NOV 2012 Volume 85 Number 1 Volume

of www.commprac.com | www.unitetheunion.org/cphva www.commprac.com Research News feature Practice Standardising school Bed sharing – is it Identifying refl ux nursing practice worth the risk? disease in infants

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Cetraben_297x210_elderly.indd 1 25/07/2012 11:19 Community CONTENTS Practitioner

Unite/CPHVA Existing Unite/CPHVA members with queries relating to their membership should contact: 0845 850 4242 or see: www.unitetheunion.org/contact_us.aspx for further details. To join Unite/CPHVA, please see: www.unitetheunion.org Unite/CPHVA is based at: Transport House, 128 Theobald’s Road, London WC1X 8TN Tel: 020 3371 2006

Community Practitioner journal Unite/CPHVA members receive the 34 journal free each month and have free access to all content from 2004 onwards via the online archive. 3 Editorial 20 Professional and 34 First person Non-members of Unite/CPHVA and Finding ways to research Return to health visiting? institutions may subscribe to the journal to receive it every month and access the continue learning A healthier health You must be mad! online journal archive. By Dave Munday visiting workforce: By Algar Goredema- Non-member subscription rates: findings from the Braid Individual (UK) £125 4 News round-up Restorative Supervision Individual (rest of world) £145 The latest in policy Programme Institution (UK) £145 and practice Sonya Wallbank, 37 Practice: peer Institution (rest of world) £195 Georgina Woods reviewed Institution online access: Getting to the bottom Up to five users £195 10 Association Parent and group leader Six to 10 users £390 Unite in Health Thinking 26 of nappy rash 11 to 20 users £780 Thursday; New reflections on a group- By Heather Morris 21 to 50 users £1560 members required for based programme for Developmental dysplasia Subscription enquiries may be made to: CNN Forum parents and babies 42 Community Practitioner subscriptions, Catrin H Jones, Judy of the hip Ten Alps Subscriber Services 11 Antenna Hutchings, Mihela By Daniel Westacott, Abacus e-Media Limited Book review; Silent Erjavec, J Carl Hughes Giles Pattison, Bournehall House, Bournehall Road Stephen Cooke Bushey WD23 3YG voices: parental alcohol abuse 30 Standardising school Tel: 020 8950 9117 Identifying gastro- [email protected] nursing practice: 46 oesophageal reflux www.cphvabookshop.com 14 News feature developing and disease in infants The journal is published on behalf of Bed sharing - Is it implementing a care Unite/CPHVA by: worth the risk? pathways package By Sara Patience Ten Alps Creative By Chloe Harries Nicy Turney, Maggie One New Oxford Street Clarke, Emily Steventon 48 Diary & London WC1A 1NU Tel: 020 7878 2300 16 150 years Noticeboard

For editorial contacts, please see the panel over the page. Advertising queries: COVER STORY: Claire Barber Tel: 020 7878 2319 CELEBRATING 150 YEARS OF [email protected] PUBLIC HEALTH NURSING Sponsorship/supplement queries: Sunil Singh Tel: 020 7878 2327 [email protected] Production: Ten Alps Creative – Design and production Williams Press – Printing Community © 2012 Community Practitioners’ and Health Visitors’ Association Practitioner ISSN 1462-2815 The journal of the Community Practitioners’ and The views expressed do not Health Visitors’ Association (Unite/CPHVA) necessarily represent those of the editor nor of Unite/CPHVA. Paid advertisements in the journal do not imply endorsement of the products or services advertised.

November 2012 Volume 85 Number 11 Community Practitioner | 1 03928_ocdcal_ads_Calprofen_CP.indd 1 2/23/12 9:56 AM EDITORIAL Community Practitioner

Editorial Advisory Board Gaynor Kershaw (Chair) – , Finding ways to Heywood, Middleton and Rochdale PCT Obi Amadi – Unite/CPHVA Lead Professional Officer continue learning Maggie Breen – Macmillan Clinical Nurse Specialist – Children and Young t the CPHVA conference in 2009 I People, The Royal Marsden Hospital NHS prophesied to the then Department for Foundation Trust A Children, Schools and Families minister (a Toity Deave – Senior Research Fellow, Centre for Child and Adolescent Health, certain Ed Balls) that I was hoping to become University of the West of England, Bristol a dad in 2010 and I wanted to find out what I Barbara Evans – Community Nursery should tell my wife to expect in the HV service at Nurse, Leicestershire Partnership NHS that point. I actually misjudged things a bit and Trust missed that pledge by 16 days, with Holly being Gavin Fergie – Unite/CPHVA Professional born in 2011. Officer for Scotland and Northern Ireland I’ve been so privileged to be able to watch her Margaret Haughton-James – School Nurse grow and I still look in wonder at the beautiful Team Leader and Practice Nurse, Guy’s and person she is becoming. One of the wonders St Thomas’ Hospital is the way she picks up things, even without Catherine Mackereth – Public Health being taught in the ‘adult’ sense of the word. We Lead, South Tyneside Primary Care Trust noticed that when we said things like, ‘Holly, Brenda Poulton – Emerita Professor what do you think about that?’, her finger of Public Health Nursing, University of Ulster would fly up to her lips as if she was in deep thought mode. As we get older, we still learn in lots of Editorial Team subliminal and subconscious ways; but at the 150th birthday of health visitors, we’re Polly Moffat – Editor we also need ways that are much more ‘in launching this for all our CPHVA members to [email protected] your face’. Conference is one of those great get them to stop every now and then, and bring Jane Appleton – Professional Editor [email protected] opportunities! I have also been keen to their finger to their lips. think about thinking, and that’s why we’ve Chloe Harries – Assistant Editor [email protected] developed and launched Unite in Health Tel: 020 7878 2404 Thinking Thursday (#UiHTT). Some of you will have been involved in its Naveed Khokhar – Designer As we get older, [email protected] embryonic formation through our previous online training sessions, which have covered we still learn in Unite/CPHVA Honorary Officers subjects like the school nurse plans from the lots of subliminal Department of Health and the Unite briefing Lord Victor Adebowale – President and subconscious on SCPHN practice teachers. #UiHTT is the Elizabeth Anionwu – Vice-President ways; but we also next step to this, with at least monthly online Alison Higley – Chair training sessions that will encourage members need ways that are to think about the subjects of the day that much more ‘in your Unite Health Sector Officers matter to them (see p.10 for more details). face’. Conference is Tel: 020 3371 2006 However, this is just the start. At our CPHVA one of those great conference this month, we’ll also be launching Obi Amadi – Lead Professional Officer opportunities! CPHVA CPD. This is a project that the Rachael Maskell – Head of officer team has been working on Gavin Fergie – Professional Officer for Scotland and Northern Ireland for much of the year and will link our excellent journal output, our new #UiHTT and our Rosalind Godson – Professional Officer for School Health and Public Health conference to an online CPD system that will Dave Munday – Professional Officer help our members not only to think, but also to build and develop their own personal online Shaun Noble – Communications Officer [email protected] training portfolios. In 1896 when the CPHVA was formed it was Fiona Farmer – National Officer born from the early health visitors wanting to Dave Munday Barrie Brown – National Officer share and develop their knowledge. In 2012, Unite/CPHVA Professional Officer James Lazou – Research Officer

