CLINICAL PROTOCOL FOR THE HEALTHY CHILD PROGRAMME

CLINICAL PROTOCOL FOR THE HEALTHY CHILD PROGRAMME RATIONALE In establishing the foundations of good health, the Healthy Child Programme (HCP) makes a crucial contribution to the Every Child Matters outcomes and to delivering the legal duties to promote these, as well as to the National Service Framework for Children, Young People and Maternity Services (DH, 2004). The HCP feeds directly into The Children s Plan (DCSF, 2011), which includes strengthened support for all families during the formative early years of children s lives, and helps parents to ensure that children are ready for early years education, school and later life. The Trust is committed to supporting the Healthy Child Programme - Pregnancy and the first five years of life (2009) as part of the Governments strategy set out in Every Child Matters Change for Children (DfES 2004) to ensure that services are of high quality, and are responsive to the needs, and expectations of those who use them. CORE CONTACTS THE HEALTHY CHILD PROGRAMME Universal Antenatal contact Face to face Between 30-36 weeks gestation Birth Visit for health review by 14 days Face to face By mutually agreed appointment 4-8 week health review Face to face By mutually agreed appointment 12-16 week contact Face to face By mutually agreed appointment 9 12 month health review Face to face By mutually agreed appointment 2 2½ years health review Face to face By mutually agreed appointment The Trust s Healthy Child Programme outlines the recommendations made by: The Royal College of Paediatrics and Child Health (2003 RCPCH) in the 4th Edition of Health for All Children (Hall 4). The National Service Framework for Children, Young People and Maternity Services (DH 2004). Update of Standard One (incorporating Standard Two) of the National Service Framework for Children, Young People and Maternity Services (2004). The Healthy Child Programme Pregnancy and the first five years (DH 2009). The Health Visitor Implementation Plan (DH 2011). Every Child Matters (DfES 2006). Health Visiting Service 1/23

Healthy Lives Brighter Futures: The Strategy of Children and Young Peoples Health (DH 2009). Fair Society, Healthy Lives (Marmot, 2010). Health Visiting Implementation Plan a call to action 2011-2015 (DH 2011) No Health without Mental Health (DH, 2011). Working Together to Safeguard Children (DH, 2010). Aiming High for Disabled Children (DCSF 2007). Achieving better health for children, families and communities: the health visiting contribution, (DH 2011). Early Intervention: The Next Steps (Allen G 2011). NICE (2009) Public Health Guideline number 21 Reducing differences in the uptake of immunisations. The Munro Review of Child Protection (Munro E, 2011). ACCESSIBILITY/ACCEPTABILITY The service must be offered to every eligible family, at a time when the foundations of future health and wellbeing are laid down; when parents are particularly receptive to learning and making changes. Outcomes for both children and adults are strongly influenced by the factors that operate in pregnancy and the first years of life, making early intervention and prevention an imperative. All services/sessions/contacts must be provided by skilled practitioners utilising research based approaches to working with families in child and family friendly environments; offering choice in the timing and venue/setting of the service wherever possible. Practitioners will recognise that the communication requirements which will support these relationships are likely to be complex, particularly where the geographical residency of the child is not congruent with other services which are accessed on a registered basis; the named Health Visitor (HV) will need to be flexible and innovative in the ways they ensure effective communication about the needs of families in their care. At a population level, each local GP practice should be informed of, and given contact details for, a named HV who will act as a bridge between those GPs and the Health Visiting service in that locality at a mutually convenient time for information sharing. Similarly a named HV will act as a bridge between maternity services and locality-based Health Visiting services. Where complex needs, issues or concerns have been identified, an individual HV to individual GP working relationship will need to be developed and maintained effectively. EXCLUSION CRITERIA Eligible families must reside in Wirral and have a child aged less than 5 years within the family. GEOGRAPHIC COVERAGE/BOUNDARIES All eligible families resident within the boundaries of the Metropolitan Borough of Wirral. Health Visiting Service 2/23

