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The Effectiveness of Interventions to Address Health Inequalities in the Early Years: A Review of Relevant Literature

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CHAPTER THREE BIRTH ONWARDS: NUTRITION, SMOKING CESSATION AND SAFETY IN THE HOME AND COMMUNITY

3.1 Breastfeeding

Breastfeeding has a major role to play in public health, promoting health in both the short and long term for baby and mother. As well as providing complete nutrition for the development of healthy infants, human breast milk has an important role to play in protection against gastroenteritis and respiratory infection. There are also strong indications that breastfeeding plays an important role in preventing otitis media, urinary tract infection, atopic disease, juvenile onset insulin-dependent diabetes mellitus and obesity. Breastfeeding is also beneficial to the mother's health. Women who do not breastfeed are significantly more likely to develop epithelial ovarian cancer and pre-menopausal breast cancer than women who breastfeed. Other benefits for the breastfeeding mother include the increased likelihood that she will use up the body fat deposited in pregnancy (Protheroe et al, 2003 includes a number of references for each of these findings).

The UK has one of the lowest rates of breastfeeding worldwide, especially among disadvantaged families. In Scotland, figures from the Information Statistics Division (February 2007) indicate that both maternal age and deprivation have an independent effect on breastfeeding. Breastfeeding rates are higher in the less deprived areas and, within each deprivation quintile, breastfeeding rates generally improve as maternal age increases.

Figure 3.1 Breastfeeding 1,2 at the first visit by maternal age and Scottish Index of Multiple Deprivation ( SIMD): 2001-2006

Figure 3.1 Breastfeeding at the first visit by maternal age and Scottish Index of Multiple Deprivation (SIMD): 2001-2006

Early findings from the GUS study indicate that levels of intended and actual breastfeeding varied greatly across different groups. Older mothers, those in higher income households and those with higher levels of educational qualifications were much more likely to have intended to breastfeed, to have done so at all, and to have still been breastfeeding at 6 months. Only 8% of mothers aged under 20 who breastfed at all were still doing so at 6 months, compared with 33% of those aged 30-39 and 40% of those aged 40 and over ( GUS, 2007).

Evidence from Scotland: Modelling consultation rates in infancy: influence of maternal and infant characteristics, feeding type and consultation history (McConnachie et al, 2004)

  • A 6-month cohort study of newborn babies was carried out at 13 general practices in Glasgow
  • Multilevel models were used to analyse the number of consultations for each baby during its first 26 weeks
  • Adjusting for other factors, babies breastfed at the time of discharge from hospital had consultation rates 15% lower than babies fed formula milk, lending weight to the costs and benefits associated with efforts to increase breastfeeding
  • Findings add to previous research linking breastfeeding with reduced morbidity in infancy
  • Low socioeconomic status did not appear to be an independent predictor of infant consultations, but two factors associated with deprivation (lower maternal age and formula feeding) are major contributors towards an apparent link between deprivation and higher consulting rates found in univariate analyses

Five key types of intervention designed to promote the initiation of breastfeeding have been identified in the literature ( NHSCRD, 2000; Protheroe et al, 2003):

  • Health education interventions
  • Health sector initiatives
  • Peer support programmes
  • Media campaigns
  • Multi-faceted interventions

3.1.1 Summary of the international evidence base re initiation and duration of breastfeeding (Asthana and Halliday, 2006)

  • Health education - small, informal discussion classes, led by health professionals that emphasise the benefits of breastfeeding and provide practical advice can increase initiation rates. However, one-to-one education sessions may be necessary to persuade women to breastfeed when they have already decided to feed infant formula
  • Health sector initiatives -
    • changing organisational structures to make it easier to promote breastfeeding - multifaceted approaches include health education, changes to maternity ward practice to encourage unrestricted breastfeeding, skin-to-skin contact, advice and treatment
    • training of health professionals - few training courses have been formally evaluated, but evidence suggests that training is most likely to be effective when delivered as part of a package and on a mandatory basis 3
  • Peer support programmes - Initiation rates can be increased among low-income women if they include a peer support component. Such programmes offer contact over time with role models often lacking in deprived communities and counter problems non-professional women may have in seeking advice from professionals. Standalone effectiveness is restricted, however, to those women who wish to breastfeed
  • Multi-faceted interventions - efficacy is increased if sessions are broad-based, span the ante and postnatal period and draw on repeated contacts with either a professional or peer educator