November 2012 Volume 85 Number 11 Community Practitioner | 3 NEWS ROUND-UP Pregnant women to receive whooping cough vaccine

n a bid to curb the worst whooping Whooping cough can last for up to three Icough outbreak for more than a decade, months and is also known as the ‘100-day which has so far claimed 10 lives, pregnant cough’. Before a routine was women between 28 and 38 weeks are to introduced in the 1950s around 1 000 be offered the combined whooping cough, people died of the infection each year tetanus, diphtheria and polio vaccines. Unite/CPHVA Professional Officer Ros The most vulnerable group at risk of Godson said: ‘CPHVA fully supports contracting complications from whooping this additional protection for newborn cough are newborn babies, who are too babies, as whooping cough can be difficult young to be protected by the vaccine, to diagnose in the early stages, but the which is first administered at eight weeks consequences on the very young can be of age. devastating. Older siblings attending Professor Dame Sally Davies, England’s nursery or school may unwittingly bring , said: ‘Whooping the virus home’. cough is highly contagious and newborns are particularly vulnerable. It’s vital that babies are protected from the day they Northern Ireland are born – that’s why we are offering the coughing in short bursts, followed by a In the wake of the 10 deaths this year from whooping cough, one of which vaccine to all pregnant women’. ‘whoop’ sound as the baby gasps for air. was in Northern Ireland and the other The vaccine became available in the first Both Scotland and Northern Ireland have nine in England, Northern Ireland’s week of October 2012, and should provide also suffered from unusually high levels of Public Health Agency (PHA) has babies with enough protection to last them whooping cough, with Scotland reporting confirmed that it will be offering the jab until two months of age. Around 730 000 508 cases in the first six months of this to pregnant women also. women are eligible for the jab. year. Northern Ireland had 139 cases in the PHA Consultant in Health Protection, Director of Immunisation at the first seven months of this year. Dr Maureen McCartney, said: ‘The Department of Health, Professor David Dr Mary Ramsay, Head of Immunisation PHA can confirm that the whooping Salisbury, said: ‘There is a clear benefit and at the HPA is in favour of the programme, cough vaccination programme has now begun, with all women who are 28 no evidence of risk. The vaccine that we stating: weeks pregnant or more being offered are offering to pregnant women has been ‘We have been very concerned about the the vaccine. This will be co-ordinated recommended by experts and a similar continuing increase in whooping cough through GPs who will contact eligible vaccine is already being given to pregnant cases and related deaths. We welcome the women. We would ask expectant women in the US. If you are pregnant, urgent measure from the Department mothers to await notification from their getting vaccinated is the best way you can of Health to minimise the harm the GP to ensure the programme can be protect your baby against whooping cough’. from whooping cough, particularly in implemented.’ Whooping cough, also knows as pertussis, young infants, and we encourage all can lead to complications, including pregnant women to ensure they receive Scotland pneumonia and brain damage, and in some the vaccination to give their baby the best Health Protection Scotland’s latest cases it is fatal. Ten babies have died so far protection against whooping cough. figures show that there have been 1 037 in 2012 alone. ‘Parents should also be alert to the confirmed cases of whooping cough Whooping cough infection surges come signs and symptoms – which include this year – 65 of these were in babies under three months of age. in three-to-four-year cycles, with the last severe coughing fits accompanied by the Michael Matheson, Minister for Public peak in 2008 when 908 cases were reported characteristic ‘whoop’ sound in young Health Scotland, said: ‘Over recent to the Health Protection Agency (HPA) children but as a prolonged cough in older months we have seen an increase in in the first six months of that year. So far children or adults. It is also advisable to cases of whooping cough, and this this year more than 4 791 cases have been keep their babies away from older siblings vaccination programme aims to give reported, including over 1 200 in August. or adults who have the infection.’ newborn babies the protection they Adults are often infected, but mistake The Joint Committee on Vaccination and need. It’s also important that parents whooping cough for a cold, which can Immunisation (JCVI) is considering the ensure their children are vaccinated then be passed onto infants. Common possible introduction of a booster jab in through the Childhood Vaccination Programme.’ signs of whooping cough in babies include adolescents.