WHOLE SYSTEM RELATIONSHIPS The delivery of a high quality HCP requires a very high level of service integration at all levels; although the service is led by the Health Visiting teams, it draws on a range of practitioners, and will be delivered through a variety of settings including General Practice and Sure Start Children s Centres. This document is not a comprehensive guide to all child health, as further guidelines and pathways may be required when services develop and new research findings are published. Throughout this document, the term "parent" includes all those with parental responsibility, including carers. As enshrined in the Children Act 2004 the rights and responsibilities to provide for children's health and welfare rest with parents. Community and Health Visiting services and Children s Centres community-based support have a vital role in helping parents to achieve this, through promoting their child's healthy development and helping maximise their potential. The strong evidence base for the Healthy Child Programme (HCP) is set out in Health for All Children (Hall and Elliman, 2006) and underpins the universal programme. This has been supplemented by guidance from the National Institute for Health and Clinical Excellence (NICE) and a review of health-led parenting programmes by the University of Warwick. The evidence base is less clear for some public health interventions (such as obesity prevention). However, there is no doubt about the importance of these public health issues therefore they have been included based on expert consensus (Cross- Government Obesity Unit 2008). The recommendations in Hall 4 and direction in the HCP reflect a move away from a medical model of screening for disorders, towards greater emphasis on health promotion, primary prevention and early intervention. The HCP offers every family a programme of screening tests, immunisations, developmental reviews and information and guidance to support parenting and health choices all services that children and families need to receive if they are to achieve their optimum health and wellbeing. BACKGROUND The HCP is a key service for delivering the 2008 2011 Public Service Agreements (PSA) for improving the health and well being of children, specifically around the indicators for breastfeeding. Public Service Agreement (PSA) 12: Improve the health and wellbeing of children and young people (HM Government, 2007) supports Health Visiting teams to actively promote breastfeeding and support mothers to continue and sustain breastfeeding. Universal health and development reviews are a key feature of the HCP. It is a universal service that is offered to all families, with additional services for those with specific needs and risks. The HCP offers 3 levels of care: Universal, Universal Partnership and Universal Health Visiting Service 3/23

Partnership Plus. The Health Visiting service provides a universal offer to all families with children under the age of five. Additional service offer of Universal Partnership and Universal Partnership Plus are offered to families with identified additional needs. If we are to reduce inequalities in children s health, wellbeing and achievement, we need to focus on the most vulnerable children and families, and allocate resources accordingly. One of the HCP s key roles is to identify children with high risk low protective factors, and to ensure that these families receive a personalised service. Standard One of the National Service Framework for Children, Young People and Maternity Services (DH, 2004) highlights that health promotion, in terms of awareness raising, information giving and support services, including the HCP, is reflected in improving outcomes for children and young people. The 4 th Edition of Health for All Children, (Hall and Elliman, 2006) stresses that the social, economic and environmental context in which children grow up can have a very significant effect upon their health. This indicates a need to move away from a narrow focus on health screening and developmental reviews to a more broad-based programme of support to children and their families that help to address the wider determinants of health and to reduce health inequalities. The UK National Screening Committee (NSC) endorses the recommendations in Hall 4 and the shift away from child health surveillance activity that concentrates on holistic approach which supports parents to ensure that they have the information, skills and resources they need to maximise their potential. AIMS: The Healthy Child Programme is key to delivering the Public Service Agreements for improving the health and wellbeing of children (PSA 12) specifically the indicators for breastfeeding, obesity prevention, and improving emotional health and wellbeing. It is led and delivered by Health Visiting teams and other frontline practitioners across the health economy and the wider children s workforce. Health Visitors and all involved in delivering the HCP for Wirral Community NHS Trust will have targeted training to increase their knowledge and skills. THE CORE PRINCIPLES OF HEALTH VISITING ARE: The identification of individuals/families and communities assets and resilience. The search for health needs. The stimulation of awareness of health needs. The influence on policies affecting health. The facilitation of health enhancing activities. Reducing inequalities. Health Visiting Service 4/23

Tackling anti-health forces. Promotion of sustainable development. TO DELIVER THIS, THE SERVICE AIMS TO: Deliver a programme which includes a universal service which is offered to all families. In addition, the service offer includes a Universal Partnership and Universal Partnership Plus offer for those with specific individual needs. Increase the detection of health problems, and reduce health inequalities. Encourage strong parent-child attachment and positive parenting, resulting in better social and emotional wellbeing among children. Promote partnership working with parents/carers, Children s Centres, General Practitioners (G.P s) and relevant health and local authority partners when delivering care packages. Identify and take actions to address developmental delay, abnormalities and ill health. Identify safeguarding concerns and ensure support is given to children as soon as they are recognised as being in need, averting escalation to the point at which families are in crisis. Provide health professionals and parents with the required information to enable better health outcomes for children. Improve healthy eating and increased activity leading to reduction in obesity. Increase rates of initiation of and continuation of breast feeding. Improve the uptake of immunisations. TARGET GROUP The Healthy Child Programme in Wirral is delivered by Health Visitors, Community Health Nurses and Community Nursery Nurses to all families with children under the age of 5 years. This protocol applies to all Health Visiting teams employed by the Trust who are required to follow this protocol as part of their role and job description. There may be occasions where Specialist Community Public Health (health visiting pathway) students will be appropriately delegated to carry out this contact under the supervision of a Health Visitor. Health Visiting Service 5/23

