Child Health Service Policy
Rationale
2010
Statewide Policy unit
Child and Adolescent Community Health
Child and Adolescent Health Service
WA Health
Revised August 2013
Contents
Page
1. Executive Summary
3
2. Introduction
5
3. General demographic information for children (0-4 years) in WA
3.1 Future increase in population
7
9
4. Health status of children in Australia
4.1 Health status of children in Western Australia
10
10
5. Changing family structures in Australia
11
6. Emerging themes (child)
6.1 Childhood obesity
6.2 Dental health
6.3 Injury and preventable deaths
6.3.1 Sudden Infant Death Syndrome
6.3.2 Injury prevention
14
14
17
18
18
19
7. Emerging themes (adult)
7.1 Parental mental health
7.1.1 Screening and assessment
7.2 The role of fathers
7.3 Alcohol and drug use
7.4 Family and domestic violence
7.5 Child abuse and neglect
20
20
21
23
24
25
27
8. Health and development surveillance
8.1 Physical health
8.2 Vision
8.2.1 Targeted assessments
8.3 Hearing
8.4 Examination of hips
8.5 Undescended testes
8.6 Growth monitoring
8.6.1 Universal growth monitoring
8.6.2 Targeted growth monitoring
8.7 Developmental delay
8.7.1 Child developmental screening tools
8.8 Infant mental health
28
28
29
29
30
31
32
32
32
34
34
36
37
9. Health promotion
9.1 Family health and wellbeing
9.2 Parenting groups
9.3 Disease Prevention
38
38
39
39
10. Promoting healthy eating and optimum growth
10.1 Breastfeeding
10.2 Formula feeding
10.3 Transition to family diet and beyond
10.4 Promoting a healthy lifestyle
40
40
41
42
42
Conclusion
References
43
45
Child Health Policy Rationale 2010
2
1. Executive Summary
The health status of Western Australian children reflects broader national
trends with the overall health, development and wellbeing of children being
high on many indicators. However, there are significant areas of concern, with
emerging health issues including increasing proportions of children and young
people with complex diseases such as asthma, diabetes, overweight and
obesity, increasing levels of behavioural, developmental, mental health and
social problems, along with the significant gap in health outcomes between
Aboriginal1 and non-Aboriginal children. The origins of these morbidities can
be traced back to childhood and are closely related to the social determinants
of health.
Sub-population groups of children are at higher risk of various health and
developmental issues adding to their diverse and complex needs, and the
demands on services that support them. These groups include children with
disabilities, parents with mental illness or who misuse alcohol/drugs, children
from socio-economically disadvantaged backgrounds who are geographically
isolated, involved with the juvenile justice system, homeless, from culturally
and linguistically diverse backgrounds, born prematurely or of low birth weight.
Many of these health and social issues are more prevalent in disadvantaged
and vulnerable children such as children from refugee and Aboriginal families,
children in the care of the state and children with disabilities.
Since the last review of the child health policy, the knowledge base regarding
the importance of the early childhood years in laying the foundations for future
health and wellbeing is indisputable and information that supports a better
understanding of the key issues affecting children and their families is critical
in the development of new policy.
The 2010 child health policy aims to improve health outcomes for children by
providing effective early interventions at critical periods in a child’s life to
minimise the harmful effects of disadvantage and increase the likelihood of
children achieving their social, educational and personal aspirations. The
policy is informed by scientific evidence and responsive to national
frameworks and reports.
Child health services are informed by a population health approach through
the provision of universal child health services supplemented by more
targeted and specialist services. This approach facilitates the identification of
children and families who require further assessment through the birth to
school entry universal schedule of contacts at key developmental stages and
the offer of intervention services, referral and/or support through targeted and
intensive/specialist services. The universal and targeted approaches
complement each other and families move between the two streams as their
needs and circumstances dictate. Examples of targeted approaches include
1
Within Western Australia, the term Aboriginal is used in preference to Aboriginal and Torres
Strait Islander, in recognition that Aboriginal people are the original inhabitants of Western
Australia. No disrespect is intended to our Torres Strait Islander colleagues and community.
Child Health Policy Rationale 2010
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intensive home visiting delivered in collaboration with the Department of Child
Protection through the Best Beginnings Program and the comprehensive
schedule of contacts for Aboriginal infants and young children with identified
health and developmental conditions.
The child health service is predominately delivered by child health nurses,
who are registered nurses with post graduate qualifications in child and family
health. They are experienced professionals who work as part of a
multidisciplinary team (Remote Area Nurses, Aboriginal Health Workers,
Medical Officers and Allied Health) and provide services in different settings,
at home, parenting groups, in a clinic or other community venues. They have
a vitally important role in supporting parents with infants and young children;
for many families they are the only link into health services. The role of the
child health nurse is to enhance child health and development by identifying
family strengths and risk factors, providing information and psychological
support, and working collaboratively to address specific family concerns.
The importance of the primary relationship between child and parent is being
increasingly understood, and evidence is emerging about effective
interventions to facilitate sensitive parenting strategies to enhance
relationships. The changing role of the father has prompted investigation into
how best to engage fathers with early childhood services to enhance family
relationships and developmental outcomes.
As the family has the greatest influence on a child’s health and development it
is essential that health services engage with and work in partnership with
families using a strengths-based approach to effect change in health
behaviour and health outcomes. Flexibility in service delivery will allow staff to
deliver care tailored to individual needs.
The Australian Institute of Health and Welfare (AIHW) released the fourth
comprehensive national statistical report “A picture of Australia’s children
2009”. This report provides information on child health, development and
wellbeing on a broad range of indicators, including health status. The
indicators are priority areas of children’s health where the identified conditions
are amenable to change by prevention and/or early intervention over time. A
number of the indicators that are specifically addressed within the child health
policy include breastfeeding, overweight and obesity, mortality, dental health,
physical activity and injury. 1
The child health policy and delivery of child health services will continue to
evolve in response to new evidence, societal changes, and the needs of the
children and families of Western Australia. Ongoing research in child health
care provision is essential and will continue to inform the future directions of
child health services. The child health services policy has been developed to
describe a clear direction for contemporary Child Health Services in Western
Australia.
Child Health Policy Rationale 2010
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2. Introduction
Since the 1920’s universal child health services in Western Australia (WA)
have had a key role in supporting and monitoring the wellbeing and healthy
development of infants and children 0-4 years of age. In the last decade there
has been overwhelming research evidence on the importance of the early
years and its impact on human development, which has seen a major shift in
the way child health services are delivered. There is increasing importance on
supporting parents to enhance their children’s cognitive, social and emotional
development, as well as their physical health. In addition, there is increasing
recognition of the need to respond to the social factors that are important
determinants of health outcomes, and which underlie health inequalities.
Child health services offer a universal schedule of child health and
developmental assessments and a range of other services which support
parents to care for their infants and young children. In addition, a range of
targeted and specialist services are offered as required. Included in the
universal assessments are: developmental assessments; screening and
surveillance; psychosocial assessments; information regarding parenting,
child health and development, child behaviour, maternal health and wellbeing,
child safety, immunisation, breastfeeding, nutrition and family planning.
Since the last update of the child health schedule in 2006, there has been a
critical review of the evidence informing best practice for universal family and
child health services and the development of a draft national framework for
family child health services in Australia. The changes in practice in are in
response to new evidence and are consistent with current national guidelines
and international practice.2, 3 The timing of the universal contact schedule will
remain at the key developmental ages of 0-10 days, 6-8 weeks, 3-4 months, 8
months, 18 months and three years.
The contact times are based on a series of principles including:
Aligning child health assessments against critical periods of a child’s
development
Offering more frequent contacts in the first 12 months to facilitate the
development of a relationship between family and child health service
and identify early health conditions that if left untreated are likely to
result in significant costs to the child and wider community e.g.
congenital eye conditions, hearing loss, developmental dysplasia of the
hip and un-descended testes, physical development, language
development, social and emotional development.
Provision of age-specific health information and targeted anticipatory
guidance
Promotion and/or provision of immunisation which is the most cost
effective public health intervention in preventing childhood morbidity
and mortality.
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The Vision
All Western Australia children benefit from quality child health services that
support optimal health, development and wellbeing
Objectives
The vision is achieved through the following objectives:
Promote the health and wellbeing of infants, young children and
families
Support parents/carers to optimise the health, wellbeing and
development of the infant/child through a comprehensive approach
including universal and targeted prevention, early detection, and early
intervention activities and appropriate referral systems
Identify parents, families and children who may require additional
support early to enable access to timely and appropriate interventions
Provide evidence informed information and support in response to the
individual needs of each family
Promote population health through preventing avoidable illness, injury
and disease
Provide parental peer support and community networking either on an
individual or group basis
Work collaboratively with other services to support children and
families.
In 2009, the Australian Institute of Health and Welfare released the Indicator
framework for “A picture of Australia’s children”, which includes the key
national indicators of children’s health, development and wellbeing. The
indicators are 19 priority areas of children’s health where the identified
conditions are amenable to change by prevention or early intervention over
time. A number of the indicators are specifically addressed within this
document including breastfeeding, overweight and obesity, mortality, dental
health, physical activity and injury. 1
Child health practice has undergone significant change in recent years.
Traditionally, nurses took the role of the expert, informing parents about child
growth and development, performing screening and surveillance activities,
immunising children and supporting parents with nutrition, sleep, and
behaviour management. Today, the focus has shifted to providing
preventative care within a population health and primary health care
framework. Nurses have moved away from the expert model and now work in
partnership with the families.
The family centred approach acknowledges that families have the biggest
influence on their children’s growth and development, and that parents have
expert knowledge about their own child. The role of the child health nurse is to
identify family strengths and risk factors, provide information and
psychological support, and work collaboratively with other agencies to
address specific family concerns with a focus on enhancing child
development. Child health nurses continue to perform screening and
Child Health Policy Rationale 2010
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surveillance activities for the purpose of early detection of developmental
issues and referral to appropriate services.
The universal schedule provides an entry point to the child health service for
all families, and is widely accepted by parents due to the non-stigmatising
nature of the service. The schedule contains elements of screening and
surveillance, delivered within a holistic approach to the child and family.
Individual and family needs are identified through nursing assessment and
appropriate strategies are implemented.