4 | Community Practitioner November 2012 Volume 85 Number 11 NEWS ROUND-UP

Government offers NMC £20m bail out

he government has offered the Nursing there would still need to be an increase in fee Tand Midwifery Council (NMC) a one-off rate. The DH estimates that fees could level sum of £20million to help the troubled out at around £100. regulator out of financial difficulty, and lower A decision on whether or not to accept the proposed registration fee hike. the government’s offer is expected to be The deeply unpopular rise in nurses’ announced shortly. and midwives’ registration fees has been Health Minister Dan Poulter said: universally denounced. If carried out, the fees ‘I am pleased to be able to offer £20million could rise from the current £76 per year to of support to the Nursing and Midwifery £120 per year – an increase of 58%. Council, because the NMC is an important In response to the government’s offer of a body with an important role to play in grant, an NMC spokesperson said: protecting patients. ‘Patients must be able to have confidence ‘I am also mindful that in these times of in the quality of care they receive from nurses pay restraint, it is not right that hard working Jackie Smith, NMC Acting Chief Executive and midwives, and we share the government’s nurses and midwives are burdened with the commitment to improve nursing and offer of a grant to give us further options to full financial cost of improving the NMC’s midwifery regulation. The NMC’s Council has contribute to the costs of regulating nurses fitness to practise function. a responsibility to ensure that the organisation and midwives’. ‘We want to support the council and its is adequately resourced for the future in Even if the offer of a bail out is accepted by new leadership in getting back on its feet order to deliver effective and efficient public the NMC, the proposed fee rise is expected financially and operationally, and I hope that protection. We welcome the government’s to generate around £29million, meaning that it will accept our offer.’

Ministers clash over abortion time limit debate

aria Miller, Secretary of State for minister responsible for women and equalities MCulture, Media and Sport and the wants to restrict access to abortion – one of the Minister for Women and Equalities has most important women’s health services – is backed calls for a reduction in the legal time really alarming’. limit for abortions. However, Nadine Dorries MP, an outspoken Ms Miller said that as a result of advances critic of the current termination time limit in medical technology the limit should now praised Miller’s statements. Dorries instigated change to reflect the fact that premature babies the 2008 attempt to reduce the time limit for have a better odds of survival. abortions, and last year proposed a heavily She commented: ‘You have got to look at defeated amendment that would mean that these matters in a common-sense way. I looked termination service providers, such as Marie at it from the really important stance of the Stopes, could no longer be allowed to provide impact on women and children. pregnancy counselling. ‘What we are trying to do here is not to put For: Maria Miller, Minister for Women Pro-choice supporters have been pacified by obstacles in people’s way, but to reflect the way the appointment of Daniel Poulter MP and medical science has moved on.’ Anna Soubry MP in the recent Department of However, the British Pregnancy Advisory Health reshuffle, who both spoke put publicly Service’s Chief Executive, Ann Furedi, said: against Dorries’ proposals last year. ‘Scientific evidence does not show that survival Miller’s statement coincides with the opening rates before 24 weeks have improved in recent of Northern Ireland’s first private abortion years, as the Minister seems to believe. It is clinic. The clinic, which is run by Marie also important for a Women’s Minister to Stopes and located in Belfast, will provide recognise that, every year, a small number of terminations within Northern Ireland’s women in often very difficult and unenviable current legal framework, which states that circumstances will need to end a pregnancy abortions can be carried out only in cases after 20 weeks’. where continuing the pregnancy would have a Campaign Co-ordinator for Abortion serious, permanent or long-term effect on the Rights, Darinka Aleksic, said: ‘The fact that the Against: Daniel Poulter, Health Minister physical or of the woman.

November 2012 Volume 85 Number 11 Community Practitioner | 5 NEWS ROUND-UP

Hunt ‘out of his depth’ as NHS crisis mounts n his debut speech as Health Secretary cuts currently taking place in England, or Iat the Conservative Party conference, to the damage that the so-called £20billion newly appointed former culture secretary, efficiency savings are doing to the NHS that Jeremy Hunt, announced that he has Jeremy Hunt professes to care for. There was identified four key priorities for the future no indication how he would improve the of the NHS. He said: ‘The first is quality of mortality rates for the main ‘killer diseases’ care. Good-quality care is as important as – cancers, strokes and heart disease. good-quality treatment. We don’t always ‘When Jeremy Hunt came into office have great care quality’. last month he had a fantastic opportunity The remaining three priorities were: to make a name for himself as the health caring for people with dementia; long-term secretary who saved the NHS – he has conditions; and lowering mortality rates for Priorites: Health Secretary Jeremy Hunt flunked it at the first hurdle.’ ‘the major diseases’. In contrast, at the Labour Party conference Hunt, who replaced Andrew Lansley as in October, Shadow Health Secretary Health Secretary in September’s cabinet Andy Burnham pledged to reverse the reshuffle, said: ‘If Andrew is the health ‘marketisation’ that the current government secretary who helped give us the structures has imposed on the NHS and to ‘restore for a modern NHS, I want to be the health the legal basis of the NHS to a national, secretary who helped transform the culture planned, collaborative system’. of the system – to make it the best in the Burnham said: ‘We’re on a fast track world at looking after older people’. to fragmentation. Partnership is very Commenting on the speech, Dr Mark important in that context. Once it’s been Porter, Chair of BMA Council, agreed smashed to bits we have to try and glue bits with the priorities but pointed out that back together’. the current competitive structure of the He added that a more integrated system NHS would only hinder this: ‘We also agree for health and social care, which covers with him on the massive importance of physical, mental and social demands is what meeting the challenges posed to the NHS by is needed for the future. Shadow Health Secretary Andy Burnham the ageing population. But elderly care in ‘We can save the NHS without another particular requires a joined-up, collaborative best way to achieve the aspirations he has structural re-organisation. I’ve never approach. set out.’ had any objection to involving doctors ‘The changes currently being implemented Unite’s Head of Health, Rachael Maskell, in commissioning. It’s the creation of a in the NHS in England will generate more said: ‘It was evident that Jeremy Hunt has full-blown market I can’t accept. competition and more fragmentation. Mr either not got a grip of the scale of the ‘So I don’t need new organisations. I Hunt says he wants to tap into the ideas crisis facing the NHS or he is in complete will simply ask those I inherit to work of frontline staff. We hope he will listen to denial – or both. The NHS deserves better differently. Not hospital against hospital or us when we say that allowing us to work than this short, vacuous, policy-light speech. doctor against doctor. But working together, collaboratively, not in competition, is the There was no reference to the scale of the putting patients before profits.’ Flying Start scheme to be expanded in Wales

