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Clinical guidelines

Guidelines for preventive activities in general practice 9th edition

3. Preventive activities in children and young people

Age 0-9 10-14 15-19 20-24 25-29 30-34 35-39 40-44 45-49 50-54 55-59 60-64 65-69 70-79 > 80

Early intervention

Prevention and health promotion in the early years, from conception to 5 years of age, is important for an individual’s lifelong health and wellbeing.1 It may also be an opportunity to redress health inequalities.2, 3 In adolescence, neurodevelopmental studies support the value of early intervention to prevent ongoing harm.

Many infants and children visit their general practitioner (GP) frequently, and adolescents visit at least once a year.5 This frequent contact provides opportunities for disease prevention and health promotion.

Evidence provides moderate support for the hypothesis that ‘accessible, family-centred, continuous, comprehensive, coordinated, compassionate and culturally effective care improves health outcomes for children with special healthcare needs’.6 There is also evidence that supports the beneficial impact of similar care for children without special healthcare needs.7-8

Health inequity

What are the key equity issues and who is at risk?

  • Low socioeconomic status (SES) is associated with increased childhood morbidity and mortality.9 This includes higher rates of death from neonatal hypoxia, sudden unexpected death in infancy (SUDI), prematurity-related disorders, and accidental and non-accidental injury;10,11 hospitalisations related to asthma;12 and risk of child abuse.13 Low SES is also associated with overweight and obesity in children.14
  • While there has been a decline in infant mortality since the 1990s, infant mortality in Aboriginal and Torres Strait Islander peoples is more than twice that of non-Indigenous children,10 in part due to pregnancy, labour and delivery complications, and trauma and congenital malformations.15 Aboriginal and Torres Strait Islander infants have higher rates of death from SUDI.16 They are also more likely to be born premature or with low birth weight17,18 and are more likely to be hospitalised before 1 year of age.19
  • Aboriginal and Torres Strait Islander peoples and people from socioeconomically disadvantaged backgrounds are more likely to experience low immunisation rates.20

What can GPs do?