3.1.2 Lack of review-level evidence re breastfeeding

There is a lack of review-level evidence re breastfeeding in the following areas:

  • Media campaigns - evidence relating to the success of media campaigns is scarce and dated, although research suggests that their potential to raise awareness and promote breastfeeding is effective as part of a multifaceted intervention
  • Evaluation of public policy; for example, rest periods or flexible working arrangements on return from maternity leave to encourage mothers to continue breastfeeding
  • Whether a supportive environment (public acceptability and no social barriers to breastfeeding) encourages mothers to breastfeed

3.1.3 Evidence from the UK - NICE and the Health Development Agency

A number of relevant documents were published in England between 2003 and 2006. Protheroe et al (2003) The effectiveness of public health interventions to promote the initiation of breastfeeding, published by the Health Development Agency, provided a review of reviews of the evidence base. Only two reviews met the criteria for inclusion (Tedstone et al, 1998 and Fairbank et al, 2000) and, in general, findings appear to be superseded by Asthana and Halliday. However, from an inequalities perspective, there are one or two additional findings of interest.

  • Health education -
    • Breastfeeding literature and formal education delivered to low income groups in the USA were not effective at promoting the initiation of breastfeeding, although evidence was based on small-scale studies
    • Paying participants to attend increased participation rates for group classes
    • Promotion efforts may be assisted by including partners, providing incentives and changing the content of commercial hospital packs given to women on discharge from hospital, although evidence is not strong
    • The least successful interventions were those where breastfeeding promotion was only one part of a multiple health promotion programme
  • Health sector initiatives - one UK based RCT evaluated the effect of social support for socially disadvantaged women (home visits and telephone calls from a midwife on hospital discharge). No significant difference was reported in initiation rates between the intervention and control groups, but feedback given by the women was positive and suggested that they valued a midwife listening to them
  • Peer support programmes - qualitative research exploring why some women on low incomes do not want to breastfeed concluded that breastfeeding is a practical skill. Confidence and commitment to breastfeed successfully are best achieved by exposure to breastfeeding, rather than talking or reading about it
  • Multi-faceted interventions - effective multi-faceted interventions have included a media campaign in combination with health education programmes, training of health professionals, a peer support programme and/or changes in government and hospital policies. Evidence from Sweden indicates the effectiveness of a combination of problem-based information about breastfeeding (written mostly for and often by mothers); increased availability of mother-to-mother support groups; increase in paid maternity leave with guaranteed return to previous employment; changed maternity ward practices. However, no evaluation has been undertaken to examine which, if any, of these aspects was more effective, or if the combined package was necessary.

NICE: The effectiveness of public health interventions to promote the duration of breastfeeding: systematic review (Renfrew et al, 2005)

This paper follows on from the previous review of interventions to promote the initiation of breastfeeding. However, only 17 studies (21%) examined the needs of women from disadvantaged groups. Ways of raising breastfeeding rates among groups where the rates are lowest remain to be explored further. The review identified a number of gaps in the evidence base, but all of these are included in the 2006 NICE paper (see below).

NICE: Promotion of breastfeeding initiation and duration: Evidence into practice briefing (Dyson et al, 2006)

This document (published later than Asthana and Halliday's summary, although individual reviews used here were included by Asthana and Halliday) presents evidence based actions for promoting the initiation and/or duration of any and/or exclusive breastfeeding among full term, singleton, healthy babies. The evidence based actions include all population groups, with a particular focus among population groups where breastfeeding rates are low.

The actions were formulated through the integration of published scientific literature with practitioner expertise and experience. Studies of effectiveness from four systematic reviews (Fairbank et al, 2000; Protheroe, 2003; Renfrew et al, 2005; Tedstone et al, 1998) were assessed against agreed criteria, including recognised quality appraisal criteria. A list of 'plausible evidence-based actions' for practice were drawn up based on the available studies considered to be of good quality. These were then used as the basis of a national consultation with a range of mainstream practitioners and representatives of service users, with the aim of moving from a list of 'what works from international research evidence' to 'what will really work in practice in England.' Eight actions were identified:

  • Baby Friendly Initiative 4 ( BFI) in maternity and community services. In particular, all maternity hospitals should be encouraged to attain the BFI Full Accreditation Award to increase initiation rates for all women; and hospitals with a BFI Certificate of Commitment should progress to the BFI Full Accreditation Award to increase breastfeeding initiation for all women.
  • An appropriate mix of education and/or support programmes to be routinely delivered by both health professionals/practitioners and peer supporters in accordance with local population needs. Focus on informal, practical sessions, breastfeeding-specific problem solving support, peer support to provide information and listening support to women on low incomes, to increase initiation and duration rates
  • Changes to routine policy and practice within the community and hospital settings to encourage unrestricted baby-led breastfeeding; teach breastfeeding technique and provide sound information and reassurance for breastfeeding women with 'insufficient milk.'
  • Routine policy and practice for clinical care in hospital and community should abandon restriction of the timing and/or frequency of breastfeeds during immediate postnatal care; restriction of mother-baby contact; supplemental feeds given without medical reason in addition to breastfeeds; separation of babies from mothers for the treatment of jaundice; provision of hospital discharge packs which include promotional information for formula feeding
  • Peer or volunteer support delivered by telephone to complement face-to-face support in the early postnatal period
  • Breastfeeding education and support from one professional should be targeted to women on low incomes to increase rates of exclusive breastfeeding
  • One-to-one needs-based breastfeeding education through the first year should be available to increase intention, initiation and duration rates, particularly among white, low income women
  • Local media programmes should be developed to target teenagers to improve and shift attitudes towards breastfeeding

The briefing paper identifies the following gaps in the evidence base:

  • UK based studies
  • Evaluations of interventions directed at particular groups where rates of breastfeeding are low
  • Participants' views of interventions.
  • Studies evaluating the effects of supportive environments ( e.g. breastfeeding facilities outside the home)
  • Large, good quality studies evaluating the ways national media campaigns can be used to shift cultural values for breastfeeding to be recognised as a cultural norm
  • Large scale, high quality UK evaluations of the BFI in the community.
  • Studies evaluating the effects of non-health sector interventions (such as school programmes targeting both girls and boys prior to pregnancy)
  • Studies addressing clinical problems associated with breastfeeding (such as 'insufficient milk,' sore nipples)
  • Studies including outcomes related to costs for families, employers and health services

Methodological weaknesses in the evidence base

  • Terms 'breastfeeding,' 'exclusive breastfeeding' and 'partial breastfeeding' were often used loosely or left undefined, leading to confusion as to whether babies were fed only breast milk or received additional fluids
  • Lack of information about how women were recruited into the studies suggests that many participants volunteered. This means there may be sample bias within the studies reviewed, leading to non-representative samples affecting study findings
  • Papers often lacked the information needed to evaluate an intervention and or replicate it in the future
  • Potential confounders for evaluating breastfeeding were not always taken into account ( e.g. whether a mother was a first-time mother; mother's feeding intention)
  • Power and sample size calculations were often omitted, making it impossible to assess the adequacy of the study
  • Outcome assessment was rarely validated and attrition was often high or unreported
  • The relative effectiveness of different intervention components was not evaluated within individual studies, and neither was the effect of the same intervention on different sub-groups.

3.1.4 Evidence from Scotland: the Breastfeeding Expert Group

In October 2003, the Breastfeeding Expert Group ( BEG) was convened under the auspices of the Early Years National Learning Network at NHS Health Scotland. This group was charged with a remit to assemble the best available evidence to support Scotland's efforts to increase rates in breastfeeding initiation and duration.

The membership of BEG was multi-agency and multidisciplinary, comprising policy makers, practitioners and academics, all with interest and expertise in breastfeeding issues. BEG's membership provided an opportunity to capitalise on the respective strengths of a wide range of professions. The Early Years National Learning Network has a specific remit to disseminate lessons learned from Starting Well; so two of the project's health visitors were members of this group. Also, bearing in mind the work of the HDA and (subsequently) NICE, a lead person from the HDA was included in the group.

BEG welcomed the publication of the HDA review in 2003 and acknowledged the work (in development at the time) on the subsequent documents produced by NICE. Notwithstanding the value of these documents, BEG members recommended that the evidence base could be usefully augmented by the consideration of issues missing from the NICE review:

  • A consideration of psychosocial issues related to infant feeding, (including an assessment of the measurement tools used in breastfeeding research)
  • A focus on breastfeeding of babies in neonatal units
  • Published qualitative data on beliefs, attitudes and experiences of infant feeding.