Children and families who have identified risk factors or specific issues to be
addressed are provided with additional interventions based on their identified
needs and/or referred to specialist services if available. The universal and
targeted approaches complement each other and families move between the
two streams as their needs and circumstances dictate. Examples of targeted
approaches include intensive home visiting delivered by child health nurses in
collaboration with the Department for Child Protection through the Best
Beginnings Program and the comprehensive schedule of contacts for
Aboriginal infants and young children with identified health and developmental
conditions.
3. General demographic information for children (0-4 years) in
Western Australia
Western Australia has experienced an unprecedented increase in population
with a 22% state-wide increase in the number of births between 2003 and
2009*, from 24493 to 29854 (Figure 1), a corresponding increase each year in
children aged 0 – 4 years and a significant increase in migration.
The greatest increase in the number of births has occurred in the metropolitan
region (Figure 2), with areas such as Wanneroo Local Government Area
(LGA) experiencing a 64% increase in the number of births and Peel and
Rockingham/Kwinana LGA’s experiencing a 49% and 53% increase
respectively. Although metropolitan services have been affected the most, WA
Country Health Services have also experienced rapid growth in the number of
births, with an increase of 30% in the Pilbara and 26% in the South West. This
increase in births has an immediate impact on current maternal and child
health and development services, and impacts on other resources such as
increased demand for childcare, primary schools and other services.
Western Australia has also had a population growth rate of 0.9%, well above
the National rate of 0.5% and highest among the States and Territories, with
an estimated resident population of 2,149,066 in the March 2008 quarter.4
Child Health Policy Rationale 2010
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Figure 1
Trends in the number of live births between 1995-2009 in Western Australia
34000
32000
Live births
30000
28000
26000
24000
22000
20000
1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009*
Years
Source: Department of Health, Midwives Notification System, 21 September 2010.
* Please note that 2009 birth numbers are preliminary.
Figure 2
Percentage increase in the number of live births in Western Australia from
2003-2009
30%
25%
24%
22%
20%
15%
15%
10%
5%
0%
Metropolitian
Country
State
Source: Department of Health, Midwives Notification System, 21 September 2010.
Birth notifications based on maternal region of residence
Figures rounded up to nearest whole number
Please note that 2009 birth numbers are preliminary
In addition to an increase in births, there has been a corresponding increase
in children aged 0 – 4 years (Figure 3). The number of children aged 0 - 4
years in WA increased by 17% between 2003 and 2009. There is
considerable variation between geographical areas, and there are particular
pressures in inner city suburbs of Perth and in the Pilbara (in connection with
the mining boom). For example in Victoria Park and South Perth LGA’s
Child Health Policy Rationale 2010
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experienced a 60% increase in the 0-4 population from 2003-2009 and
similarly in the East Pilbara there was a 63% increase.
Figure 3
Trend in the number of children aged 0-4 between 1995-2009 in Western
Australia
150,000
Population
145,000
140,000
135,000
130,000
125,000
120,000
115,000
1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009
Years
Source: Department of Health, Epidemiology Branch, 21 September 2010
ABS B Series Projected Population Estimates for WA adjusted using age, sex and SLA proportions
3.1 Future increase in population
When the increase in births and 0-4 population is factored into population
projections, it is estimated that there will be a 16% increase in the number of
children aged 5-9 between 2009 and 2015 (Figure 6). The 0-4 population is
also projected to increase 11% (Figure 7).
Figure 6
Population projections for the number of children 5-19 years from 2009-2015 in
Western Australia
165,000
Population
160,000
155,000
150,000
145,000
140,000
135,000
130,000
2009
2010
2011
2012
2013
2014
2015
Years
5-9 population
10-14 population
15-19 population
Source: Department of Health, Epidemiology Branch, 21 September 2010
ABS B Series Projected Population Estimates for WA adjusted using age, sex and SLA proportions
Child Health Policy Rationale 2010
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Figure 7
Population projections for the number of children 0-4 year from 2009 - 2015
in Western Australia
165,000
Population
160,000
155,000
150,000
145,000
140,000
135,000
2009
2010
2011
2012
2013
2014
2015
Years
Source: Department of Health, Epidemiology Branch, 21 September 2010
ABS B Series Projected Population Estimates for WA adjusted using age, sex and SLA proportions
4. Health Status of Children in Australia
In Australia, the overall health, development and wellbeing of children is high
on many indicators. Childhood mortality rates have halved over the last two
decades and the incidence of vaccine-preventable diseases has been
reduced following the introduction of immunisation programs. However,
concerns have emerged about health issues related to rapid social changes
and their associated new morbidities. There are increasing proportions of
children and young people with complex diseases such as asthma, diabetes,
overweight and obesity, increasing levels of behavioural, developmental,
mental health and social problems, along with the significant disparities
between Aboriginal and non-Aboriginal children.5
Many of the health and wellbeing problems seen in adults such as obesity,
diabetes, heart disease, mental health problems, family violence, poor
literacy, unemployment, and welfare dependency have their origins in
pathways that begin in early childhood.6
4.1 Health Status of Children in Western Australia
The overwhelming majority of WA children are healthy. However there are
sub-population groups of children in Western Australia who are at higher risk
of various health and developmental issues. These groups include children
with disabilities, children who have parents with mental illness or who misuse
alcohol or drugs, children who have backgrounds of socio-economic
disadvantage, geographical isolation, involvement with the juvenile justice
system, homelessness, culturally and linguistically diversity, and being born
prematurely, or of low birth weight. All these factors add to the diverse and
Child Health Policy Rationale 2010
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complex needs of children and their families, and the demands on services
that support them.
Aboriginal and non-Aborignial children are a particularly vulnerable group
evidenced by the over representation of Aboriginal children in prevalence
rates for nearly all health problems. The relative mortality risk among these
children has remained between 2 to 4.5 times higher than other children for
the past 20 years.7
In 2006 Aboriginal mothers represented 6.3% of women who gave birth and
Aboriginal women had birth rates on average almost twice as high as nonAboriginal women. Of births to teenage mothers, the proportion to Aboriginal
mothers was six times greater than for non-Aboriginal mothers. Children born
to adolescent mothers are at increased risk of being premature and of low
birth weight.
In 2006-07, 8.5% of the total births were premature (less than 37 weeks
gestation) and 6.8% of births were of low birth weight (weighing less than
2500 grams). Low birth weight infants face a higher risk of death within the
first year of life and have higher rates of disability, developmental delay and
disease than other infants. Trends indicate that the proportion of low birth
weight infants from Aboriginal mothers ranged between 13.1% in 1993 to a
high of 16.5% in 2005. In contrast, the proportion of low birth weight infants
from non-Aboriginal women ranged between 6.0% in 1994 and 6.6% in 2004.8
Children in the care of the Chief Executive Officer of the WA Department for
Child Protection (referred to as ‘children in care’) are a highly vulnerable group
with often complex and undefined health needs. They therefore often require
additional support from community health providers.
In 2009 in WA, there were 3,195 children in care of the Department of Child
Protection, a 16% increase in the last two years. The majority of these
children in care (52%) were under four years of age, with 22% less than one
year old, 30% aged one to four years, 25% aged five to nine years, 21% aged
10 to 14 years and 2% aged 15 or older. Forty-four percent were Aboriginal.
Living arrangements vary although home-based out-of home care is the most
common type of living arrangement across all ages.
National reports indicate that Australian children living in state care
experience poorer levels of physical, developmental, behavioural and
emotional health than those of the general child population.
5. Changing Family Structures in Australia
With the changing social attitudes towards marriage and fertility choices,
Australian families have changed dramatically in the last 30 years. The result
has been an increasing diversity of family types within which Australian
children are brought up. Throughout their lives, a number of children will
experience a change from living with two parents in residence to having only
one resident parent, while others will move from a lone parent family to a
Child Health Policy Rationale 2010
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situation where they have new family members. Some children may even
experience a number of family transitions before they reach adolescence.
These types of changes can impact significantly on children. A child’s
personal experience of family change can sometimes result in poorer health
and wellbeing, especially if changes to family structure are the result of a
family breakdown. However, child outcomes resulting from family change are
not always negative. Children who have been in a family environment of
conflict or abuse may experience positive outcomes following the transition.
The Australian Bureau of Statistics (ABS) categorises Australian families into
two broad groups: couple families which includes intact, step, blended and
other families and lone parent families. The dominant type of family in
Australia is still the couple family; however lone parent families are becoming
increasingly common particularly over the past three decades. This has
resulted in an increasing number of women acting as the main parent
responsible for both childrearing and income support.9
According to the ABS in 2006, the living arrangements for children under 15
years old were:
74% lived with both of their biological parents.
18% lived in a lone-parent family. Of these children, 88% lived with
lone mothers.
6% lived in a step- or blended family.
A small proportion of children (less than 1% or approximately 28,100)
aged 0–14 years lived with grandparents.
Other significant statistics affecting family structures includes the number of
women giving birth when at least 30 years old (which has increased in recent
decades), and this group is also increasingly likely to be first-time mothers.
The impact on families of global recession and changing employment can
significantly affect family structures. In 2003, in couple families where the
youngest child was under the age of 15 years, at least one parent was in
employment in 94% of families. In 59% of families where the youngest child
was under 15 years of age, both parents were employed. In lone mother
families where the youngest child was under 15, nearly 55% of mothers were
not employed in 2003. In lone mother families where the youngest child was
aged 0–2 years, only 28% of mothers were employed.9
Perhaps the most significant shift affecting family structure is the rise in
maternal employment. The rate of maternal employment has a direct bearing
on the number of children spending some time in non-maternal child care,
estimated at 50% in 2006. As a consequence, maternal employment has also
resulted in greater participation of fathers in childrearing.9
In, Western Australia the resources boom has increased the numbers of
families who are involved in fly in fly out (FIFO) work and lifestyles. Recent
studies of FIFO note that most families are resilient and generally manage to
negotiate the challenges of this lifestyle. However there are some families
Child Health Policy Rationale 2010
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who may have mental health or other illnesses where the stress of this
lifestyle only exacerbates the problem and diminishes coping skills.10
Changes in family structure and the conditions under which families are
raising children create significant challenges for existing child health services.
There are more single parent families, blended families and shared custody
arrangements and parenting has become more complex for a number of
reasons. Many families have less exposure to parenting role models and
reduced support from extended family networks; therefore they may rely on
child health services to offer this support.
