FDL0074
Written evidence from Royal College of Paediatrics and Child Health
Executive summary
1.1. The Royal College of Paediatrics and Child Health (RCPCH) is responsible for training and examining paediatricians, setting professional standards and informing research and policy. RCPCH has over 18,000 members in the UK and internationally. We work to transform child health through knowledge, research and expertise, to improve the health and wellbeing of infants, children and young people across the world.
1.2. RCPCH is pleased to share evidence to the Inquiry into the First 1,000 Days of life. The earliest stages of a child’s life are incredibly formative and are critical to health outcomes throughout an individual’s life.
1.3. This response was drafted with input from the British Association for Child & Adolescent Public Health (BACAPH).
1.4. Our response largely draws on evidence from the RCPCH State of Child Health 2017 Report, which provides a comprehensive overview of child health across the UK. The report highlighted worrying trends in child health, particularly amongst the youngest and most deprived children.
Top priorities for a national strategy – based on existing evidence and lessons from other countries, particularly the devolved administrations
2.1. RCPCH supports notions for the development of a national strategy for the First 1,000 Days of life. Evidence has shown that early interventions in childhood will create healthier adult populations and significantly reduce NHS spending in the medium- and long-term (Marmot Review, 2010). Furthermore, RCPCH supports the vision outlined in the Wave Trust’s 1,001 Critical Days report (2014), which outlines key recommendations to improve services for families and children in the child’s first two years of life. RCPCH supports paediatricians to appropriately care for children in the first 1,000 days through provision of the Healthy Child Programme e-learning programme.
2.2. RCPCH recommends that the Health and Social Care Select Committee take a life course approach to the first 1000 days. In our response, we have focused on the following priorities: infant mortality, maternal health, breastfeeding and immunisation. In each of these areas, childhood poverty has caused poorer health outcomes and increased mortality rates. RCPCH recommends that the Committee recognise the role of inequality and maternal health in exacerbating health issues for children within the first 1,000 days.
2.3. RCPCH recommends that addressing the First 1,000 Days of life requires a cross-government approach with child health as a priority throughout. It also requires appropriate thought as to the necessary links with the education, support and care that children and families will receive beyond the first 1000 days. State of Child Health (2017) recommends that the government adopt a ‘child health in all policies’ approach to decision-making, policy development and service design. It also recommends that the Government establish a Cabinet Sub-Committee on child health – to prioritise children and their health and wellbeing across government policy development.
Inequality and maternal health
2.4. In 2014/15 in the UK, 19% of children were living in relative poverty[1] (DWP, 2015) and the Institute for Fiscal Studies (IFS) have estimated that this will rise to 25.7% by 2020/21 (Browne & Hood, 2016). Children living in poverty are more likely to die before the age of one, become overweight, have tooth decay or die in an accident (Pillas et al., 2014).
2.5. Higher levels of maternal deprivation are specifically correlated with increased risk of infant mortality, maternal health during pregnancy and the uptake of recommended practices in the first 1,000 days (RCPCH, 2017). Furthermore, children born to mothers under the age of 20 are associated with higher infant mortality rates. Maternal health is important as poor nutrition, substance abuse and smoking can increase the risk of mortality and/or create poor child health outcomes. Maternal mental health before, during and after pregnancy is vital in promoting positive wellbeing for the child – there is evidence to suggest that children who are exposed to Adverse Childhood Experiences will develop poorer mental health outcomes later in life. Uptake of guidance on safe infant sleeping positions is lower in areas with higher deprivation, therefore we recommend that support is targeted in order to reach these families.
2.6. RCPCH recommends the introduction of comprehensive programmes to reduce maternal and child poverty, including supporting universal early years’ public health services and ensuring effective prevention care is provided in primary care. Alongside this, RCPCH recommends that health professionals are made aware of the health impacts of child poverty.
