1. Early childhood health promotion and its life-course consequences Bernard Guyer MD MPH Johns Hopkins Bloomberg School of Public Health 1 Univ. Minnesota & Federal Reserve Bank, Minneapolis MN, October 14-15, 2010

2. Defining Health & Health Problems in Early Childhood Health is more than absence of disease Health in early childhood linked to development & growth; brain & organ systems Health begins with mothers’ “girlhood,” extends through pregnancy into preschool Early health problems with lifelong consequences: tobacco exposure, unintentional injury, obesity, mental illness 2

3. 3 If concerned about health in early childhood… Need to know what are the important problems to address; Need to know the cost implications; Need to critically investigate the effective and cost effective/beneficial interventions; Need to bring reliable information to the policy-making process. Need “social strategies” that work.

4. 4 Objective & approach In 2008, produced review for Pew: Partnership for America’s Economic Success Objective: short- and long-term impact of interventions for children 0-5, including pregnancy Selected 4 areas of preschool child health: Tobacco exposure, Obesity, Injury, Mental health Systematic review of literature- preventive interventions and CE/CB studies- 1996-2007 Updated review for 2008-2010 for this paper: – No substantive changes in findings or conclusions

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7. Framework for review of interventions Tobacco, Obesity, Injury, Mental health Life Stage of InterventionAdult Impact Level of intervention Preconception/ pregnancy Infant/childAdolescentAdult Individual Family/houshol d Local/communi ty National/state policies 7

8. 8 Tobacco and Child Health Smoking impacts children through: – Prenatal exposure (10.2% of babies) – Environmental tobacco smoke (25-50%) – Teen smoking Extra costs for prenatal care and complicated births due to maternal smoking are $4 B/year* Direct medical cost of all pediatric disease** attributable to parental smoking $7.9 B/year Could save $1 billion/year in direct medical costs with a 15% reduction in parental smoking * Costs in this presentation have been standardized to 2006 dollars **Birth to 18; Low birth weight, SIDS, RSV, otitis media, asthma, burns

9. 9 Lifespan: Tobacco Impact and Prevention Level of Intervention Lifespan Stage Intervention and Impact Impact of Early Intervention Preconception/ Pregnancy Infant / ChildhoodAdolescenceAdulthood Individual Smoking cessation therapy 1 Smoking cessation therapy 2 Smoking cessation therapy with partner support 3 Smoking cessation therapy targeting relapse 4 Family Smoking cessation for adults living with children 5 Local / Community / Workplace / School Media campaigns 6 Bans / restrictions in workplace and public 7 Community mobilization 8 National / State Price increases 9 Enforcement of age ban on sales 10 Age period when interventions take place Age period with continuing positive impacts of intervention

10. 10 Obesity and Child Health Emerging major public health problem – Obesity tripled in 20 years (5% to 14%) – 17-18% of children 6-18 overweight (2006) Patterns of obesity begin in childhood – 50 to 80% overweight children and teens become obese adults Implications for lifetime of health problems – Links to type 2 diabetes, cardiovascular diseases, pregnancy complications, alienation and depression

11. 11 Costs of Overweight & Obesity Early stage to assess cost of obesity “epidemic” – Cost estimate: Direct $109B; Indirect $75B (annually in 2006 dollars); Medicare and Medicaid cover 50% Four-fold increase in obesity-related hospital costs for children age 6-17 from 1979-1999 – $44 M in 1979 to $160 M in 1999 (annually in 2006 dollars) Difficult to ascertain indirect costs

12. 12 Lifespan: Obesity Impact and Prevention Level of Intervention Lifespan Stage Intervention and Impact Impact of Early Intervention Preconception/ Pregnancy Infant / ChildhoodAdolescenceAdulthood Individual Observational Studies 1 Observational Studies 2 Family Preschool Education 3 Parent Education 4 Local / Community / Workplace / School Teacher curriculum 5 National / State Age period when interventions take place Age period with continuing positive impacts of intervention

13. 13 Injuries and Child Health Magnitude of the problem – Leading causes of child death- 15,755 in 2004 – Leading causes of hospitalization- 240,000 (<15yo) – Leading causes of ER visits- 9 million – Leading cause of disability- 150,000 permanent Cost of child injury: – Both fatal and nonfatal injuries of children (0-4) resulted in 4.7 billion for life-long medical costs & 14 billion for both present and future productivity losses Trends in injury reduction: – 52% decrease in rate between 1979 and 1998 – Current approaches: public health education, safety behavior, legislative, environmental engineering, EMS

14. 14 Lifespan: Impact of Injury Prevention Level of Intervention Lifespan Stage Intervention and Impact Impact of Early Intervention Preconception/ Pregnancy Infant / ChildhoodAdolescenceAdulthood Individual Gun safety education 1 Family Home visits 2 Prenatal home visitation 3 Education against the use of baby walkers 4 Local / Community / Workplace / School Community education combined with incentives distribution for safety 5 Smoke detector distribution National / State Changes in baby walker safety standards 6 Child passenger safety laws 7 Age period when interventions take place Age period with continuing positive impacts of intervention

15. 15 Mental Health Disorders Magnitude of the problem – Estimated ~20% of children-at least mild mental functional impairments. – For children between the ages of 1-6 years old: 3.4%-6.6% have externalizing behaviors 3.0%-6.6% have internalizing behaviors Cost of child mental health disorders – The estimated cost of treating children aged 1-5 nationwide approached $864 million annually. – Unsolved conduct disorder is estimated to incur average societal cost of £70,000 by age 28, 10 times higher than those without conduct disorders

16. 16 Level of Intervention Lifespan Stage Intervention and Impact Impact of Early Intervention Preconception/ Pregnancy Infant / ChildhoodAdolescenceAdulthood Individual Child-focused training 1 Parent support programs: Healthy Steps 2 Parent-focused training programs; Triple P 3,4,5 Family Parent- and child- focused training programs 6 Local / Community / Workplace / School School-based: Fast Track 7 National / State New Hope 8 Lifespan: Impact of Interventions for Mental Health Disorders Age period when interventions take place Age period with continuing positive impacts of intervention

17. 17 What we’ve learned Overall magnitude of health burden – Early child health related to high prevalence, expensive health problems across lifespan: Four health problems affect about 1/3 to ½ of U.S. birth cohort- 1.3-2.0 million; Estimate that $50,000 in lifetime cost per child translates to $65-$100 Billion for the whole birth cohort Most successful interventions for injury and exposure to tobacco; need more…

18. What we’ve learned (2) Child health is more than absence of disease – Health is linked to development and learning – Children must be healthy to learn at school – A lifespan perspective- early antecedents – More than access to medical care Effective policy/program based on broad public health approaches rather than on individual behavior change or medical interventions alone (e.g. tobacco, injury) – Multiple societal determinants – Multifaceted approaches; systems 18

19. 19 What we’ve learned (3) Challenges ahead: – Need better research on definition of health & measures in early life – Need more high-quality intervention studies to demonstrate long-term effects. – Need “attributable risk” estimates “Societal investment” approach needed to promote early child health now and assure health, development, education & productivity of next generation – Expect return on investment; reduced lifetime costs

20. Acknowledgements Colleagues and co-authors: Sai Ma, PhD, Kevin Frick, PhD, Alyssa Crawford, BA Academic Pediatrics Zanvyl & Isabelle Krieger Family Fund Partnership for America’s Economic Future, Pew Charitable Trust 20