Evidence was obtained by systematically reviewing published studies that were published in English and considered to be culturally relevant, to complement the NICE report. The reviews were carried out by two independent reviewers and BEG members commented upon successive drafts of the review. The final drafts were subjected to both an academic peer and practitioner review process, the feedback of which has been responded to in the final report.

Three sections of the full report are particularly relevant to addressing inequalities. Each of these will be considered in turn.

Breastfeeding in neonatal units. A review of breastfeeding publications between 1990-2005 (McInnes and Chambers, 2006a)

This report presents a review of publications on evaluations of interventions to support breastfeeding in neonatal units. Babies admitted to such units are more likely than others to come from families who experiencing inequalities in terms of health. Thirty-six papers listed in medical electronic databases between 1990 and June 2005 which had breastfeeding or the provision of breast milk as an outcome and which targeted low birthweight or premature infants or their parents or were based in a neonatal unit were identified.

The papers comprised 25 randomised controlled trials ( RCTs), eight quasi-experimental, one randomised trial, one case-control and one cohort study.

Summary of the evidence from the reviewed articles:

  • Most authors acknowledged that breast milk benefited preterm or high risk infants but that achieving breastfeeding success was less likely among mothers of these infants
  • The publications targeted a diverse range of topics ( e.g. the use of bottles, cups, teats or dummies; parental support, staff education, skin-to-skin care or Kangaroo Mother Care ( KMC) 5, early discharge from the neonatal unit, breast milk fortifiers, the Baby Friendly Initiative ( BFI)) so the pooling of common themes was limited.
  • The largest published evidence base was for KMC, where studies consistently demonstrated advantages for the infant in terms of physiological stability, reduced morbidity and improved breastfeeding rates. The majority of KMC studies were based in developing countries, but may provide significant advantages for the infant, the mother and health services within the UK
  • Other interventions were less conclusive with only one cup-feeding study showing a positive result compared to three demonstrating no significant differences in breastfeeding. Other interventions, which may have a positive impact on breastfeeding duration, were supplementation by naso-gastric tube ( NGT) rather than bottle, use of powder fortification of breast milk rather than a liquid and the Baby Friendly Initiative ( BFI).
  • Few studies followed up the population beyond discharge and only two interventions were shown to have an impact beyond three months: KMC (2 studies) and supplementation by NGT (1 study)
  • Only five of the 36 studies were conducted in the UK

Gaps in the evidence

  • In general the studies focused on quantifiable, physical aspects of care and did not fully address the potential emotional barriers to breastfeeding and/or expressing breast milk
  • A variety of clinical outcomes were recorded for most studies and 25 papers measured breastfeeding outcome, usually at the point of discharge from the neonatal unit. None of the studies evaluated maternal satisfaction with their experience of breastfeeding and/or the expressing of breast milk often under very difficult circumstances. There was also limited assessment of the long-term impact on breastfeeding continuation or maternal satisfaction
  • There was an overall lack of good quality UK based studies.

Infant feeding: A review of qualitative studies exploring psychosocial factors relating to infant feeding and the breastfeeding of babies in neonatal units 1990-2005 (McInnes and Chambers, 2006b)

This report presents a synthesis of qualitative studies that explored the psychosocial factors related to breastfeeding, and breastfeeding in neonatal units from the perspective of the parent/s and/or health professionals. The search was limited to papers from the UK and other developed countries: 54 papers listed in medical electronic databases (between 1990 and June 2005) which addressed a psychosocial aspect of breastfeeding, or targeted low birth weight or premature infants and/or their parents or were based in neonatal units were identified. Twenty-three papers were based in the UK.