TRAINING All Health Visitors are trained in Promotional Interviewing, Motivational Interviewing and the Solihull Approach. Community Health Nurses and Nursery Nurses are trained in Motivational Interviewing and the Solihull Approach. RELATED POLICIES Please refer to relevant Trust policies and procedures. POLICY RECOMMENDATIONS The Government wants to see more Health Visitors in disadvantaged areas leading and delivering services that improve the health and life chances of children in these communities. (The government response to Facing the Future: a review of the role of Health Visitors, DH, 2007 and the Health Visiting Implementation Plan 2011). Wirral Community NHS Trust supports a refocused universal core programme of child health contacts that all families can expect, with additional support and contacts agreed in partnership with those families or communities on the basis of assessed need. To deliver all aspects of this Protocol requires integrated working to ensure that parent support, health promotion and other related child health promotion activities are undertaken and delivered by a range of children s services across the local authority and health economy to promote the early identification and referral of children with additional needs. BODY OF PROTOCOL All staff working within the Health Visiting Service will comply with this Protocol. The HCP provides valuable opportunities to assess and provide support and information for parents/carers at key stages in the early years. This Protocol recognises the regular contact that children and families have with other professionals and highlights the need to work more effectively in partnership with parents and through professional liaison, consultation and referral when there are concerns about a child. THE UK NATIONAL SCREENING COMMITTEE (NSC) The NSC has endorsed the recommendations in Hall 4 and the shift away from child health screening activity to a more holistic approach which supports parents to ensure that they have the information, skills and resources they need to maximise their child's potential. Health Visiting Service 6/23

UNIVERSAL ANTENATAL CONTACT RATIONAL The Healthy Child Programme (HCP) Pregnancy and the first five years of life (DH, 2009) states that health professionals, such as Health Visitors are the universal first point of contact for families during pregnancy and the first years of life. The National Service Framework for Children, Young People and Maternity Service (DH, 2004) focuses on assessing needs and intervening early. It highlights Health Visitors as the professional that should start the process of assessing the needs of the child and family before birth, thus ensuring a smooth transition between Midwifery and Health Visiting services. According to Hall (2006) the antenatal contact promotes good parental understanding of the role of the Health Visitor. The client led antenatal contact provides the opportunity for assessing the health and social care needs of the family which will determine levels of support the family will require following birth. This is an opportunity for discussion for health improvement activity particularly around the benefits of breastfeeding, prevention of sudden infant death and promoting positive bonding and attachment. Midwives from Wirral University Teaching Hospital NHS Trust, Liverpool Women s NHS Foundation Trust, The Countess of Chester NHS Trust and One to One midwives will refer clients to the appropriate Health Visiting team at 28 weeks gestation. This aims to ensure that all pregnant women within Wirral are offered an antenatal contact. Targeted antenatal referrals will be referred to Health Visiting from Midwifery providers from 20 weeks gestation. Prior to contact with the client, a member of the Health Visiting team must contact the client s midwife and/or General Practitioner (GP) to ensure the client is still pregnant to prevent any insensitive contact. Health Visitors are then required to contact their client via telephone or letter to arrange a mutually convenient appointment between 30 36 weeks gestation. This will ensure consistency in the offering and the timing of antenatal visits. A family health record will be commenced to adhere to the principles of safe record keeping. If a woman declines an antenatal contact, it must be documented in the Health Visitor record, to adhere to the principles of safe record keeping. During the antenatal contact the Family Health Review (FHR) will be initiated. This will ensure any problems are identified and referrals are made to appropriate services, thus demonstrating multidisciplinary working across all agencies. The FHR will ensure a consistent approach to antenatal care. At all antenatal contacts the Health Visiting and Projecting Privacy Leaflet will be given to ensure that clients have essential contact details for the Health Visiting service. At all antenatal contacts, direction to the Birth to Five Book (DH, 2009) website should be given and discussed and documented in the Health Visitor records. This will ensure consistency of Health Visitor advice and education around key health promotion and health prevention topics. Health Visiting Service 7/23

If safe to do so, the question `Do you feel at risk of domestic abuse? must be asked. If abuse is disclosed, an Interagency Monitoring Form (IAMF) should be completed in agreement with the client and forwarded to the Safeguarding Adults Lead. The benefits of breastfeeding should be discussed with all clients antenatally, to ensure that all women are aware of the benefits of breastfeeding and the support that is available in the community. Mental disorders during pregnancy and the postnatal period can have serious consequences for the mother, her infant and other family members. Early detection and management of maternal depression ensuring support for families are a priority in the work of the Health Visiting teams. The NICE guidance for Antenatal and Postnatal Mental Health states a key priority is to identify women with mental health issues in the antenatal and postnatal period. All pregnant women will be asked 2 key mental health questions as detailed in National Institute for Health and Clinical Excellence (NICE 2007) clinical guideline 45. Mental health disorders during pregnancy can have serious consequences for the health and well being of a mother and her baby (NICE 2007). By asking key questions, it will help identify depression and anxiety prior to the birth of the baby. Health practitioners will ask two trigger questions: During the past month, have you often been bothered by feeling down, depressed or hopeless? During the past month, have you often been bothered by having little interest or pleasure in doing things If a woman answers `yes to either of the two questions, then a third question should be considered If a woman answers `yes to the third question, then a mental health assessment needs to be completed, and the Perinatal Mental Health Specialist Midwife informed. This approach will aid early intervention and referral to the GP/Mental Health Services. If needs are identified at the antenatal contact, the Health Visitor will implement a Package of Care (POC) in partnership with the family and this will be recorded in the FHR. This will ensure identified needs are documented in the records and appropriate referrals made in relation to: Universal Universal Plus Universal Partnership Plus If a family is identified as having additional needs above the core Heath Visiting programme, a Common Assessment Framework (CAF) will be offered. This is the Health Visiting Service 8/23

