Introduction
One of the most important foundations for building caring, productive and healthy families and communities is the nurturing of children in early life. For this reason, helping children get a better start is both good for them and good for society[i].The first five years of a child’s life are critical to their future development and opportunities. There is mounting evidence that shows the benefits and cost effectiveness of focusing on the development and health of infants and children. Conception to age two has been described as a crucial phase of human development and is the time when focused attention can reap great dividends for society[ii].
A child’s physical, social and cognitive development strongly influences how ready they are to start school and their educational attainment, as well as their health and employment prospects as an adult[iii] . This development begins before birth when the health of a baby is affected by the health of their mother and is influenced by the socio-economic status of their parents. The best possible health underpins a child’s ability to flourish, stay safe and achieve as they grow up; and lifestyles and habits established during childhood, influence a person’s health throughout their life.
Loving, secure and reliable relationships with parents, together with the quality of the home learning environment, foster a child’s:
- emotional wellbeing (sometimes referred to as infant mental health);
- capacity to form and maintain positive relationships with others;
- brain development (c.80% of brain cell development takes place by age 3);
- language development, physical literacy and
- ability to learn (the ‘soft’ skills that equip a child to relate to others, thrive and then go on to learn the ‘hard’ cognitive skills needed to succeed academically are embedded in the earliest months of life. Poor support, particularly a failure to prevent abuse or neglect, at this stage can have a lifelong adverse impact on outcomes)2.
Focusing on prevention and early intervention has a vital role to play in improving child health outcomes and breaking the cycle of health inequalities within families. The local authority became responsible for commissioning public health services for 0-5 year olds on October 1st 2015. This provides further opportunities to ensure a coordinated pathway of evidenced based preventative health care for all children from birth, all the way through their crucial developmental during preschool and school years.
Several of the issues that impact on the development of 0-5 year olds are covered in depth in other JSNA chapters, such as nutrition, physical activity, oral health, safeguarding and domestic abuse. This chapter therefore does not go into detail for these issues, although it is important that these chapters are also reviewed for a full understanding of the needs of this population.
Unmet needs and service gaps
- The health and well-being of children in Nottingham is generally worse than the England average for 0-5 year olds.
- An increasing number of Nottingham’s babies are being born to mothers born outside of the UK, who are some of the least likely to access maternal and health services.
- More than a third of Nottingham’s children aged 0-4 years are living in low income families. Children are particularly susceptible to economic and social deprivation resulting in unfair inequalities in health that contribute to generational cycles of deprivation.
- These inequalities mean delayed early development, lower educational achievement, lower aspirations and mental well-being and poorer health outcomes for many of the city’s children, which continue into adulthood.
- Although the inequality gap in infant mortality between Nottingham and England is narrowing, Nottingham’s rate of infants dying before their first birthday remains significantly higher than the England average.
- Local coverage is below the recommended target (of 95%) for several of the scheduled immunisations for 0-5s; this will be putting children at risk of infections that are most dangerous for the very young. Recent data appear to show that coverage is decreasing further.
- Babies of mothers aged less than 20 are four times more likely to die of Sudden Unexplained Infant Death (SUDI) than those of mothers aged 20 and over and babies of mothers who smoke during pregnancy or smoke at home are five times more likely to die of SUDI. Nottingham’s high rate of teenage conception and smoking in pregnancy may partly explain why Nottingham’s rate of SUDI is significantly higher than the England average.
- During 2013, 360 babies (8.4% of all births) born to Nottingham mothers had a low birth weight.
- In 2014/15, the percentage of babies receiving their new-born bloodspot screening was below the national recommended target of 95%.
- Despite significant improvements in breastfeeding prevalence in Nottingham and narrowing of age related inequalities, there remains a substantial gap in breastfeeding rates between those aged under and over 25 years of age.
- Parental health and behaviours makes a significant contribution to the health and developmental outcomes of young children; this is an important consideration in Nottingham where there are high rates of adult alcohol consumption, smoking in pregnancy, obesity and poor mental health.
- It is estimated that 14% of Nottingham residents with dependent children have poor mental health putting children at risk of poor attachment and consequent poor cognitive, developmental and social and emotional health outcomes.
- More than a third of parents with dependent children in Nottingham smoke, placing a significant amount of young children at risk of poor health and developmental milestones. The post-natal period is a high risk time for relapse to smoking for those mothers who quit during pregnancy.
- New mothers who report that they are smokers at the time of delivery are not routinely provided with brief intervention and referral to smoking cessation services by hospital midwifery services.
- There are limited referrals from early years services (health visiting, FNP, Early Help and other early years providers) of mothers who smoke to smoking cessation services.
- It is estimated that at least 210 under 5s in Nottingham are affected by Foetal Alcohol Spectrum Disorders (FASD).