Summary of the evidence from the review of qualitative studies

  • Despite variations in breastfeeding rates, many issues were common across the range of countries ( e.g. the unacceptability and difficulty of breastfeeding in public, the influence of a mother's social network, the lack of health service support for breastfeeding and the negative representation of breastfeeding in the media)
  • Issues affecting mothers of infants in neonatal units were similar to those affecting other mothers, e.g. confidence in their ability to breastfeed, breastfeeding in public, the influence of the social network and health service support
  • Successful breastfeeding was associated with confidence and high self-esteem, working in harmony with the baby, a commitment to breastfeeding and a determination to overcome problems. Mothers were holistic in assessing their infant's health and the adequacy of breastfeeding, and made breastfeeding a priority in their lives.
  • Successful breast feeders usually had a supportive social network and received praise and recognition for their efforts as well as practical help. They tended not to see health service support as the most important source of support, thus minimising any effect of conflicting advice
  • Unsuccessful breast feeders reported greater incongruity between their expectations and the reality of breastfeeding. Concerns about breast milk inadequacy were common, and the behaviour of the infant, was often taken to indicate a lack of milk. Emphasis was placed on weight gain as external verification of breastfeeding success
  • Mothers who were unsuccessful at breastfeeding often had an unsupportive social network and frequently felt undermined in their attempts to breastfeed, thus relying more on health service support, which was not always forthcoming. These mothers were particularly susceptible to conflicting advice
  • Unsuccessful breast feeders tended to give up if breastfeeding became problematic and resented the lack of freedom associated with breastfeeding, desiring instead to get their lives and/or bodies 'back to normal'
  • Breastfeeding was particularly undermined by detrimental practices ( e.g. the use of dummies, supplementary feeding) and the pervasive bottle-feeding culture associated with some low-income areas
  • Mothers identified a number of key areas as being unsupportive of breastfeeding: their lack of knowledge about the practical and emotional aspects of breastfeeding, lack of encouragement to breastfeed from social networks and from health care professionals, lack of appropriate and effective support once breastfeeding was initiated, negative attitudes of some societies to breastfeeding (especially in the UK), disapproval of breastfeeding in public; difficulties combining breastfeeding and employment.

A number of recommendations are made by the review:

  • Breastfeeding education and promotion prior to conception is required, for prospective fathers as well as mothers. The introduction of breastfeeding education in schools should be considered. Once pregnant, individualised advice on the value of breastfeeding may encourage women to choose to breastfeed. Thereafter, education should focus on realistic emotional and practical issues (including problem solving), with greater exposure to real breastfeeding mothers
  • Health professional support needs to be effective, timely and acceptable. This requires appropriate and skilled staffing in postnatal wards who consider breastfeeding as a priority.
  • Health professionals should identify the mother's individual breastfeeding goals and help her to achieve them, with provision of appropriate information/advice and techniques to build her confidence in herself as a new mother
  • Health professionals should explore techniques for teaching mothers to express breast milk, including computer simulation
  • The expressed views and attitudes of society have an important impact on the success of breastfeeding. Every effort should be made to encourage public breastfeeding as the social norm and pressure should be brought to bear on the media to enhance the representation of breastfeeding. The methods used to enable mothers to combine breastfeeding with work should be evaluated
  • Mothers who intend to bottle-feed also require adequate preparation and information. Health services should follow WHO/ UNICEF6 advice about the support of bottle-feeding mothers and avoid being judgmental or unsupportive

Summary: what do we know about the effectiveness of interventions to support breastfeeding?

  • The evidence base on the initiation and duration of breastfeeding is relatively comprehensive, although research relating specifically to Scotland is sparse
  • Multi-faceted interventions, focused specifically on breastfeeding, appear to be the most effective. Interventions should span the ante and postnatal period and draw on repeated contacts with professionals and/or peer educators
  • A review of evaluations to support breastfeeding in neonatal units found considerable support for Kangaroo Mother Care ( KMC), with studies consistently demonstrating advantages for the infant in terms of physiological stability, reduced morbidity and improved breastfeeding rates
  • Eight actions were identified by NICE on the basis of evidence from systematic reviews:
    • support for the Baby Friendly Initiative in maternity and community services
    • a mix of education and/or support programmes routinely delivered by health practitioners and peer supporters
    • changes to policy and practice to encourage and promote breastfeeding
    • clinical care to support mother-baby contact
    • peer or volunteer support for mothers in the early postnatal period
    • breastfeeding education and support targeted on women on low income
    • one-to-one needs-based education throughout the first year
    • local media programmes to target teenagers to improve attitudes to breastfeeding
  • Gaps in the evidence base include: evaluation of interventions directed at groups where rates of breastfeeding are low; participants' views of interventions; evaluations of national media campaigns; evaluations of the Baby Friendly Initiative; evaluation of the effects of interventions targeting girls and boys prior to pregnancy; studies addressing clinical problems associated with breastfeeding; studies including outcomes related to costs; studies addressing the potential emotional barriers to breastfeeding

3.2 Exposure to passive smoking in early life

Asthana and Halliday (p 157) claim that increasing support for smoking cessation during pregnancy and its subsequent maintenance could affect breastfeeding rates and thus be a legitimate component of breastfeeding support programmes.

