First published in 1989, the original Health for All Children report produced guidance on child health surveillance and screening for preschool children. The working party commissioned to produce the report was convened because of a lack of consensus on the role and value of the programmes already in use.
This and subsequent reports have been colloquially referred to as the 'Hall Reports' after their editor Professor David Hall. The third report, 'Hall 3',1 has suggested a reduction in some of the routine examinations, a greater emphasis in some areas and a change in the overall emphasis of the programme. The key points are listed in Table 1 (below).
The recommendations in the report are described as a guide. This means that they will have to be adapted according to specific local needs, facilities and infrastructures. Local child health surveillance committees will have produced, or be working on, their own guidelines based on the recommendations of the report.
No-one can argue against partnership instead of supervision as a principle that we should all be following. The report recommends a change in emphasis from supervision to one where 'parents are empowered to make use of services and expertise according to their needs'. We may already be putting this into practice in our day to day work, but to change our approach from the rigid core programme of examinations in early childhood may be more difficult.
Although surveillance has always been just one part of the child health surveillance programme, the programme as a whole has maintained this title.
Hall 3 recommends changing to a child health promotion programme in recognition of this and to encompass the principle of greater primary prevention, health promotion and empowerment. In itself this might seem a minor change, but it is the very foundation of the report's more detailed recommendations.
Families who might benefit from targeted services are listed in the report. Of the 13 examples, some will seem obvious, e.g. the premature infant, previous infant death, first-time parents and those in temporary accommodation.
Others, however, such as the victims of domestic violence, infants with difficult temperaments, and mothers lacking in confidence or with low self-esteem, raise the question of identification and resources.
Even if we do identify these families, will we be able to redistribute work without a significant loss in our provision and services to others? The report raises the possibility that targeting health provision may stigmatise the groups selected as most needy.
Hall 3 recommends the production of guidelines on clear referral procedures for problems identified, as a 'seamless pathway to secondary and if necessary tertiary specialists'. Local child health promotion commitees will have the responsibility of producing and auditing these.
Personal child health records (PCHRs) have been used for a number of years, and are now commonplace. All staff involved in primary, secondary and tertiary care for preschool children should be familiar with the PCHR books and should use them when seeing children.
The books contain basic information on health and development topics, and to contradict these messages through lack of familiarity will not help parents. Hall 3 recommends using this information in combination with Birth to Five2 issued to all new parents.
Birth to Five is an informative book for parents produced by the Health Education Authority. It deals with many of the problems and issues that arise during infancy and early childhood.
Unless you are a new parent yourself you may not have access to the book. Following the guidance from Hall 3, it has become an essential part of the child health team's equipment.
A core programme was part of the original recommendations of the first Hall Report. Although reinforcing the need for this to remain part of the overall programme, Hall 3 has recommended a decrease in the number of routine tests and, controversially, who should do them.
For example, no routine measurements of weight beyond the age of 6 weeks and the possibility of health visitors taking over the 8-month examination of the hips.
Physical examinations: The routine physical examinations that we are all used to have not changed significantly, and the components of each examination are detailed in the report.
Vision and hearing: The importanceØof examining the eyes as part of the neonatal and 8-week examinations is emphasised. Awareness of the clues to a visual defect and defects in hearing are also highlighted, with the need to respond to parental concerns.
Although screening of high-risk groups continues to be a major priority, testing for visual acuity and hearing of preschool children by the primary care team is no longer recommended. Instead, when there is concern, referral for orthoptic or audiological assessment should be made.
Growth monitoring: Those familiar with the terminology of preschool surveillance will have noticed the change from growth screening to growth monitoring.
Hall 3 points out that, with the exception of a single growth measurement, routine measurements do not meet with the definition of screening tests.
The measurement of growth has long been enshrined in the monitoring of a child's health, both by health professionals and by parents. The necessity for, and benefits of, regular measurements are challenged in the report.
Growth monitoring was discussed by Tam Fry in the March issue of Guidelines in Practice. A few points are, however, worth emphasising:
- Head circumference need not be measured beyond 6-8 weeks of age if there is no concern. If there is concern, a decision should be made as to whether or not to refer. The report comments that repeated measurements over many months cannot be justified.
- Length does not need to be measured beyond 8 weeks unless there are specific indications. Further measurements of height are recommended at 18-24 months and at 3.5 years or soon after school entry.
- Weight need not be measured routinely beyond 6-8 weeks unless there are specific indications or the parents request it, in which circumstances they should have the opportunity to weigh the baby themselves. Such a fundamental change in our routine and that expected by parents is unlikely to be adopted with enthusiasm.
The importance of staff training, calibration of equipment and use of the 9 centile charts is emphasised, as is the need to weigh and measure the baby when there are concerns.
Screening tests and their criteria are reviewed in detail. Four points are raised which we may perhaps forget during our day to day work.
- Anxiety: Our knowledge of the problems being screened for and the likelihood of these being found might not match those of the parents. How do we discuss and inform them of the principles of false-positive and false-negative results?
- False-positive results: These lead to further tests and investigations, which will, in retrospect, have been unnecessary and again cause further anxiety.
- Litigation: Conditions that are not identified by screening tests may lead later to litigation, emphasising the importance of ensuring that parents understand the nature of the tests.
- Information: The report clearly states that 'parents must have full information and the opportunity to "opt out" of tests whose purpose they do not understand or accept'. In view of this, we must have the knowledge and willingness to discuss with parents the screening tests that we strongly believe are in the best interests of their child. This will take time and, as this seems to be in ever shorter supply, will have implications for the provision of the service.
The importance of parental concerns is emphasised throughout the report. Expressed concerns on many issues should result in further assessment, particularly with vision and hearing.
Behaviour will become an increasingly important topic. Hall 3 reviews the screening for behavioural and emotional problems in addition to development.
One interesting recommendation that is worthy of mention is further training for staff in 'news breaking' an area of great concern to parents.
Hall 3 is a report with many recommendations and guidelines and has been seen as setting a national standard. An area of concern that remains is the effect of radically changing a structure that is familiar to us all.
Empowering parents to access services while targeting those at greatest need may not overcome the inverse care law. There will surely be a temptation to reduce routine services before ensuring by audit that targeting and empowerment are proving successful. If this is the case, then although there might be a shift in priorities, the most needy will still have the lowest uptake of services.
Points to reflect on and act on if necessary
Using the personal child health record (PCHR) should be easy quick and helpful to all. How many of us actively do this when we see preschool children? Ask for the book every time, and write in it or encourage the parents to do so.
|Do you have a copy of Birth to Five available as a reference? Do you know the contents well enough to use them in partnership with parents?|
Are you familiar with the details of the local child health promotion policy and its guidelines on referral procedures?
|When did you last calibrate your equipment and review your knowledge and skills in child development?|
|Could you discuss the screening tests adequately if put on the spot by a questioning parent?|
- Hall DMB. Health for All Children. 3rd edn. Oxford: Oxford Medical Publications 1996.
- Birth To Five. The Health Education Authority's Complete Guide To The First Five Years. Health Education Authority, 1998. ISBN 07521084SX.