Healthy Birth & Early Years

Why Birth and the Early Years is an important period

A child’s earliest years, from their birth to the time they reach statutory school age, are crucial. All the research shows that this stage of learning and development matters more than
any other

Unknown children – destined for disadvantage?³³

Families are the most important influence on a child – particularly in the early years – and identifying those families who need help as early as possible opens opportunities to offer evidence-based interventions. Several related protective factors can be optimised to support a healthy birth and the early years including:³⁴

• Authoritative parenting combined with warmth, with an affectionate bond of attachment being built between the child and the primary care-giver from infancy
• Parental involvement in learning
• Protective health behaviours e.g. stopping smoking
• Psychological resources including self-esteem
• Breastfeeding

What is the local picture?

The most recently compiled and published data is compared with other local authorities of similar deprivation, unless stated otherwise, as of April 2021.

Table 2: Healthy Birth and Early Years in Central Bedfordshire

Significantly worse than comparator

Not significantly different than comparator

Significantly better than comparator

No IMD Decile Comparison

Healthy Birth and Early Years Indicator	Previous period   [Comparator IMD 2019] (Date)	Most recent available period [Comparator IMD 2019] (Date)
Breastfeeding initiation (%)
	75.3% [74.0 England] (2015/16)	77.0% [74.5 England] (2016/17)
Breastfeeding at 6-8 weeks (%)
	50.2% [46.2 England] (2018/19)	53.6% [48.0 England] (2019/20)
A&E attendances aged 0-4 years (Rate per 1,000)
	430.0 [540.9] (2017/18)	351.3 [565.9] (2018/19)
Low birth weight of all babies (%)
	7.1% [6.5%] (2017)	6.1% [6.3%] (2018)
Admissions for gastroenteritis in infants aged 1 year (Rate per 10,000)
	100.3 [79.8] (2018/19)	102.7 [77.1] (2019/20)
Admissions for lower respiratory tract infections in infants aged under 1 year (Rate per 10,000)
	1,124 [738] (2018/19)	949 [742] (2019/20)
Infant immunisations – MMR one dose at 24 months (%)*
	94.5 [91.3] (2018/19)	94.0 [92.8) (2019/20)
New-born Blood Spot Screening Coverage (%)	Bedford Hospital: 99.6% L&D: 99.1% [England: 98.0%] (Q2 2019/20)
Domestic abuse incidents (Rate per 1,000)
	24.4 [27.4 England] (2018/19)	27.6 [28.0 England] (2019/20)
11. Early Years Foundation Stage: good level of development at age 5 (%)
	73.2% [NA] (2017/18)	72.5% [75.9%] (2018/19)
12. Hospital admissions for dental caries (0-5 years) (Rate per 100,000)
	31.0 [251.8] (2016/17-18/19)	23.2 [218.8] (2017/18-19/20)

* Benchmarked against <90% 90% to 95% ≥95% Central Bedfordshire’s overall score for deprivation (using the 2019 Index of Multiple Deprivation) relative to all other local authorities in England, puts it in the least deprived decile. Throughout this report, Central Bedfordshire’s performance is compared to other areas of similar deprivation where possible. For comparison to other local authorities of similar deprivation (IMD 2015), please refer to the reference35 Table Sources: Public Health Outcomes Framework: CYP JSNA – Section 2 (IMD 2019): https://fingertips.phe.org.uk/indicator-list/view/wGGsClEvSk#page/4/gid/1/pat/10113/par/cat-113-7/ati/302/are/E06000056/iid/93580/age/309/sex/4/cat/-1/ctp/-1/yrr/1/cid/1/tbm/1 [Accessed 1 April 2021]. Public Health Outcomes Framework: CYP JSNA – Section 2 (IMD 2015): https://fingertips.phe.org.uk/indicator-list/view/wGGsClEvSk#page/4/gid/1/pat/10105/ati/302/are/E06000056/iid/93580/age/309/sex/4/cid/4/tbm/1 [Accessed 11 July 2021].

Compared to other local authorities in the same deprivation decile, we are significantly worse for the rate of admissions for lower respiratory tract infections in infants aged under 1 year, and for children achieving a good level of development at age 5 (EYFS). We have significantly better rates for breastfeeding at 6-8 weeks compared with national rates, and significantly better A&E attendance rates for children aged 0-4 years, compared with the deprivation decile.

A healthy childhood

We are aiming for parents and carers to feel supported to: make decisions to improve their child’s health
outcomes and life chances; be their child’s first educator; feel confident to manage their child’s minor illnesses and health issues.

