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Clinical guidelines

Guidelines for preventive activities in general practice 8th edition

3. Preventive activities in children and young people

Early intervention

Prevention and promotion in the early years, from conception to age 5 years, is important for an individual’s lifelong health and wellbeing.77 It may also be an opportunity to redress health inequalities.78,79 In adolescence, neuro-developmental studies support the value of early intervention to prevent ongoing harm.80

Many infants and children visit their GP frequently and adolescents visit at least once a year.81 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’.82 There is also evidence that supports the beneficial impact of similar care for children without special healthcare needs.83

There is little Australian research investigating interventions based in general practice. Recommendations in this section are largely drawn from expert consensus and parental values.

Health inequity
Compared with non-Indigenous Australians, Aboriginal and Torres Strait Islander children are three times more likely to die before their first birthday, five times more likely to succumb to sudden infant death syndrome (SIDS), twice as likely to be born premature or with low birthweight, and nearly four times as likely to be hospitalised with respiratory infection. Indigenous Australian mothers are eight times more likely than non-Indigenous mothers to receive inadequate antenatal care and rates of breastfeeding are lower in Indigenous than non-Indigenous communities.84
There is a socioeconomic gradient in the health of Australian children and young people, both Indigenous and non-Indigenous, which has an impact that is both immediate and lifelong. There are large numbers of vulnerable children in the mid-socioeconomic range of the population and it is the size of this group that justifies universal intervention. On the other hand, the magnitude of the ill-health experienced by the smaller number at the bottom of the spectrum justifies targeted intervention. Michael Marmot has attempted to resolve this tension by arguing for ‘proportionate universalism’.78
Maternal smoking during pregnancy is more prevalent among women of lower socioeconomic status (SES) and single mothers, and is strongly associated with low birthweight. Mothers from lower socioeconomic backgrounds have fewer and less regular antenatal visits. Lower rates of breastfeeding and shorter duration of breastfeeding have been reported for mothers in a variety of disadvantaged backgrounds including single, low income, migrant, unemployed families, poorly educated parents and disadvantaged communities. Higher mortality rates in infancy and childhood including deaths from neonatal hypoxia, SIDS, prematurity-related disorders, and accidental and non-accidental injury are reported for lower socioeconomic children and children living in disadvantaged neighbourhoods.84 Health inequity present at school entry gets worse thereafter. The Australian data was summarised in Alan Hayes in 2011.79

 