Changing work patterns mean that there are more parents, (including mothers
with infants) doing shift work and non-standard hours and it is likely that
father’s or other relatives may attend child health services. The other reality is
parents are also going to be less likely to be able to attend child health
centres during normal business hours because of working commitments.
Therefore, services need to consider alternate methods to accommodate
families such as out of hour’s sessions or other community venues where
parents and children congregate such as playgroups and early childhood
centres.
Implications for child health practice
The following examples are not an exhaustive list, but may help staff consider how
best they can provide services to meet the needs of families in their communities:
Provide father friendly facilities – display positive images of fathers at child
health centres, offer parenting groups for dads only and offer sessions at
appropriate times and venues for fathers
Contacts with families maybe offered in alternative settings and formats such
as drop in centres, group sessions, telephone calls, emails, providing health
promotional information via website or text messages, and meeting parents
outside the home in alternative community venues such as playgroups and
sporting clubs
Offer services during extended hours, i.e. Saturday mornings or evenings
during the week
Offer services in other settings such as childcare, early years learning
centres in schools, Aboriginal community controlled health organisations,
women’s refuges, or other service locations such as shopping centres
Offer services and supports to ‘children in care’ which are responsive to their
additional health needs.
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6. Emerging Themes (Child)
6.1 Childhood obesity
Childhood obesity has been identified as a major public health issue both
nationally and internationally.1, 11 Childhood obesity is a preventable disease
that has significant short and long term effects on a child’s health and
development. Short term effects on mental health include poor body image,
disordered eating, low self esteem and bullying. Physical health issues
experienced by overweight or obese children can include asthma, sleep
apnoea, raised blood pressure and type 2 diabetes.12 In the long term,
children who are overweight or obese are more likely to remain obese in
adulthood.
Rates of overweight and obesity among WA children have nearly trebled over
the last two decades, making the future adult population at much higher risk of
glucose intolerance, type 2 diabetes, heart disease and hypertension.13
Childhood obesity is a multi-faceted condition that occurs because of the
interplay between environmental, genetic and social conditions. An
individual’s risk factors can be identified. Parental obesity is the strongest
predictor for a child’s risk of obesity. Significantly, only three percent of
overweight or obese children have parents who are not overweight or obese. 3
Genetics and ethnicity contribute to obesity. Children from Middle-Eastern,
Mediterranean, Pacific Islander and Aboriginal backgrounds have a higher risk
than others.14 Lower socio-economic status is a risk factor as there appears to
be an inverse relationship between income and education level and obesity.
Maternal factors that increase a child’s risk of obesity are maternal smoking
and maternal obesity before or during pregnancy. Growth patterns associated
with an increase risk of obesity in adolescence and adulthood are being born
small or large for gestational age at birth, or being born small and having a
rapid catch-up growth in infancy. Feeding patterns that contribute to obesity
are early cessation of breast feeding, prolonged bottle feeding past 15 months
of age, and the increased maternal control over a child’s food intake, that
occurs when mothers have difficulty in allowing children to self-regulate their
dietary intake.
Because of the complex nature of childhood obesity, treatment options need
to address many factors. Conventional weight management strategies for
adults involve decreasing energy intake and increasing energy expenditure by
increasing physical activity, behaviour modification and family involvement. 13
There is some evidence to suggest that programs using these strategies have
some success with children over the medium to long term. Research also
indicates that involvement of parents in the programs improve outcomes.
However, due to lack of successful evidence based treatment programs and
the burden of disease on individuals and society, primary health care efforts
are directed into prevention, early detection and referral to treatment.
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Prevention of childhood obesity requires a whole of population and a whole of
family approach. From the first contact with families, child health nurses
promote adoption and maintenance of healthy lifestyles. Child health nurses
are well positioned to identify children at risk, promote preventative strategies,
identify overweight or obese children, and work sensitively with parents to
make lifestyle changes to address their child’s health issues.
Promoting physical activity is an obesity prevention strategy. The national
physical activity guidelines recommend that infants have daily opportunities
for active play time and are offered a range of activities to stimulate their
senses and encourage physical development.14
From one to five years, it is recommended that children have at least three
hours of physical activity over the course of every day. Play should be varied,
allowing the children to develop fine and gross motor skills, balance and coordination, muscle strength, and social and intellectual skills.15
There is a link between screen time, (that is time spent watching television
and using computers and playing electronic games), and the development of
obesity. Excessive television viewing can impact on the development of
vision, especially regarding the range of eye movement, and it can impact on
the child’s concentration span.
It is recommended that children under two years do not watch any television,
and children aged between two and five years of age have a maximum of one
hour of screen time per day, including using computers and playing electronic
games. 16
Early detection of obesity is essential to improve life outcomes for affected
children. Research findings indicate that the critical period for preventing
childhood obesity is during the first two years of life. Childhood obesity is a
sensitive issue, and one that parents and health carers may find difficult to
address. The reluctance of parents and health care professionals to identify a
child as suffering from overweight or obesity is a barrier to the child and family
receiving appropriate intervention. Offering universal growth assessments as
oppose to offering targeted assessments reduces the stigma associated with
a targeted assessment, and provides an opportunity to start a discussion,
provide a brief intervention and referral.17
Implications for child health practice
In the antenatal period:
Wherever possible (some child health nurses may come into contact
with pregnant women at antenatal education or attending centres with
older siblings), provide nutrition information to mothers and fathers in
the antenatal period to promote a healthy diet and healthy weight gain.
Parents who are overweight or obese maybe identified in the antenatal
period and may need extra support and encouragement to maintain a
Child Health Policy Rationale 2010
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period and may need extra support and encouragement to maintain a
healthy lifestyle
Promote breastfeeding
Support parental efforts to cease smoking including referral for brief
interventions.
In the early postnatal period:
Support and encourage breastfeeding, with an emphasis on exclusive
breastfeeding for the first six months. Refer women with breastfeeding
problems to appropriate health care professionals
Provide parents with healthy eating guidelines in the initial post-natal
period as this is a critical time for making changes. The birth of a new
baby provides an opportunity for parents to review their own eating and
lifestyle habits, to decide whether this correlates with their future
expectations for their children and to consider making changes. It is
important to acknowledge the role and influence of the child’s father
and include him in discussions about nutrition
Support parental efforts to cease smoking
Encourage parents to exercise regularly within the national physical
activity guidelines and to allow infants to have unrestricted floor time
when awake and content.
Introducing complementary foods and beyond:
Encourage parents to delay the introduction of solids until around six
months, and to maintain breastfeeding until twelve months and beyond
Encourage parents to offer a variety of foods, allow the child to eat to
satiety and respect the child’s signals that the meal has finished
Discuss nutrition at every scheduled contact. Provide information and
anticipatory guidance regarding changing feeding patterns related to
normal growth patterns and development
At the 18 month assessment weigh and measure all children seen at
this contact, if there are any parental or nurse concerns refer to
specialist services
Incorporate nutritional and physical activity information into toddler
education session
Promote national physical activity and nutrition guidelines and
recommended screen times
Discuss the importance of parental role modelling healthy eating and
physical activity behaviours for their children
Discuss the negative impact watching television has on development,
and the relationship between screen time and childhood obesity
Identify families in need of more support and provide support as
appropriate. Refer to other agencies or health professionals as needed,
e.g. GP or community dietician.
Child Health Policy Rationale 2010
16
6.2 Dental Health
Early childhood is a critical time for the development of healthy dental habits
that can last a lifetime. There is an increasing awareness of the impact of oral
health on growing children and mature adults. Good dental habits can prevent
decay, teeth loss, infection and gum disease. There is a growing body of
evidence to link periodontal disease with cardiovascular disease and
diabetes.18
Despite dramatic improvements in children’s dental health over the last thirty
years in Western Australia, there is still an unacceptably high level of dental
decay detected in pre-school children. Over forty precent of six year olds have
decayed deciduous teeth or early childhood caries (ECC). 19 Dental decay is a
preventable disease, and one of the national headline indicators.
Healthy deciduous (“baby”) teeth are necessary for normal speech and jaw
development, good nutrition, maintaining the space for permanent teeth and
development of positive self image.
Consequences of dental decay for children are pain, infection and admission
to hospital to have dental surgery under general anaesthetic.20 Additionally,
children with ECC have altered growth patterns because they have difficulty
sleeping due to pain and infection, and their quality of life is decreased. 21
Cognitive development can be impeded due to difficulties with comfort,
nutrition, concentration and school participation.20
ECC is considered to be a severe and rampant disease of the primary teeth
that begins immediately after tooth eruption. It is a multi-factorial disease with
a complex aetiology, but it is notably a disease of social disadvantage.22
Contributing factors are prematurity, prolonged bottle or breast feeding,
frequent consumption of sugary snacks, paediatric syrups, lack of fluoride
toothpaste, transmission of bacteria from a parent to child’s mouth and poor
paternal oral hygiene.21 Prevention and management of dental disease
requires a holistic approach.
Treatment varies according to the stage of the disease, but if detected early,
treatment may be simple and effective. Early intervention limits the impact of
the disease as well as cost and length of treatment. Effective interventions
should occur in the first two years of a child’s life, however despite
recommendations that children should attend a dentist at around twelve
months of age, before the age of two years is uncommon.
Prevention of ECC starts with pregnancy, and all pregnant women should be
encouraged to visit their dentist during pregnancy. Dental education by child
health nurses begins in the early days with encouragement and support of
breastfeeding, and discussion of oral care and sound dietary habits.
Anticipatory guidance is given at scheduled contacts regarding care of teeth,
dietary recommendations and timing of dental visits. Infants and toddlers
should attend the dentist regularly, commencing around the first birthday.
Child Health Policy Rationale 2010
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Implications for child health practice
Offer oral health information to parents at all scheduled contacts
including encouraging breastfeeding, discussion of oral care (care of
teeth), dietary recommendations and timing of dental visits
Offer the ‘Lift the Lip’ program which includes oral examination of the
child and parent teaching at the scheduled visits of 8 months, 18
months and three years
Referral as indicated. (Children whose parents hold a health care
concession card and require treatment can be referred to the local
government dental health service for assessment and treatment. All
other families; encourage to seek private dental care where it is
indicated).
