T-cell mediated effector functions as a general rule, the closer a vaccine is to the natural disease, the more effective the induced immune response in the recipient the valency of a vaccine denotes the number of strains of a microorganism it targets vaccinations are key in the effective control of infectious diseases e.g. smallpox has been eradicated incidence has been dramatically reduced in measles, mumps, poliomyelitis, diphtheria, rubella and many more economics and unequal distribution of wealth is a major obstacle in vaccine development - those who need it the most cannot afford it so there is a lack of commercial incentive to develop them active the administration of a vaccine or toxoid that stimulates the body's immune system to produce antibodies and/or immunization cell-mediated immunity that provides long-term protection against the infectious agent passive the administration of preformed antibodies to provide temporary protection immunization protective effects of antibodies neutralization of bacterial exotoxin (antitoxin) neutralization of viruses (neutralizing abs) initiation of complement-mediated lysis of bacteria (lysins) initiation of phagocytosis (opsonins) prevention of bacterial adhesion to mucosal surfaces (anti-adhesins) types of antigens 1. T-cell dependent antigens Child Health Page 40  1. T-cell dependent antigens 2. T-cell independent antigens T-cell dependent T-cell independent activate T-cells B-cells structure protein polysaccharide long-term protection yes no useful in kids < 2 years yes no effective booster yes no structure of vaccines vaccine constituents bacterial antigen aluminium stabilizing agent other diluting agent antibiotic (neomycin) mercury conjugation conjugate vaccines consist of a polysaccharide coupled to a protein carrier changes the immune response from T-cell independent to dependent e.g. Haemophilus influenzae (Hib) vaccine, Meningococcal C conjugate vaccine active immunization - 5 main types of vaccine live attenuated e.g. measles, mumps, rubella, polio (Sabin), varicella, BCG, oral typhoid suspensions of living organisms reduced in virulence but still immunogenic immune response similar to natural infection life-long protection with one dose (in theory) cheaper than other vaccines disadvantages concern over potential reversion to virulence cause of severe disease in IMCP persistent infection hypersensitivity reaction inactivated e.g. Polio (Salk), influenza, Hep A, rabies, Japanese encephalitis, pertussis, injectable typhoid, cholera, plague consists of killed organisms less effective than live attenuated at inducing long-lasting immunity weakly immunogenic, require several doses safer than LA, but more expensive inactivated by formaldehyde, acetone, phenol, beta-propiolactone, heat toxoids e.g. tetanus toxin can be detoxified to form tetanus toxoid by the action of formaldehyde & heat, without loss of antigenic properties modified bacterial toxins rendered non-toxic but still retaining the ability to stimulate anti-toxin formation exotoxins can be made into toxoids, endotoxins can naaat subunit or subcellular fraction (i) polysaccharide capsule e.g. pneumococcal, meningococcal, H. influenzae type b (ii) fragmented virus or surface antigen e.g. influenza recombinant vaccine e.g. Hep B an attenuated virus or bacteria is used as a vector to transport the vaccine material into the host cells a product of genetic engineering technology Child Health Page 41 passive immunization pts. are injected with preparations from plasma of immune individuals containing immunoglobulins against certain infections confers immediate but transient protection non-specific immunoglobulins aka Human Normal Immunoglobulin (HNIG) pooled blood of donors contain antibodies to common virus infections indications: measles prophylaxis, Hep A prophylaxis, hypogammaglobulinemia (primary immunodeficiency disease) specific immunoglobulins e.g. tetanus, Hep B, rabies, Varicella-Zoster indications for Varicella-Zoster immunoglobulin (VZIG) 1. significant exposure 2. clinical condition which increases risk of chicken pox (esp. pregnancy/IMCP) 3. no antibodies to V-Z virus Child Health Page 42 Vaccines with the exception of BCG, oral typhoid and oral polio vaccine, all vaccines should be given by intramuscular or deep subcutaneous injection in infants, the anterolateral thigh or deltoid area are recommended in the buttock, injection into the upper outer quadrant avoids sciatic nerve damage risk DTaP (diphtheria, tetanus & pertussis) diphtheria & tetanus are inactivated toxoids + adjuvant acellular pertussis is now used (previously the vaccine contained a suspension of killed Bordetella pertussis) severe adverse effects include prolonged inconsolable crying (> 3hrs), convulsions & hypotonic hyporesponsive collapse a big drop in uptake (due to these S/Es) in the UK in the 1980s coincided with a whooping cough epidemic the severe S/Es were formerly considered contraindications but now considered precautions (b/c whooping cough is worse) vaccine side effects diphtheria swelling, redness, malaise, fever, headache severe anaphylaxis rare