Introduction
The RCPCH works to transform child health through knowledge, innovation and expertise. We have over 550 members in Wales and over 17,000 worldwide. The RCPCH is responsible for training and examining paediatricians. We also advocate on behalf of members, represent their views and draw upon their expertise to inform policy development and the maintenance of professional standards. For further information please contact Gethin Jones, External Affairs Manager for Wales: gethin.jones@rcpch.ac.ukor 029 2050 4211.
Our response to this consultation draws heavily from the State of Child Health[1]report, which we published recently and provides a comprehensive overview of child physical and mental health across the UK. We also published a series of recommendations specific to Wales[2]based on the data contained in the report. These recommendations are referenced throughout this document.
The extent to which Welsh Government policies and programmes support the early parent role, before birth and during the first two years of a child’s life, and crucially how effective these are in supporting children’s emotional and social capabilities and development.
We welcome the Children, Young People and Education Committee’s focus on infants, very young children and their families. Healthy children are more likely to become healthy adults and good support during early life has huge benefits for the child. Early intervention will also lead to significant savings to the NHS in the medium and long-term, and there is increasingly good data on future cost savings from prevention and early intervention[3].
Achieving the best child health outcomes has to be a priority across government and we believe that highlighting the complex and interlinked challenges for the first 1000 days of a child’s life demonstrates the need for a coordinated approach to child health in Wales. In particular, vulnerable and hard to reach groups require a joined-up approach by health services and other agencies. For example, children and young people with long term or complex conditions often need care from a variety of health professionals and navigating that system can be daunting and confusing.
The Healthy Child Wales Programme will help ensure every child aged 0-7 receives a consistent range of services and could form the basis of a strategy for the whole of childhood that seeks to reduce child deaths, increase the visibility of infants, children and young people in the debates about services that affect their wellbeing and ensure that Wales has the workforce to meet their needs.
These responsibilities are held across government and would require coordinated action from the Cabinet Secretaries for Children and Communities; Health, Well-being and Sport; and Education, along with the Minister for Public Health.
The State of Child Health 2017 report examined the data on child health in Wales and makes the following overarching recommendations:
· The Welsh Government should develop an evidence-based child health and wellbeing strategy covering the whole of childhood. The strategy should include a clear accountability framework setting out responsibilities for professionals, the public and civil society as well as details about resources and funding to implement it.
· The Welsh Government should adopt a ‘child health in all policies’ approach to decision making, policy development and service design.
· Health Education Wales should fund mandatory child health training for all GP trainees.
Promote and protect the health and wellbeing of children from pregnancy (for example through positive parenting, high immunisation rates and tackling smoking in pregnancy).
Maternal health and wellbeing has a profound impact on the health of children. Being a healthy weight, breast feeding and stopping smoking all improve health outcomes for both mothers and infants.
Breastfeeding is beneficial for the overall health and wellbeing of infants and children[4]. In line with recommendations from the World Health Organisation, in the UK exclusive breastfeeding is recommended for around the first six months of a baby’s life. The following conditions have been found to be more prevalent in infants who are not breastfed[5]:
• Gastroenteritis (diarrhoea and vomiting)
• Respiratory disease
• Sudden infant death syndrome (SIDS)
• Otitis media (middle ear infection)
For infants born preterm, breastmilk has been shown to be of considerable benefit, reducing the risk of potentially life threatening conditions such as necrotising enterocolitis (where tissues in the bowel can become inflamed and die)[6]. Breastfeeding is also associated with reduced teeth misalignment, increased scores on tests of intelligence and possible reductions in later overweight and diabetes[7].
The Welsh Government conducted an Infant Breastfeeding Survey in 2010 which showed that Breastfeeding rates for Wales showed an initial incidence rate of 71%, substantially below rates in England (83%)[8]. UK-wide, the rate at 6 months is just 34%[9].
Maternal smoking during pregnancy places unborn babies at an increased risk of[10]:
• Impaired fetal growth and development
• Being born small for gestational age
• Having reduced birth weight
• Developing some congenital abnormalities, including those of the heart, limb and face
Passive smoking (i.e. the smoke of others which the mother is exposed to) is likely to have similar adverse effects on fetal growth and development, but to a lesser extent[11].
Pregnancy is a good opportunity to promote smoking cessation, however it is estimated that 43% of UK women who quit smoking during pregnancy resume smoking within six months of giving birth[12].
Recommendations:
• Public Health Wales should undertake sustained public health campaigns about the dangers of second hand smoke.
• Public Health Wales should protect services that help pregnant women stop smoking and ensure they are accessible to all.
• Public Health Wales should undertake a targeted awareness campaign promoting smoking cessation, breastfeeding, heathy weight in women of childbearing age and safe sleeping practices for babies.