The 0-5 years element of the Healthy Child Programme³⁶ is led by the Health Visiting Service and involves integrated working with all partners across the system, including maternity services, children’s centres, Early Years settings, children’s social care and GPs. It offers every family a programme of screening tests, developmental reviews, immunisations and guidance to support parenting and healthy choices until the child reaches statutory school age. In addition to universal services, The Healthy Child Programme provides additional support to families who need it to reduce the risk of adverse outcomes for the child.

Ensuring children are ready to learn

In Central Bedfordshire, an Integrated Education and Health Review is now offered to all children at the age of 3 years and 3 months, which incorporates a health and development review and the Early Years Foundation Stage check. Collaboration between Health Visiting and Early Years professionals ensures high quality and comprehensive assessment of need, that includes the child, their family and the wider context. The review provides an opportunity to discuss and assess a child’s health, wellbeing and development and to identify those children and families who may need additional support.

To support parents and carers in their crucial role as their child’s first educator, evidence-based parenting
programmes such as Parents as First Teachers,³⁷ Triple P,³⁸ Parent Puzzle and Mellow Parentin³⁹ are offered in Central Bedfordshire.

Development by 5 years

A child’s development, and a gauge of their readiness for school, is next measured at age 5, using the Early Years Foundation Stage Profile (EYFSP).⁴⁰ Improving the number of children who achieve a good level of development when starting school remains a priority for Central Bedfordshire.

Reduced emergency hospital attendances and admissions

The main causes of Accident & Emergency (A&E) attendances and hospital admissions amongst children
and young people are acute illnesses (such as gastroenteritis and upper respiratory tract infections), and
injuries caused by accidents in the home. Unintentional injuries are the main cause of death in children
and young people.

In the UK, 1 in 11 children have asthma, and every 20 minutes a child is admitted to hospital due to an asthma attack.⁴¹ BLMK CCG has developed a systems approach to improving the management of asthma in children and young people. This includes GPs, the 0-19 Healthy Child Programme Service, schools and hospitals.

Adverse childhood experience and trauma

Adverse childhood experiences (ACEs) and trauma⁴² are highly stressful, and potentially traumatic, events or situations that occur during childhood or adolescence.

These can be a single event, or prolonged threats to, and breaches of a young person’s safety, security, trust or bodily integrity. These experiences directly affect the young person and their environment, and require significant social, emotional, neurobiological, psychological or behavioural adaptation.

• Survive in their immediate environment
• Find ways of mitigating or toleration the adversity by using available resources
• Establish a sense of safety or control
• Make sense of the experiences they have had

What kinds of experiences are adverse?

1. Maltreatment: including physical, sexual, emotional and financial abuse and neglect
2. Violence and Coercion: including experiencing, or directly witnessing, domestic abuse, assault, harassment or violence, sexual exploitation, sexually harmful behaviour, being the victim of crime or terrorism, experience of armed conflict, gang or cult membership and bullying.
3. Adjustment: including moving to a new area where there are no social bonds, migrating, seeking and gaining refuge or asylum and the ending of a socially significant or emotionally important relationship.
4. Prejudice: including discrimination, victimisation, hate incidents and crime, other attitudes, chronic exposure to behaviours and institutional processes driven by LGBT+ prejudice, sexism, racism or disablism.
5. Household or family adversity: including living in a household with adults or adolescents who misuse substances, engage in criminal activities, are not supported to manage their mental ill health, making sense of intergenerational trauma (e.g. experiences of genocide). It also includes living in poverty, destitution or facing significant social, material and emotional deprivation. It also includes being looked after, leaving care, being detained in a secure children’s service (e.g. young offender institution) and family or placement breakdown
6. Inhumane treatment: including torture, forcible imprisonment, confinement or institutionalisation, non-consensual and coercive scarification and genital mutilation.
7. Adult responsibilities: including being the primary carer of adults or siblings in the family, taking on financial responsibility for adults in the household and engaging in child labour.
8. Bereavement and survivorship: including death of care-giver or sibling (including through suicide or homicide), miscarriage, acquiring or surviving an illness or injury, and surviving a natural disaster, terrorism or accident.

Often risk factors occur together – particularly children living in a family affected by the ‘toxic trio’ of parental mental illness, substance misuse and domestic violence. Over a quarter (26%) of babies in the UK, have a parent affected by one of these issues.⁴³

Children and young people who witness and live with these stressful incidents are more likely to have low self-esteem, attachment issues and difficulties managing their emotions.

Individuals who experience 4 or more Adverse Childhood Experiences or traumatic events have an increased risk of high-risk behaviours and poorer outcomes as adults,⁴⁴ as shown in the graphic below.

Breastfeeding

Supporting families to breastfeed and increasing the number of babies who are breastfed gives babies the best possible start and is considered to be a public health priority. There is extensive evidence on the breastfeeding benefits to mothers, and to their babies’ health, as well as evidence on how breastfeeding increases the level of attachment and bonding between mothers and their babies. The longer breastfeeding continues, the longer the protection lasts and the greater the benefits. The World Health Organization and the Department of Health recommend exclusive breastfeeding for the first 6 months of life.

