Dr Gabrielle Laing,

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Teaching community paediatrics to undergraduates
July 2009

• Dr Gabrielle Laing,
• Consultant Community Paediatrician,
• City and Hackney Community health services
• Honorary Senior Lecturer

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Builds on a previous workshop led by Dr Sian
Stanley that focused on teaching students to
recognise the sick child. This workshop is
primarily about the well child
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Aims of today

• To outline the opportunities that students have
  for learning in community paediatrics
• To refresh your knowledge about changes in
  service delivery and consider how they impact on
  teaching, in relation to child development, child
  health promotion and immunisation
• To provide a reminder about the WHO growth charts
• To discuss how students should advise parents
  about immunisation

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What teaching do they have?

• Year 1 PBL and learning landscape on normal
  child development and injury prevention, workshop
  on immunisation
• Year 2 PBL and learning landscape on disability
  6 week child health module
• Half day community paediatric workshop
• 1 week in a GP practice
• 2 specialised clinics in a department of
  community paediatrics

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Objectives

• Understand normal child development, growth and
  its variations within the context of child health
  promotion
• Describe the aims and methods of Child Health
  Promotion and the professionals involved in its
  delivery. List the core programme offered to all
  children in the district where you worked

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Objectives

• Carry out a physical and mental state examination
  for children of different ages
• Carry out a basic developmental examination
• of a child at key stages e.g. 6 weeks, 12 months
  and 3 years

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The Child health promotion programme

• Child health surveillance
• Child health promotion
• The healthy child

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Child health surveillance

• For many years, the surveillance and monitoring
  of child health, growth development has been
  regarded as good practice
• However, there was limited evidence as to the
  effectiveness of this practice
• In 1989 Health for all children recommended a
  core programme with a series of checks which
  were treated like screening tests but did not
  fulfil the criteria for a screening programme
• One of the main aims was to identify children
  with defects

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Child health promotion programme

• In 1996, the 3rd edition of Health for all
  Children recommended a change in name to Child
  Health Promotion
• The emphasis shifted from the identification of
  problems to preventative health care
• Checks were recommended at birth, 6 weeks, 8
  months, 18 months and 3 years
• Subsequent editions have increasingly noted a
  community based response to the needs of children
  and families

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Child health promotion programme

• In March 2008, DH and DCSF launched the revised
  Child Health Promotion Programme, updating the
  NSF for Children, Young people and Maternity
  Services (2004).
• This document aimed to establish the CHPP within
  joint commissioning and integrated childrens
  services across general practice and childrens
  centres

www.dh.gov.uk/en/Publicationsandstatistics/Publica
tions/DH_083645 www.dcsf.gov.uk/publications/pregn
ancyandthefirstfiveyears/pdfs/ChildHealth.pdf
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Child health promotion programme

• Recommends that every child and parent has access
  to a universal/core programme of preventative
  pre-school care
• Recommends a progressive universal service i.e.
  offered to all families with additional services
  for those with specific needs and risks
• Formal screening should be confined to evidence
  based programmes agreed by the National Screening
  Committee

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Child health promotion programme

• The new programme includes a major emphasis on
  parenting support
• Application of new information about child
  development, specifically the importance of
  attachment, maternal and paternal well being
• Changed public health priorities breastfeeding,
  obesity, social and emotional development
• Emphasis on integrated services Children
  centres, health visitor lead with early years
  staff, general practice, co-ordinated by public
  health/community paeds
• Increased focus on vulnerable children and
  families

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Screening as part of the CHPP

• Antenatal
• Immediate physical inspection at birth
• Physical examination within 72 hours
• 5 days blood spot for hypothroidism, sickle cell,
  phenylketonuria, cystic fibrosis, MCAD
• Universal neonatal hearing screening
• Physical examination at 6 weeks eyes, cardiac,
  hips, testes, general examination
• Orthoptist led assessment of vision at 4-5 yrs
• Measurement of height, weight and hearing test at
  school entry
• Obesity/healthy weight monitoring not
  officially a screening programme

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Health and development reviews

• Neonatal examination
• New baby review
• 6-8 week examination
• By the time the child is one year old
• Between 2 and 2 ½ years olds
• A core function is to recognise disability and
  developmental delay but reviews must include an
  evaluation of the strengths and needs of
  individual children and families, preventative
  health care, signposting and an assessment of the
  need for additional support

