Paediatrics is the branch of medicine which deals with diseases of children, but many paediatricians have a wider role, being employed largely outside acute hospitals and dealing with child health in general.
History Child health services were originally designed, before the NHS came into being, to ﬁnd or prevent physical illness by regular inspections. In the UK these were carried out by clinical medical oﬃcers (CMOs) working in infant welfare clinics (later, child health clinics) set up to ﬁll the gap between general practice and hospital care. The services expanded greatly from the mid 1970s; ‘inspections’ have evolved into a regular screening and surveillance system by general practitioners and health visitors, while CMOs have mostly been replaced by consultant paediatricians in community child health (CPCCH).
Screening Screening begins at birth, when every baby is examined for congenital conditions such as dislocated hips, heart malformations, cataract and undescended testicles. Blood is taken to ﬁnd those babies with potentially brain-damaging conditions such as HYPOTHYROIDISM and PHENYLKETONURIA. Some NHS trusts screen for the life-threatening disease CYSTIC FIBROSIS, although in future it is more likely that ﬁnding this disease will be part of prenatal screening, along with DOWN’S (DOWN) SYNDROME and SPINA BIFIDA. A programme to detect hearing impairment in newborn babies has been piloted from 2001 in selected districts to ﬁnd out whether it would be a useful addition to the national screening programme. Children from ethnic groups at risk of inherited abnormalities of HAEMOGLOBIN (sickle cell disease; thalassaemia – see under ANAEMIA) have blood tested at some time between birth and six months of age.
Illness prevention At two months, GPs screen babies again for these abnormalities and start the process of primary IMMUNISATION. The routine immunisation programme has been dramatically successful in preventing illness, handicap and deaths: as such it is the cornerstone of the public health aspect of child health, with more potential vaccines being made available every year. Currently, infants are immunised against pertussis (see WHOOPING COUGH), DIPHTHERIA, TETANUS, POLIOMYELITIS, haemophilus (a cause of MENINGITIS, SEPTICAEMIA, ARTHRITIS and epiglottitis) and meningococcus C (SEPTICAEMIA and meningitis – see NEISSERIACEAE) at two, three and four months. Selected children from high-risk groups are oﬀered BCG VACCINE against tuberculosis and hepatitis vaccine. At about 13 months all are oﬀered MMR VACCINE (measles, mumps and rubella) and there are pre-school entry ‘boosters’ of diphtheria, tetanus, polio, meningococcus C and MMR. Pneumococcal vaccine is available for particular cases but is not yet part of the routine schedule.
Health promotion and education Throughout the UK, parents are given their child’s personal health record to keep with them. It contains advice on health promotion, including immunisation, developmental milestones (when did he or she ﬁrst smile, sit up, walk and so on), and graphs – called centile charts – on which to record height, weight and head circumference. There is space for midwives, doctors, practice nurses, health visitors and parents to make notes about the child.
Throughout at least the ﬁrst year of life, both parents and health-care providers set great store by regular weighing, designed to pick up children who are ‘failing to thrive’. Measuring length is not quite so easy, but height measurements are recommended from about two or three years of age in order to detect children with disorders such as growth-hormone deﬁciency, malabsorption (e.g. COELIAC DISEASE) and psychosocial dwarﬁsm (see below).
All babies have their head circumference measured at birth, and again at the eight-week check. A too rapidly growing head implies that the infant might have HYDROCEPHALUS – excess ﬂuid in the hollow spaces within the brain. A too slowly growing head may mean failure of brain growth, which may go hand in hand with physically or intellectually delayed development.
At about eight months, babies receive a surveillance examination, usually by a health visitor. Parents are asked if they have any concerns about their child’s hearing, vision or physical ability. The examiner conducts a screening test for hearing impairment – the so-called distraction test; he or she stands behind the infant, who is on the mother’s lap, and activates a standardised sound at a set distance from each ear, noting whether or not the child turns his or her head or eyes towards the sound. If the child shows no reaction, the test is repeated a few weeks later; if still negative then referral is made to an audiologist for more formal testing.
The doctor or health visitor will also go through the child’s developmental progress (see above) noting any signiﬁcant deviation from normal which merits more detailed examination. Doctors are also recommended to examine infants developmentally at some time between 18 and 24 months. At this time they will be looking particularly for late walking or failure to develop appropriate language skills.