Child Public Health

What every GP should know

David Stone

Paediatric Epidemiology and Community Health (PEACH) Unit

University of Glasgow/Yorkhill Hospital

04/21/23

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 Relationship Individual

The Social Ecological Model

Main global threats to child health in

21st century• Injury and abuse

• Congenital anomalies

• Infection

• Respiratory disease

• Cancer

• Psychosocial disorders

Sensitive Periods in Early Brain Development

VisionVision

0 1 2 3 7654

High

Low

Years

Habitual ways of Habitual ways of respondingrespondingEmotional Emotional

controlcontrol

SymboSymboll

Peer social skillsPeer social skillsNumbersNumbers

HearingHearing

Graph developed by Council for Early Child Development (ref: Nash, 1997; Early Years Study, 1999; Shonkoff, 2000.)

Pre-school years School years

LanguaLanguagege

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, 1979-86

Source: Sharples et al, 1990

0

2

46

8

1012

14

16

1 2 3 4 5 6 7 8 9 10

Mortality per 100,000

Deprivation rank of wards

0.9

3.4

5.7

3.74.7

3.44.2 4.4

5.8

14.0

Categories of Deprivation(% of population) in Britain

Most affluent 1 6.1 23.8

2 13.7 30.4

3 21.8 21.5

4 25.5 14.1

5 14.8 6.7

6 11.4 2.9

Most deprived 7 6.8 0.5

DeprivationCategory Scotland

England& Wales

Proportion of 15 year old children with decay experience in the British Isles 2002-3

Source: Nunn JH. The burden of oral ill health for children. Archives of Disease in Childhood 2006; 91: 251-253

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 measuresand

Clinical services

Examples of overlap:surveillance, immunisation, screening, childprotection, parenting support

Contribution to additional life years (Bunker and MacFaul)

1900-1950 +30 yrs 1950-2000 +7 yrs

0

5

10

15

20

25

1900-1950 1950-2000

Public healthClinical care

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 21st 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 theRights of the Child 1991

• Protection from hazards and exploitation

• Provision of basic care and services

• Participation 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