- It is estimated that there are 6,900 under 5s in Nottingham with poor attachment to at least one parent. The implications of this on school readiness, learning and academic success, behaviour and emotional health and wellbeing are significant.
- In 2015, approximately 1,560 reception children in Nottingham did not reach a good level of development by age five and there is a significant gender gap with boys being less likely to meet expected levels than girls. Literacy and mathematics were the areas of learning in which the lowest percentage of children achieved at least the expected level.
- It is estimated that 50% of children in areas of deprivation start school with language delay; this equates to approximately 1,850 reception aged children in Nottingham per annum.
- Low interest by fathers in their children’s education (particularly boys) has a stronger negative impact on their achievement than contact with the police, poverty, family type, social class, housing tenure and child’s personality.
- There is wide variation in participation in the free nursery education for 2 year olds (Early Learning Programme) across the City.
- There is varied and inconsistent provision of parenting programmes across the City.
- Stretched capacity within Early Help services (60 family support workers to cover the city), coupled with high levels of need, make it challenging for Children’s Centres to meet OFSTED requirements regarding reach.
Recommendations for consideration by commissioners
- Maximise opportunities for greater partnership working to offer all children in Nottingham the best start in life and realise their full potential; integrated early years teams may help to build capacity reduce duplication.
- Acknowledge the vital role that focusing on prevention and early intervention has to play in improving child health outcomes and breaking the cycle of health inequalities in Nottingham City.
- Consider a local review in order to identify factors which might be responsible for Nottingham University Hospital’s reported high rate of stillbirth, neonatal and extended perinatal mortality.
- Ensure staff that has contact with families are aware of Sudden Infant Death prevention advice and share this in the antenatal and new-born period. This includes: always placing a baby on its back to sleep; keeping a baby smoke free environment during pregnancy and after birth; placing a baby to sleep in a separate cot in the same room as the parents for the first 6 months; and breastfeeding the baby.
- Focus SUDI prevention programmes on families most at risk, in particular those with social circumstances that expose infants to more risk and promote parental behaviour change.
- Midwifery, Health Visiting, breastfeeding peer supporters and Early Help to provide information to all pregnant women and new mothers on housing quality and tenancy rights, undertake home quality assessments and refer to the Safer Homes team as required.
- Midwives, Health Visitors/FNP and Early Help to undertake financial assessments with parents with children aged 0-5 and refer to Debt Advice services as required.
- Explore ways to nurture social and emotional development from the earliest stage for example through perinatal and maternal mental health programmes.
- Midwifery services to implement brief sensitivity-focused interventions (e.g. Mother-Infant Transaction Programme; Nursing Systems Towards Effective Parenting-Preterm; Guided Interaction) in improving maternal sensitivity in mothers of preterm infants.
- Promote Kangaroo Mother Care (KMC) in low birth weight infants.
- Health Visitors to assess health behaviours of new mothers and refer appropriately.
- During the 6 to 8 week postnatal check, or during the follow-up appointment within the next 6 months, health visitors should provide clear, tailored, consistent, up-to-date and timely advice about how to lose weight safely after childbirth and refer to weight management services as required.
- Midwifery services to validate ‘smoking at time of delivery’ data via carbon monoxide monitoring.
- Extend the New Leaf smoking in pregnancy service to include the postnatal period.
- Include parents of children as a key priority group within the New Leaf service specification and explore the introduction of an intensive tailored smoking cessation programme for families with children under 5 years.
- Extend the ‘opt-out’ referral to smoking cessation services for pregnant smokers to include all smokers with children aged under 5 years through hospital midwifery, health visiting and Family Nurse Partnership.
- Explore ways for ensuring that data on alcohol use in pregnancy is recorded by midwives in a way that enables it to be transferred to health visiting and other services; this would enable the identification and follow up of children exposed to alcohol during pregnancy.
- Continue to embed the Baby Friendly Initiative within health visiting/FNP and the Early Help service, including the universal and targeted provision of Breastfeeding Peer Support.
- Ensure the co-ordination of Healthy Start/Vitamin D is incorporated into the Health Visiting Specification including universal provision for infants and children.
- Health professionals should take particular care to check women are following advice to take a vitamin D supplement during pregnancy and while breastfeeding.
- Pregnant women (and those intending to become pregnant) should be informed that dietary supplementation with folic acid, before conception and throughout the first 12 weeks, reduces the risk of having a baby with a neural tube defect.
- Consider expansion of cook and eat sessions for families with toddlers and young children provided by the Public Health Nutrition Team through Nottingham City Council Early Help service.
- Health Visiting service to actively promote the flu vaccine with families.