Table 3.1 Age-related health checks in children and young people
AgeWhat should be done?
Neonatal
  • Vitamin K and immunisation as per the Australian Government Department of Health and Ageing Australian Immunisation Handbook at www.immunise.health.gov.au (A)
Assessment Preventive counselling and advice
  • Injury prevention: promote safety from accidental and non-accidental injury. This includes the risks to baby of passive smoking, SIDS and UV exposure (III,B)87
  • Settling (Practice Point)
  • Maternal health (Practice Point)
2, 4, 6 months
  • Immunisation as per the Australian Government Department of Health and Ageing Australian Immunisation Handbook at www.immunise.health.gov.au (A)
Assessment
  • Physical exam as outlined in the Child Health Record (C) (see Table 3.3 comment b)87
  • Nutrition assessment: promote breastfeeding appropriately. Introduction of solids: be aware of conflicting expert advice concerning the best age at which to introduce solids (B) (see Table 3.3 comment a) New NHMRC guidelines expected in 201286,89
  • Developmental progress including vision and hearing (see Table 3.3 comment c)88
  • Quality of child–parent relationship (C)88,90
  • When the baby is presented as a ‘problem’ assess parental mental health, family functioning (including the possibility of domestic violence) and social support (C) (see Table 3.3 comment d)91
  • Encourage discussion related to physical activity recommendations (B) (see Table 3.3 comment e)
Preventive counselling and advice
  • Injury prevention – promote safety from accidental and non-accidental injury, includes the risks to baby of passive smoking, SIDS, UV exposure, water, home environment (III,B)87,92,93
  • Settling (Practice Point)
  • Maternal health (Practice Point)
  • Teething (Practice Point)
  • Play (Practice Point)
12 & 18 months Assessment
  • ‘Lift the lip’ dental check (C) (see Table 3.3 comment f)
  • Nutrition and physical activity (B) (see Table 3.3 comment e). New NHMRC guidelines expected in 201294,95
  • Risk of iron depletion and vitamin D deficiency (C)86,91
  • Developmental progress including vision and hearing (see Table 3.3 comment c)96,97
  • Family functioning, dysfunction (including domestic violence) and the social environment (C) (see Table 3.3 comments h and i)88,90
Preventive counselling and advice
  • Social and emotional wellbeing (Practice Point)88,90
  • Toilet training (Practice Point)
  • Behaviour and behaviour management techniques (Practice Point)
2 years
  • Immunisation as per the Australian Government Department of Health and Ageing Australian Immunisation Handbook at www.immunise.health.gov.au (A)
Assessment
  • Physical exam as outlined in the Child Health Record (C) (see Table 3.3 comments b and g) 87
  • Developmental progress including vision and hearing (see Table 3.3 comment c)
  • ‘Lift the lip’ dental check (C) (see Table 3.3 comment f)94,95
  • Nutrition and physical activity (B) (see Table 3.3 comment e). New NHMRC guidelines expected in 201286,91
  • Emerging behavioural or emotional problems (C)
  • When the child presents with behavioural or emotional problems consider family functioning (including the possibility of domestic violence) and the family environment more generally (C) (Practice Point explanatory comments h and i)88,90
Preventive counselling and advice
  • Injury prevention (III,B)
  • Sun protection (Practice Point)87,92,93
  • Social and emotional wellbeing (C)88,90
3 years Assessment
  • Check vision (B) (see Table 3.3 comment j)98
  • The Universal Child Health Check at age 3 years will replace the current Healthy Kids check at age 4 years. To be introduced by the Australian Government in 2013. Details not available at the time of publication.
4 years
  • Immunisation as per the Australian Government Department of Health and Ageing Australian Immunisation Handbook at www.immunise.health.gov.au (A)
Healthy Kids Check see Table 3.3 comment k99-102
Assessment
  • Physical assessment (B) (see Table 3.3 comment k)
Also recommended
  • Developmental and emotional progress (see Table 3.3 comment c)
  • ‘Lift the lip’ dental check (C) (see Table 3.3 comment f)94,95
  • Nutrition and physical activity (B) (see Table 3.3 comment e). New NHMRC guidelines expected in 201286,91
  • Assess the quality of family functioning when there are emotional or behavioural problems (C)
    (see Table 3.3 comments h and i)88,90
Preventive counselling and advice
  • Injury prevention (III,B)92,93
  • Sun protection (Practice Point)
  • Social and emotional wellbeing (C)88,90
6–13 years Assessment
  • Growth velocities including BMI opportunistically (B)103
  • Discussion relating to progress at school (C) 88
  • ‘Lift the lip’ dental check (C) (see Table 3.3 comment f). Encourage regular dental reviews94,95
  • Nutrition and physical activity (B) (see Table 3.3 comment e). New NHMRC guidelines expected in 201286,91
  • Family functioning and family environment (C) (see Table 3.3 comments h and i)88,90
  • Anticipate and look for emerging behavioural or emotional problems (C)88,90
Preventive counselling and advice
  • Injury prevention (II)92,93
  • Sun protection
  • Social and emotional wellbeing (C)88,90
14–19 years
  • Immunisation as per the Australian Government Department of Health and Ageing Australian Immunisation Handbook at www.immunise.health.gov.au (A)
Assessment
  • Growth velocities including BMI opportunistically (B) (see Table 3.3 comment l) 103,104
  • Nutrition and physical activity (B) (see Table 3.3 comment e). New NHMRC guidelines expected in 201286,91
  • Screen sexually active young people for chlamydia (Section 6.2.1: Chlamydia and other STIs)
  • Screening of adolescents (age 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) (see Table 3.3 comment m)105
Preventive counselling and advice
  • Injury prevention – harm minimisation (C) (see Table 3.3 comment n)88,92,93
  • Sun protection
  • Social and emotional wellbeing (II,C)88,90
  • Oral health94,95
  • Advocate for 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

 

Table 3.2 Age-related physical assessment in children and young people
AgeRequired physical assessment
Neonatal
  • Weight
  • Length
  • Head circumference
  • Head shape, including fontanelle
  • Mouth/palate, facies and ears
  • Eyes: observation, appearance and red reflexes
  • Neurological and developmental status, including responsiveness and tone
  • Cardiovascular status
  • Umbilicus
  • Skin
  • Femoral pulse (for radio-femoral delay)
  • Hips (Barlow and Ortolani), limbs, joints, hands (palmar creases), feet (for talipes)
  • Genitalia, testes, anal region
  • Any parental concerns?
2, 4 & 6 months
  • Weight
  • Length
  • Head circumference
  • Eyes: observation, fixation and following
  • Cardiovascular status
  • Umbilicus
  • Skin
  • Femoral pulse
  • Hips, limbs, joints
  • Genitalia, testes, anal region
  • Oral health, ‘lift the lip’ from age 6 months
  • Developmental progress
  • Any parental concerns?
12 & 18 months
  • Weight velocity
  • Height velocity
  • Head circumference velocity
  • Eyes and vision: observation, fixation and following, corneal light reflex
  • Testes
  • Oral health, ‘lift the lip’
  • Developmental progress
  • Any parental concerns?
2 years
  • Weight velocity
  • Length velocity
  • Head circumference velocity
  • Evaluate gait
  • Oral health, ‘lift the lip’
  • Assess development and behaviour
  • Any parental concerns?
3 years
  • Vision screening
  • The Universal Child Health Check at age 3 years will replace the current Healthy Kids check at age 4 years. To be introduced by the Australian Government in 2013. Details not available at the time of publication.
4 years
  • As outlined by the Health Kids Check:
    • height and weight (plot and interpret growth curve/calculate BMI)
    • eyesight
    • hearing
    • oral health (teeth and gums)
    • toileting
    • allergies.
6–13 years
  • Weight and height (plot and interpret growth curve and calculate BMI)
14–19 years
  • Weight and height (plot and interpret growth curve and calculate BMI)