responsibility of the Health Visitor as the professional identifying need. A CAF s aim is to identify, at the earliest opportunity, a child or young person s additional needs which are not being met by the universal services to provide timely and co-ordinated support to meet those needs. How staff will demonstrate procedure is being followed: Family Health Record will have evidence of a client led antenatal contact; Family Health Record will have evidence of an initiated client led Family Health Review; Family Health Record will have evidence of a completed CAF (if relevant); Family Health Record will have evidence a Package of Care has been implemented (if relevant). RATIONAL FAMILY HEALTH REVIEW The ultimate purpose of the purpose of the Family Review (FHR) is to use a holistic approach to identify the health of individuals and families in order to provide a client centered service. The FHR will focus on encouraging families to acknowledge and address their health needs and plan appropriate intervention strategies jointly to address identified needs. In order to plan future care, all clients should be sensitively asked about their ability to read and understand written literature. If a concern is identified, it should be documented on the Chronological Significant Events form in the family section of the Health Visiting record, to alert other members of the team to this issue. An additional package of care support should be considered to ensure equity of access to information for individuals with limited literacy skills. AIMS The Family Health Review will empower clients to engage in a process that will enable them to identify their own health needs. To enable Health Visiting teams to plan and design packages of care in conjunction with families, to meet the identified health needs. To enable Health Visiting teams to target services to individuals and families most in need. OUTCOMES Families will receive evidenced based care and are appropriately reviewed for Universal, Universal Partnership and Universal Partnership Plus level of care. Health Visiting teams will adhere to this protocol for Family Health Reviews. Identified needs are addressed and a package of care is agreed with the family. Health Visiting Service 9/23

INFORMATION All clients should be provided with a verbal explanation regarding the boundaries of confidentiality in relation to safeguarding issues and this discussion should be documented in the FHR. The FHR will commence at the first contact with families i.e. targeted and universal antenatal visit, transfer into the area or new birth. Health Visitor teams will use discretion when it may not be appropriate to use the FHR and a separate visit should be arranged. The FHR should be reviewed at each core contact and when family circumstance change. HOW STAFF WILL DEMONSTRATE THE PROTOCOL IS BEING ACHIEVED Health records will have evidence that the FHR was completed in partnership with the family. Health records will include evidence of the use of the FHR documentation. Health records will have evidence of referrals to other agencies and document if copy of referral is given to family. Health records will have evidence of package of care, if relevant. BIRTH VISIT NEONATAL HEALTH ASSESSMENT The Birth Visit must be completed face to face by the Health Visitor by 14 days following the birth, by a mutually agreed appointment, preferably at the family home. The following documentation will be completed: - Immunisation intent; - Family Health Review; - Neonatal Health Assessment. In addition: Share Health Visiting team contact details and information regarding local clinics, groups and Children s Centres. Inform clients of current Healthy Child Programme. Complete details in parent held record. Interactions to cover: Infant feeding; Promoting sensitive parenting; Promoting development; Reduction of the risk of Sudden Infant Death advice about sleeping position, smoking, co-sleeping, room temperature and other information in line with best evidence; Home safety. Is the client at risk of domestic abuse Health Visiting Service 10/23

AIMS The neonatal health assessment will encompass the requirement of the HCP and the UNICEF Baby Friendly Initiative. To provide a framework for Health Visitors to universally assess neonatal health within the first 14 days following birth. To provide a tool that enables review of weight gain and assessment of effective feeding techniques. To provide a tool for discussing infant safety. To enable Health Visitors to discuss the HCP and immunisation programme with families. To enable Health Visitors to work in partnership with families involving them in decision making around future packages of care. OUTCOMES To ensure all families receive evidence based care and are appropriately assessed for universal, universal plus or universal partnership plus levels of support. To identify early identification and referral of children who are struggling to regain birth weight. Health Visiting teams will adhere to Wirral Community NHS Trust Breast feeding Policy to avoid conflicting advice. Health Visiting teams will follow this Protocol to ensure standardised care across the Trust. Families will be involved in identifying health needs pertaining to their new baby The neonatal health assessment will include a review of weight gain, an infant feeding assessment, discussion on infant safety and details of the HCP. Package of care form to be completed on all breastfeeding mothers. Negotiate a package of care as appropriate for individual families. Refer families to appropriate service as required. BREASTFEEDING Promoting and supporting sustainable breastfeeding is an essential part of an integrated programme of child heath promotion and parenting support as set out in the HCP and Every Child Matters (DFES, 2003). There is clear evidence that breastfeeding has positive health benefits for both mother and baby in the short and longer term (beyond the period of breastfeeding). PSA 12: sets out the Government s commitment to improve the physical, mental and emotional health and wellbeing of children and young people from conception to adulthood. Breastfeeding offers long term emotional, physical and mental health benefits to mother and child. The Government wants to see the level of breastfeeding as high as possible with parents getting help with breastfeeding and other aspects of parenting and health from the health visiting service. The Department of Health (DH), is committed to encouraging the NHS to adopt United Nations International Children s Emergency Fund (UNICEF) Baby Friendly Initiative (BFI) to promote good practice in hospitals and the community to encourage mothers to initiate Health Visiting Service 11/23