2.7. Maternal health is vital to the outcomes of children, especially in their early years. Mothers should be supported during pre-conception, the antenatal period, labour and birth, and the post-natal period. RCPCH (2017) recommends mothers can be supported by:
Infant mortality
2.8. Around 60% of deaths during childhood occur before the age of one. In 2016, there were 2,587 infant deaths[2], with an infant mortality rate of 3.9 per 1,000 live births in England and Wales (ONS, 2017). The total number of infant deaths has risen by 479 since 2014. The majority of these deaths occur before the child is 28 days old, with the neonatal mortality rate at 2.8 per 1,000 live births – which has increased by 0.1 since 2015 (ONS, 2017). Furthermore, the UK compares unfavourably with other Western European countries; only Denmark, Poland, Hungary and Slovakia having higher infant mortality rates (Wolfe et al., 2015). These figures highlight an alarming rise in infant mortality in England, which requires attention.
2.9. Many of the causes of infant mortality can be prevented, as deaths during infancy are strongly associated with preterm birth, fetal growth restriction and congenital abnormalities. Furthermore, injuries in young children can largely be prevented and parents should be supported to provide safe play environments in the home.
Smoking during pregnancy
2.10. In the UK, rates of smoking during pregnancy are higher than many European countries. In England, 11.4% of women were smoking at the time of delivery in 2014/15 (HSCIC, 2016). Both the mother’s age and level of deprivation increase the likelihood of smoking whilst pregnant (RCPCH, 2017).
2.11. Research has found that smoking during pregnancy can lead to 2,200 preterm births, 5,000 miscarriages and 300 perinatal deaths per year (RCP, 2010). It can also pose health risks to infants, including: impaired growth, reduced birth weight, reduced lung function, development of some congenital abnormalities (RCP, 2010) and Sudden Infant Death Syndrome (SIDS) (Shah et al., 2006). Additionally, smoking puts the child at risk of obesity (von Kries et al., 2002), asthma (Neuman et al., 2012), impaired intelligence, mental health problems (Moylan et al., 2015) in later life. RCPCH recommends that all maternity services implement the NICE Guidance ‘Smoking: Stopping in pregnancy and after childbirth’. Also, RCPCH also recommends that the smoking status of pregnant women should be better collected and recorded.
Breastfeeding
2.12. Breastfeeding rates in the UK are lower than many other comparable high-income countries. In 2014/15 in England, 44% of mothers were breastfeeding at their 6-8 week health visitor review, though only 30% were being breastfed exclusively (NHSE, 2016). An international study found that just 34% of babies in the UK were being breastfed at 6 months, compared to 71% in Norway. RCPCH recommends that mothers should be supported to breastfeed their healthy term infant exclusively for up to 6 months. This is supported by a number of other recommendations in our evidence-based position statement on breastfeeding. (RCPCH, 2017).
2.13. Breastfeeding is important for infants as it helps protect against infections (Renfrew et al., 2012). It is also thought that breastfeeding contributes to higher intelligence, reduced risk of developing obesity and Type 2 diabetes (Victora et al., 2016).
2.14. RCPCH recommends initiating several measures to support mothers to breastfeed:
Immunisation
2.15. By 12 months of age, babies should have received several vaccinations, including three doses of the 5-in-1 vaccination. In 2015, England’s 5-in-1 immunisation rate was 93.6% (NICE, 2009), which is below the WHO target of 95% of children receiving the full course of the vaccine by 12 months. The 5-in-1 vaccine protects children against the following communicable diseases: diphtheria, tetanus, whooping cough, polio and Haemophilus influenzae type b (Hib).
2.16. In 2015, England’s uptake of both doses of the MMR vaccination was 88.2%, a 0.4% reduction from the previous year. The first dose of the MMR vaccine is offered at one year of age (with the second at three years and four months).
2.17. RCPCH recommends implementation of NICE guidance ‘Reducing differences in the uptake of immunisations’.
Obesity
2.18. Childhood obesity presents is at an epidemic level in the UK. Overweight children are likely to present with other health and wellbeing problems and are likely to become overweight adults. It is important that weight in early childhood is recorded, monitored and maintained at a healthy level. RCPCH’s Tackling England’s Childhood Obesity Crisis (2015) outlines a full list of policy recommendations.
2.19. Since we know that early interventions, prior to starting school, can significantly change trajectories for overweight and obese children, it is important to provide opportunities in primary care to develop and deliver targeted weight management education for parents and carers. So, it is imperative that growth trends are tracked more closely between birth and starting school in order to identify patients at risk of childhood obesity. Sharing the health visitor or other community measurements that take place from ages 0-5 with GPs would improve the quality of trend mapping, however currently there is no universal system to support this data sharing.