The Welsh government has announced it numbers of Flying Start children as well leading to improvements in language and plans to double the number of children as demonstrating that their proposals cognitive development; emotional and benefitting from the Flying Start programme represented the best value for money. Bids social development; parental confidence and by 2015 through support for families, health were submitted for projects in all 22 local engagement and health. visiting and childcare places. authority areas. Deputy Minister for Children and Social A total of £19million of funding will Flying Start is a programme for families Services, Gwenda Thomas, said: ‘We must be used to help develop the facilities and with children up to four years old, which remember that the areas in which Flying infrastructure needed to deliver such an is targeted at Wales’ most deprived Start runs are among the most disadvantaged expansion. In addition, the government has communities. The programme encompasses areas in Wales and families within them pledged an extra £55million over the next free childcare, parenting support, intensive some of the hardest to reach. three years. health visitor support and support for early ‘Flying Start is starting to have a real, Local authorities were invited to submit language development. positive impact on children. When they go to bids identifying the changes needed Early evaluation evidence of the school they are ready to learn and are more to achieve the target of doubling the programme found that Flying Start is confident at mixing with other children.’

6 | Community Practitioner November 2012 Volume 85 Number 11 NEWS ROUND-UP ADVERTISEMENT

Huge increase predicted in diabetes cases

iabetes UK has spoken of ‘grave Dfears’ for the future health of nearly a quarter of a million Britons who they predict will be diagnosed with diabetes by 2020. Chief Executive of Diabetes UK, Barbara Young, warned that the government is ‘sleepwalking’ towards a disaster, as the NHS faces increased strain to treat the condition. Currently, 3.7 million people in Britain have diagnosed diabetes, with estimates that 850 000 are living with the condition undiagnosed. The projected increase is based upon research compiled by the Yorkshire and Humber Public Health Observatory. Barbara Young said: ‘I have grave fears about the potential impact of an extra 700 000 people with diabetes, which is almost the combined population of Liverpool and Newcastle. If this projected increase becomes a reality it would be a calamity for the healthcare system and a disaster for public health’. A statement from the Department of Health said: ‘We are taking wide-ranging action to tackle diabetes. First, through prevention, by encouraging healthier lifestyles and identifying those at risk and supporting them to take the necessary action to prevent diabetes. Secondly, by better management of the condition, both in hospital and the community’. The warning comes after it emerged that screening for type 2 diabetes does not make an impact on mortality rates. A 10-year study carried out by Addenbrooke’s Hospital, Cambridge, of over 20 000 patients aged between 40 and 69 in the high-risk category for contracting the disease, showed that death rates were not reduced despite screening.

ERIC recognised at bedwetting awards Children’s charity Education and Resources for Improving Childhood Continence (ERIC) has been honoured at the British Medical Association’s Patient Information Awards 2012 for their website and information leaflet ERIC’s Guide to Teenage Bedwetting. Commenting on the award Eileen Jacques, ERIC Information and Helpline Manager said: ‘We are delighted to receive commendations from the BMA for our website and our teenage bedwetting leaflet. ‘Our resources are used by thousands of people every month and this type of recognition of excellence validates the hard work the team at ERIC put in to providing resources that are not only accessible but are also well designed and clinically balanced.’ Childhood continence problems such as bedwetting, daytime wetting, constipation and soiling affect one in 12 children and young people, and new census figures show that this amounts to 1.1 million children and young people in the UK. ERIC provides an information website, confidential helpline and a range of specialist resources and products designed to overcome or manage the problem.

November 2012 Volume 85 Number 11 Community Practitioner | 7 NEWS ROUND-UP

Newsinbrief After school exercise does little to The five C’s: new improve health New evidence has been revealed by Plymouth University, showing that nursing strategy extra-curricular exercise has a ‘small to negligible’ impact on childrens activity HS Information Centre statistics levels and minimal impact on BMI or Nshow that 700 nursing posts were lost boday fat levels in under-16s. in June of this year alone, and that 5 780 The results, published in the BMJ, nurses have left the NHS since the coalition looked at data from 30 trials taking place between 1990 and 2012. The results of the was formed in 2010. extra exercise sessions over a four-week The statistics were revealed at the same period was only equivalent to four minutes time as the Department of Health (DH) of extra walking per day, which was and NHS Commissioning Board’s Vison equivalent to a reduction of 2mm in waist and Strategy for Nurses, Midwives and circumference. Caregivers was published. Launched by Viv Bennett, DH Director Viv Bennett (second right) pictured of Nursing (pictured) and England’s Chief with Unite/CPHVA’s Obi Amadi and New non-executive role for Beasley Victor Adebowale Former Chief Nursing Officer, Christine Nursing Officer Jane Cummings, the Beasley, has been confirmed as one of the strategy is out for consultation until maximising wellbeing and improving new non-executive directors of the NHS 16 November and sets out the five health outcomes Trust Development Authority. ‘C’s’: care, compassion, competence, l Working with people to provide a Ms Beasley will be chair of the communication and courage. positive experience of care Appointments Committee. Also appointed l was Sarah Harkness, who will chair the The vision document states: ‘You will Delivering high-quality care and Audit and Risk Committee. influence the next steps we will collectively measuring impact Ms Beasley said: ‘I am delighted to be take to set a course for the nursing, l Building and strengthening leadership joining this new organisation, which has midwifery and care-giving contribution to l Ensuring that we have the right staff, such an important job to do. I am looking developing the culture of compassionate with the right skills in the right place forward to working with colleagues to l support the development of high quality care and meeting health needs for the Supporting positive staff experience. clinical services, which improve the care of coming years’. patients across England.’ It goes on to explain the way in which the Feedback should be made by 16 November Chair of the NHS Trust Development vision will be delivered, outlining key areas: via the electronic form at: www. Authority, Sir Peter Carr, said: ‘It’s great to l Helping people to stay independent, commissioningboard.nhs.uk/nursingvision/ welcome Christine and Sarah as the first non-executive appointments to the NHS TDA Board. They bring a wealth of senior experience in the fields of quality and finance respectively’. Reform a ‘necessity’ – Poots Northern Ireland’s Health Minister, in your area and you have the right to Edwin Poots, has addressed around 150 comment, challenge and let me know Eating disorder hospital admissions rise by 16% in a year nurses and midwives at the Northern how you feel about it. It’s important and Hospitals recorded 2 290 eating disorder Ireland Practice and Education Council’s it needs careful consideration. admissions in the 12 months to June annual conference for nursing and ‘We cannot continue delivering services 2012; a 16% rise on the previous 12-month midwifery, calling for a response to the in the same way as we have been – people period, provisional figures from the Health proposed reforms on the . are living longer, demand on the service and Social Care Information Centre (HSCIC) show. Children and teenagers The key aspects of the draft plans for the is rising and ultimately, we need to make aged 10 to 19 accounted for more than reform to the system are outlined in the better use of technology and resources to half of admissions in the latest 12 month consultation document Transforming Your ensure the money we have is being spent period, up from 49% (960) in the previous Care: Vision to Action. in the best way. Without addressing these 12 months (July 2010 to June 2011). The Poots said: ‘Yesterday, I announced the challenges, there is an increased risk of biggest number of admissions were for 15-year-old girls who also accounted for consultation on proposals arising from the system failing patients. One case of the most admissions in the previous 12 Transforming Your Care and I encourage poor care is one too many in my eyes and months. Anorexia accounted for 74% everyone to respond. This reform we must continue to strive for excellence. (1 700) of all eating disorder admissions, programme will have a greater impact on To achieve this, reform is not an option, it while bulimia accounted for 7% (150). the delivery of services than anything that is a necessity.’ The remaining 19% (440) were for ‘other eating disorders’ such as overeating has gone before’. You can comment and resopnd to the or vomiting associated with other Poots added: ‘Let me be clear: this draft before the consultation closes on 15 psychological disturbances. reform will affect you and your family, it January 2013 at: The report can be accessed at: will change how is delivered www.tycconsultation.hscni.net/ www.ic.nhs.uk/pubs/provisionalmonthlyhes