Breastfed babies have lower rates of gastroenteritis, respiratory infections, sudden infant death syndrome,
obesity and allergies. The health benefits of breastfeeding for the mother include lower risks of breast and ovarian cancers, cardiovascular disease, osteoporosis and obesity in later life.

Breastfeeding rates at 6-8 weeks have increased slightly in Central Bedfordshire over recent years and are
now better than the national average. However, there is still work to do to increase these rates, and there is significant variation across Central Bedfordshire localities.

Preventable childhood diseases

Antenatal and new-born screening is part of the routine maternity care pathway. Through the robust programme provided locally, screening can help to prevent infection of the new-born child, and ensure that appropriate care is made available. The antenatal and new-born screening timeline goes from pre-conception to 8 weeks after birth.⁴⁵ Vaccination is recognised as one of the most effective public health interventions in the world, and the UK has one of the best immunisation programmes. Coverage of over 95% protects the whole community not just those vaccinated – by reducing the likelihood of infectious diseases being able to spread. Research shows that children under the age of 5 years have the highest rate of hospital admissions of any age group. The purpose of the childhood vaccination programme is to help to protect children against preventable diseases, including measles, mumps and rubella.

Central Bedfordshire, for the 12-month indicators of Diphtheria/tetanus/Pertussis/Polio/Hib Influenza/Hepatitis B, Rotavirus, Pneumococcal and Meningitis B vaccines, are all above the England and East of England average for Q1-3 2020-21. Most vaccines types, other than Rotavirus, have sat consistently above the national COVER target of 95%, even within the constraints of the COVID-19 pandemic. Sustaining uptake is very much attributed to the work of both General Practice and the support of the redeployed Community and School Age Immunisation team.

Considering the 2nd MMR dose at age 5, Central Bedfordshire has performed above the England and East of England average, although has not reached the 95% target. It is currently at 92.6% for Q3 2020-21. Strategies are in place with the ICS, NHSE and the Child Health Information Service, to improve uptake through targeted work at practice level, for all children with outstanding MMR vaccinations. Full uptake figures can be found in the COVER programme, 2020.⁴⁶

The annual ‘flu vaccination programme now includes children; this helps to protect them from catching ‘flu, and also helps to prevent them spreading infection to their families and the wider community. Reporting as Bedfordshire CCG, ‘flu vaccination uptake in 2020-21 for 2 & 3 year olds was above both the England and East of England uptake and a significant improvement on 2019-20.

The NHSE Screening & Immunisation Team continue to update all members of the wider team, in partnership with Public Health: this includes 0-19 Healthy Child Programme Teams, Looked After Children teams, General Practice staff – both clinical and non-clinical, pharmacists, Foster Carers, Childminders, and Early Years staff, on the changes in the UK Routine Vaccination Schedule, strategies on improving uptake, the role of Child Health Information Service and reducing inequalities.

Oral Health

Poor oral health can affect children’s ability to speak, eat, sleep, play and socialise and can negatively impact on a child’s school attendance and wellbeing. In the UK, tooth decay is still the commonest cause of admission to hospital in 5-19 year olds. Through the locally commissioned Oral Health Promotion (OHP) Service, health education advice, information and training is provided in various settings, to a range of groups in Central Bedfordshire, which includes:

1. Nursery Schools
2. Pre-Schools
3. Foster carers
4. Other groups by request

The team, who are part of Cambridgeshire Community Services (CCS), also provide training to other CCS
children’s teams including the 0-19 HCP Service, specialist school nurses and the Looked After Children (LAC) health team. Oral health is discussed by the HCP team in all 0-5 mandated contacts, with staff using activities and materials provided by the OHP team. The training delivered to 5-19 teams covers specific areas – i.e., interdental cleaning, HPV awareness, piercings etc.

Professionals in oral health promotion offer health protection messages for families to promote the importance of good oral health using a range of evidence based approaches such as: apps and websites through Start4Life and Change4Life; encouraging children and their families to register and attend a dentist if they have not done so already; making every contact count by delivering brief intervention and advice to parents/carers including making the link between healthy eating (low sugar diet/drinks) and good oral health; promoting good oral health practices such as effective tooth brushing, and the use of fluoride paste.

The OHP team also deliver the ‘My Smile’ accredited programme for early years’ settings and Children’s
Centres. The programme guides settings in the application of the 4-step approach to providing a tooth-friendly environment for children within their care, including a supervised tooth-brushing programme. The ‘My Smile’ accreditation is given to settings that can demonstrate to the ‘My Smile’ team that all 4 steps are in fully in place and are being implemented effectively.