- Identify a named professional in every health and social setting where children and families attend who is responsible and provides leadership for the local childhood immunisation programme e.g. GP surgeries, nurseries, schools, colleges of further education and children centres.
- Commissioners of children's services in primary care, children's centres and immigration services should improve access to immunisation services for those with transport, language or communication difficulties, and those with physical or learning disabilities. For example, provide longer appointment times, walk-in vaccination clinics, services offering extended hours and mobile or outreach services. The latter might include home visits or vaccinations at children's centres
- Ensure there is a mechanism to assess the risks of children and families for targeted vaccinations e.g. BCG and Hepatitis B.
- The nature of the mother-baby relationship should be assessed, including verbal interaction, emotional sensitivity and physical care, at all postnatal contacts through midwifery, health visiting and FNP.
- Explore the feasibility of using Video-feedback Intervention to promote Positive Parenting (VIPP) to improve parental sensitivity and secure attachment.
- Continue the provision of infant massage with disadvantaged mothers and those with low level anxiety/depression whilst implementing a robust evaluation to include outcomes on attachment and maternal wellbeing.
- Parents and key professionals need to have the knowledge and understanding of how to build social and emotional capability within children. Consider the implementation of ‘attachment aware schools’ and emotional coaching training for the early years workforce to support this.
- Re-introduce the Leuven scale of wellbeing within early years settings.
- Ensure there is a robust and systematic approach within Health Visiting to screen for domestic abuse within the perinatal period and refer to appropriate services.
- Evaluate and develop the integrated 2 ½ year review with health visitors and early years providers.
- Create and implement central data collection for the 2 ½ year integrated review.
- Consider wider implementation of the Fathers Reading Every Day (FRED) programme through early years settings in line with SSBC, following a local evaluation.
- Explore the opportunity of the 0-5 workforce to be trained in the Communication Trust evidence based competency framework in line with SSBC so that the early years workforce has strategies to support children with low level speech and language needs.
- Raise awareness amongst parents/carers of expected developmental milestones.
- Ensure all early years professionals (including the private, voluntary and independent (PVI) childcare sector) are aware of how to identify children who may need additional support around the 5 domains of the Early Years Foundation Stage (EYFS) and have knowledge of referral pathways (i.e. speech and language).
- Evaluate and review the impact of enhanced book giving within Nottingham City (including Book Start, Dolly Parton Imagination Library).
- Explore the opportunity for Midwives, Health Visitors, Early Years Providers and Early Help Teams to share language development messages at key developmental points using evidenced based resources such as Nottingham Natters Materials and training. Health Visitors to promote early language development and use of the Baby Buddy app at the 3-4 month additional contact.
- Explore ways to promote and enable parent-implemented language interventions for young children with language impairments.
- Review pathways to speech and language support to ensure adequate and accessible service provision at a range of levels, from early intervention to more specialist support.
- Continue to ensure the provision of good quality childcare for pre-school children promoting social, emotional and mental development.
- Increase the percentage of eligible 2 year olds participating in the Early Learning Programme and address inequalities in access across the city by implementing the actions which were developed from the ‘Drill Down Project’.
- Explore the opportunity for the Early Help Service to contribute to children’s health outcomes through 'every contact counts' with parents (smoking, healthy weight, alcohol, physical activity, drugs, oral health).
- Ensure all early years providers are aware of referral processes onto the behavioural, emotional or mental health pathway if there are concerns about the child.
- Provide an adequate level of evidence based parenting programmes to families of children under five; consider universal use of Triple P in line with Small Steps Big Changes (SSBC) through Nottingham City Council Early Help service.
- Consider the evaluation of the New Forest Parenting Programme and implement more widely, if successful.
- Explore the possibility of implementing a pilot of Family Foundations intervention.
- Explore the contribution of Nottingham City Libraries towards School Readiness and how this can be optimised.
- Health visitors to conduct a universal ‘school readiness assessment’ in the year prior to the child starting school; this would replace the universal ‘school entrant health assessment’ carried out by school nurses in Reception year. This earlier assessment will contribute to the identification of needs and the provision of necessary support prior to the child commencing school.
- Develop a communication plan regarding what is meant by ‘school ready’ so that parents are aware of the expected development milestones and are knowledgeable about how to support their child in meeting them.
- A flexible child-centred approach to supporting school readiness should be adopted in Nottingham which recognises the individual needs of children and families.
- Increase co-ordination across planning and delivery of health, social and education services to support children and their families with Special Educational Needs and Disability (SEND), as required by the SEND reforms (Children and Families Act, 2014).
- Expand and embed the role of specialist services to train universal services to support enabling early identification, early support and early intervention and prevention of problems (e.g. as in the Behavioural, Emotional, Mental Health pathway pilot).