8 | Community Practitioner November 2012 Volume 85 Number 11 12785 SMAAd210x297.indd 1

BREASTFEEDING IS BEST

Drop for drop, no other formula comes close1-9

Breast milk New SMA Other first infant milks First Infant Milk

References: 1. Aptamil website accessed December 2011 http://www.aptamil.co.uk/products/article/aptamil-fi rst?tr=carousel 2. Bettler J, Kullen MJ. J Pediatr Gastroenterol Nutr 2007;44 (Suppl 1): e197. PN1-11. 3. Kennedy K et al. Am J Clin Nutr 1999; 70: 920-7. 4. Yao M et al. J Pediatr Gastroenterol Nutr 2010; 50 (Suppl 2): PO-N-444. 5. Yao M et al. Poster presented at 43rd Annual Meeting of ESPGHAN, Istanbul, Turkey, June 9-12, 2010. 6. Lien EL et al. J Pediatr Gastroenterol Nutr 2004; 38: 170-6. 7. Carnielli VP et al. Am J Clin Nutr 1995; 61: 1037-42.

8. Carnielli VP et al. J Pediatr Gastroenterol Nutr 1996; 23: 553-60. 9. Trabulsi J et al. Eur J Clin Nutr 2011; 65: 167-74.

IMPORTANT NOTICE: Breastfeeding is best for babies. provides babies with the best source of nourishment. Infant formula milk and follow on New SMA First Infant Milk milks are intended to be used w hen babies cannot be breastfed. The decision to discontinue breastfeeding may be diffi cult to reverse and the introduction of partial bottle feeding may reduce breast milk supply. The fi nancial benefi ts of breastfeeding should be considered before bottle feeding is initiated. Failure To find out more, visit smahcp.co.uk

08/06/2012 15:29 to follow preparation instructions carefully may be harmful to a babies health. Infant formula and follow up milks should be used only on the advice of a healthcare professional.

ZGW0460/02/12 ASSOCIATION

Unite in Health Thinking Thursday #UiHTT

nite knows how important it is to members in the health sector that Once you’ve registered, you’ll get an email telling you about the Uthey have time to develop their skills and knowledge. We also know webinar log-in details. It will include a number for you to phone (so that with the current climate in the health sector, this has become more you can hear the presentation) and a website for you to visit (so you and more difficult to achieve. That’s why a new training programme has can watch the presentation slides). It might sound complicated but in been launched – Unite in Health Thinking Thursday (#UiHTT). early pilot sessions, members found this style easy to join in with. #UiHTT will cover topics that our members tell us are important. And to help with less time being available to be involved in training Happy Birthday to You; A Health Visiting 150th we’ve developed it in a ‘webinar’ style. The modules are free to Unite Thursday 18 October 2012 at 4:00pm Health Sector members and once you apply on the online form for a In this session Unite Professional Officer Dave Munday will be talking session, we’ll send you details of how to join in that session. about the 150th anniversary of health visiting. The session will include information about the development of the profession, the changes in How will each session work? society over that period and how CPHVA has changed over the years to If you’re a member and want to join in one of the sessions, visit: ensure members have the support needed to improve and develop. The www.unitetheunion.org/sectors/health_sector/online_training_-_ training is taking place on Thursday 18th October starting at 4:00pm thinking_thi.aspx to book on to the session (if you want to book on and lasting about an hour. Once the session has been completed, we’ll two sessions, all sessions or somewhere in between, you’ll need to fill email out asking for feedback and let members know where they can out a form for each separate session). find copies of the presentation.