Table 3.3 Explanatory notes for Practice Points
Practice PointComment
a The Australasian Society of Clinical Immunology and Allergy (ASCIA) issued a position paper (2008) that supports ‘the introduction of solids that the family usually eats after 4 months regardless of whether the food is thought to be highly allergenic’89 The ASCIA position is in conflict with the current policy of the RACGP on breastfeeding, based on the NHMRC guideline,86 which recommends exclusive breastfeeding until age 6 months. This uncertainty merits frank discussion.
b Physical exam:
  • complete the Child Health Record (also known as the Parent Held Record), which is given at birth87
  • see outline in Table 3.2 Age-related physical assessment in children and young people.
Note: Parents value reviewing completed growth charts. Velocities are more important than the centile position of single measurements. Multiple measurements have the further advantage of allowing inaccurate measurements to become evident as outliers.
c Developmental progress
Evidence continues to build that early intervention can counteract biological and environmental disadvantage and set children on a more positive developmental trajectory.106
Early intervention presupposes early detection. Prior to age 3 years 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 age 3 years.
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. ‘Asking repeatedly should help reluctant parents gain confidence in their observations and facilitate their willingness to share concerns. The value of such discussions is clear; children with disabilities are 11 times more likely to be enrolled in needed interventions.’107
There is little evidence available; however, early detection is known to help reduce disability in some instances, and also allows for referral to community services, which can potentially decrease family stress.
Developmental milestone assessments are outlined in the Child Health Record, which is provided at birth.
Acknowledging that parents are the best source of information about their own children, a parent-completed screening tool, such as the Parent Evaluation of Developmental Status (PEDS), can be used 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 can be accessed at www.rch.org.au/ccch/ resources_and _publications/ Monitoring_Child_ Development/
Prompts to assist assessment of development include: See also Appendix 2. Further information on the Ages and Stages Questionnaire is at http://agesandstages.com 
d
  • 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 both PND108 and for improving the quality of mother–infant interaction adversely affected by PND.109,110
e Physical activity recommendations for children aged 0–5 years
  • Being physically active every day is important for the healthy growth and development of infants, toddlers and preschoolers.
  • For infants (birth to 1 year) physical activity – particularly supervised floor-based play in safe environments – should be encouraged from birth.
  • Before infants begin to crawl, encourage them to be physically active by reaching and grasping; pulling and pushing; moving their head, body and limbs during daily routines and during supervised floor play, including tummy time. Once infants are mobile, encourage them to be as active as possible in a safe, supervised and nurturing play environment.
  • Toddlers (age 1–3 years) and preschoolers (age 3–5 years) should be physically active every day for at least 3 hours, spread throughout the day.
  • Young children don’t need to do their 3 hours of physical activity all at once. It can be accumulated throughout the day and can include light activity such as standing up, moving around and playing, as well as more vigorous activity like running and jumping. Active play is the best way for young children to be physically active.
  • Children aged younger than 2 years should not spend any time watching television or using other electronic media (DVDs, computer and other electronic games) and for children aged 2–5 years these activities should be limited to less than 1 hour per day.
  • Watching television and DVDs and playing computer games usually involve sitting for long periods – time that could be spent playing active games or interacting with others.
  • Infants, toddlers and preschoolers should not be sedentary, restrained or kept inactive for more than 1 hour at a time, with the exception of sleeping.
Physical activity recommendations for children aged 5–12 years
  • A combination of moderate and vigorous activities for at least 60 minutes a day is recommended. Examples of moderate activities are a brisk walk, a bike ride or any sort of active play.
  • More vigorous activities will make kids ‘huff and puff’.
Physical activity recommendations for young people aged 12–18 years
  • At least 60 minutes of physical activity every day is recommended. This can be built up throughout the day with a variety of activities.
  • Physical activity should be done at moderate to vigorous intensity.
f ‘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 child, looking for signs of tooth decay (e.g. white lines on top of teeth below 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 under 17 months and low fluoride toothpaste up to age 5 years
  • encourage dental visits annually after age 12 months.
See also NHMRC research at www.nhmrc.gov.au/ national_ register_public_health_research/ 29331 and  Section 11: Oral hygiene.