breastfeeding and provide them with the necessary skills to continue breastfeeding for as long as possible. Wirral Community NHS Trust is fully accredited. The Baby Friendly Initiative is a worldwide programme of the World Health Organisation (WHO) and United Nations International Children s Emergency Fund (UNICEF). To achieve Baby Friendly status, the Seven Point Plan for Sustaining Breastfeeding in the Community states that a full breastfeeding assessment should be carried out with each breastfeeding mother at the first face-to-face contact by community health-care staff, resulting in the development of an individual plan of care. The Unicef UK Baby Friendly Initiative for community services was launched in 1998 and states that if Health Visitors make a point of confirming that mothers are able to position and attach their babies for breastfeeding and have been provided with information about hand expression, parents are more likely to avoid breastfeeding problems or to be able to resolve them without resorting to supplements. The guidance also says that Health Visitors have to undertake an Infant Feeding Postnatal Checklist in the community. Staff to refer to Wirral Community Trust s Procedure for Breastfeeding HOW STAFF WILL DEMONSTRATE PROTOCOL IS BEING ACHIEVED Health records will have evidence that the neonatal health assessment was completed in partnership with the family. Health records will include evidence of the neonatal assessment documentation. Health records will have evidence of referrals to other agencies and document a copy of referral given to parent. Health records will have evidence of package of care, if relevant. MENTAL HEALTH Assessment of the mother s mental health at each contact by asking the two trigger questions for the identification of depression as recommended by NICE (see page 8) LEAFLETS Recommended evidence based leaflets are given at the birth visit which contribute to reducing key mortality and morbidity rates and link to achieving local health targets. Health Promotion Specialists and a library of health promoting resources are available from the Health and Wellbeing Team. The Trust supports a range of methods for providing patient information, this could be either:- Verbal information and the discussion recorded in the family health records An internally produced patient information leaflet An externally produced patient information leaflet DVD s Names of websites recommended Health Visiting Service 12/23

FALTERING GROWTH There is no universally accepted definition of Faltering Growth, however if there is a downward deviation in weight across 2 or more centile spaces or a marked discrepancy between height and weight centiles then faltering growth should be considered. Faltering growth occurs in children from all socio-economic groups and cultures. Children with disabilities are at particular risk. Nutrition in early life is a major determinant of growth and development and also influences adult health. If faltering growth is not addressed, the child s development may be delayed and there is also some evidence around delayed cognitive development. Faltering growth may also result in increasing family stress and poor parent/child interaction. Faltering growth related to undernutrition is caused by inadequate energy intake and can arise when food is not available or is not eaten in sufficient amounts. Despite a seemingly adequate intake, gastro-intestinal disorders can lead to faltering growth due to malabsorption of nutrients, neurological disorders may result in problems with oral motor development which may affect ability to suck or swallow or present as hypersensitive mouth which can lead to food refusal. Children with congenital heart or respiratory disease may have reduced appetite, breathing difficulties or increased requirements resulting in faltering growth. However the majority of children will have no organic problems and therefore inadequate intake of energy is the underlying cause. For many children the problem starts around the time of weaning as the infant s motor skills develop allowing the acceptance of new tastes and textures. If this opportunity is missed, the progression through weaning and the acceptance of more solid textures can be difficult. Identification of faltering growth and assessment of the severity of undernutrition is important to provide an appropriate intervention. Faltering growth is usually identified from weight and therefore weight should be recorded at times of routine reviews and where the health professional identifies cause for concern. If a child appears to be consuming adequate amounts of food and does not appear to be unwell and they have dropped through 2 centile spaces without obvious reason, they must be referred to the General Practitioner for a medical assessment and also refer dietetics. If a child cannot tolerate sufficient amounts of food which is impacting on weight gain and they have fallen through 2 centile spaces they must be referred to the General Practitioner for a medical assessment and also refer to a Dietitian. Staff to follow referral criteria to dietetics AIMS 4 8 WEEK CONTACT To provide a framework for Health Visiting teams to universally review all children and families aged 4 8 weeks. To provide an opportunity for parents to raise concerns regarding the child s growth and/or development processes. Health Visiting Service 13/23