6.3 Injury and Preventable deaths
6.3.1 Sudden Unexplained Deaths in Infancy and Co-Sleeping
The number of Sudden Unexplained Deaths in Infancy (SUDI) in Australia has
decreased by over 80% from 526 in 1984 to 87 in 2005. However, Aboriginal
infants were found to be nearly eight times more likely to die from SUDI than
non-Aboriginal infants. With the overall decline in numbers of SUDI deaths,
attention has now turned to explained deaths and in particular sleep accidents
due to unsafe sleep environments. There is evidence that co-sleeping is
associated with a greater incidence of SUDI where certain factors are also
present.
During 2008, Child and Adolescent Community Health assisted the Women’s
and Newborns’ Health Network to develop a co-sleeping/bed-sharing
Operational Directive for all health professionals in maternity and community
health settings. The aim of the operational directive is to:



ensure the safest possible sleeping environment for parents and infants
ensure that parents are provided with all the information to make an
informed choice
reduce the risk of SIDS associated with co-sleeping.
Implications for child health practice
Strategies used within child health practice to help parents identify modifiable
risk factors for their child were revised in 2012 in response to Ombudsman’s
recommendations. The child health nurse will complete an assessment at the
universal postnatal contact to determine if parents and caregivers are
demonstrating appropriate SUDI prevention behaviour. The assessment will
vary depending on where the first contact takes place i.e. home visit, centre
visit or other community setting. The following questions about safe sleeping
Child Health Policy Rationale 2010
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practice will be asked at each universal contact up to and including the 8
month contact, and have been included in the Personal Health Record.
Is your baby placed on his/her back for sleeping?
Is your baby’s head and face uncovered for sleep (No
beanie/bonnet/hood/loose blankets/toys/pillow/cot bumpers)?
Does your baby have a safe sleeping space, day and night (safe cot/safe
mattress/safe bedding)?
Does your baby have his/her own sleeping space (eg cot) in your room?
Does your baby sleep with you?
Do you provide a smoke free environment for your baby?
Are you breastfeeding your baby?
For further information about co-sleeping, please refer to operational directive
0139/08
http://intranet.health.wa.gov.au/circularsnew/pdfs/12410.pdf
6.3.2 Injury Prevention
As infants grow and develop, they are at increasing risk of accidental injury
due to a number of factors. Children have little experience of the world, and
consequently are not able to anticipate danger. Their natural curiosity leads
them to experiment with every thing around them. They lack physical strength
and physical skill to manoeuvre out of danger. Children also develop new
skills at a rapid rate, often beyond their carer’s expectations. Parents and
carers learn through experience that their children require constant
supervision to prevent accidental injury.
Childhood injuries in Western Australia are responsible for an average of thirty
deaths per year.23 The 2007-2008 Western Australian Child Injury
Surveillance report noted that the rate of injury remains consistently high, with
over 12,000 children presenting to Princess Margaret Hospital Emergency
Department for treatment of injures. The majority of these injuries are
accidental.24 Injury has been identified as a national headline indicator,
because injuries are largely preventable through implementation of effective
strategies.
As over half of childhood injuries occur within the home parent education is
focussed on encouraging parents to provide a safe home environment. 24 Key
areas in the home are the living room, bedroom and kitchen. When visiting
other homes, children are likely to be injured in the living room or yard. 23
Drowning is the most common cause of preventable death in Australian
children in the birth to four year age group. Nurses are ideally placed to
promote pool and water safety strategies and encourage parents to learn first
aid.
It is a core role for child health services to provide parent education about
child development and give anticipatory guidance to parents highlighting
common dangers and injuries at specific ages and inform about preventative
Child Health Policy Rationale 2010
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strategies e.g. promote pool and water safety strategies, encourage parents to
learn first aid and the poisons information line. Safety education begins with
the first contact, and is incorporated into every scheduled contact and maybe
offered individually or in group settings such as postnatal parenting groups or
seasonal promotion campaigns in conjunction with Kidsafe.
Implications for child health practice
No change in current practice
7. Emerging Themes (ADULT)
7.1 Parental Mental Health
Parental mental health impacts on a child’s health and development. Parents
who are capable of nurturing and sensitively parenting their children provide
the optimum emotional climate for secure attachment and all the long term
benefits that result. When parents suffer from poor mental health related to
anxiety and depression in the perinatal period, the impacts on a child’s health
and emotional, cognitive and social development can be significant.
Child health services have an important role in assessing parental mental
health status, informing parents about and implementing strategies to promote
good mental health, identification of risks for and/or current emotional distress
and making appropriate referrals in accordance with local referral pathways.
Parental mental health should be assessed by clinical observation and
enquiry, at every visit and the findings should be documented in the child
health records.
The common serious mental health issues faced by parents are antenatal
anxiety, antenatal depression, post-natal anxiety and post-natal depression.
These conditions are not exclusive to each other. Research indicates that
when a parent experiences both anxiety and depression, the effects on their
child’s development can be magnified. 25
The incidence of perinatal anxiety is not clear, however some studies have
shown anxiety is more common than postnatal depression. 22 Continuous or
high levels of anxiety can be debilitating and indicative of an anxiety disorder.
Where parents are identified as experiencing persistent heightened feelings of
anxiety or panic, the child health nurse should explore the issue and refers the
parents for assessment and treatment as per local pathways. Perinatal
depression can have significant effects on the family functioning and infant
outcomes. It has been estimated that 10% of pregnant women in Australia
experience antenatal depression and 16% of women in Australia experience
postnatal depression. Estimates of paternal postnatal depression (PPD) range
from 1.2%- 25% in community samples, and from 24% to 50% in among men
whose partners were experiencing PND. 26, 27
Child Health Policy Rationale 2010
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There are a number of ways that postnatal depression affects child
development. A depressed carer may be less available to sensitively meet the
infant’s attachment needs and this can impact on the infant’s socio-emotional
development and well being. Depression may also hinder a carer’s ability to
meet the infant’s needs for nutrition, safety, development and health
promoting behaviours. There are longer term impacts on healthy
development, behaviour and school readiness Risk factors that predispose
women to postnatal depression are:
past history of depression, especially perinatal depression
strong family history of depression
past history of abuse or dysfunctional family
little social support
having a preterm or sick baby
long term difficulties with partner
traumatic birth experience
adverse life events
changes in work or financial circumstances.
Maternal depression has been identified as the most important risk factor for
paternal depression in the perinatal period. Ecological risk factors that
predispose fathers to postnatal depression are: excessive stress from
becoming a parent, lack of social supports for parenting, and feeling excluded
from mother - infant bonding.27 Biological factors that may influence paternal
mental health are changes in fathers’ testosterone, oestrogen, cortisol, and
prolactin levels observed to occur in men during the last months of a
pregnancy and the post-partum period.27 More research is needed to explore
the impact of hormonal changes on men’s mental health in the perinatal
period.
Preventative strategies include enhancing social connections, providing
parenting education and skills programmes, encouraging parents to take care
of their physical health and encouraging people to talk about their feelings and
to seek help from professionals when needed.
7.1.1 Screening and Assessment
As with other treatable conditions, the role of child health services is to offer
universal screening for early recognition of a possible condition (anxiety and /
or depression) and refer parents for further clinical assessment, diagnosis and
treatment. Diagnosing mental health conditions lies outside the scope of child
health practice. However, child health nurses are ideally placed to provide
ongoing support for parents, even if they are accessing other professional
help.
The most appropriate tool to use is the Edinburgh Postnatal Depression Scale
(EPDS). The EPDS is a validated tool that has demonstrated high reliability
and specificity as an indicator of significant depressive symptoms. In addition,
scoring of the subscale of questions 3, 4 and 5 can indicate the presence of
anxiety.28
Child Health Policy Rationale 2010
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The EPDS measures self-reported mood in the last seven days prior to the
scale being administered. It does not predict future emotional status, and it
does not generate a diagnosis, (diagnosing medical conditions lies outside the
scope of nursing practice). The EPDS does indicate the need for further
assessment and/ or intervention. Using the EPDS often encourages parents
to talk about their feelings, and may elicit areas of concern to the parents. The
score is interpreted in the context of the parent’s appearance, behaviour and
self report of how they are managing daily life.
In consultation with the Western Australian Perinatal Mental Health Unit
(WAPMHU), child health services have adopted new recommendations
regarding the timing and frequency of screening for mothers and new cut off
scores (3.8.4 guidelines for EPDS use). These changes are in line with the
National Perinatal Depression Initiative Framework National Guidelines. The
WAPMHU has also developed a referral pathway for use with the EPDS.
Further information can be accessed via the link below:
http://wnhs.hdwa.health.wa.gov.au/wards__and__depts/psychological_medici
ne_ccu/perinatal_mental_health/publications__resources
Implications for child health practice
Universal
All mothers must be offered the opportunity to complete an EPDS at the
six to eight week contact, and the 3-4 month contact and at any time when
there are clinical indications or the mother reports changes in affect. (Refer
to the updated guidelines for interpreting the score when using an English
language version of the form)
Provide additional support and/or early interventions i.e. group
interventions or refer to specialist services e.g. General Practitioner,
Mental Health Services.
Using translated versions of EPDS for families from Culturally and Diverse
Backgrounds
Translated EPDS forms are available in many languages –
approximately half of the translated versions have been validated by
research and each translated version has a recommended cut-off mark
applicable to the postnatal period.
Fathers:
Child health services may consider offering fathers an EPDS if he is
present at the contact, has clinical indications, or reports a change in
affect and there are services available to support - A score of 6 or
above for men indicates a high risk of depression 28
Child Health Policy Rationale 2010
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Refer to specialist services e.g. General Practitioner, Mental Health
Services.
7.2 The role of fathers
The importance of fathers and the role they play in their children’s’ lives is an
area of increasing interest. A growing body of evidence highlights the
important role a father plays in his children’s physical, cognitive, social and
emotional development. The role of fathers is evolving from the traditional
protector and provider role to that of a more involved parent who meets his
child’s social, emotional and educative needs.29
There are particular groups of fathers that have been identified as more
vulnerable in their parenting role. Young fathers, separated and divorced
fathers may need more support to remain engaged in their children’s lives.
Changes in working arrangements, a greater emphasis on work-life balance
and the number of fly in fly out families in WA has seen an increase in the
number of fathers attending child health centres with their children.
