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Chapter 1 The health of Scotland's children

Good health for children is important morally, politically and economically.

The importance of good health in childhood cannot be overstated:

• Poor emotional, physical or mental health causes a child to suffer
• Poor health in a child impacts on the family, affecting parents' and carers' health, relationships and employment
• A healthy lifestyle, which includes a good diet, physical activity, positive coping strategies and psychological resilience, established in childhood sets the pattern for adult life
• Physical damage sustained as a child is not always reversible: decayed teeth will not re-grow, type II diabetes developing in adolescence will not resolve and disability as a result of trauma will not be fully repaired
• Poor mental health in childhood can lead to a greater risk of developing mental health problems in adult life
• If poor physical or mental health in childhood leads to poor educational attainment and disaffection with society, the resulting underachievement and low self esteem will affect an individual's well-being for life
• Children and young people who learn to take control of their own lives in the short term develop the long-term vision and skills required to reduce risks to health.

Very young children cannot argue for themselves. Society has a duty to support their families and enable them to fulfil their potential, whatever their circumstances.

The health of Scotland's children is improving but can be further improved.

There are some encouraging trends that will be important in improving the health of children and young people.

Breastfeeding

The higher the breastfeeding rate, the healthier the population. Breast milk protects against infections and allergies, and has been shown to be associated with improved intelligence and reduced risks of obesity and hypertension in later life.

Rates of breastfeeding have increased, even in the most deprived areas, although the increase is small (Figure 1.1). Elements contributing to the increase include:

• fifty-eight per cent of Scottish babies are now born in a UNICEF Baby Friendly Initiative accredited unit
• in 1996 only one NHS Board had a breastfeeding strategy: in 2005 only one did not
• the number of breastfeeding support groups increased from four in 1993 to 150 in 2005 and peer support programmes from one in 1994 to 11 by 2005
• the Scottish Executive, working with Health Boards and voluntary organisations, has brought forward legislation (The Breastfeeding etc (Scotland) Act 2005) to support breast feeding.

Immunisation

Immunisation rates continue to be high, exceeding the national 95% uptake targets for all the primary immunisations by 24 months of age, except for MMR. The previous decline in MMR uptake has reversed, increasing from 86.8% in 2003 to 89.9% in 2005 ( 1). It is essential to sustain this increase. Outbreaks of measles in Scotland in recent months have occurred in communities where MMR uptake rate is low. The consequences of measles can be extremely serious.

Oral health

The 2004 National Dental Inspection Programme ( NDIP), which reported on the oral health of Primary 1 (P1) children across Scotland, demonstrated that for the first time, the number of P1 children with no obvious decay exceeded 50%, with 50.7% showing no obvious signs of decay. This represents modest progress towards the National Target of 60% of P1 children free from decay by 2010, and a considerable improvement on the 2003 Survey, where 45% of P1 children had no obvious decay.

However, there is little room for complacency, with the 2004 NDIP Survey demonstrating a sharp contrast in decay experience between children in the most deprived communities in Scotland, where only 33% of P1 children had no obvious decay, compared to 68% of children in the most affluent communities.

Oral Health Action Teams in Glasgow deliver oral health promotion predominantly to the most vulnerable communities. An evaluation of their effectiveness has shown that focussing an intervention on the most deprived communities had a significantly beneficial impact on aggregated data for the whole NHS Board area (Figure 1.2).

Figure 1.2. Oral health in five year old children

The Dental Action Plan, published in March 2005, has identified a number of initiatives which will continue to improve the oral health of children in Scotland, through the national toothbrushing programme and the West and East of Scotland Demonstration Programmes. The Demonstration Programmes will bring together a range of stakeholders concerned with the oral health of children, and will target preventive activity on those children most at risk of tooth decay.

The West of Scotland Programme is already up and running, and aims to improve the oral health of very young children, establishing formal links between the General Dental Services and Health Visitors. It will seek to raise parental awareness of the importance of good oral health and to offer oral health promotion and prevention within participating dental practices.

The East of Scotland Programme aims to reach children after they start school, offering them an assessment and additional preventive advice using dedicated local teams of dental care professionals. The Programme will be launched in 2006.