3.2.1 What works to help smoking cessation in the postnatal period? Evidence and practice (Asthana and Halliday, 2006)

  • The most effective strategies concentrate on strengthening parents' faith in their ability to create a smoke-free environment, and on behavioural strategies to achieve this goal, rather than focusing on stopping smoking. There is evidence in favour of interventions delivered by clinicians in both the home and the clinic ( e.g. information, advice and counselling) But studies tend to rely on self-reported behaviour rather than biochemical measures
  • Intensive counselling increases knowledge, but few studies show a statistically significant intervention effect in terms of attitudes and behaviour (and hence exposure to environmental tobacco smoke ( ETS) as opposed to changes in knowledge). There was, however, a generally observable reduction in child ETS exposure for participants
  • Smoking bans with widespread public support are a prerequisite for the adoption of smoking restrictions at home, since interventions to decrease exposure to second-hand smoke 'can act as a method to 'de-normalise' tobacco use … and smoking prevalence will fall as a result'

Evidence from Scotland: Evaluation of smoke-free legislation

  • Health Scotland, in conjunction with Information Services Division Scotland and the Scottish Government, have developed a comprehensive evaluation strategy to assess the short, immediate and long term outcomes of the smoking ban
  • Early findings indicate that there is no evidence of smoking shifting from public places into the home
  • There is a high level of public support for the legislation even among smokers, whose support increased once the legislation was in place

3.2.2 Limitations to the evidence base on smoking cessation/passive smoking

There are a number of key areas where the current evidence base provides a poor foundation for policy and practice. These include:

  • The efficacy of individual components of a programme (including the effectiveness of interventions when delivered by different medical staff in different settings)
  • Features that might increase cessation among particular risk groups (such as heavy smokers and/or women of lower socio-economic class)
  • Strategies that are effective against relapse
  • Interventions that include the family as a whole and are culturally appropriate

There are also methodological problems with much of the research carried out to date. For example:

  • Too great a reliance on self-reported behaviour
  • Failure to take into account confounding variables such as age and socio-economic status
  • Failure to consider the very different experiences of heavy and light smokers

Summary: what do we know about the effectiveness of initiatives to help smoking cessation in the postnatal period?

  • Supporting parents to achieve a smoke-free home environment appears to work better than focusing on stopping smoking.
  • Smoking bans with widespread public support are a prerequisite for the adoption of smoking restrictions at home
  • Early findings from the evaluation of smoke-free legislation in Scotland indicates that there is no evidence of smoking shifting from public places into the home
  • However, research to date has relied too heavily on self-reported behaviour and has failed to focus on the impact of factors such as socioeconomic status and the different experiences of heavy and light smokers

3.3 Maternal and child nutrition

Poverty is associated with food insecurity, hunger and poor diet, with the poorest 10% of households spending a higher proportion of their income on food, but consuming less in real terms. The Avon Longitudinal Study of Pregnancy and Childhood found that only three nutrients among the 20 studied in the diets of women were unaffected by financial constraints (Rogers and Emmet, 1998). Children living in households on Income Support appear at particular risk, although research suggests that parents frequently forsake food themselves in order to feed their children (Dowler et al, 2001).

Nutritional interventions for early life have tended to focus on the health of the pregnant mother and the subsequent adequacy of the diet, measured primarily through infant health gain. With greater acknowledgement of the lifecourse approach, there is now increasing interest in the effects of nutritional status on long-term health.

Guidance for midwives, health visitors, pharmacists and other primary care services to improve the nutrition of pregnant and breastfeeding mothers and children in low income households is expected to be published by NICE in February 2008. NHS Health Scotland has been a stakeholder for the work and will be producing a commentary on the guidance once it is published.