Child health services have traditionally focussed on the needs of children and
their mothers. In line with the family partnership approach to child health and
in light of the changing role of fathers, there is a need for the child health
service to become more father-inclusive. The ‘father inclusive’ approach
occurs when the needs and perspectives of fathers are incorporated into the
planning, development and delivery of services. For services aiming to
support families, bringing fathers into everyday activities is a crucial part of
inclusive practice.
Implications for child health practice
Recommended strategies for engaging fathers include:
Working from a strengths-based perspective that recognises fathers’
aspirations for their children’s wellbeing and the experience, knowledge
and skills they contribute to this wellbeing
Develop an understanding of the role and impact of fathers, including
separated fathers, father figures and step fathers
Invite fathers to be present at the home visit and attend appointments
and groups
Use the terms “dads and mums” instead of “parents” as many fathers
assume that “parents” refers to mothers only
Be flexible in service delivery, offer appointments when fathers are able
to attend.
7.3 Alcohol and Drug use
Offer father only sessions and display positive images of fathers
Use islanguage
and Australians
analogies that
fathers
can and
relate
to (sporting,
Alcohol
used by many
in social
situations
for relaxation
and
mechanical, workplace)
Work in collaboration with other agencies.
Child Health Policy Rationale 2010
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Alcohol is used by many Australians in social situations and for relaxation and
enjoyment. However, there are specific situations where alcohol use is not
recommended such as pregnancy and during the establishment of lactation.
The 2009 national guidelines for safe alcohol consumption recommend no
alcohol use during pregnancy to prevent the development of foetal alcohol
spectrum disorder, (FASD) as safe drinking levels during pregnancy have not
been established.30 FASD has lifelong effects on an individual’s personal,
social and educational success. All pregnant women should be advised that
no alcohol during pregnancy is best. For post-natal mothers, giving this
information may prevent harm in a future pregnancy.
It is recommended that mothers who are breastfeeding do not consume
alcohol, particularly in the first month. Alcohol is present in the breast milk at
levels similar to the maternal blood alcohol level, and dissipates at
approximately the same rate. Infants who are exposed to alcohol can feed
poorly, and have difficulties settling, resulting in maternal engorgement and an
over tired baby. Alcohol can inhibit the let down reflex and reduce milk supply.
31
Recognising that some breastfeeding women will continue to drink alcohol;
there are recommendations for harm minimisation e.g. timing alcohol
consumption to just after baby has had a feed and limiting alcohol to two
standard drinks on any occasion. Mothers who consume three or more drinks
in one occasion may become under the influence of alcohol and not be able to
properly care for their baby at that time.
Alcohol and drug misuse are common issues in the general population.
Misuse can be defined as use that causes social, physical, or psychological
harm to the user and their families. It is estimated that approximately ten
percent of children live in a household where there is parental alcohol abuse
or dependence and/or substance dependence.32
The results of alcohol and drug misuse to the individual and their family may
include physical harm and health issues, child protection issues, family and
domestic violence, disrupted relationships and ineffective parenting, and
separation of children and parents through breakdown of parental and family
relationships and incarceration. Children may become socially isolated, blame
themselves for parental problems and develop problems of their own. Parental
alcohol misuse may impact on child’s health and development because of
their inability to provide a safe, secure environment for the children.
Thorough history taking is important, and asking questions about alcohol and
drug use can be asked in a health context, along with enquiries about general
health, diet and exercise. When a child health nurse has identified that
parental alcohol or drug use may be impacting on the child, addressing the
following points (developed by Tunnard), may give more insight into the
family’s situation and assist decision making:33
Child Health Policy Rationale 2010
24
Develop an understanding of the place of alcohol in the life of the
parent. Ask questions to determine how much alcohol, when, with
whom, in what circumstances?
Examine the effects of alcohol on the parent and on their availability as
parents and on their expression of affection, control and discipline.
Assess the effects on the child of this style of parenting, assessing
how well the child’s needs for basic care, protection, stimulation and
love are being met?
Does the parent have to provide for all of the child’s needs or are
others available to share this responsibility?
Implications for child health practice
Wherever possible (some child health nurses may come into contact
with pregnant women at antenatal education or attending centres with
older siblings), advise pregnant women that no alcohol during
pregnancy is best
Ask parents about any drug or alcohol concerns at the universal
postnatal contact - The safety and well being of the child is the primary
consideration.
Strategies that may assist families are:
Encouraging parents to make safety provision if they are planning to
use drugs or alcohol e.g. that the child is in the care of a responsible
adult
Providing parenting support and education
Assisting families to engage with parent support services, in particular
the use of in home care is helpful to help parents to establish routines
and boundaries
Encouraging parents to seek counselling for their relationship issues if
there is discord in the parental relationship
Facilitating quality childcare and educational opportunities for children,
working with families to improve social and behavioural skills. The
circle of security model may be particularly useful in working with these
families
Taking a collaborative approach and working with other agencies to
support the family
Identifying and supporting a key figure (e.g. grandparent) to support the
child. This may include referral to other agencies
Referring the parent to a drug and alcohol service as needed.
7.4 Family and Domestic Violence
Family and domestic violence is a serious public health issue that has long
lasting physical, psychological and emotional consequences for the people
involved. Family and domestic violence (FDV) can be defined as the ongoing
Child Health Policy Rationale 2010
25
and purposeful use of physical, emotional, social, financial and/or sexual
abuse tactics that intimidate and instil fear. Such tactics enable the one
partner to control and have power over the other partner, and any dependant
children in an ‘intimate’ relationship. 34
FDV occurs in all strata’s of society, cultures and religions. Over ninety
percent of the victims of FDV are women and children. It is estimated that one
in four women who have ever been in a married or defacto relationship have
suffered from domestic violence at some time during the relationship.35
Aboriginal women and children have higher rates of family and domestic
violence than non-Aboriginal women and children. Pregnancy and early
parenting are peak times for first episodes of violence.34
The effects of FDV on victims ranges from serious physical injuries requiring
hospital care, chronic fear and anxiety and periods of acute psychological
distress and death in some instances. Parents who are experiencing violence
are often unavailable to meet their children’s needs, and children suffer from
neglect.
FDV crosses all generations. When children witness violence in the home, it
can have short and long term effects on their emotional, social and intellectual
development. They are more likely to exhibit behavioural and emotional
problems than children from non-violent homes. Children who are exposed to
family violence are more likely to be victims of physical abuse and sexual
abuse than children from non-violent families. They are also more likely to be
perpetrator or victims of FVD as adults.
Child health services are ideally placed to offer early detection and
intervention with individuals suffering FDV. The universal nature of the service
means that it is non-stigmatising and widely accepted by parents. Child health
staff are highly trained and able to discuss sensitive issues including drug and
alcohol use with parents, and have the skills to include FDV as part of their
routine family health assessment.
By routinely asking all mothers about their safety at the first universal contact
and at any other time if indicated, child health staff can create awareness of
FDV, provide women with an opportunity to disclose their situation and be
heard and believed, and can assess present danger to parents and children if
there is a disclosure of FDV. Child health staff are able to provide nonjudgemental and respectful support, appropriate information and referral to
crisis and non-crisis counselling. However, if there are concerns for the safety
of the child/children this takes precedence and the nurse has a responsibility
to report the matter to the Department for Child Protection.
Assessing family safety is done through a combination of observation and
asking specific questions in a sensitive manner. Signs that may indicate family
domestic violence are physical injury, emotional state of family members,
body language, developmental delay, restriction placed on the ability of the
mother to move freely around the home and the freedom to attend child health
services on her own.36
Child Health Policy Rationale 2010
26
When asking direct questions about family safety, it is essential to ensure that
the woman’s partner is not present or within hearing range. It is advisable to
preface the questions with a short explanation indicating that all mothers are
asked these questions. If the mother requests assistance, refer to local
support services, explore her social supports, encourage the development of
a safety plan and if there are any concerns about the safety of the
child/children, report the matter to the Department of Child Protection.
Implications for child health practice
Routinely ask all mothers the following questions about their and their
children’s safety at the first universal postnatal contact
 Are you in any way worried about the safety of your children?
 Are you afraid of anyone in your family?
 Has anyone in your family ever pushed, hit, kicked, punched or
otherwise hurt you?
 Would you like some help with this now?
If there are any concerns for the safety of the child/children, report the
matter to the Department for Child Protection.
Refer the parent to support services as needed.
7.5 Child Abuse and Neglect
Child abuse and neglect affects a small but significant proportion of children in
our society at any time. Child abuse and neglect can be defined as the harm
or likely harm experienced by a child as a result of the action, or inactions, of
an adult who has care responsibility of the child. 37 Abuse can be physical,
emotional, psychological or sexual. Being subject to abuse or neglect can
have detrimental effects on a child’s development and wellbeing, including
higher rates of alcohol and drug issues, criminal behaviour and poor academic
achievements in adolescence. Adults who were abused in childhood often
face difficulty parenting their own children.
Children under three years old are at higher risk of neglect and sustained
physical abuse, particularly in the first year of life. Older children are at higher
risk of sustained sexual abuse.37 Children with disabilities have a higher risk of
abuse, particularly those with hearing impairment and severe physical and
intellectual disabilities. Aboriginal and Torres Strait Islander children are at
higher risk than non-Aboriginal children.
Family factors that may contribute to abuse or neglect are low socioeconomic
status, crowded dwellings, poverty, residential instability, alcohol and drug
use, domestic violence, intellectual or psychiatric disability. Affected families
often have complex needs.
The Department of Health (DOH) recognises the right of every child and
young person to live without fear and violence in their families and
communities.37 DOH employees are obliged to take action if they become
Child Health Policy Rationale 2010
27
aware of children who are at risk of, or have been subject to abuse and
neglect. Staff are required to act to promote the safety and well being of
children and young people, and if necessary, to make reports to the
appropriate authorities, such as the Department for Child Protection and the
WA Police.
Child health nurses have always had a duty of care to children and young
people in regards to abuse, neglect and domestic violence. Legislation was
introduced in 2009 that formalised procedures regarding reporting of sexual
abuse to the relevant authorities. Nurses, midwives, and doctors are now
mandatory reporters of suspected cases of child sexual abuse and are at risk
of incurring penalties if they fail to discharge their obligations.