New members required Infant Massage Training for CNN Forum throughout the UK he CPHVA Community Nursery Nurse (CNN) Forum currently Become a Certified Infant Massage Thas some regional areas without CNN representation. These are Instructor with the International Northern Ireland, Wales and South East England. The Forum meets three times a year in London and travel expenses Association of Infant Massage are paid. In between meetings work is carried out, usually by email, developing leaflets, publications, articles for the journal and We are the only infant massage training provider with more than 30 years teaching experience in over 40 countries. commenting on any queries we may have been asked to respond to. We ask that you are able to collect information and to cascade items Our four-day highly acclaimed course was recently endorsed as between the CNNs of your region, so good networking skills are the highest quality for parent education and comprises theory and supervised practical teaching sessions with parents and babies. required from members. If you work in an area that has a vacancy and are interested in We value our members... becoming a member please contact Stella Mann (Stella.Mann@dhuft. IAIM (UK) Membership is given to all students and includes: nhs.uk) for more details. • Support and networking at local, national and international levels. • Continued Professional Development – regular educational Alternatively, if you have any queries about the forum please contact conferences, massage stroke refreshers and workshops. the rep in your area from the following list: • Marketing advice on l South West: Stella Mann [email protected] class set-up and an informative newsletter, l London and Eastern: Sujata Mahendran three times a year. [email protected] • Ongoing support from l London and Eastern: Colette Lighthill [email protected] our trainers. l North East: Fiona Ferguson [email protected] l North East: Brooke Wilson [email protected] For further details please contact the IAIM on: l North West: Caroline McKean [email protected] l West Midlands: Di Hickinbothan [email protected] 020 8989 9597 • [email protected] l East Midlands: Barbara Evans [email protected] www.iaim.org.uk l Scotland: Wendy Kelman [email protected] 0020/0211/Embody

10 | Community Practitioner November 2012 Volume 85 NumberEmbody 11 Advert v1.indd 1 21/02/2011 10:05 ADVERTISEMENT FEATURE Eggs with benefits

Official new data from the Department of Healthi shows that today’s eggs contain more than 70% more vitamin D and double the amount of selenium than when previous analyses were carried out 30 years agoii, as well as less fat and fewer calories. This news adds to the growing evidence of the health benefits of eating eggs, and follows an end to concerns linking eggs to high blood cholesterol levels. So is it time to take a fresh look at eggs and the nutritional benefits they can offer to patients?

Eggs have long been recognised as a good source of high quality protein, but the new survey shows there are higher levels of nutrients than previously thought lying beneath their shells... Vitamin D The new analysis found that two medium eggs can provide around two thirds of the EU labelling RDA for vitamin D. The finding that eggs make a more important contribution to vitamin D intake than previously thought is particularly significant given concerns that around 20% of UK adults and 18% of children have inadequate levels of vitamin Diii and because there is emerging evidence that low vitamin D status may be linked to increased risk of heart disease and some cancers as well as to amounts of this nutrient - two medium eggs would There is increasing evidence to suggest that poor bone healthiv. provide about 50-65% of the US AI (Adequate eggs can help with weight management due to Intake) for choline. their satiating qualities. Several studies have shown Selenium that meals containing eggs can reduce hunger, the Two medium eggs now provide 42% of the RDA Omega 3 desire to eat, and subsequent short-term energy of selenium, meaning eggs qualify as a rich The omega 3 fatty acid content of eggs was intakevi. One study also showed that when an egg selenium source. Selenium is a mineral that is analysed for the first time and the results indicate breakfast was consumed as part of a calorie- involved in the body’s antioxidant defences and that, according to EC nutrition claims regulations, controlled diet, there was significantly greater thyroid hormone metabolism. Recent Government UK eggs qualify as a source of the fatty acid weight loss and reduction in waist circumferencevii. datav indicate that low intakes are widespread, DHA. DHA is involved in maintaining normal brain Cholesterol levels in eggs have decreased by especially amongst women, so eggs could make and heart function. about 12% - a medium egg now contains around an important contribution to selenium intake in 177mg of cholesterol. However, it is now generally the UK. Fat, cholesterol and acknowledged that cholesterol in foods such as weight management eggs does not have a significant effect on blood Choline The levels of total fat, fatty acids, cholesterol and cholesterol in most peopleviii. All major UK heart There are also new data for choline, which is an energy have decreased in eggs with a medium and health advisory bodies, including the British important component of cell membranes and is egg now containing 66 calories, 4.6g of fat and Heart Foundation, have already removed the involved in fat metabolism. Eggs contain significant 1.3g of saturated fat. previous limits on egg consumption. i. Data produced by the UK Foodcomp project consortium funded by the Department of Health as part of their rolling programme of nutrient analysis survey, led by the Institute of Food Research and comprising partners including British Nutrition Foundation, Royal Society of Chemistry, Laboratory of the Government Chemist and Eurofins Laboratories. ii. Th e changes are believed to be the result of improvements to hens’ feed, an increase in the ratio of white:yolk in an average egg, and improved analytical methods since the last official Government analyses were carried out in the 1980s. Vegetable oils replaced meat and bonemeal in UK hens’ feed in the 1980s and it is believed that better quality oils, together with other enhancements to hens’ feed, have improved the hens’ absorption of fat-soluble vitamins and the take-up of nutrients. iii. Ba tes B et al. (2012) National Diet and Nutrition Survey. Headline results from Years 1, 2 and 3 (combined) of the Rolling Programme (2008/2009–2010/11) http://transparency. dh.gov.uk/2012/07/25/ndns-3-years-report/ iv. Ruxton CHS and Derbyshire E (2010) Health impacts of Vitamin D: are we getting enough? Nutrition Bulletin 34, 185-197. v. Bates B et al. (2011) National Diet and Nutrition Survey. Headline results from Years 1and 2 (combined) of the Rolling Programme (2008/2009–2009/10). Department of Health and Food Standards Agency vi. Ruxton C (2012) Eggs and satiety. Network Health Dietitians Issue 76 vii. Van der Wal JS et al. (2008) Egg breakfast enhances weight loss. Int. J. Obesity 32, 1545-51. viii. Gray J & Griffin B (2009). Eggs and dietary cholesterol – dispelling the myth. Nutr Bull 36, 199-211 ANTENNA