  • Refer to the general strategies for supporting patient education and health literacy in disadvantaged groups.
  • Consider advocating for and supporting community-based strategies or policies for health promoting changes within the environments in which families live (eg school-based programs targeting nutrition and physical activity).21–27
  • Use resources supporting the provision of culturally competent care to adolescents from culturally diverse backgrounds.28
Table 3.1. Age-related health checks in children and young people
AgeWhat should be done?
Neonatal Assessment
  • Metabolic screen (IV, B) 29
  • Universal hearing screen 30
  • Physical exam as outlined in the Child Personal Health Record (C; refer to Practice Point a in Table 3.2) 31
  • Identify family strengths, elicit concerns and promote parental confidence, competence and mental health (C) 32
Preventive counselling and advice
Injury prevention: Promote protection from accidental and non-accidental injury. This includes protecting against the risks of 31,33:
  • passive smoking
  • sudden unexpected death in infancy (SUDI)
  • use of appropriate restraints in motor vehicles
2, 4, 6, 12 and 18 months; and 3 years
  • Immunisation as per the Australian immunisation handbook (A)
  • Immunisation includes seeking informed consent and identifying Aboriginal and Torres Strait Islander babies, infants and toddlers
  • Physical exam as outlined in the Child Personal Health Record (C; refer to Practice Point a in Table 3.2). This includes regular measurement, plotting and interpreting of length, weight and head circumference on growth charts. Include body mass index (BMI) from 2 years of age 31
  • When a baby or child is presented as a ‘problem’, assessment should include parental mental health, family functioning, the possibility of domestic violence and adequacy of social support (C; refer to Practice Point b in Table 3.2) 34
  • From 12 months, ‘Lift the lip’ dental check (C; refer to Practice Point e in Table 3.2)
Health promotion
  • Support breastfeeding (refer to Practice Point c in Table 3.2 for introduction of solids and reduction of food allergy) 35,36
  • Promote healthy eating in the second year of life as per Australian dietary guidelines
  • Promote physical activity as per Australian recommendations for children aged 0–5 years
  • Promote healthy sleep
  • Enquire about developmental progress including behaviours that suggest normal hearing and vision (refer to Practice Point d in Table 3.2)
  • From 6 months of age, consider the use of tools such as Parents’ evaluation of developmental status (PEDS) and the Early intervention referral guide (refer to Appendix 3A. ‘Red flag’ early intervention referral guide)
  • Promote early interactive reading with children 37,38
  • Promote secure attachment
Preventive counselling and advice 31
3.5–5 years Assessment
  • Physical exam (include checking vision and calculating BMI; refer to Practice Point g and j in Table 3.2
  • ‘Lift the lip’ dental check (C; refer to Practice Point e in Table 3.2) 40,41
  • Promote healthy eating, drinking and physical activity (refer to Practice Point F in Table 3.2) 36
  • Promote healthy sleep as per advice from 6 months of age 42
  • If behaviour is a concern, consider the quality of family functioning and the possible contribution of factors in the child’s wider social environment (C; refer to Practice Point h and i in Table 3.2)
  • Elicit concerns regarding development, social and emotional wellbeing (refer to Practice Point l in Table 3.2)
Preventive counselling and advice
  • Injury prevention: Promote protection from accidental and non-accidental injury
  • Promote sun protection (refer to Section 9.4. Skin cancer)
6–13 years Assessment
  • Measure growth and BMI routinely (B; refer to Practice Point k in Table 3.2)
  • Promote oral health 40,41
  • Promote healthy eating and drinking 36
  • ‘Lift the lip’ dental check (C; refer to Practice Point e in Table 3.2). Encourage regular dental reviews
  • Promote healthy physical exercise and reduction of sedentary behaviour 43
  • Enquire about progress at school as an index of wellbeing (C)
  • When behaviour is a concern, explore possible contributing factors within the family and the wider social environment
Preventive counselling and advice
14–19 years
  • Promote immunisation as per the Australian immunisation handbook (A). Note the electronic version of the handbook is regularly updated in between editions of the hardcopy
  • Measure growth and BMI routinely (B; refer to Practice Point k in Table 3.2) 44,45
  • Promote healthy eating, drinking, physical activity and sleep 36,43
  • Screen sexually active young people for Sexually Transmissible Infections (STIs; refer to Section 6.2.1. Chlamydia and other STIs)
Preventative counselling and advice
  • Assess for risky behaviours (refer to Practice Point m in Table 3.2). In one study, risky behaviours occurred in 90% of young Australians attending a general practice 32,46,47
  • Promote oral health (also refer to Chapter 11. Oral health)
  • Use models of care that facilitate the transition of young people with chronic disease or disability from tertiary paediatric care to effective primary care with access to adult specialist care. The NSW Agency for Clinical Innovation has models of care for transition for most paediatric centres across Australia
  • Ask about smoking and provide a strong anti-smoking message (III, C; refer to Section 7.1. Smoking) 64
AEDC, Australian Early Development Census; BMI, body mass index; NHMRC, National Health and Medical Research Council; PEDS, parents’ evaluation of developmental status; SUDI, sudden unexpected death in infancy
Table 3.2. Explanatory notes for Practice Points
Practice PointComment
a Physical exam
  • Complete the Child Personal Health Record, which is given at birth in New South Wales,31 or refer to relevant programs in individual states and territories
Note: parents value reviewing completed growth charts
b At present, there is insufficient evidence for either benefit or harm in screening for postnatal depression (PND). However, PND is known to have an unfavourable impact on the quality of attachment and family functioning. Further, there are evidence-based interventions for PND48 and improving the quality of mother–infant interaction adversely affected by PND.49,50 GPs should be alert to the possibility of impaired parental mental health and family dysfunction.

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Also refer to Table 10.1.2 and Section 10.3. Intimate partner violence
c The Australasian Society of Clinical Immunology and Allergy’s (ASCIA) 2016 Guidelines for allergy prevention in infants supports the introduction of complementary ‘solid’ foods within four to six months of age and preferably while breastfeeding. 51 The introduction of allergenic food should not be delayed. However, the ASCIA position is in conflict with the 2012 National Health and Medical Research Council (NHMRC) guideline, which recommends exclusive breastfeeding until 6 months of age35

The new ASCIA guidelines provide:
  • good evidence* that introducing peanut into the diet of infants who already have severe eczema and/or egg allergy before 12 months of age can reduce the risk of these infants developing peanut allergy
  • moderate evidence† that introducing cooked egg into an infant’s diet before 8 months of age, where there is a family history of allergy, can reduce the risk of developing egg allergy. Raw egg is not recommended
Also refer to Table 7.3.2
∗High/good/strong evidence means convincing evidence from well-conducted studies, or many well-conducted studies results pooled into a large analysis (meta-analysis)

✝Moderate evidence means evidence from reasonably well-conducted studies or well-conducted single studies
d Developmental progress

Early intervention presupposes early detection. Prior to 3 years of age, the rate of attaining developmental milestones varies so much that the simple application of screening ‘tools’ would excessively detect developmental delay (false positive). This risk is reduced after 3 years of age

In the earliest years, guides to developmental progress can be used to initiate an ongoing conversation with parents to elicit their concerns about their child’s progress 52,53

Developmental milestone assessments are outlined in the Child Personal Health Record, which is provided at birth in New South Wales

