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 3 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 4 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. Child Health Policy Rationale 2010 5 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 6 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 7 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 8 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 9 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 10 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 11 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 12 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. Child Health Policy Rationale 2010 13 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. Child Health Policy Rationale 2010 14 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 15 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 17 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 18 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 19 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 20 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 21 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 22 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 23 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 30 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 31 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 Child Health Policy Rationale 2010 32 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 Child Health Policy Rationale 2010 33 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 34 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 35 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 36 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. Child Health Policy Rationale 2010 37 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. Child Health Policy Rationale 2010 38 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 39 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 40 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 41 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 42 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 43 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 References Australian Institute of Health and Welfare. A picture of Australia’s children 2009. Cat. no PHE 112. Canberra: AIHW. 2009 1. 2. Hagan JF, Shaw JS, Duncan PM, editors. 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