Good pregnancy care (refer to Chapter 5: Preconception and pregnancy care) and nutrition are pivotal to achieving healthy birth weight, healthy growth and weight gain in the infant, as well as preventing chronic, non-communicable diseases later in life.65
Scheduled and opportunistic growth monitoring and development tracking, usually provided by child health clinicians and using tools such as age-appropriate growth charts and KAS or ASQ-TRAK,66 and opportunistic child health checks should be prioritised throughout the first 2000 days of life. Local child health models of care will differ, but regular and opportunistic checks align with and can leverage the national immunisation schedule where possible. The CARPA standard treatment manual outlines a practical approach to supporting child health, wellbeing, growth and development that follows three steps (ie Ask, Do and Follow-up), which direct clinicians to identify health needs, respond appropriately and monitor.15
The earliest baby health checks are an opportunity to connect parents/carers and families with local Aboriginal and Torres Strait Islander-led initiatives to build connections and linkages that benefit children, parents and the broader family network. In many communities, Elders can advise the appropriate Welcome to Country, Smoking and other cultural ceremonies and activities in the newborn and toddler phase.
Every child’s birth weight should be recorded in their medical records and electronic growth chart, as well as entered into the hard copy of their child health record (Red Book in Queensland; Blue Book in New South Wales, the Australian Capital Territory, South Australia and Tasmania; Purple Book in Western Australia; Green Book in Victoria; and Yellow Book in the Northern Territory). It is important to check birth discharge information and ask the parents/carers whether their child had newborn screening completed shortly after birth, including bloodspot (heel-prick) tests12 and hearing tests,13 confirm the results and document them in the baby’s personal health record.14
Follow-up and referral processes must always acknowledge the importance of responding in a timely and culturally safe way to any concerns that arise. Families need to be appropriately supported to navigate secondary and tertiary health systems that may not be culturally safe or easily accessible. The involvement of Aboriginal and Torres Strait Islander health workers and practitioners is especially important when family vulnerabilities are identified to facilitate early and culturally safe approaches to instigating wrap-around support. Targeted advocacy and action may also be required where waiting times are inappropriately long.
Growth monitoring and promotion
Child growth is assessed by measuring height, weight and head circumference in the early years, with measures of waist circumference and body mass index introduced from the age of five years.15 There are two main growth charts in use in Australia:67 the WHO growth standards (2006) have been approved by all jurisdictions for children aged 0–2 years (with correction for prematurity continuing until at least two years of age); and the US CDC growth charts, which are used for children and adolescents from ages 2–18 years. Specific growth charts are also available for some congenital conditions (eg Trisomy 21 and Turner syndrome).16
Recording regular growth measurements using the growth chart in the child’s health record and discussing progress with parents and carers as each new measurement is documented supports and builds health literacy over time and is an opportunity to engage families in monitoring from the earliest stages. Both under- and overweight trends should be noted and discussed with families; the cause should be identified, including investigations and referrals when needed; and a growth monitoring action plan developed where there are concerns.
Promote healthy weight
Where possible, exclusive breastfeeding (or Stage 1 infant formula until age 12 months) is recommended to six months of age.15 Iron-rich foods are introduced with breast milk (or Stage 1 formula if not breastfed) from around 4–6 months of age (and not before age four months), and iron supplements should be considered from 1–12 months of age if there is a high risk of anaemia (refer to Chapter 6: Child health, Childhood anaemia).
Slow weight gain (also referred to as ‘growth failure’ or ‘failure to thrive’) describes the situation when a child’s expected growth trajectory is not met, and is usually applied when growth measurements cross two or more centile lines downwards on a standard growth chart.16 Slow weight gain is best identified using serial measures plotted on the appropriate growth charts and should always trigger medical and psychosocial assessments in timely, culturally safe ways (see Box 1).
Poor nutrition, which may be due to inadequate access, intake, absorption or metabolism, is the most common cause of over- and underweight gain for Aboriginal and Torres Strait Islander children;68 however, other biomedical causes should always be identified or excluded. Social and economic factors are important contributors to disordered growth, and the broader context and determinants of health should always be considered. Comprehensive assessment, involving history, examination, growth chart interpretation and appropriate investigations (including urine, blood and stool samples), will inform management and referral processes.16,69
Childhood overweight and obesity has been acknowledged by the WHO as an increasing public health concern, with rates increasing 10-fold from 1975 to 2016.70 In Australia, childhood obesity rates for Aboriginal and Torres Strait Islander children aged 2–17 years have increased from 31% in 2012–13 to 38% in 2018–19, and are higher than rates experienced by non-Indigenous Australian children (24% in 2017–18).71 Efforts to promote healthy weight in childhood have the potential to promote wellbeing in the short term and to reduce the incidence of non-communicable diseases, such as cardiovascular disease, diabetes, obesity and chronic kidney disease, later in life and should be prioritised.23 Healthy eating and drinking, adequate sleep, adequate physical activity24 and limited screen time15 all contribute to healthy weights for children (see Chapter 2: Healthy living and health risks, Healthy eating, Physical activity and sedentary behaviour, Sleep).