Book review: School nurse survival guide

School Nurse Survival Guide Unite was implacably opposed to the Bill Jane Wright (ed) from its inception. Quay Books (2012) This book is up to date with the changes £19.99 and choices of schools in England, such ISBN 9781856424226 as academies and free schools. New school nurses will probably turn straight to the he title of this book is reassuring – chapter entitled ‘Child Protection’, which is Talthough it is is far too large to hide a short chapter outlining case conferences in a pocket for a quick ‘crib’. It is, however, and providing some case studies, which ideal basic guidance for those starting touch upon some of the main school out on a new career as a school nurse, or nurse issues. moving jobs or areas and taking up new There is another practical chapter about ways of working. contributing to Personal, Social, Health and There are seven chapters, each by a Economic education (PSHE) which will different author, focusing on exactly what it hopefully encourage more school nurses says on the cover – ‘common questions and into this rewarding aspect of the job. answers for the school nurse’ – followed by Under ‘Essential skills’ there is a very good a lovely list of references. tutorial on how to chair meetings; if only all The first chapter, ‘Working in the chairs followed these guidelines! There are community as a school nurse’, acts as an lots of lists and boxes, as befits a textbook, introduction to the whole book and so gives but hardly any flow charts or diagrams that a broad outline of the role and the rationale would help pictorial learners. behind it. awareness. The quick guide to the political Finally, there is description of There is a full account of the English process is relevant as we are currently commissioning, how to develop a business government’s Healthy Child Programme working in times of great upheaval for the model and how to sell the service, which for 5–19 year olds, as well as coverage health service. has become an essential part of the school of the Nursing and Midwifery Council One omission is that the author lists some nurse’s skill set. (NMC) standards of proficiency. There is of the trade unions that were in outright reference to working safely and professional opposition to the Health and Social Care Ros Godson responsibilities, including political Bill (England), but fails to mention that Professional Officer Unite/CPHVA

Silent Voices: parental alcohol abuse rapid evidence review from the is both heartrending and inspiring to read l That all those working with children Children’s Commissioner in England about the systems they employ to comfort are vigilant about problems related to Ahas now been published entitled Silent themselves and their siblings, and deal with parental alcohol misuse and are trained Voices: Supporting Children and Young People their parents. to understand what may lie behind Affected by Parental Alcohol Misuse. For those The report’s key findings cover children’s troublesome or coping behaviour who are used to such reports it is an interesting experiences, wider issues, protective factors l That there is more focused research about read, although long at over 100 pages. and processes, services and the policy context. the impact of parental alcohol misuse; in As well as reviewing the literature, focus It makes three recommendations: particular, how the response of universal groups were held for children and young l That the government and local policy services might be improved. people across the age range, which validated makers give as much attention to alcohol some of the literature and raised other misuse as to drug misuse, focusing policies This report is recommended reading for all ideas for research. Using children’s voices on children and families, not just on health those who work within public health services to demonstrate the facts is effective; and it and crime issues for 0 to-19-year-olds.

12 | Community Practitioner November 2012 Volume 85 Number 11 ANTENNA

Research evidence New resources Passive smoking on mother–infant bonding in Sexual behaviours early postpartum in women with traffic light tool and tobacco child abuse and neglect histories. Young people’s sexual health charity Brook has a The findings also shed light on the control policies launched an online sexual critical need for early detection in European behaviours traffic light tool and effective treatment of countries for all professionals working postpartum mental illness in order with young people. The tool The World Health Organization to prevent problematic parenting uses a ‘traffic light’ system developed the Framework and the development of disturbed of red, amber and green Convention on Tobacco Control mother–infant relationships. to provide a simple guide (FCTC), an international legally Arch Womens Ment Health 2012 to distinguishing between binding treaty to control tobacco [Epub ahead of print] healthy and harmful use. Adoption and implementation behaviours. The tool is an of specific tobacco control aid to decision making and measures within FCTC is an Paternal influences can help professionals in outcome of a political process, on adolescent their work to support young where social norms and public people to stay safe and sexual risk needed. The study authors provide opinion play important roles. healthy and ensure that all recommendations for primary agencies are working to the The objective of this study was to behaviour To date, most parent-based care providers and public health same criteria. Visit: www. examine how a country’s level of research has neglected the role practitioners to better incorporate brook.org.uk/traffic-lights tobacco control is associated with of fathers in shaping adolescent fathers into interventions designed smoking prevalence, two markers sexual behaviour and has focused to reduce adolescent sexual risk New Times In The NHS of denormalisation of smoking on mothers. The objective of behaviour. reps training (social disapproval of smoking this study was to conduct a Pediatrics 2012 [Epub ahead Expected to lead in your and concern about passive job, and as a Unite rep, structured review to assess the of print] smoking), and societal support for but needing support? You role of paternal influence on tobacco control. Concerns about need new skills to help you passive smoking seem central in When infant operate effectively and the implementation of tobacco chronic illness and efficiently in the rapidly control measures, stressing the disability interfere changing terrain. You importance of continuing to need... educate the public about the harm with breastfeeding • Unite health sector accredited training for all from passive smoking. The aim of this study was to representatives - new and BMC Public Health 2012 Oct explore the emotional adjustments experienced that women make when their 12(1): 876 • 2-day regional courses. baby’s chronic illness or disability Visit:: www.unitetheunion. threatens breastfeeding. Varying org/sectors/health_sector/ Mother–infant levels of emotional adjustment reps/new_times_in_the_ bonding were experienced by the women, nhs_-_reps_t.aspx and a process or path reflected impairment their efforts to cope. Adjustments BNF for Children app The goal of this study was are discussed in terms of The National Institute to examine the trajectory of practical issues of coping and for Health and Clinical bonding impairment across the biographical disruption, thereby Excellence (NICE) has first six months postpartum in adolescent sexual behaviour and raising awareness of challenging announced the launch of its the context of maternal risk, to assess the methodological aspects. Breastfeeding provided third free smartphone and tablet application in 2012 including maternal history of quality of the paternal influence a sense of control and purpose. – NICE BNFC. The NICE childhood abuse and neglect and literature related to adolescent Understanding issues around British National Formulary postpartum psychopathology, and sexual behaviour. Existing research breastfeeding an ill or disabled for Children (NICE BNFC) to test the association between preliminarily suggests fathers child can help healthcare providers app follows the successful self-reported bonding impairment influence the sexual behaviour of offer more appropriate care to launch of the NICE BNF and observed positive parenting their adolescent children; however, women who wish to breastfeed in and NICE Guidance apps. behaviours. The results highlight more rigorous research examining spite of chronic illness. The BNF and BNFC are the adverse effects of maternal diverse facets of paternal influence Midwifery 2012 [Epub ahead of available on the internet at: postpartum depression and PTSD on adolescent sexual behaviour is print] www.evidence.nhs.uk

November 2012 Volume 85 Number 11 Community Practitioner | 13 NEWS FEATURE

Bed sharing – Is it worth the risk?