To provide a framework for Health Visiting teams to universally assess postnatal maternal mental health at 4 8 weeks. To ensure that the review is completed in partnership with families. To deliver key health and parenting messages. OUTCOMES To ensure all families receive evidenced based care and are appropriately assessed for the Health Visiting levels of care i.e. Universal, Universal Partnership and Partnership Plus. Needs are identified in partnership with parents and addressed through delivery of a negotiated package of care. Health Visiting teams will follow the Protocol for 4 8 week contact. Children will be referred to appropriate services as required. Women identified as having a mental health issue will be offered support, further assessment or referral as appropriate. THE 4 8 WEEK CONTACT WILL INCLUDE THE FOLLOWING AREAS: All results of the newborn bloodspot screening will be discussed with the parents and recorded in the Personal Child Health Records (PCHR) and the Child section of the Health Visiting Records. Review of infant feeding. Key messages regarding timely weaning and share information regarding the dangers of early weaning. Review of general progress and delivery of key messages about parenting and baby s health. Reminder to parents regarding baby s 6 8 week review with General Practitioner and first set of immunisations. Temperament based anticipatory guidance practical guidance on managing crying and health sleep patterns, bath, book and bed routines and activities and encouragement of parent-infant interactions. Promoting development through use of books, music and interactive activities to promote development and parent-baby relationships. Keeping safe raise awareness of accident prevention in the home and car safety. Be alert to risk factors and signs and symptoms of child abuse. Follow local safeguarding procedures where there is cause for concern. Reduction of the risk of Sudden Infant Death Syndrome (SIDS) advice about safe sleeping position, smoking, co-sleeping, room temperature and other information in line with best practice. Parenting support establish what each parent s individual support needs are. Address and respond to the specific concerns of fathers including emotional issues arising from fatherhood. MENTAL HEALTH Assessment of the mother s mental health at each contact by asking the two trigger questions for the identification of depression as recommended by NICE (see page 8) Health Visiting Service 14/23

12 16 WEEK CONTACT The Healthy Child Programme (DH, 2009) supports the NICE quidelines to assess maternal mental health at 12 16 weeks. The Healthy Child Progamme also recommends that universal areas to be covered at this contact are parenting support, review of immunisations, routines and parent-infant interaction, promoting infant development, keeping safe and review of infant feeding. Packages of additional support will be implemented for families that require them. BACKGROUND Providing a high quality HCP that is visible and accessible to families with children is a core health responsibility contributing to the goals of Every Child Matters (HM Government, 2004). The programme provides the opportunity to assess the strengths and needs of individual children and families and to plan for the next stage of the development. AIMS To provide a framework for Health Visiting teams to universally review all children aged 12 16 weeks. To provide a framework for Health Visiting teams to universally assess postnatal maternal mental health at 12 16 weeks. To provide an opportunity for parents to raise concerns regarding the child s developmental process. To ensure that the review is completed in partnership with families. Deliver key health and parenting messages. OUTCOMES To ensure all families receive evidenced based care and are appropriately assessed by Universal, Universal Partnership and Universal Partnership Plus. Identified needs are assessed and a package of care is agreed with the family. Health Visiting teams will follow this protocol for the 12 16 week contact. Children will be referred to appropriate services as required. Women identified as having a mental health issue will be offered support, further assessment or referral as appropriate. The areas to be discussed with the family are: Supporting parenting by providing access to parenting and child health information and guidance on Children Centre s and family information services. Review of immunisations. Identification of health and development problems and abnormalities. Review of infant feeding and identification of children at risk of obesity. If parental or professional concern about a child s growth then an assessment including: accurate measurement, interpretation and explanation of the child s weight in relation to length and growth potential and earlier growth measurements of the child. Health Visiting Service 15/23

Temperament based anticipatory guidance, crying and healthy sleep practices, bath, book, bed time routines and activities. Encouragement of parent-infant interaction. Promoting development use of books, music and interactive activities to promote development of parent-baby relationship. Keeping safe accident prevention in the home and safety in cars and being alert to risk factors and signs and symptoms of abuse. MENTAL HEALTH Assessment of the mother s mental health at each contact by asking the two trigger questions for the identification of depression as recommended by NICE (see page 8) THE 9-12 MONTH HEALTH REVIEW The HCP emphasises that between 6 months and 1 year is one of the most appropriate opportunities to review a child s physical, emotional and social needs in the context of their family, including predictive risk factors. Health promotion including raising awareness of dental health and prevention, healthy eating, promoting development, injury and accident prevention relating to mobility, safety in cars and skin cancer prevention should be included in this contact. Standard One of the National Service Framework for Children, Young People and Maternity Services (DH, 2004) also states that health visiting teams should be reviewing children s progress by the child s first birthday. Wirral Community NHS Trust is committed to supporting the HCP as part of the Government s strategy set our in Every Child Matters. By the child s first birthday a face to face contact is completed by appropriate member of the Health Visiting Team. AIMS To provide a framework for Health Visiting teams to universally review all children between 9 and 12 months. To provide an opportunity for parents to raise concerns regarding their child s growth and/or development processes. To provide an opportunity for the Health Visiting team to identify deviation from the normal parameters of growth/development. To ensure that the review is completed in partnership with families. To deliver the key health improvement and parenting messages. This contact can either be at the family home or a mutually agreed location. OUTCOMES To ensure all children receive the HCP universal core programme in a timely manner and are appropriately assessed for additional services. Those children with high risk and low protective factors receive personalised service delivery. Needs are identified in partnership with parents and addressed through delivery of a negotiated package of care. Health Visiting Service 16/23

