Child Public Health What every GP should know David Stone Paediatric Epidemiology and Community Health (PEACH) Unit University of Glasgow/Yorkhill Hospital

WHY FOCUS ON CHILD PUBLIC HEALTH? Children are as deserving of good health as adults Today’s children are tomorrow’s adults Early origins of major adult diseases (Barker and ACE Hypotheses) Children have specific legal rights that are relevant to health services

All doctors are public health practitioners now Patients must be able to trust doctors with their lives and health. To justify that trust you must show respect for human life and you must: Make the care of your patient your first concern Protect and promote the health of patients and the public Provide a good standard of practice and care Duties of a Doctor, Good Medical Practice (GMC 2006)

WHAT IS CHILD HEALTH? WHO definition of health as it relates to children A state of complete physical, mental and social wellbeing and not merely the absence of disease or infirmity

WHAT IS PUBLIC HEALTH? “The science and art of preventing disease, prolonging life and promoting health through the organised efforts of society” Faculty of Public Health Medicine 1992

Child public health is an interface activity Clinical child care Public health Child public health

The Public Health Approach Needs assessment (“diagnosis”): What are the nature, scale, and determinants of the problem in the population? Population-wide intervention (“treatment”): What can and is being done to address the problem? Evaluation or monitoring (“follow up”): How well are interventions currently being implemented and how might they be improved?

KEY ELEMENTS OF CHILD PUBLIC HEALTH Epidemiological indicators of need Causes and consequences of child illness/health Types of intervention Ethical and legal aspects

Evidence of “need” for child public health in UK High level of relative poverty/inequality in UK UNICEF 2007 report Links between child and adult health (Early Origins, ACE* hypotheses) Breaches of UN and European law *Adverse childhood experiences

UNICEF review of child well-being 2007 Of the 21 countries of the OECD UK children had the lowest level of well-being as measured across six dimensions: Material Health and safety* Educational Family and peer relationships Behaviours and risks Subjective * UK level close to (but still below) average

Epidemiological indicators of child health Demography Mortality Morbidity Use of services Other

Geography of Demography (GROS 2006 based)

Determinants of child health (after LaLonde 1974*) Biology (e.g genes, viruses) Environment (e.g. poverty, climate) Lifestyle (e.g. smoking, alcohol) Services (e.g. health, education) * A New Perspective on the Health of Canadians

Public Health Diagnosis - Dahlgren and Whitehead model

Societal Community RelationshipIndividual The Social Ecological Model

Main global threats to child health in 21 st century Injury and abuse Congenital anomalies Infection Respiratory disease Cancer Psychosocial disorders

Sensitive Periods in Early Brain DevelopmentVision High Low Years Habitual ways of responding Emotional control Symbol Peer social skills Numbers Hearing Graph developed by Council for Early Child Development (ref: Nash, 1997; Early Years Study, 1999; Shonkoff, 2000.) Pre-school years School years Language

LIFECOURSE INFLUENCES ON HEALTH: 3 INTERCONNECTED “PROGRAMMING” HYPOTHESES Biological (Barker et al) Psychological (Felitti et al) Social (Ben Shlomo et al )

SOME KEY EARLY BIOLOGICAL PREDICTORS OF LATER HEALTH Maternal health and nutritional status Birth weight Breast feeding in infancy BMI in childhood/catch up growth

ACE studies of Felitti et al

Mortality from childhood injuries involving head injury in Northern Region, Source: Sharples et al, Mortality per 100,000 Deprivation rank of wards

Categories of Deprivation (% of population) in Britain Most affluent Most deprived Deprivation Category Scotland England & Wales

Proportion of 15 year old children with decay experience in the British Isles Source: Nunn JH. The burden of oral ill health for children. Archives of Disease in Childhood 2006; 91:

Who currently practices child public health in the UK? Public health professionals General practitioners and paediatricians Academics/researchers Others (e.g. teachers, social workers, planners)

Improving child health depends on both Public health measures and Clinical services Examples of overlap: surveillance, immunisation, screening, child protection, parenting support

Contribution to additional life years (Bunker and MacFaul) yrs yrs

Treating individual children contributes to public health Acute illness (e.g. infection, respiratory disease, surgical conditions) Chronic disorders (e.g. cerebral palsy, Down syndrome, asthma, diabetes )

EARLY YEARS - THE GROWING RESEARCH EVIDENCE That early life experience influences later life outcomes That early life interventions can make a difference to later life outcomes Parents are key in both causing and preventing poor health and other outcomes

Parenting support is potentially the most powerful and useful vaccine of the 21 st century but don’t forget other interventions in early life: -Preconception and genetic counselling -Screening (antenatal, neonatal, childhood) -Immunisation programmes -Nutrition (pregnancy, infant, child) -Lifestyle (diet, alcohol, smoking, drugs) -Creating a healthy and safe environment -Antipoverty and inequality policies -High quality health and social care

UN Convention on the Rights of the Child 1991 P rotection from hazards and exploitation P rovision of basic care and services P articipation in decision making 3 Ps

Children’s (Scotland) Act 1995 and medical consent Applies to children under 16 Children can give own consent if judged capable Parents/guardians lose veto but should be involved in discussion If in doubt, best interests of child are paramount

Summing up Children are a vulnerable minority Children (usually) grow into adults Role for health promotion and healthcare Children have specific legal protection Poverty is greatest global threat to health Growing parenting/pre-school agenda