2.20. Since children aged <4 years have frequent contact with their GP, primary care is perfectly positioned to collect this early childhood weight data and deliver effective early intervention. Integration of electronic growth charts and centile calculators into GP health systems would support this commitment and benefit both health professionals and the children they care for. We therefore believe that this should be implemented as a priority alongside the both the Childhood Obesity Plan and the NHS 10-year plan as part of an ongoing commitment to the prevention agenda.
Recent public spending on services covering the First 1,000 Days
3.1. A key recommendation within the State of Child Health (2017) was: ‘Government should place a moratorium on further public health funding cuts until a clear impact assessment of the effects of the most recent cuts is undertaken’. However, King’s Fund projections state that councils will spend £2.52 billion on public health services in 2017/18, compared to £2.60 billion the previous year. Estimates highlight a 5% deduction in public health spending from 2013/14 (RCPCH, 2018). Reductions in public health spending have led to vital children’s services being cut, including those that support the first 1,000 days. RCPCH recommends that dedicated funding is provided for services that support the first 1,000 days.
Difficulties in making the case for investment nationally and locally
3.2. Evidence has indicated that prevention and early intervention improve health outcomes and represent value for money, by reducing pressure on public services (i.e. NHS / social care) and supporting economic growth (i.e. increased productivity). Public Health England have produced guidance on the importance of health economics and ‘making the most of your budget’ (PHE, 2018).
The scope, scale and current performance provision for First 1,000 Days of life – including universal and targeted approaches
4.1. Health inequalities are a key issue for children in the first 1,000 days. RCPCH endorses suggestions outlined in the Marmot Review of health inequalities (2010), which recommend that there should be a key focus on providing universal services for children with a scale and intensity proportionate to the level of disadvantage (termed ‘proportionate universalism’).
Barriers to delivery – e.g. workforce shortages, financial constraints on councils
4.2. Paediatricians have an important role to play in supporting mothers and children in the first 1,000 days. Findings from RCPCH State of Child Health workforce report (2017) highlights an unsustainable paediatric consultant workforce at present. Though the UK paediatric consultant workforce grew by 7.5% between 2013 and 2015, the number of associate specialists fell by 12.5%. Worryingly, there is an estimated 241 whole time equivalent (WTE) career grade vacancies. Furthermore, workforce analysis found that an extra 752 WTE consultants and 465 new trainees annually are required to meet the RCPCH (2015) Facing the Future standards. The shortfall in the paediatric workforce has not kept pace with increasing patient numbers, placing services under increased pressure and gaps in the paediatric rotas have created difficulties for teams and individual consultants who have reported ‘burn out’ (RCPCH, 2018).
4.3. Health visiting and maternity services are vital for delivering services for mothers and children during the first 1,000 days, including providing support and guidance. Unfortunately, early years services in England have faced cuts over recent years. NHS Digital statistics highlight a decrease of 903 health visitors working in the NHS from 2016 to 2017 – a drop of 9.5%.
4.4. RCPCH recommends that funding is provided to increase recruitment to paediatric, maternity and health visiting professions. Our State of Child Health workforce report (2017) outlines specific recommendations for how the paediatric workforce can be supported and expanded – including identifying a responsible body for workforce planning and providing central funding to increase the number of paediatric trainee places.
What a high-quality evidence-based approach to service provision would look like for the First 1,000 Days of life
4.5. RCPCH recommends a ‘proportionate universalism’ approach to service provision for the first 1,000 days of life. This would include universal access to paediatrics, health visiting and maternity services. Providing this would aid in health promotion, early identification and early intervention.
4.6. An example of high quality service provision can be seen in Sweden’s child health centres. The UK has more than 2,000 excess child deaths a year compared to Sweden, which performs favourably among European counterparts (RCPCH, 2014).
September 2018
References
Browne, J. & Hood, A. (2016) Living standards, poverty and inequality in the UK: 2015-16 to 2020-21.
Department for Work and Pensions (2015) Households below average income; an analysis of the income distribution.
von Kries R., Toschke, A.M., Koletzko, B. et al. ‘Maternal smoking during pregnancy and childhood obesity, American Journal of Epidemiology, 156(10), pp. 954-961.