Further information can be accessed via the following link:
http://www.health.wa.gov.au/mandatoryreport/docs/2193CHILDABUSEGUIDE
LINES.pdf
Implications for child health practice
With the introduction of the Legislation in 2009 that formalised
procedures regarding reporting of sexual abuse to the relevant
authorities. Child health nurses are now mandatory reporters of
suspected cases of child sexual abuse and are at risk of incurring
penalties if they fail to discharge their obligations.
8. Health and Developmental Surveillance
8.1 Physical Health
Physical health checks are still included in the universal schedule @ 6-8
weeks and 8 months to identify health issues and problems that would benefit
from early intervention or treatment. A full physical assessment should include
examination and assessment of the infant e.g. head shape and size, eyes,
mouth, skin colour and texture and body shape. Physical examinations also
provide an opportunity for health professionals to observe the child's
behaviour, (assessing social and emotional development), observe parents
interaction with the child, reassure parents by normalising behaviour, identify
delays and provide anticipatory guidance. Physical examinations may also
indicate signs and symptoms of child abuse or neglect and a secondary
outcome is the opportunity for the health professional to model appropriate
and responsive handling and interaction with the child.
Implications for child health practice
No change in current practice
Child Health Policy Rationale 2010
28
8.2 Vision
Vision is vital for the optimal development and wellbeing of children as it
affects both physical and psychosocial areas of development such as motor
skills and parent - infant interaction. Vision matures over the first year of life
and any condition that interferes with the exposure of the retina to focussed
images will impact on a child’s development. Eye examinations and screening
in infancy are performed to detect serious conditions including congenital
cataracts, congenital glaucoma, retinoblastoma, corneal opacity, hypheama,
vitreal opacity and retinal disease. More common conditions that may be
detected include conjunctivitis, mild cataracts, corneal abrasion, amblyopia
and strabismus and unequal refractive errors.
The National Children’s Vision Screening Report (2009 – not yet released)
recommended:
The Red Reflex test be carried out on all newborns as part of a
universal health check
An eye-health professional (optometrist, orthoptist, ophthalmologist) is
responsible for further evaluation where indicated
Children considered at increased risk (including those born
prematurely, with disabilities, or Aboriginal children in remote
communities) require an in-depth assessment even if they are
checked in the universal screening program
All Australian children be offered vision screening in the year prior to
commencing school. The most appropriate age for visual acuity is
when a child is four years old (range of 3.5 to 5 years of age).38
Implications for child health practice
Review of procedural guidelines in 2013 in relation to vision screening have
resulted in the following recommendations:
Red Reflex Test and Corneal Light Reflex Test to be performed at each child
health universal contact.
8.2.1 Targeted assessments
Additional vision assessments and screening should be conducted for any
child with the following risk factors: maternal antenatal infection with rubella,
cytomegalovirus, toxoplasmosis, syphilis, and herpes or any other illness with
a fever or rash, prematurity, low birth weight, children who have a family
history of congenital cataracts, retinoblastoma and metabolic or genetic
disease, Aboriginal children in remote communities and/or children with
multiple disabilities. Any parental or professional concern or unusual
behaviours such as abnormal head movements and posturing, indicates a
need for further investigation.
Child Health Policy Rationale 2010
29
Implications for child health practice
Distance vision testing using the Lea Symbols Chart and Cover Test may be
performed as a targeted assessment from three years onwards, where there
is a professional or parent concern, or a relevant family history. If there is any
concern, children should be referred to a general practitioner, paediatric
ophthalmologist or optometrist for further assessment.
8.3 Hearing
Development of hearing behaviours is important in the development of
language and speech acquisition. Listening and hearing is conducive to how a
child will learn to communicate through hearing and observation. Effects of
hearing loss can also adversely affect later education achievement. The
severity of these effects will depend on a range of factors including which
include age of onset, type of hearing loss, degree of the loss, age at
identification and other contributing factors such as developmental delay.
Permanent congenital hearing loss (PCHL) occurs in one or two infants per
1,000 births and has serious impacts on a child’s development.
Newborn hearing screening leads to earlier identification and intervention, and
ultimately leads to better language development. In the absence of newborn
hearing screening, three out of four children with PCHL remain undiagnosed
by 12 months and their capacity for normal language and cognitive
development is greatly diminished.
Newborn Hearing Screening (NBHS) Services have operated in selected
metropolitan hospitals since 2000. From 2010 onwards, following a staged
roll-out of services, all WA public birthing hospitals will be required to screen
all newborns for PCHL. It is recommended that the test is conducted prior to
infant’s discharge from hospital. However, due to a number of circumstances
such as early discharge, home births, and migration to Australia in the neonatal period, some infants may not have had the test completed. Additionally,
approximately ten percent of infants require a repeat test. The majority of
theses infants will pass the second test, with only a few referred to the
audiologist.
The role of child health services is to follow up with parents about the outcome
of the newborn screening test; encouraging those parents who have not had
the test completed about the benefits of newborn hearing screening.
Further information can be accessed via the following link:
http://intranet.health.wa.gov.au/circularsnew/circular.cfm?Circ_ID=12578
Hearing loss can develop over time due to infection and trauma and can
contribute to developmental delay. Parental concerns about hearing are
Child Health Policy Rationale 2010
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elicited at each of the scheduled contact through completion of the PEDS tool,
hearing questions in the PHR and discussion with the family. Nurses should
give extra attention to children with the following risk factors for hearing loss:
family history of congenital hearing loss
any infections during pregnancy
admission to neonatal intensive care
anoxia from any cause around time of birth
apgar score less than 4 at 5 minutes
birth weight below 1500 grams
exchange transfusion for serum bilirubin level greater than 350
micromoles per litre
congenital abnormalities of the head, face or neck
parental concern
later risk factors including bacterial meningitis, developmental delay
and head injury.
Implications for child health practice
Ascertain the results of the newborn hearing screening test at the
postnatal universal contact, note any follow up required and encourage
parents to attend subsequent appointments. If the newborn screening
has not been completed, provide parents with contact details and
encourage them to attend with their child for a test within the first
month of life
At each universal contact, ask parents questions about their
infant/child’s hearing
Respond to risk factors for acquired hearing loss and offer additional
assessments e.g. otoscopy to assess for abnormalities of the ear canal
or drum, tympanometry, and/or play audiometry from three years or
referral to audiology services and/or general practice
Offer surveillance and management of conductive hearing to
Aboriginal infants/children with a high prevalence of otitis media
If there is any parental or clinical concern regarding a child’s hearing,
offer targeted assessment and/or refer the child onwards for further
investigation.
8.4 Examination of hips
Developmental dysplasia of the hip (DDH) is a condition that occurs when the
normal relationship between the acetabulum and femoral head is interrupted.
It occurs in approximately 1.5% of neonates.39 If the condition is not detected
and treated appropriately, significant morbidity can occur. The first six weeks
are critical in hip development.
Child Health Policy Rationale 2010
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Current literature supports examination of newborn’s hips using the Ortolani
and Barlow manoeuvres at birth, and up to six to eight weeks of age, then
Abduction assessment from 8 weeks to walking for children who have not
been examined in the newborn period or where there is parent or professional
concern. Testing should be performed by staff that have been adequately
trained and that there is a clear pathway for referral and treatment for
developmental dysplasia of the hip. 40 Research does not support universal
ultrasound screening for DDH.40 Child health nurses should pay particular
attention to infants who have the following risk factors for developmental
dysplasia of the hip:
family history of DDH
female sex
breech presentation
multiple gestation
first pregnancy
high birth weight
oligohydramnios and postural and non-postural abnormalities.
If there are any concerns, infants should be referred to the general practitioner
for further assessment and referral to an orthopaedic surgeon.
Implications for child health practice.
From 2012, in addition to the above pathway, infants up to four months of age
may be referred directly to Princess Margaret Hospital Orthopaedic Clinic
using the referral form (CHS 663) or electronically via CDIS.
8.5 Undescended Testes
Cryptorchidism or undescended testes is the most common genital problem
encountered in children, and occurs in approximately five percent of newborn
boys.41 Prematurity, low birth weight and family history are risk factors. There
is some spontaneous correction of the condition with approximately half of all
cases resolving by nine months of age. It is essential that the condition is
treated before the child’s first birthday. If left untreated, there are potential
consequences as undescended testicles are associated with infertility,
testicular tumour, inguinal hernia, testicular torsion, and cosmetic
dissatisfaction. 41
Implications for child health practice
No change in current practice
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8.6 Growth Monitoring
8.6.1 Universal
Growth monitoring remains a contentious issue for clinical practice. In the
past, routine monitoring of growth (by taking regular measurements of head
circumference, weight and length/height, plotting and interpreting results) was
an accepted and expected component of child health care. However, there is
a lack of clear scientific evidence in developed countries about the benefits
and potential harm of universal routine weighing and measuring of children
and plotting results on percentile chart.
The benefits of universal routine weighing include early identification of
feeding difficulties, chronic disease and failure to thrive, inappropriate diets
and the beginnings of obesity. Undressing the child to check weight provides
an opportunity to observe the child closely for skin and other conditions that
may not be obvious otherwise. Attending for a growth assessment provides
the parents the opportunity to raise other concerns.
The potential harm associated with growth monitoring is increased parental
anxiety, potentially leading to early cessation of breastfeeding and
inappropriate feeding practices. This can occur because parents,
grandparents and health workers do not understand normal growth patterns or
‘spurts”, or take into account individual factors, such as ethnicity, that will
influence growth patterns. Placing too much emphasis on growth can detract
from building the relationship between the child health nurse and the family,
especially when the parent perceives that there is a problem with their child’s
growth. Obtaining accurate results can be problematic as variations between
scales and resulting discrepancies with measurements can cause parental
distress. It is difficult to achieve accuracy when measuring height or length in
children under 2 years of age.