• The Welsh Government should develop a national strategy on infant feeding.
• The Welsh Government should mandate that all maternity services achieve and maintain UNICEF UK Baby Friendly Initiative Accreditation by January 2019.
• The Welsh Government should set and monitor targets for increasing breastfeeding and reducing smoking in pregnancy and early childhood.
• Public Health Wales and Health Boards should provide local breastfeeding support that is planned and delivered to mothers in the form of evaluated, structured programmes.
Deliver improved child health outcomes across Wales (for example prevention of obesity and the promotion of health-enhancing behaviours for every child such as eating a well-balanced diet, playing actively, and having an appropriate weight and height for their age and general health).
27% of children in Wales start primary school overweight or obese[13] – a higher percentage than in Scotland or England. The State of Child Health report illustrates the need for continued efforts by government and partners to reduce childhood obesity.
There is no silver bullet for tackling childhood obesity, which is why we are calling for a comprehensive package of measures from the Welsh Government.
Recommendations:
• The Welsh Government should develop and implement an evidenced-based childhood obesity strategy for tackling the current crisis and preventing further escalation, which must include programmes to support prospective and expectant parents and ensure that infants get the best nutrition and healthiest start possible in life.
• Public Health Wales should expand the Child Measurement Plan for Wales to measure children after birth, before school and in adolescence.
• NHS Wales should ensure that all health care professionals can make every contact count by having difficult conversations with children and their families, when a child is obese or overweight at a very young age, particularly given that many parents are unable to recognise that their children are overweight. Healthcare professionals should also be able to talk to parents about their weight if they have overweight or obesity and encourage families to eat a healthy diet.
Tackle child health inequalities, with a specific focus on child poverty and disabled children.
An estimated 200,000 Welsh children live in poverty and are more likely to experience negative health outcomes due to maternal smoking during pregnancy, low birth weight and poor diet, as well as undertaking greater risky/experimental behaviours themselves such as drinking, drug use and smoking.
Tackling child health inequalities cannot be done in isolation and the Welsh Government must meet the challenges outlined above on smoking, obesity, breastfeeding rates and other public health priorities. We also note the recommendations on inclusivity from infancy set out by Disability Matters[14]. This demonstrates the need for an evidence-based child health and wellbeing strategy covering the whole of childhood and a ‘child health in all policies’ approach to decision making, policy development and service design.
We welcome the introduction of the Healthy Child Wales programme which we hope will go some way to addressing these issues. We welcome also the Flying Start programme which has delivered benefits in some of Wales’ most disadvantaged areas.
Recommendation
• We recommend that the Welsh Government should continue to extend the Flying Start project so all children living in poverty have access to the enhanced services and support it provides.
Reduce child deaths and injury prevention, particularly in the most deprived parts of Wales where infant mortality is much higher than the least deprived.
Wales has a robust child death review system and this is vital in informing the policy changes that are required in order to prevent avoidable deaths. Each year an average of 210 infants, children and young people die in Wales. The majority of these deaths occur in infants under one year of age. Additionally, the impact of poverty on child mortality rates in Wales is stark: children from the most deprived fifth of the population have a rate of child death 70 percent higher than those in the least deprived fifth[15].
The reasons why children die are complex and will require a range of interventions and policy solutions to reduce avoidable mortality. The reasons include maternal risks during pregnancy (e.g. smoking, nutrition and substance abuse) and uptake of recommended practices such as breastfeeding and safe sleeping position.
Recommendation
• The Healthy Child Wales Programme should ensure local authorities and health boards prioritise children’s safety, and through utilising resources such as health visitors and home safety equipment schemes, educate and equip parents and carers to keep their children safe, with a focus on water safety, blind cord safety and safe sleeping.
Reduce the adverse impact on the child of psychosocial issues such as poor parenting, disruptive family relationships, domestic violence, mental health issues and substance misuse through effective safeguarding
The mental health of a pregnant or new mother has a major effect on the health and wellbeing of her child. Perinatal mental health problems affect up to 20% of women at some point during pregnancy or in the year after childbirth. This is a major public health issue impacting on both women and baby[16]. Women affected respond well to treatment, but about half of all cases of perinatal depression and anxiety go undetected and many of those which are detected fail to receive evidence-based forms of intervention[17].
One recent report found that on a UK level, one in eleven women who died during or up to six weeks after pregnancy died from mental health-related causes. Almost a quarter of all maternal deaths between six weeks and a year after birth are related to mental health problems, and one in seven of the women who died in this period died by suicide[18]. Severe perinatal mental health problems do not only have negative repercussions for the women directly dealing with them, but also for the family life and development for the children involved[19].