All Health Visiting teams follow this Protocol. Children are referred to appropriate services as required. THE HEALTHY CHILD REVIEW AT 9-12 MONTHS WILL INCLUDE: Growth monitoring. Measurement of length does not have to be done routinely at the Healthy Child Review at 9-12 months: however, use professional judgement for each individual child. Observation of the child s posture and movements while the child is awake. Review of hips. Asking parents if there are any concerns regarding undescended testicles and offering an information leaflet which highlights the importance of identifying that both testicles are in the scrotum by the age of one. Review of vision. Completion of the hearing questionnaire. Review of the speech and language development. Discussion of social and behavioural development. Immunisation status. Public health and community support. Discussion on healthy lifestyle and dental health. Childhood safety. Any additional parental or carer concerns should be discussed and documented with clear action plans/packages of care agreed in partnership. Parents should always be offered a copy of any referrals arising from the review. The child s General Practitioner should be informed of any referrals. HOW STAFF WILL DEMONSTRATE THE PROTOCOL IS BEING ACHIEVED Health records will have evidence that the review was completed in partnership with the family. Health records will include evidence of the use of the Healthy Child Review at 9 12 months documentation. Health records will have evidence of referrals to other agencies and document if copy of referral was given to family. Health records will have evidence of referral to other agencies, if relevant. Health records will have evidence of package of care, if relevant. Maternal mental health assessment and identification of post-natal depression and/or other maternal health needs as completed at previous contact. Information resulting from this review is recorded in thepchr, on the Medical Examination form (MEF) and in the family and child s records. If there are any concerns regarding the child s development progress then referrals to other services should be made on the Trust multi agency referral form, with the parent s consent, with accompanying letter for complex referrals. The GP will be informed of any referrals made. Health Visiting Service 17/23

THE 2 2½ YEAR HEALTH REVIEW The HCP emphasises that the 2 year review aims to optimise child development and emotional wellbeing and reduce inequalities in outcome This contact can either be at the family home or a mutually agreed location. It can be completed by an appropriate member of the Health Visiting team. AIMS To provide a framework for Health Visiting teams to universally review all children aged 2-2½ years of age. To provide an opportunity for parents to raise concerns regarding the child s growth and/or development processes. To provide an opportunity for the Health Visiting team to identify deviation from the normal parameters of growth/development. To ensure that the review is completed in partnership with families. To deliver key health improvement and parenting messages. OUTCOMES All children receive the HCP universal core programme in a timely manner. Those children with high risk and low protective factors receive personalised service delivery. Needs are identified in partnership with parents and addressed through delivery of a negotiated package of care. All Health Visiting teams follow this protocol. Children are referred to appropriate services as required. Information resulting from this review is recorded in the PCHR, on the Medical Examination Form (MEF) and in the family and child s records. The 2-2½ year Healthy Child review will include hearing, speech and language development, vision, public health and community support, healthy lifestyle and safety, height, weight and body mass index (BMI) will also be recorded. The screening tool to support practice is The Ages and Stages ASQ and Ages and Stages Social and Emotional Development ASQ SE as recommended in the HCP (2009). Children will be referred to appropriate support services as required and offer a copy of the referral letter to the family. HOW STAFF WILL DEMONSTRATE PROTOCOL IS BEING ACHIEVED Health records will have evidence that the review was completed in partnership with the family. Health records will include evidence of the use of the Healthy Child Review at 2-2½. Health Visiting Service 18/23

Health records will have evidence of Ages & Stages Questionnaires (ASQ) being completed. Health records will have evidence of referrals to other agencies and document if copy of referral given to family Health records will have evidence of package of care, if relevant. GUIDANCE FOR COMMUNITY HEALTH SERVICES RERRALS All referrals must be in typed letter and include: Gestation at birth, Apgar score and birth weight. Details of general development and functioning. What the expected outcome/purpose of the referral are Current HV assessment of presenting problem. Parental observations/concerns of presenting problem. Details of any interventions. Details of other professionals or teams etc. who have been involved with the child/family (with parental consent). Any medical background. Any safeguarding concerns identified. If there is any urgency it must be highlighted. If there are nursery concerns a nursery/pre-school report of HV information from the nursery should be included (with parental consent). Attach Ages and Stages questionnaire with referral completed. Family health problems that may impact on the child s health and well being. The GP will be informed of any referrals made. Parental informed consent for referral will be detailed. Parent will be offered copy of referral. Any unexpected delays in the referral process which has a detrimental impact on the child s health should be reported using the Wirral Community NHS Trust on line incident form. ADDITIONAL PACKAGES OF CARE In line with the Health Visiting Service offer, intervention will depend on assessment at family level. The purpose is to promote the health and wellbeing of children from prebirth through to adulthood using a co-ordinated programme of evidence-based prevention and early intervention in partnership with parents/carers. For all vulnerable families e.g. parents with learning difficulties, drug/alcohol abuse and domestic abuse a package of care will be implemented If a need for additional support from the Health Visiting service is identified an additional package of care will be negotiated, relevant documentation completed and agreement gained from parents/carers for actions, outcomes and timeframes. This will be reviewed three monthly and evaluated at least monthly. Health Visiting Service 19/23