In recent years, researchers have been examining patterns of head growth in
children and adults diagnosed with Autism Spectrum disorder. The literature
regarding the link between atypical head growth and autism spectrum disorder
has been reviewed. At present, there is insufficient evidence to support
implementation of routine universal measurement of head circumference and
monitoring of head growth. 43
However, as noted earlier, childhood obesity has been identified as a major
public health issue both nationally and internationally and it is a preventable
disease that has significant short and long term effects on a child’s health and
development. 2, 11 The worrying indicators are that the rates of overweight and
obesity among WA children have nearly trebled over the last two decades,
making the future adult population at much higher risk of glucose intolerance,
type 2 diabetes, heart disease and hypertension.13
Parents and health care providers are often reluctant to acknowledge the
issue of obesity in otherwise healthy children, and therefore the condition is
not diagnosed and treatment is not offered.17 Nurses have been identified in
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the literature as the health professionals who have the most contact with
parents and children during the early critical years, and are ideally placed to
identify affected children. Child health nurses have contact with children under
two years old through the universal contact schedule, drop-in centres and
parenting groups (particularly toddler parenting groups).
The scheduled eighteen month contact creates an opportunity to perform
universal growth assessments and provide parents with information about
current nutritional and physical activity guidelines, (e.g. through using the
Commonwealth government “Get up and grow” resources). Weight
management can be presented as a normal parenting activity and a
preventative health measure. For parents of children at risk of obesity, it
provides the opportunity to offer a brief intervention and referral if indicated.
When measuring growth, it is vital that the results are plotted accurately and
interpreted correctly, and communicated clearly to parents and care-givers.
This should occur in conjunction with assessment of a child’s health and
feeding patterns, provision of parent education, and brief intervention and
referral as necessary. Growth assessment provides an opportunity to
motivate, reinforce and support positive parental practices.
Implications for child health practice
The recommended universal growth assessments at the 6-8 week, 3-4
month and 8 month checks remain unchanged
At the 18 month assessment weigh and measure all children seen at
this contact, children who have a weight to length ratio at or above the
85th percentile are considered at high risk for becoming overweight
If there are parental or professional concerns, or underlying medical
conditions that would impact on growth, it is advisable to conduct more
frequent growth.
8.6.2 Targeted
Weight and length/height and head circumference should be measured more
frequently if the infant is likely to be at risk of under or over-nourishment. This
includes routine measurement for all infants in high risk groups including
Aboriginal and Torres Strait Islander infants, and in children with underlying
medical conditions that can impact on growth. It is also appropriate to do more
frequent measurements of weight and length where there is professional or
parental concern.
Managing sub-optimal growth and failure to thrive necessitates closer growth
monitoring of affected children. The child’s growth assessment must be
viewed in the context of ethnicity, physical characteristics and medical history,
gestation, birth complications, general development, family relationships and
quality of attachment as well as feeding patterns and nutritional intake. Based
on the assessment, and as appropriate, referrals to a general practitioner,
Child Health Policy Rationale 2010
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paediatrician, lactation consultant, dietitian or the Princess Margaret Hospital’s
Feeding Team should be initiated after a brief intervention.
Implications for child health practice
No change in current practice
8.7 Developmental Delay
There is no universally agreed definition of developmental delay. Rather,
developmental delay is a term frequently used to describe a child who does
not reach developmental milestones at the expected age. Development is a
continuous physical and psychological process of maturation and it requires
positive appropriate stimulation and support for optimum outcomes.
Development is a dynamic process that occurs over time. There are accepted
milestones that a child should achieve at specified times. When a child fails to
meet the milestones, developmental delay has occurred. The delay might be
in one or more areas, for example, gross motor skills, fine motor skills, speech
and language, cognitive or social and emotional. In some instances, a
developmental delay may be temporary, for example premature infants may
show a delay in the area of sitting, crawling and walking but then progress on
at a normal rate. Other causes of temporary delay may be related to physical
illness and prolonged hospitalisation, immaturity, family stress or lack of
opportunities to learn. Developmental delays can be signs of more serious
conditions such as intellectual disability and autism. Children who have
developmental delay are at greater risk of academic failure, behavioural
problems and social and emotional issues.
In 2009, The Australian early Development Index (AEDI) revealed that one in
four WA children is developmentally vulnerable on at least one of the five
domains measured, and one-in-eight children is developmentally vulnerable
on two or more domains. Comparative results show that WA children are
ranked sixth overall behind Victoria, New South Wales, South Australia,
Tasmania and the ACT.43
Development is assessed by way of screening and assessment – performing
specific activities at specific times, and surveillance – monitoring a child over
time. Ongoing contact with infants/children and their families provide
opportunities to assess the growing child as evidenced by the sequential
achievement of developmental milestones and early identification of children
who require further assessment or referral. In partnership with parents,
clinicians use their skills, knowledge, clinical judgement and validated
screening tools in assessing a child’s development
In Western Australia, universal developmental assessments are conducted at
six to eight weeks, four, eight, and eighteen months and three years of age
and at any other occasion if indicated. The domains of development assessed
are sensory, cognitive, speech and language, gross and fine motor,
behavioural, social and emotional. Between 6 and 18 months of age there is
Child Health Policy Rationale 2010
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rapid development of the infant/child’s motor, language and cognitive skills.
Delays in communication and language development are often evident by 18
months and mild motor delays that were undetected earlier may be more
apparent at 18 months of age. In addition symptoms of autism are often first
identified at around 18 months of age. In addition, ongoing contacts between
2 and 4 years of age enable early detection of physical and developmental
concerns which will allow a smoother transition to school and minimises the
impact of health issues on learning.
Where there is concern about a child’s development, or a child is at risk of
delay, the child should have a detailed assessment and be offered referral to
the appropriate early intervention service. Parents should be offered
counselling and information regarding their child’s development. Appropriate,
effective and timely interventions at critical points in a child’s development can
have significant long lasting positive impacts for children with developmental
delay.
8.7.1 Child Developmental Screening Tools
The evidence confirms that the use of child developmental screening tools
enables children with more subtle developmental delay to be identified and
assisted at an earlier age. The National Health and Medical Research Council
(NHMRC) review of the evidence in 2002 recommended that services review
their early detection systems and consider the use of screening tools. 44
In 2007, a critical analysis of the available tools was completed and the Parent
Evaluation of Developmental Status (PEDS) was introduced into practice in
2009 as a primary screening tool. For those children identified as medium to
high risk, a secondary tool is recommended and the Ages and Stages
Questionnaires (ASQ and ASQ/:SE) is the preferred secondary tool.45
PEDS and the ASQ were chosen because it was recognised that it is often the
parent who detects subtle variations in development and behaviour. Using
parental questionnaires and engaging parents in the process rather than
imposing a health professional lead screening tool is an important strategy in
the community health context in Western Australia. The tools are congruent
with a family partnership approach, have adequate sensitivity and specificity,
are easy to complete for the parent and for the professional to score and are
appropriate to use at the scheduled development assessments. Using the
PEDS and ASQ engages parents and elicits their knowledge of their child’s
development. The use of tools enhances child health practice as it
complements the nurse’s unique skills and knowledge.
Since the 2007 report was released, the literature regarding the link between
atypical head growth and autism spectrum disorder has been reviewed and
consultation with experts in this field has been undertaken. Currently there is
insufficient evidence to support implementation of routine universal
measurement of head circumference and monitoring of head growth at each
of the universal child health and developmental assessments.
Child Health Policy Rationale 2010
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Further information can be accessed via the link below:
http://cahs.hdwa.health.wa.gov.au/__data/assets/pdf_file/0020/85331/Review
_of_Developmental_Screening_Tools_December_2007.pdf
Implications for child health practice
Offer the PEDS to all parents at the following universal contacts: 3-4
months, 8 months, 18 months, and 3 years. PEDS can also be offered
when parents attend outside of the universal schedule and have
concerns
Offer a secondary tool those children identified as medium to high risk.
The ASQ and ASQ/SE questionnaires are the recommended
secondary screening tools as they provide increased specificity and
reliability in prediction of developmental delay, and justification for
referral to specialist services such as the child development service.
8.8 Infant Mental Health
A baby’s brain is not ‘pre-wired’ at birth, rather the ‘hard wiring’ occurs at
critical periods during the first few years of life, shaped by exposure to a
variety of experiences and pre-determined by genetics. The impact of different
early childhood interactions and experiences can determine social and
emotional outcomes such as the development of empathy and self-confidence
or aggression and poor self-esteem.
Infants and children are more likely to reach their potential when they are
growing up in an environment where their parents display positive interactions
and being sensitive and responsive to cues from the baby, build positive brain
pathways that become reinforced each time they are repeated and eventually
become ‘hard wired.’ By contrast, negative environmental influences, such as
poverty, family discord, abuse and neglect during the early years can delay or
disrupt learning and social and emotional development. It is vital that children
are protected against such risk factors in these critical early years and instead
experience environments which promote their wellbeing. 46.
Although many parents know that infants have special abilities, they benefit
when someone else notices and discusses specific special abilities of their
baby. The most successful approach is to ask parents what they have noticed
about their baby’s development and demonstrate an interest in what the
parent has said rather than making general statements about infant
development.
Child health staff can help parents to become more sensitive to their infant’s
cues by noticing and commenting on these cues by noticing examples of the
baby attending to parent movement and facial expressions.
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The circle of security is a model used by child health services to demonstrate
secure attachment and sensitive parenting. The circle of security model can
assist parents and other carers to look beyond the child’s immediate
behaviour, to follow the child’s cues and to learn how to become more
emotionally available to the child.
Further information can be accessed via the link below.
http://www.circleofsecurity.org/
Implications for child health practice
No change in current practice
9. Health Promotion and Disease Prevention
9.1 Family Health and Well Being
Families have a key role in caring and raising their children. They provide love
and support, transmit values, culture, language and traditions between
generations.47
The elements of family wellbeing are physical and emotional health and
safety, social connectedness, quality relationships and economic prosperity.
Family functioning is defined as “the capacity of the family system to meet the
needs of its members through developmental transitions”.47 This includes the
transition into parenthood and grandparenthood.
Effective family functioning and healthy relationships are essential for
individual, family and community wellbeing, and society as a whole. Child
health nurses are able to positively influence family functioning and wellbeing
via health promotion activities focussing on physical and mental health,
facilitating the development of social support networks and encouraging the
development of quality family relationships. Child health nurses use the “Circle
of Security” and sensitive parenting concepts to promote secure attachment
and positive relationships between parents and their children. Child health
nurses are able to identify and support families at risk, and facilitate early
intervention as appropriate.