Unintentional injuries

Rates of death and admission as a result of unintentional injuries in childhood have fallen ( 2). (Figures 1.3 and 1.4).

Figure 1.3: Standardised death rate per 100,000 population in children under 15 years

Figure 1.4: Standardised discharge rate per 100,000 population for under 15s: emergency admissions for unintentional injuries

Source: ISD.

The reduction in deaths and injuries may have been the result of a number of interventions, including:

• increased awareness
• speed limit legislation and enforcement such as "Twenty's Plenty"
• Safe Routes to Schools
• traffic calming
• seatbelt legislation
• speed cameras
• improvements in car design (although urban 4x4s are a greater risk than other cars to child pedestrians in a collision ( 3,4))
• child-resistant containers for drugs and household chemicals.

Despite improvements, many challenges remain, particularly in relation to inequalities in health.

Inequalities in health are still seen in many important child health indicators ( Figure 1.5). Children from deprived communities are more likely to experience a range of adverse risk factors. They are more likely to be born to mothers who smoke, to have a low birthweight and are less likely to be breastfed. Low weight at birth can increase the risk of illness in later life and be associated with obesity and diabetes.

Low birthweight can be the end result of a variety of different processes, including:

• prematurity
• poor fetal nutrition
• exposure to toxins (such as nicotine) in pregnancy.

Figure 1.5: Inequalities in health

Source: ISD ( 5)

Rates of obesity in childhood in Scotland are increasing: from those born in 1995 to those born in 2001, the percentage of pre-school children (receiving a review) who were obese increased from 7.9 to 8.6%. From school year 2000/2001 to 2004/2005, the percentage of P7 children (receiving a review) who were obese increased from 16.6 to 19.4%.

The prevalence of conduct disorders in Scottish children is on the rise. The Office of National Statistics survey ( 6) of five to 15 year olds found 4.6% with conduct disorder in 1999, rising to 5.3% in 2004 (in girls, 2.5% rising to 4.4%). Those with a diagnosis of conduct disorder represent the tip of an iceberg, with many more children having challenging behaviour. Children with a conduct disorder are much more likely to have:

• low household income
• parents with no educational qualifications
• hearing and speech problems
• problems with spelling, reading and maths
• lower overall scholastic ability.

The same survey ( 7) demonstrated a smaller rise in the prevalence of a diagnosis of hyperkinetic disorder, from 1.1% in 1999 to 1.6% in 2004. However, figures set out in the NHSQIS indicators report ( 8) demonstrate a much greater rise in Methylphenidate prescriptions, from 69 prescriptions per 10,000 population in 1996 to 603 in 2003.

SALSUS (The Scottish Schools Adolescent Lifestyle and Substance Use Survey) demonstrated that rates of consumption of alcohol (and other substances of abuse) in childhood are increasing ( 9). (Figure 1.6)

Figure 1.6: Alcohol consumption

Consumption of alcohol was associated with a higher rate of reported involvement in:

• arguments
• fights
• having tried drugs
• having had unprotected sex
• having stayed off school
• having been involved in accidents or crime.

Conclusion

In deprived areas of Scotland, many children's prospects are still being damaged by one risk factor after another, ensuring they do not fulfil the potential they had at the moment of their conception (Figure 1.7).

Many public health strategies are now showing highly encouraging effects and major legislative change such as the smoking ban is likely to produce further improvements. However, major public health challenges which remain include inequalities in child health, the rising obesity prevalence and the mental health of young people. These must continue to be addressed through a combination of national policy and local initiatives, with effective focus of resources and action on children living in the most disadvantaged circumstances.

The 2005 Health for All Children: The Hall IV Report recommendations ( 10) and the Education (Additional Support for Learning)(Scotland) Act 2004 are welcome developments to make sure the needs of individual children and families are considered, so that appropriate support can be provided. Hence, in pregnancy women can be supported to make healthy choices. After birth and throughout the childhood years, support should be delivered at the appropriate level by the appropriate services at the appropriate time, with full involvement of the family. This is in contrast to previous piecemeal projects and provisions. Most important now is to put sufficient resource behind the changes, so that the needs identified can truly be met. In areas of deprivation the investment has to be very significant.

Figure 1.7: Spiral of decline in potential of pre-school child suffering multiple deprivation

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