High quality personal, social and health education including sex and relationships education is essential to ensure that the next generation of parents have the knowledge and skills to make positive, healthy decisions and are equipped to understand how to manage their own well-being and minimise their children’s exposure to the adverse childhood experiences listed above. It is positive that the new curriculum for Wales, due from September 2018, establishes health and wellbeing as one of the six Areas of Learning and Experience.
Recommendations
· The Welsh Government and NHS must ensure that every woman has access to appropriate perinatal mental health treatment and support
· Professional bodies representing all those working with infants, children and young people in health, social care, education, criminal justice, and community settings should equip their members with the necessary tools to identify mental health issues through the promotion of resources such as the MindEd portal.
· The Welsh Government should take immediate steps to embed statutory and comprehensive personal, social and health education programmes (including sex and relationships education) across all primary and secondary schools. The new curriculum for Wales should use the Health and Wellbeing Area of Learning experience to continue that approach.
· Estyn should inspect the provision of personal, social and health education programme within a robust framework.
· The Welsh Government should ensure that compulsory evidence based health and wellbeing programmes are embedded in all primary and secondary schools which foster social and emotional health and wellbeing, through building resilience, and specifically tackling issues around social inclusion, bullying, drug and alcohol use and mental health.
[3] Fair Society, Healthy Lives, The Marmot Review http://www.instituteofhealthequity.org/projects/fair-society-healthy-lives-the-marmot-review , February 2010
[4] Scientific Advisory Committee on Nutrition SoMaCNS. Paper for discussion: Introduction of solid foods Agenda item: 3, 2003. ;Infant and young child nutrition (WHA55.25). 55th World Health Assembly; 2002.
[5] Renfrew MJ, Pokhre S, Quigley M, et al. Preventing disease and saving resources: the potential contribution of increasing breastfeeding rates in the UK: UNICEF, October 2012. See also Bowatte G, Tham R, Allen K, et al. Breastfeeding and childhood acute otitis media: a systematic review and meta-analysis. Acta Pædiatrica 2015;104:85-95.
[6] Lucas A, Cole T. Breast milk and neonatal necrotising enterocolitis. The Lancet 1990;336(8730):1519-23.
[7] See for example Victora C, Bahl R, Barros A, et al. Breastfeeding in the 21st century epidemiology, mechanisms, and lifelong effect. The Lancet;387(10017):475-90.
See also Horta B, Loret de Mola C, C V. Long-term consequences of breastfeeding on cholesterol, obesity, systolic blood pressure and type 2 diabetes: a systematic review and meta-analysis. Acta Pædiatrica 2015(106):30–37
[9] McAndrew F, Thompson J, Fellows L, Large A, Speed M, Renfrew M. Infant Feeding Survey 2010
[10] Royal College of Physicians. Passive smoking and children. A report by the Tobacco Advisory Group., 2010.
[11] Leonardi-Bee J, Britton J, Venn A. Secondhand Smoke and Adverse Fetal Outcomes in Nonsmoking Pregnant Women: A Meta-analysis. Pediatrics 2011;127(4):734-41.
[12] Jones M, Lewis S, Parrott S, et al. Re-starting smoking in the postpartum period after receiving a smoking cessation intervention: a systematic review. Addiction 2016.
[13] Public Health Wales. Child Measurement Programme for Wales: Public Health Wales; Available from: http://www.wales.nhs.uk/sitesplus/888/page/67762
[14] Disability Matters is a free learning resource to help those who work, volunteer or engage with disabled children and young people and their families to support them as effectively as they can. http://www.rcpch.ac.uk/Disability-Matters
[15] Public Health Wales Child Health Review Programme 2015, p7 http://www.wales.nhs.uk/sitesplus/documents/888/CDR%20patterns%20%2B%20trends%20v1%20EN.pdf
[16] The costs of perinatal mental health problems, A. Bauer, M. Parsonage, M. Knapp, V. Iemmi & B. Adelaja, http://www.centreformentalhealth.org.uk/costs-of-perinatal-mh-problems , October 2014.
[17] We are not aware of Wales-specific data. NSPCC Cymru, The National Centre for Mental Health and Mind Cymru are developing a project to investigate perinatal mental health services in Wales which will map out statutory and voluntary sectors services and whether statutory services in Wales are meeting national standards and recommendations.
[18] See MBRRACE-UK’s recently published report into maternal deaths, ‘Mothers and Babies: Reducing Risk through Audits and Confidential Enquiries across the UK’
[19] Further information on the impact of perinatal mental health problems see Mind Cymru’s Two in Mind project: https://www.twoinmind.org/for-professionals