Why GPs play a vital role in child health promotion
Child health surveillance is an important part of GP workload Dr David Hall explains why
eyond life as a GP registrar the NHS (GMS) regulations 1992 state that services should comprise the monitoring of the health, well-being and physical, mental and social development of the child with a view to detecting any deviations from normal development1. In 1999, 94 per cent of principals were on the primary care organisation child health surveillance list2.
CHS is a programme of care intended to prevent and identify illness and disease at the earliest opportunity, manage pre-existing disease and illness optimally, and promote good health and development3.
Its desired precise content has been debated for years. According to the Joint Working Party made up of paediatricians, GPs, health visitors and nurses, this monitoring involves health promotion, surveillance, intervention, prevention, primary, secondary and tertiary health education, and screening3. The report from this group, Health for All Children, is currently in its third edition and has had a huge positive impact.
The trend is shifting from CHS to child health promotion (CHP), or accident prevention3. Recently there have been calls to reduce routine CHS checks, with health visitors carrying out development checks and doctors concentrating on the six- to nine-week check.
Some areas of surveillance may be changing. The National Screening Committee on the subject of universal neonatal hearing screening says 20 pilot sites in the NHS were announced in December 2000 with a planned phased implementation of the service to replace the infant distraction test9. Screening for developmental dysplasia of the hip (a term that is replacing congenital dislocation of the hip) is also being reviewed as even with a system like CHS the condition is being missed.
· Six-eight weeks The first check is at six to eight weeks and is usually done by a GP. Birth and family history are important to ascertain and special care should be taken to listen to parents' concerns. Physical examination is carried out with particular attention paid to head circumference, checking the hips for developmental dysplasia. Cardiovascular and eye examination are also important at this stage. The opportunity is taken to discuss immunisation and other health education topics such as feeding, weaning, sudden infant death syndrome, effects of parental smoking, awareness and detection of postnatal depression, accidents and their prevention.
· Six-nine months This check can be done by either the GP or the health visitor. Discover if there are any parental concerns, especially about vision and hearing. Conduct a physical examination, especially looking for hip dysplasia, undescended testes and squint. The distraction test requires skill and time on the operator's part and this may well be phased out in favour of universal neonatal hearing screening. Health education is important, especially accident prevention, nutrition and dental care.
· 18-24 months This check is the domain of the health visitor. The importance of listening to the parents' concerns cannot be stressed enough, especially with respect to behaviour, vision and hearing. Assess the child's walking and gait, measure height and reinforce health education, especially accident prevention, the effects of parental smoking and the general developmental needs of the child.
· 39-42 months The aim of this check, according to Health for All Children, is to ensure the child is physically fit and there are no medical disorders or defects that may interfere with education, to ensure immunisations are up to date, and to determine whether there are problems with development, language or behaviour that may have educational implications.
Inquire about vision, squinting, hearing, behaviour, language acquisition and development. Measure height, weight if indicated and check for descent of testes if not previously documented. Physical examination is carried out as indicated. Cover health education issues such as accidents, road safety, and preparation for school, nutrition and dental care.
Aim of child health checks
· Detect disorders early
· Work with parents
· Explore parents' concerns
· Examine testes, hips and cardiovascular system
· Check vision and hearing, and refer if concerned
· Educate about immunisations
· Prevent accidents
· Keep accurate records
1. United Kingdom Parliament. The National Health Service (General Medical Services) London: HMSO, 1992
2. Department of Health Statistical Bulletin. Statistics for General Medical Practitioners in England: 1984/94.
London: HMSO, 1995
3. Third Joint Working Party on Child Health Surveillance. Health for All Children. London: Oxford University Press, 1996
4. Hampshire AJ et al. Are child health surveillance reviews just routine examinations of normal children? Br J Gen Pract 1999;49:981-5
5. Brown K et al. Changes in the role of general practitioners in child health surveillance. Public Health. 1998;112:399-403
6. Hampshire AJ et al. Is pre-school child health surveillance an effective means of detecting key physical abnormalities?
Br J Gen Pract 1999;49:630-3
7. Butler JR. Child Health Surveillance in England and Wales: the good news. Child Care Health Dev. 1997;23:327-37
8. Butler JR. Child Health Surveillance in England and Wales: the bad news. Child Care Health Dev. 1997;23:339-54
9. National Screening Committee: Child Health Subgroup Report 1998/2000