3.3.1 Nutrition in the weaning and post-weaning period - evidence and practice (Asthana and Halliday, 2006)

  • Income measures; improvements in accessibility and movements to promote cheap food in the community; and community cafes are all considered to be of greater relevance to improving nutrition than nutritional education through didactic means
  • The evidence indicates the importance of early intervention, and the promotion of breastfeeding as an integral part of a much wider nutritional agenda

3.3.2 Lack of review-level evidence on nutrition in the weaning and post-weaning period

There is a lack of review-level evidence on nutrition in the weaning and post-weaning period:

  • There is limited evidence in support of promoting good feeding practice in the weaning and post-weaning period
  • There is a paucity of nutritional intervention aimed specifically at families with young children
  • A focus is needed on key target groups such as low-income and minority ethnic families, and to consider the relationship between early nutrition, income and work

3.3.3 Limitations to the evidence base on nutrition

  • It is difficult to assess exactly what works, because of a lack of structured evaluation, a multiplicity of variables and lack of baseline data.
  • Randomised controlled trials admit only a portion of the available research
  • Evidence to date draws heavily on the US experience

Summary: what do we know about the effectiveness of initiatives to address maternal and child nutrition in the early years?

  • Broad measures to improve income in disadvantaged households, and improve access to cheap, nutritious food, are more likely to be effective than providing information and education about nutrition
  • Breastfeeding should be promoted as an integral part of a wider nutritional agenda
  • There is a need to focus research on specific vulnerable groups, and to consider nutrition as part of a broader, life course issue

3.4 Oral and dental health

Dental decay is largely preventable and yet is the single biggest reason for children being admitted to hospital for an anaesthetic. Where sugary food and drink intake is high and frequent, dental decay begins almost as soon as the teeth come through. Infected and abscessed teeth are regularly removed from children as young as three years (chapter seven of an unnamed document, probably published by Argyll and Clyde). By the age of 3, over 60% of children from areas of deprivation have dental disease (Scottish Executive, 2005a).

Figure 3.2 indicates the difference in dental health between Primary 1 children in the most deprived and least deprived areas. Children in the two least deprived categories have already reached Scotland 2010 National Target of 60% with no obvious decay experience, while children in the most deprived category fall well short, with only 31% with no obvious decay experience.

Figure 3.2: Proportion of Primary 1 children with no obvious dental decay experience (by deprivation category) 7

Figure 3.2: Proportion of Primary 1 children with no obvious dental decay experience (by deprivation category)7

As well as bearing the overall brunt of dental decay experience, children from more deprived areas suffer more from severe decay. In some cases, this means the provision of a general anaesthetic for dental extractions, with its attendant risks (Merrett et al, 2006).

Dietary and oral health habits established in the very early years of life influence dental and oral health into adulthood, so early action is essential.

I was unable to find any systematic reviews of the evidence on what works to promote dental health but, clearly, steps to raise awareness and understanding about nutrition more generally will be relevant.

Provision of free toothbrushes and toothpaste, free dental checks, promotion of information about healthier snacks and about the relationship between sugary foods and tooth decay are all useful interventions ( NHS Health Scotland recently launched a new DVD for parents on how to care for their children's teeth). However, each is unlikely to be effective in isolation and, if the key principle of meeting the oral health needs of those in the most disadvantaged circumstances (Scottish Executive, 2005a) is to be met, it is important to acknowledge that the most disadvantaged families are the least likely to engage with relevant public health messages.

Evidence from Scotland: Childsmile (West) 2006

Childsmile (West) is a 3-year demonstration programme designed to improve the oral health of young children within identified deprived communities in Greater Glasgow and Clyde, Lanarkshire and Ayrshire and Arran.

Childsmile is the name given to link all the oral health improvement programmes. The three main components of the comprehensive programme are:

  • pre school health promotion and tooth brushing programmes in nurseries and schools
  • demonstration programme West - prevention from birth
  • demonstration programme East - nursery and school preventive programme

The Childsmile (West) programme will be evaluated over the 3 years and using the concept of action research will develop best practice. Building on the experience from this initial project will inform the development of the programme across the rest of Scotland.

The overarching aim of Childsmile (West) is to prevent oral disease from birth and to introduce preventive measures targeted at those at greatest risk of oral disease. Evidence based early intervention before the disease appears is the core concept. If successful, such programmes could significantly reduce disease levels in targeted groups of children in Scotland and ensure that Scotland achieves the target set for the year 2010: that 60% of 5 yr olds will have no obvious signs of dental decay.

Summary: what do we know about what works to promote oral and dental health?