Any delegated care package whether to a Community Health Nurse or Community Nursery Nurse will be reviewed at least monthly by the Health Visitor who delegated the care. Actions as appropriate will be documented in the PCHR and in the family and child s records. ALL BABIES WITH HEALTH OR DEVELOPMENTAL PROBLEMS OR ABNORMALITIES REQUIRE: - Early referral to specialist team; - Package of care to support additional needs; GROUPS THAT MIGHT REQUIRE ADDITIONAL RESOURCES WOULD INCLUDE: CHILDREN Children In Need (Hall 4 page 19) Children with safeguarding concerns Care of the Next Infant (CONI) programme Children with special needs Children with identified complex behaviour problems Complex feeding problems Breast feeding support, particularly In areas with lower continuation rates Children requiring Team Around the Child Looked After Children FAMILIES Teenage Parents Families affected by domestic abuse Moderate to enduring mental health needs Parents with a disability Substance and alcohol misuse Social exclusion Additional parenting support e.g. using the Solihull Approach WHERE TO GET ADVICE FROM This list is not exhaustive advice can be sought from any relevant agency. Health Visitor Team Leader. Health Visiting Managers. Safeguarding Team. Central Advice and Duty Team. Family Safety Unit. Relevant partner agencies. INCIDENT REPORTING Clinical incidents or near misses must be reported via the Trust s incident reporting system, Datix. Health Visiting Service 20/23

SAFEGUARDING In any situation where staff may consider the patient to be a vulnerable adult, they need to follow the Trust Safeguarding Adult Policy and discuss with their line manager and document outcomes. Where staff have concerns regarding safety of children, please refer to the Named Nurses for Safeguarding Children and the Local Safeguarding Children s Board http://www.wirral.gov.uk/my-services/childrens-services/local-safeguarding-childrens-board EQUALITY ASSESSMENT During the development of this protocol the Trust has considered the clinical needs of each protected characteristic (age, disability, gender, gender reassignment, pregnancy and maternity, race, religion or belief, sexual orientation). There is no evidence of exclusion of these named groups. If staff become aware of any clinical exclusions that impact on the delivery of care a Trust Incident form would need to be completed and an appropriate action plan put in place. REFERENCES Department of Health (2003) Getting the right start: the children s national service framework for children, young people and maternity services emerging findings, London: DH. Department of Health (2004a) The Chief Nursing Officer s review of the nursing, midwifery and health visiting contribution to vulnerable children and young people, London: DH. Department of Health, (2004b) National Service Framework for Children, Young People and Maternity Services, London: DH. Department of Health (2008) The Child Health Promotion Programme: Pregnancy and the first five years of life. London: DH. Department of Health (2009) Birth to Five Book Dept of Health Publication. Department of Health, Department for Children s, Schools and Families (2009) Healthy Lives, Healthy Futures: The Strategy for children and young people s health. London: DH. Hall and Elliman (2006) Health for All Children. Revised Fourth Edition. Oxford Press HM Government (2006) The Common Assessment Framework for Children & Young People : Practitioners Guide HM Government (2007) PSA Delivery Agreement 12: Improve the Health and Wellbeing of Children and Young People, London The Stationary Office. Health Visiting Service 21/23

National Institute for Health and Clinical Excellence (NICE 2006) clinical guideline 37 Routine post natal care of women and their babies July National Institute for Health and Clinical Excellence (2007) Antenatal and Postnatal mental health. Clinical management and service guidance. Clinical Guideline 45. February 2007 (reissued April 2007). NMC (2010) Record Keeping Guidance. NMC (2010) The NMC Code of Professional Conduct: Standards of Conduct, Performance and Ethics. Royal College of Nursing (2006) Getting it right for children and young people, a self assessment tool for practice nurses RCN Sheridan, M. (1997) From Birth to Five Years - Children's developmental progress (Revised and updated by Marion Frost and Dr Ajay Sharma) Routledge The Children s and Young Peoples Plan 2006-2008 working together for children and young people The Lord Laming Report (2009) The Protection of Children in England: A Progress Report: Pub; The Stationery Office: Blackwell Press Wirral Community NHS Trust Managing the Quality of Health Records Wirral Community NHS Trust Procedure for Record Keeping for Health Visitors Wirral Community NHS Trust (2009) Childhood Obesity Care Pathway Guidance Document. Health Visiting Service 22/23