Developmental monitoring and promotion
Child development is monitored in the domains of cognition, language acquisition and social and emotional development using standard developmental milestones, that are measured with appropriate screening tools. The Ages and Stages Questionnaire third edition (ASQ-3) was developed in the USA for use by early childhood educators and health professionals and is considered to be a highly accurate and reliable developmental screening tool.72 It is widely used in Australian jurisdictions. The ASQ-3 has been adapted and validated for use with Aboriginal children in Australia (the Ages and Stages Questionnaire – Talking About Raising Aboriginal Kids [ASQ-TRAK])73–75 and is currently available (for those who have completed training) in three different languages (modified English, two Yolngu Matha languages [Dhuwaya and Djambarrpuyngu] and Western Arrarnta [Arrernte]).17 The culturally adapted ASQ-TRAK screening tools have been shown to improve engagement, participation and the identification of children (and their families) at risk of developmental difficulties and assesses five domains of development:17
- fine motor
- gross motor
- communication
- problem-solving
- personal–social.
It is important to ask parents and carers whether they have any concerns about their child’s growth or development. It is also important to recognise that parents and caregivers may not recognise or see growth or developmental concerns as worrying; some families may accept their child’s delays as just part of the broader human experience and some may not have appropriate words in their local language to describe disability.76
Ear health and hearing are intimately associated with child development. Aboriginal and Torres Strait Islander infants and children experience high rates of otitis media with long-term sequelae, including hearing loss and impacts on neurodevelopment and learning, when inadequately or untreated. Urgent action must be taken to optimise learning and development if there are any concerns. Population-based screening and surveillance are recommended.18 The evidence clearly shows that parental perceptions of hearing loss can be considered accurate77 and ear health and hearing must be considered in all child health checks (refer to Chapter 10: Ear health and hearing).
The SEARCH (Study of Environment on Aboriginal Resilience and Child Health)78,79 research project is the largest longitudinal cohort study of urban Aboriginal children and their caregivers’ assessments of development risk. These communities identified an association between ear health and hearing, housing and out-of-home care (OOHC) with developmental risk. Children living in OOHC have consistently been identified as having the highest levels of developmental risk, and this has implications for policy and practice.52
Support for children with special health, growth and development needs
Early detection, diagnosis, support and action positively impact on the growth and development of children living with specific health and disability needs.
Although most Aboriginal and Torres Strait Islander children are developing typically, Aboriginal and Torres Strait Islander children are at higher risk of developmental and behavioural problems.52,80 In the Australian population overall, approximately 20% of children start school without the necessary developmental skills for success.81 This figure is estimated to be 40% for Aboriginal and Torres Strait Islander children, with those living in remote and rural areas experiencing higher rates of developmental vulnerability than those in major cities.81
Moreover, Aboriginal and Torres Strait Islander children are over-represented in the child protection system, including in OOHC, and are known to have high rates of conditions such as fetal alcohol spectrum disorder (FASD) and other neurological conditions, which continue to be largely misunderstood, unrecognised, misdiagnosed and unsupported82 (refer to Chapter 4: Child and family safety: Child maltreatment: Supporting families to optimise child health and wellbeing and Chapter 6: Child health, Fetal alcohol spectrum disorder).
Children living with chronic health conditions (defined as those lasting more than six months) are eligible for special support.83 Regular health checks, chronic disease management plans and programs,84,85 support with social and emotional wellbeing, developmental screening and assistance for families navigating mainstream services and accessing specialist and disability care in a timely and culturally safe way are all vital to achieving optimal growth and development for children with specific health and disability needs.
The NDIS86 can support children with developmental concerns prior to a formal diagnosis of a disability.
Under the NDIS early childhood approach, children who are aged under six years and are recognised as having developmental delay may be eligible for supports.10 Eligibility criteria include:
- developmental delay that substantially reduces the child’s functional capacity compared with other children their age
- the need for a mix of specialist care, treatment or other services
- the need for therapy and support for longer than 12 months
- the child is delayed in two or more of the following domains:
- self-care
- receptive and/or expressive language
- cognitive development
- motor development.10
The NDIS early childhood approach10 can be implemented for a child without a formal diagnosis and aims to improve access to inventions and therapy that improve the developmental outcomes of children. The NDIS funds ‘Early Childhood Partners’, namely services in the community that employ allied health practitioners (eg speech therapists, occupational therapists, social workers and early childhood practitioners) who can therapeutically support not only the child, but also their family and caregivers. Such support may include:
- linking children and families to activities in their local community and mainstream supports
- information gathering to better understand the child’s development and needs
- co-designing goals with the family to support their child
- delivering short-term early support for children with developmental concerns
- supporting any access requests if the child is likely to meet the access requirements of a diagnosed disability.