The impact of Covid-19 on healthy births and early years

In Central Bedfordshire, there have been several changes to labour and post-natal services. To protect families during the pandemic, there has been a reduction in postnatal, midwifery and health visiting home visits. Although partners have been able to support women during their birth, it has been necessary to limit visitors to labour, antenatal and postnatal wards.

Immunisation appointments moved to children’s centres in April 2020. Although vaccination counts fell in March 2020 when social distancing was introduced, it is now comparable to vaccination rates at this point in 2019 (before the COVID-19 pandemic).

One of the major impacts of pre-term deliveries is necrotising enterocolitis (NEC). Depending on the severity, neonates with NEC may require both neonatal services in maternity settings and surgical services in paediatric units. Studies have shown that breastmilk is one of the most effective ways to prevent or reduce the severity of NEC. Supporting breastfeeding provides an opportunity to promote neonatal health, and it appears that during the pandemic more mothers were breastfeeding at 6-8 weeks. In order to sustain this unexpected improvement, we need to understand why this increase has been seen.

There have been increased demands on neonatal and paediatric services. During the initial wave of COVID-19, there was a requirement to protect mothers and babies by reducing visitors to their homes, and so much of the postnatal visiting by midwifery and health-visiting staff was changed to telephone or virtual consultation. Breastfeeding support leaflets were co-produced to enable women to access support when they needed it.

In Central Bedfordshire, the Baby-Friendly Support team are continuing to encourage and support mothers in breast-feeding, through virtual consultations. This has encouraged an increase in breastfeeding rates. To protect families during the pandemic, the Well-Baby health visitor clinics have stopped. In addition, there are concerns that with the increase in virtual support, there is the potential to miss opportunities to identify babies who are failing to thrive, and to support those parents and families.⁴⁷

The pandemic has influenced the development and well-being of children and young people. The largest impact is likely to fall on children from the poorest families, or those with vulnerabilities and additional or particular needs.⁴⁸

In Central Bedfordshire, there has been partial closure of nurseries and face-to-face group activities in Children’s Centres. During the pandemic, there has been collaborative working between Children’s Centres, immunisation services, and maternity services to identify vulnerable and at-risk mothers and families earlier.

Changes to services have also caused some challenges due to group activities being suspended. Children and families with complex home situations, such as overcrowded housing or lack of play spaces, are unable to access safe places to play, and nurture positive social networks. These families may have some connections with Children’s Centres but not meet the threshold for other support organisations.

Both ‘flu and COVID-19 will likely be circulating at the same time, which means that it is more important than ever to help to protect against ‘flu. The ‘flu vaccination will not protect against COVID-19, but it is critical to protect the general health of the population, particularly those at high risk from COVID-19. The numbers attending vaccination clinics during March 2020 dramatically reduced, with the pandemic cited as a principal factor. In an effort to combat this, several changes were introduced to ensure that vaccination coverage for newborn babies, pregnant women and children under 1 year was not adversely affected.

Public Health England re-deployed the NHS providers of local school-aged immunisation services (SAIS)
temporarily to support GPs to deliver immunisation services in the community. The local authority health
protection team worked in collaboration with the NHS and early years and education teams within Central
Bedfordshire, to secure community-based immunisation sites to reduce pressure on GP practices at the height of the pandemic between April and July 2020. Analysis of the results and impacts of the programme are expected in the coming months.

Priorities areas we should continue to build on:

1. Develop and retain our highly skilled and motivated 0-5 workforce across the system supporting integrated working across health, social care and education.
2. Provide training for all professionals working with children and families to: recognise key risk factors (including adverse childhood experiences and trauma), improve information sharing, intervene early and refer to appropriate services.
3. Support parents and carers to ensure their children are ready to learn. This includes increasing uptake of the integrated health and education review and free nursery places at 2 and 3 years where applicable.
4. Ensure consistent messages across all health and early years providers to continue to promote and support responsive breastfeeding, responsive bottle-feeding and smoke-free environments.
5. Reduce unintentional injuries in under 5s.

Priority actions to deliver better outcomes

1. The ICS/Public Health/NHSE and all key stakeholders in delivering vaccination to children and young people to work together to continually raise the profile of immunisation, monitor activity and identify and address issues such as increased vaccine hesitancy in certain communities, in a timely manner.
2. Support with effective positive messages around immunisations to parents and young people.
3. Using the most appropriate and effective means to communicate messages, for instance, social media and trusted voices.
4. Support with access to appropriate community vaccination venues to provide easy access for all children who have not been vaccinated in a school setting.
5. Population awareness of choice of vaccine for the healthy children’s flu programme to include non- porcine vaccine.
6. Responsive 7-day services to cater to the needs of children and young people and carers to ensure children get care close to home at the right place at the right time 7 days a week.

References

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