  • There does not appear to be a coordinated evidence base on the topic, but it is likely that a combination of approaches (including information, education, promotion of healthy eating options, practical support and free dental checks) will be most effective in reducing dental decay in young children
  • Childsmile (West), which operates in several areas of Scotland and targets children at risk of tooth decay from the earliest stages of infancy, is a promising initiative which will be evaluated during its 3 year pilot period

3.5 Accidents and injuries

The association between socio-economic status and child mortality due to road-related accidents has been well established, and a relationship between social deprivation and non-fatal road injuries has also been identified. Although this section relates to school age children as well as those in the first two years of life, this chapter seemed to be the most appropriate place to include it. This section summarises Asthana and Halliday, 2006, who include a range of references to support each of these findings. A combination of factors appears to put children from deprived backgrounds at greater risk, including:

  • neighbourhood characteristics: urban deprived areas tend to have higher volumes of traffic than more affluent areas, increasing exposure to risk
  • housing design: living in a home with insufficient space to play, or in housing that opens directly onto the street also increases the risk of child pedestrian accidents
  • family circumstances: poorer children are more likely to walk to school and less likely to be accompanied on the journey, or supervised crossing roads, than children from more affluent backgrounds
  • individual behavioural and emotional factors children with hyperactivity appear to be at increased risk of accidents involving moving vehicles

In addition to road traffic accidents, over a million UK children under the age of 15 are injured every year within the home. The under fives are most at risk (accounting for 71% of all deaths and 60% of hospitalisations from home accidents in 1999. The relationship between deprivation status and home injuries in children is pronounced across a range of categories, including falls, burns/scalds and poisoning. The mechanisms by which disadvantage increases risk of home accidents are not well understood, but the following have been suggested as contributory factors (sources noted in Asthana and Halliday, 2006):

  • parental knowledge: for example, the potential for accidents; effective safety measures
  • parental behaviour: for example, drug and alcohol misuse, smoking
  • parental circumstances: such as insufficient income to purchase and maintain home safety equipment

3.5.1 What works to improve the safety of young children on the road and at home? (Asthana and Halliday, 2006)

  • There is evidence that single issue campaigns can be effective, particularly those focusing on safety equipment (such as child-resistant packaging and smoke detectors)
  • Evidence supports environmental modification (such as alterations to the road system and physical barriers to road injury - e.g. window bars, cycle helmets and mouth guards)
  • Area-wide engineering schemes and traffic calming measures are effective, relatively low cost and, while focusing on the most vulnerable groups, are effective for people of all ages and circumstances
  • Such schemes also have the (often unmeasured) potential to increase cycling and walking at the neighbourhood level, together with the potential for children to play outdoors, with benefits for both health and environment
  • There is evidence that improvements to playground design can reduce the frequency and severity of injuries
  • Home visiting programmes can substantially reduce rates of accidental injury, particularly in families at high risk, although no review of the evidence has been able to establish which components of the programme were effective in reducing childhood injury in the home
  • Educational programmes alone appear to have little effect, irrespective of the form they take (including skills training, mass media exposure and targeted education courses) or the focus (such as road safety or parental awareness of the risks from drowning in the home)
  • However, interventions incorporating legislation, education, safety equipment and environmental modification are the most likely to yield positive results

3.5.2 Limitations to the evidence base

  • The evidence base is dominated by literature from the US and too few details are often given to establish exactly what works, for whom, in what context
  • There is a lack of focus on deprived areas and deprived groups
  • Research linking problem behaviour and accidents suggests measures targeted at high-risk children need to move beyond knowledge and skills to challenge the attitudes and habits that underlie many risky behaviours

Summary: what do we know about what works to prevent accidents and injuries to young children?

  • Single issue campaigns can be effective
  • Basic modifications to the environment ( e.g. playground design) can reduce the severity and frequency of accidents
  • Relatively low cost initiatives to improve road safety can be effective and benefit the whole community, in addition to those who are particularly vulnerable. Benefits can also include improvements to health and the environment
  • Home visiting programmes can reduce rates of child injury in the home, although it is not clear which components of programmes are effective
  • Educational programmes alone have little effect
  • Interventions that address issues via a range of modes are the most likely to be successful
  • The evidence base is dominated by literature from the US and, in general, reports do not provide adequate information to indicate whether findings might be transferable to Scotland
  • Measures targeted at high-risk children need to challenge the attitudes and habits that underlie many risky behaviours