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The Healthy Child

• In February 2009, with the launch of the DH
  strategy for children and young peoples health,
  Healthy Lives, Brighter Futures, the name of the
  programme was changed to The Healthy Child
  although the content was unchanged.
• http//www.dh.gov.uk/en/Publicationsandstatistics/
  Publications/PublicationsPolicyAndGuidance/DH_0944
  00

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How have these changes impacted on how you can
teach the students?
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The 6 week review

• Offer to all infants between 6-8 weeks of age
• Includes a full physical examination
• Undertake jointly with HV team where possible
• Assess family needs and strengths
• Provide advice and information
• Deliver health promotion messages
• Plan further care according to need

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History and physical examination

• Review birth history
• Check parental concerns
• Consider maternal depression
• Fully undress and full physical examination
• Note birth marks, jaundice
• Check weight (naked) and head circumference
• Check hips, testes, heart and eyes, including red
  reflex

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Motor skills

• Observation symmetry and spontaneous movement
• Place prone and supine, pull to sit
• Weight bearing, ventral suspension
• Tone/reflexes
• Milestones 3/12 (3-6) little/no head lag when
  pulled to sitting, 6/12 (5-8) rolls over,

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Communication and behaviour

• Smiling and cooing responsively
• Crying, colic and sleeping

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What opportunities are there for teaching?e.g.
around screening programmes for children, child
health promotion or child developmentWhat works
in your practice?
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WHO growth charts

• First published in April 2006 for infants and
  children up to 4 years of age
• Describe growth of children in well supported
  health environment in 6 countries who were
  breastfed for at least 6 months with
  complimentary food by 6 months
• They represent optimal, not average growth for
  children

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What does that mean?

• If we use the WHO charts we will diagnose fair
  fewer infants losing weight by falling through
  2 centiles
• If we use the WHO charts we will identify more
  children as overweight
• There is little difference in terms of length or
  height

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Objectives

• Understand normal child development, growth and
  its variations within the context of child health
  promotion
• List the recommended schedule of immunisation and
  the major contraindications and be able to
  discuss these with parents.

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Information on immunisation

• The Green book at www.dh.gov.uk/ then search for
  green book
• Medline/Pubmed databases
• Immunisation Information England at
  www.immunisation.nhs.uk
• Department of Health at www.dh.gov.uk/
• Health Protection Agency at www.hpa.org.uk
• WHO at www.who.int
• NHS Direct at www.nhsdirect.nhs.uk/
• GOSH website at www.gosh.nhs.uk/immunisation

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What do parents want to know?

• Is the disease serious?
• Is my child likely to catch the disease?
• Does immunisation work?
• What are the side effects and risks?

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Healthy toddler died 10 days after being given
MMR vaccination A "healthy and robust"
18-month-old boy died 10 days after being given
the controversial MMR vaccination, an inquest
heard. (Dec 2008) Toddler George Fisher had been
happily playing football with his father the day
before he died Sarah and Christopher
Fisher said they believed the jab was
"implicated" in the sudden death of their son
George.
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It's time we created special schools for MMR
dodgers

• The continuing resistance by a certain kind of
  mummy
• to vaccination is selfish, ignorant and downright
  dangerous
• Catherine Bennett
• Over a decade since Dr Andrew Wakefield raised
  unfounded fears about the safety of the MMR
  vaccination, it emerges that many British parents
  are still denying their children the combined jab
  against measles, mumps and rubella. A suspicion
  evidently remains that, as Wakefield baselessly
  informed a generation of terrified parents, the
  jab may somehow be an "environmental trigger" for
  autism.
• Although subsequent studies have repeatedly
  confirmed that there is no more evidence for such
  a connection than there is, say, between toad
  contact and warts, agonised, emoticon-strewn
  discussions about the jab are a regular theme on
  mummy websites that did not exist in 1998, when
  Wakefield struck.

Observer June 2009
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Advising parents

• At their introductory workshop I ask students
• You are in a GP surgery (next week) and a parent
  asks you whether you think their child should
  have the MMR vaccine
• How do you respond?
• How would you like them to respond?

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Thank you

• Questions?