g The American Academy of Paediatrics has recommended the annual plotting of BMI for all patients aged 2 years and older, and parent-held records produced by Australian jurisdictions follow this recommendation. This is not supported by the United States Preventive Services Task Force (USPSTF). There is potential for causing harm by either inappropriate diagnosis of ‘overweight’ or inappropriate reassurance of ‘healthy weight’. The risk will be minimised if clinicians remember that in the preschool years, small errors in measuring either height/length or weight cause large errors in the position of the calculated BMI on the BMI centile chart. This is because centile lines are crowded together in the preschool ages.
h An Australian RCT demonstrated that a coordinated cross agency system of parenting support, which included general practice, produced meaningful effects at the population level.90
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’.88,106
j The USPSTF concludes with moderate certainty that vision screening for all children at least once between the ages of 3–5 years to detect the presence of amblyopia or its risk factors has a moderate net benefit.98 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.
Various screening tests that are feasible in primary care are used to identify visual impairment among children. These include visual acuity tests, stereoacuity tests, the cover–uncover test, and the Hirschberg light reflex test (for ocular alignment/strabismus), as well as the use of autorefractors (automated optical instruments that detect refractive errors) and photoscreeners (instruments that detect amblyogenic risk factors and refractive errors).
The Universal Child Health Check at age 3 years will replace the current Healthy Kids Check at age 4 years – this is to be introduced by the Australian Government in 2013 (details not available at the time of publication).
k Australian Government Department of Health and Ageing Medicare Benefits Schedule (MBS) Primary Care Items:
  • Healthy Kids Check for children aged at least 3 years and less than 5 years, who have received or who are receiving their age 4-year immunisation
  • once only to an eligible patient
  • the Healthy Kids Check is an assessment of a patient’s physical health, general wellbeing and development with the purpose of initiating medical interventions as appropriate.
The Healthy Kids Check must include the following basic physical examinations and assessments:
  1. height and weight (plot and interpret growth curve/calculate BMI)
  2. eyesight
  3. hearing
  4. oral health (teeth and gums)
  5. toileting
  6. allergies.
The medical practitioner is required to note if a copy of the department’s publication Get Set 4 Life – habits for healthy kids has been provided to the patient’s parent(s)/guardian at www.health.gov.au/ internet/main/ publishing.nsf/content/ 47B8A7F882590379CA25759B001EE259/ $File/ GetSet4LifeBrochure.pdf
The medical practitioner is also required to note that the age 4-year immunisation has been given (including evidence provided).
See also www.health.gov.au/ internet/main/publishing.nsf/ Content/Health_Kids_Check_Factsheet
l The USPSTF recommends that clinicians screen children aged 6 years and older for obesity and offer them or refer them to comprehensive, intensive behavioural interventions to promote improvement in weight status (B).103
  • 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’.103
  • The definitions used by the USPSTF have changed since the 2005 report. Overweight is now defined as having a BMI between the 85th and 94th percentiles for the individual’s age and gender, and obesity is defined as having a BMI at ≥95th percentile for age and gender. BMI-for-age percentile is not a direct measure of adiposity, but it correlates fairly well with percentile rankings of directly measured per cent body fat (with correlations generally between 0.78 and 0.88) in children. Because BMI changes with age, percentile scores based on age-specific and gender-specific norms are used to monitor growth.
National Institute of Clinical Excellence (also known as NICE)104
  • BMI (adjusted for age and gender) is recommended as a practical estimate of overweight in children and young people, but needs to be interpreted with caution because it is not a direct measure of adiposity.
  • Waist circumference is not recommended as a routine measure, but may be used to give additional information on the risk of developing other long-term health problems.
  • Bio-impedance is not recommended as a substitute for BMI as a measure of general adiposity.
m Mental, emotional, behavioural disorder in Australian young people
  • Fifty per cent of adult disorders have onset by age 14 years.
  • Fourteen per cent to 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.111
  • The USPSTF recommends 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-up105 (B).
  • 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.105
n
  • Promoting health and minimising harm is a whole-of-community opportunity and responsibility. Celebrating strengths, explaining confidentiality (including its limits) and using the HEADSS framework (below) to explore with young people the context in which they live are strategies likely to improve the clinician’s capacity to promote health and minimise morbidity112 (C).
    • Home
    • Education/Employment
    • Activities
    • Drugs
    • Sexuality
    • Suicide
  • Young people who present frequently are at higher risk of having a mental health problem.113
  • 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 the sexually active).
  • Be familiar with the resources in the community that provide harm reduction programs for substance abuse, pregnancy prevention and injury prevention.
  • 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).

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