The Marmot Review (2010) Fair Society, Healthy Lives: The Marmot Review. Strategic Review of Health Inequalities in England post-2010. Available at: http://www.instituteofhealthequity.org/resources-reports/fair-society-healthy-lives-the-marmot-review
Moylan, S., Gustavson, K., Overland, S., et al., ‘The impact of maternal smoking during pregnancy on depressive and anxiety behaviours in children: the Norwegian mother and child cohort study’, BMC Medicine, 13(1), pp.24.
National Institute for Health and Care Excellence (2009) Immunisations: Reducing differences in uptake in under 19s.
Neuman, A., Hohmann, C., Orsini, N., et al. ‘Maternal smoking in pregnancy and asthma in preschool children: A pooled analysis of eight birth cohorts’, American Journal of Respiratory and Critical Care Medicine, 186(10), pp.1037-1043.
NHS England (2016) Breastfeeding 2015/16 Q1.
Office for National Statistics (2017) Vital statistics: Population and health reference tables. Available at: https://www.ons.gov.uk/peoplepopulationandcommunity/populationandmigration/populationestimates/datasets/vitalstatisticspopulationandhealthreferencetables
Pillas, D., Marmot, M., Naicker, K., et al., (2014) ‘Social inequalities in early childhood health and development: A European-wide systematic review’, Pediatric Research, 76(5), pp.418-424.
Public Health England (2018) ‘Health matters: Health economics – making the most of your budget’. Published 27 July 2018. Available at: https://www.gov.uk/government/publications/health-matters-health-economics-making-the-most-of-your-budget/health-matters-health-economics-making-the-most-of-your-budget
Renfrew, M.J., Pokhre, S., Quigley, M. et al. (2012) Preventing disease and saving resources: The potential contribution of increasing breastfeeding rates in the UK.
Royal College of Paediatrics and Child Health (2014) Why children die: death in infants, children and young people in the UK. Available at: https://www.rcpch.ac.uk/resources/why-children-die-research-recommendations-2012
Royal College of Paediatrics and Child Health (2015) Tackling England’s childhood obesity crisis.
Royal College of Paediatrics and Child Health (2015) Facing the Future: Standards for acute general paediatric services. Available at: https://www.rcpch.ac.uk/resources/facing-future-standards-acute-general-paediatric-services
Royal College of Paediatrics and Child Health (2017) State of Child Health: 2017 Report. London: RCPCH. Available at: https://www.rcpch.ac.uk/resources/state-child-health-report-2017
Royal College of Paediatrics and Child Health (2017) State of Child Health. Short report series: The paediatric workforce. Available at: https://www.rcpch.ac.uk/resources/state-child-health-short-report-series-paediatric-workforce
Royal College of Paediatrics and Child Health (2017) Position Statement: Breastfeeding. Available at: https://www.rcpch.ac.uk/resources/position-statement-breastfeeding-uk
Royal College of Paediatrics and Child Health (2018) State of Child Health: England – one year on. Available at: https://www.rcpch.ac.uk/resources/state-child-health-england-one-year
Royal College of Paediatrics and Child Health (2018) Facing the Future: 2017 Audit. Available at: https://www.rcpch.ac.uk/resources/facing-future-audit-2017
Royal College of Physicians (2010) Passive smoking and children: A report by the tobacco advisory group.
Shah, T., Sullivan, K., Carter, J. (2006) ‘Sudden infant death syndrome and reported maternal smoking during pregnancy’, American Journal of Public Health, 96(10), pp.1757-1759.
Victora, C., Bahl, R., Barros, A., et al. (2016) ‘Breastfeeding in the 21st century epidemiology, mechanisms, and lifelong effect’, The Lancet, 387(10017), pp.475-490.
Wave Trust (2014) The 1001 Critical Days: The importance of the conception to age two period. Available at: http://www.wavetrust.org/our-work/publications/reports/1001-critical-days-importance-conception-age-two-period
Wolfe, I., Donkin, A., Marmot, M., et al. (2015) ‘UK child survival in a European context: Recommendations for a national countdown collaboration’, Archives of Disease in Childhood.
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[1] Relative poverty is defined as living in households where income is less than 60% of the national median household income.
[2] Infant deaths are defined as under one year of age.