Starting at the first contact, child health nurses are able to assist the transition
into parenthood by encouraging realistic expectations about parenthood and
discouraging myths about parenting. Parents are encouraged to recognise the
importance of self care and adopt or continue practises that enhance physical
and mental health such as eating well, exercising, resting and sharing feelings
with their partners and others. The infant’s need for safety, nutrition, positive
touch and comfort are discussed at the first contact within the context of
sensitive parenting and attachment theory and an assessment of family
strengths and risks is undertaken in planning the care in conjunction with the
family.
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Family functioning, health and wellbeing is re-assessed at every scheduled
contact and at any other time it is necessary to do so, for example when there
is a significant change in family circumstances. Families with additional needs
are identified and referred to the appropriate services, and nurses continue to
monitor the situation and provide support.
At every contact, the child health nurse provides anticipatory guidance and
information about child development. Having realistic expectations increases
parental satisfaction and confidence, and allows parents to provide
appropriate activities and supervision to enhance their child’s development
and safety.
Implications for child health practice.
No change in current practice
9.2 Parenting Groups
It is recognised that the early days in a new baby’s life are a time of transition
and that parents often require support. The aim of early parenting groups is to
provide support to new parents by way of information, opportunities to build
relationships and linking parents into the community.
Parents of toddlers share common concerns related to their children’s
changing needs and behaviours, and may need guidance about a broad
range of topics including nutrition, toilet training, sleep behaviour management
and strategies to enhance development. Group education sessions enable
parents to share information and normalise their experiences.
Toddler parenting groups create an opportunity to provide parents with
information about current nutritional and physical activity guidelines e.g. “Get
up and Grow Resources”. If considering offering toddler parenting groups,
partnerships are encouraged where other service providers run quality toddler
parenting education groups and/or provide quality crèche services.
Implications for child health practice
No change to the existing early parenting groups for parents with a new
baby 0-3 months
If offering toddler parenting groups, the content must include current
nutritional and physical activity guidelines.
Consider partnerships with other service providers who are running
quality toddler parenting education groups and/or provide quality
crèche services.
Child Health Policy Rationale 2010
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9.3 Disease prevention
Prevention of disease is a core component of child health service delivery.
The combination of monitoring of child health whilst conducting preventative
health activities provides opportunities for early intervention, detection and
prevention of ill-health. Disease prevention activities include: immunisation
promotion and delivery, promoting breastfeeding, promoting good child and
family nutrition, smoking cessation, oral health surveillance and injury
prevention.
10. Promoting healthy eating and optimum growth
Child health services have a key role in providing information about family
nutrition, breastfeeding and transition to the family diet to promote optimum
growth and development of children, and healthy eating habits for adults.
10.1 Breastfeeding
Breastfeeding is the biological norm and has many benefits for mother and
child. Breastfeeding rates have been identified as a national headline
indicator because of the known benefits and the potential for improvement.
The known benefits of breastfeeding are enhancing the immune system,
protection from infection, including gastrointestinal disease, lower respiratory
infection, otitis media, eczema, necrotising enterocolitis In addition, there is
good evidence that breastfeeding reduces the risk of overweight and obesity
in childhood and promotion of breastfeeding is a key strategy in prevention of
obesity.
The Dietary Guidelines for Children and Adolescents in Australia recommend
that as many infants as possible be exclusively breastfed until 6 months of
age. It is further recommended that mothers then continue breastfeeding until
12 months of age and beyond if both mother and infant wish. Health workers
are directed to encourage and support breastfeeding. 48 Australia has a high
initiation rate of breastfeeding, but there is a steep decline in overall and
exclusive breastfeeding rates by three months of age.49
The Baby Friendly Health Initiative (BFHI) is a successful evidence based
strategy to increase initiation and duration of breastfeeding. It is a World
Health Organisation program which aims to protect and support exclusive
breastfeeding by creating a health care environment where breastfeeding is
the norm and practices known to promote the health and wellbeing of all
infants and their mothers are followed. The project was launched in 1991 and
research has demonstrated positive outcomes on increasing the initiation and
duration of breastfeeding in many countries over time.50 There are 10 steps
that maternity service providers implement and maintain to achieve baby
friendly accreditation. Western Australian maternity services are currently in
the process of implementing the 10 steps in the hospital setting.
Child Health Policy Rationale 2010
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In 2009, the National Baby Friendly Health Initiative (BFHI) Community Health
Services Committee developed and produced “The 7 Point Plan for the
Protection, Promotion and Support of Breastfeeding in Community Health
Services”. In 2010, child health services in WA will adopt the seven steps as
outlined below:
The 7 Point Plan for the Protection, Promotion and Support of
Breastfeeding in Community Health Services
Point 1: Have a written breastfeeding policy that is routinely communicated to
all health care staff and volunteers
Point 2: Educate all health care staff in the knowledge and skills necessary to
implement the breastfeeding policy
Point 3: Inform women and their families about breastfeeding being the
biologically normal way to feed a baby and about the risks associated with not
breastfeeding
Point 4: Inform women and their families about the management of
breastfeeding and support them to establish and maintain exclusive
breastfeeding to 6 months
Point 5: Encourage sustained breastfeeding beyond six months with
appropriate introduction of complementary foods
Point 6: Provide a welcoming atmosphere for breastfeeding families
Point 7: Promote collaboration between health care staff and volunteers,
breastfeeding support groups and the local community in order to promote,
protect and support breastfeeding.
Implications for child health practice
Further research is required to identify which strategies are most successful in
engaging fathers, the strategies currently recommended include:
Understand the content of the breastfeeding policy and its implications for
practice
Understand the content of the new guidelines, protocols and assessment
forms
Participate in ongoing education sessions e.g. “Breastfeeding Matters”
Where possible provide a welcoming atmosphere for breastfeeding
families
If there are parental or professional concerns refer as per the clinical
referral pathway to specialist or other community services e.g. Lactation
Consultant, Australian Breastfeeding Association.
10.2 Formula feeding
Parents who are artificially feeding their infants should have access to
unbiased and factual information and respectful support when discussing their
child’s nutrition. Information given should include selection, preparation, use,
storage and handling of infant formula, including the health risks of
Child Health Policy Rationale 2010
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inappropriate preparation and use. This information should be given on an
individual needs basis within the context of a therapeutic intervention.
If a breast feeding mother is considering using formula, it is important to
explore her decision making process and other options to solve feeding
problems without inducing guilt in the mother.
Implications for child health practice
No change in current practice
10.3 Transition to the family diet and beyond.
Parents, especially first time parents may require support and assistance at
the time of introducing complementary foods to their infants. The method and
timing of introducing other foods remains a controversial topic and child health
nurses act as a resource and support for parents by providing current
evidence based information in accordance with Department of Health
guidelines. The three to four month contact is an ideal opportunity to provide
information, discuss concerns and pre-empt early introduction of solids. The
eight month contact provides an opportunity to assess progress to date and
provide further information about transition to the full family diet. Nutrition
remains a key area of health promotion at the eighteen month and three year
check, with relevant information given for the stages of development and
growth.
Implications for child health practice
No Change in current practice
10.4 Promoting a Healthy lifestyle
Lifestyle factors impact on an individual’s health status as well as having
implications for the wider population. Modifiable lifestyle factors that impact on
health are smoking, physical activity, diet, weight and alcohol and drug use.
The nurse’s role is to encourage parents to maintain a healthy lifestyle and
exercise as per the national physical activity guidelines so they are able to be
effective role models for their children.
Child health nurses should assess parental lifestyle at the scheduled contacts,
and using a family partnerships approach, identify areas of concern to the
family or the nurse. If appropriate, the nurse may offer information, brief
interventions and referral to services according to need.
Child Health Policy Rationale 2010
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Implications for child health practice
No change in current practice
Conclusion
Child health policy and practice is informed by the latest evidence and
responsive to population needs. The 0 to 4 year old population in Western
Australia is a rapidly growing cohort due to an increased birth rate and
increased migration, largely generated by the mining industry. Whilst the
majority of children are healthy, some groups of children are more
disadvantaged and vulnerable than others and may require more specialised
attention to attain and maintain good health. Aboriginal populations, refugee
children and children with disabilities and children in state care have specific
health needs.
Child health nurses work at a population level to positively influence child
health and developmental outcomes in the whole population. They take a
primary health care approach to deliver health promotion and preventative
health care. The universal schedule offers an entry point into the child health
service. From this entry point, vulnerable children with specific needs can be
offered targeted services to address their needs.
Rapid societal change and lifestyle changes have contributed to the
increasing rates of chronic diseases such as obesity, asthma and type 2
diabetes. Despite parent education programmes and public safety awareness
campaigns, dental decay and childhood injury rates remain at relatively stable
levels. Breastfeeding, a primary obesity prevention strategy continues to have
low duration rates. These important health issues have been addressed by
the child health policy.
Research continues to reveal the impact of the early years on a child’s long
term social, physical and emotional development. Of particular importance is
the attachment between children and their parents. Child health nurses are
able to implement evidence based strategies to enhance attachment and
promote optimum infant mental health outcomes. Parental mental health has
a strong influence on child health and development. Previously, the child
health focus has been on detection of maternal post-natal depression.
However, it is increasingly apparent that there are impacts from paternal and
maternal perinatal anxiety and depression and that child health services need
to take a wider view of parental mental health issues.
The changing role of the father and the positive influence a father has on his
child’s development has implications for the delivery of child health services.
It is essential that child health services move from the traditional mothercentric perspective to a father-inclusive environment so that child health
nurses can engage with fathers in the delivery of child health care to improve
outcomes for children.
Child Health Policy Rationale 2010
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Societal changes have impacted on the role of child health services. Child
health nurses continue to perform screening and surveillance activities with
children and their families for the purpose of early detection of developmental
issues and referral to appropriate early intervention services. However, the
emphasis is increasingly on enhancing child development by identifying family
strengths and risk factors, providing information and psychological support,
and working collaboratively to address specific family concerns. Child health
nurses use a family centred approach, acknowledging that the family is the
most important influence on a child’s development.
The child health policy addresses current health issues and provides evidence
based strategies to use in the prevention and early detection of
developmental delay and disease. New work practices have been introduced
and the changing role of the child health nurse has been articulated. Child
health nurses continue to work with families to positively impact on child
health and development outcomes.
Child Health Policy Rationale 2010
44
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