neuro reactions rare tetanus pain, redness, swelling malaise, myalgia, pyrexia acute anaphylaxis, urticaria general reactions uncommon peripheral neuropathy rare pertussis swelling & redness at injection site less common with acellular vaccine crying, fever persistent screaming and collapse now rare convulsions and encephalopathy very rare polio Salk (inactivated) introduced to Ireland in 1957 replaced by Sabin (live attenuated) in 1960 Salk returned to primary immunisation schedule in 2001 (i) Sabin aka live oral contains live attenuated strains of polio viruses types 1, 2, 3 polio vaccine (OPV) induces local intestinal immunity S/E: vaccine-associated paralytic poliomyelitis (VAPP), 1/2.5million, greater risk with first & dose and in adults OPV no longer routinely part of primary schedule b/c risk of VAPP > risk of wild virus poliomyelitis (ii) Salk aka inactivated contains enhanced potency inactivated strains of polio viruses types 1, 2, 3 polio vaccine (IPV) provides long-lasting immunity safer - on the primary schedule instead of Sabin usually given IM but may be given subcutaneously Child Health Page 43  usually given IM but may be given subcutaneously side effects pain, redness, swelling, fever, convulsion, screaming, pallor limpness (rare) anaphylaxis (very rare) Hib H. influenza type b capsular polysaccharide conjugated to protein carrier generally given in a course of three doses in the first year; over 13 months of age a single dose is effective only given after the age of 10 years in children at increased risk of invasive Haemophilus disease (sickle cell, chemotherapy, absent spleen) side effects local swelling and redness fever, convulsions, screaming, pallor, limpness anaphylaxis (very rare) MMR live attenuated given at 12-18 months booster at 4-5yrs (earlier in Africa) sometimes more boosters are required in outbreaks, etc. the Americans administer an MMRV vaccine, which includes varicella (chicken pox) - not yet licensed in Ireland highly effective at preventing viral infection any girl who missed the MMR should be immunized between the ages of 10 and 14 years S/E fever, headache, vomiting, lymphadenopathy, rash, malaise "mini-measles", "mini-mumps" very rare: sensorineural deafness, meningitis, encephalitis parotid swelling (1%) febrile convulsion (0.1%) arthropathythrombocytopenia (rare) no evidence of link with autism no evidence of link with inflammatory bowel disease C/I untreated malignant disease IMCP (except HIV) IMSP tx pregnancy Child Health Page 44 pneumococcal (i) polysaccharide incorporates 23 of most common capsular types which account for 90% of serious pneumococcal infections pneumococcal vaccine indications: >65yrs, asplenia, chronic heart/lung/liver/kidney disease, diabetes, IMCP, complement deficiency (ii) pneumococcal polysaccharide antigens conjugated to a carrier protein conjugate vaccine (PC7) heptavalent - incorporates the 7 most common serotypes responsible for 70% of invasive diseases indications: routine childhood immunisation Child Health Page 45 influenza (i) inactivated whole virus (ii) subvirion or split-virus (iii) surface antigen the vaccine composition is changed annually to incorporate strains most likely to circulate in the forthcoming season administered in winter trivalent - 2 x type A, 1 x type B 80% protection indications risk of influenza-related complications e.g. >50yrs, chronic lung illness, diabetes, IMCP, hospitalized, children on long-term aspirin tx healthcare workers working with animals e.g. park ranger Hepatitis B contains recombinant HBsAg, derived from yeast cells, adsorbed onto aluminium hydroxide adjuvant 90% of vaccinated are protected from Hep B efficacy is reduced if the vaccine is given in the fatty tissue of the buttock indications pre-exposure prophylaxis universal (routine immunisation schedule) health care workers security & prison personnel IVDA, tattoo artists, sluts family of chronic carriers haemophiliacs & anyone receiving regular transfusion chronic renal failure, chronic liver disease post-exposure prophylaxis babies born to HBsAg (+) mums household exposure sexual exposure health care workers or others exposed to blood/bodily fluid Child Health Page 46 BCG live attenuated A & C strains derived from Mycobacterium bovis variable efficacy most effective against tuberculosis meningitis & miliary TB must be given intradermally provides 80% protection against leprosy (Mycobacterium leprae) indications newborns unvaccinated children unvaccinated Mantoux (-) immigrants from a high incidence country health care workers who are Mantoux (-) & unvaccinated who are in contact with TB infants who are to travel abroad to high-prevalence areas side effects vertigo and dizziness occasional adenitis lupoid-type local reaction (rare) allergy / anaphylaxis rare severe injection site problems are usually due to poor injection technique widespread dissemination of organism (very rare) meningococcal (i) Men. polysaccharide quadrivalent vaccine effective against serogroup A, C, W135, Y meningococci indications: travellers, asplenia, complement def., close contacts drawbacks: ineffective in