A tool, such as the Parents’ evaluation of developmental status (PEDS), can be used on a regular basis to identify any concerns about their child’s development. The information gathered helps the GP gain a better understanding of the progress of each child. Further information on the PEDS questionnaire

The value of the PEDS may be increased if used in conjunction with:
e ‘Lift the lip’ screening tool for the prevention and early detection of tooth decay in children:
  • Complete and also teach parents to simply lift the top lip of their child, looking for signs of tooth decay (eg white lines on top of the teeth below the gumline, or discolouration of the teeth that cannot be brushed off). Encourage parents to complete once a month
  • Encourage dental hygiene twice a day: No toothpaste <17 months of age and low fluoride toothpaste up to 5 years of age
  • Encourage dental visits annually after 12 months of age
Also refer to Chapter 11. Oral health
f The latest Australian recommendations for healthy eating, drinking and physical exercise are summarised in The Royal Australian College of General Practitioners’ (RACGP) Smoking, nutrition, alcohol and physical activity (SNAP): A population guide to the behavioural risk factors in general practice, 2nd edn, in particular Table 15 54
g The American Academy of Pediatrics has recommended the annual plotting of body mass index (BMI) for all patients aged ≥2 years. Be aware that small errors in measuring either height/length or weight cause large errors in the position of the calculated BMI on the BMI percentile chart. This is because percentile lines are crowded together in the preschool ages
h An Australian randomised controlled trial (RCT) demonstrated that a coordinated cross-agency system of parenting support, which included general practice, produced meaningful effects at the population level 56
i For pre-school children, family support and parenting programs continue to be the most effective method of preventing the onset of emotional and behavioural problems, which predispose to mental illness in later childhood and adolescence 32,56
j The US Preventive Services Task Force (USPSTF) concludes with moderate certainty that vision screening for all children at least once between 3 and 5 years of age to detect the presence of amblyopia or its risk factors has a moderate net benefit.57 The USPSTF concludes that the benefits of vision screening for children aged <3 years are uncertain, and that the balance of benefits and harms cannot be determined for this age group
k The USPSTF recommends that clinicians screen children aged ≥6 years for obesity and offer them or refer them to comprehensive, intensive behavioural interventions to promote improvement in weight status (B) 45
  • There is a moderate net benefit for screening children aged 6–18 years
  • As a screening tool, BMI is an ‘acceptable measure for identifying children and adolescents with excess weight’ 45
  • Overweight is having a BMI between the 85th and 94th percentiles for the individual’s age and gender
  • Obesity is having a BMI >95th percentile for age and gender
l Mental, emotional, behavioural disorder in Australian young people
  • Fifty per cent of adult disorders have onset by 14 years of age
  • Between 14% and 18% of children and young people experience mental health problems of clinical significance
  • Depression and coping with stress are priorities for:
    • 16% of those aged 11–14 years
    • 21% of those aged 15–19 years 58
  • The USPSTF recommends the screening of adolescents (aged 12–18 years) for major depressive disorder when systems are in place to ensure accurate diagnosis, psychotherapy (cognitive, behavioural or interpersonal) and follow-up (B) 59
  • Risk factors for major depressive disorder include parental depression, having comorbid mental health or chronic medical conditions, and having experienced a major negative life event 59
m Assess for risky behaviours Promoting health and minimising harm is a whole-of-community opportunity and responsibility. Celebrating strengths, explaining confidentiality (including its limits) and using the HE2ADS3 framework60 (refer to below) to explore with young people the context in which they live are strategies that are likely to improve the clinician’s capacity to promote health and minimise morbidity (C):61,62
  • Home
  • Eating and exercise
  • Activities
  • Drugs
  • Sexuality
  • Suicide
  • Safety

  • Young people who present frequently are at higher risk of having a mental health problem63
  • Provide messages that encourage delay in initiation of potentially risky behaviours and, at the same time, promote risk-reduction strategies if adolescents choose to engage or are already engaging in the behaviour
  • Use principles of motivational interviewing in the assessment and discussion of risky health behaviours with adolescent patients (including safe practice for those who are sexually active)
  • Be familiar with the resources in the community that provide harm reduction programs for substance abuse, pregnancy prevention, injury prevention and road safety
  • Be familiar with resources in the community that provide parenting skills training for parents of young people
  • Advocate for the introduction, further development and evaluation of evidence-based prevention and treatment programs that use a harm reduction philosophy in schools and communities (C)
ASCIA, Australasian Society of Clinical Immunology and Allergy; BMI, body mass index; NHMRC, National Health and Medical Research Council; PEDS, parents’ evaluation of developmental status; PND, postnatal depression; RCT, randomised controlled trial; USPSTF, US Preventive Services Task Force


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