In early September 2012, Professor Ed Mitchell from the Department of Paediatrics at the University of Auckland came to London to deliver his latest findings in the form of the Dr WE (Bill) Parish Memorial Lecture: Bed sharing with baby: Is it worth the risk?

Causal factors Chloe Harries Studies have proven alcohol and bed sharing Assistant Editor to be a lethal combination. In the SWISS study (Blair et al, 2009) of 157 sudden unexpected any different factors have been deaths of Infants (SUDI), 67 of these (43%) shown to add to the risk of were explained and 90 (57%) were classed as Mcot death, including smoking SIDS. Mitchell interprets the results as 43 of both during pregnancy and infancy, 78 (55%) died of bed sharing, where alcohol overtiredness, sleeping with the baby on was implicated in 24 of these deaths. a chair, parental alcohol use and parents FSID Chair Francine Bates OBE echoes this: sleeping in the same bed as the baby. ‘Our key public health message is that the Around 290 babies still die every year from safest place for a baby to sleep is in a cot or cot death in the UK. a crib, in the same room as the parents, and Professor Mitchell’s lecture defined ‘bed that parents should never smoke, drink and/ sharing’ as a parent sleeping with the infant or take drugs and sleep together with a baby on the same sleeping surface – they key in a bed or on a sofa or an armchair. point being that the parent is asleep. ‘All our advice is supported by the latest Mitchell has worked closely with the peer-reviewed research and all infant care foundation for the Study of Infant Deaths charities are in agreement that the safest (FSID) – the UK’s leading cot death charity place of all for a baby to sleep is in a cot or a working to prevent sudden deaths and crib in the same room as the parents for the promote infant health – for many years Mitchell’s London lecture pamphlet first six months. now. The FSID has been working to provide ‘I believe that if we all came together to safe sleep advice, based on the very latest Professor Mitchell said: ‘I was asked to convey this one simple message, we could research, for over 40 years. review all infant deaths in Auckland in make real inroads in reducing unexplained To date, FSID funds research (nearly the mid-1980s. In two years I reviewed 80 deaths. We have always believed that parents £10million raised so far), supports bereaved sudden unexplained infant deaths, and should have all the information on risk factors families, promotes baby care advice, and was struck by the similarity of the cases. – however small the risk – in order to make works to improve investigations when a However, we weren’t able to interpret the an informed decision on how best to care for baby dies. FSID’s definition of cot death data as we didn’t know what the frequency their baby.’ is: ‘The sudden and unexpected death of a of normal infant care practices was. For It seems that geography, too, can be a factor. baby for no obvious reason. The post mortem example, 25% of babies died bed sharing. Location, linked to affluence, can directly examination may explain some deaths. Those Did this mean that bed sharing was a risk, affect cot death statistics. Figures released by that remain unexplained after post mortem or that this is the usual practice, or even the Office of National Statistics in August examination may be registered as sudden did bed sharing reduce the risk? We then reveal that the North West of England has the infant death syndrome, SIDS, sudden infant did a study, which compared 393 cases highest rate, with 0.53 per 1 000 live births. death, sudden unexpected death in infancy, with almost 1 800 control families which This is significantly higher than London, unascertained or cot death’. confirmed that bed sharing was a risk.’ which has the lowest rate at 0.21.

14 | Community Practitioner November 2012 Volume 85 Number 11 NEWS FEATURE

Ms Bates said: ‘Although we have seen a Statistics show that 50 to 70% of SUDI occur small reduction in the number of deaths in bed sharing, reaching a peak of 90% in the across England and Wales the figure for the first month following birth. North West is extremely concerning. The If we all came together The Department of Health website provides region has had the highest rate for the last to convey this one simple a selection of ‘Babies and Parents’ videos, seven years. We know that smoking is a major message we could make designed to give parents advice on how to risk factor for sudden, unexplained infant real inroads in reducing care for their child, and to answer answers death and the smoking rate in London is the unexplained death to common questions including: ‘How can Is it worth the risk? lowest in the UK but the rate for the North we avoid the risk of cot death?’; ‘What does West is above the national average.’ a health visitor do?’; and ‘Is my baby gaining She added: ‘Research has shown that the enough weight?’ majority of the deaths now occur in the most protective, but research does not support the vulnerable and socially deprived families. belief that bed sharing is an entirely risk-free Looking ahead Affluent parents are less likely to experience practice.’ Looking to the future, Mitchell is already such tragedy.’ involved in another SUDI case study which Benefits began earlier this year and won’t conclude for Emotive issue The benefits of bed sharing have been shown a further three years. He said: ‘This study is Bed sharing as a factor in cot death is not to include increased or maintained levels of doing an infant sleeping scene reconstruction a new theory; for decades rival groups breastfeeding; increased levels of bonding; and and is particularly looking at bed sharing, as have taken part in the debate. However, better maternal sleep. this accounts for over 50% of deaths in New now that research has been undertaken Ms bates said: ‘Some people hold the view Zealand and the UK for that matter. We hope showing a causal link, Mitchell hopes that that the benefits of breastfeeding trump that we can identify ways of bed sharing safely. the situation may be changing. The biggest all other risks and that warning against the At the moment advice on how to bed share opponent to Mitchell and FSID’s message is dangers of bed sharing is not helpful to safely is not evidenced-based.’ the breastfeeding lobby, who argue that bed mothers coping with the practicalities of Mitchell believes the following advice is key: sharing increases breastfeeding uptake. feeding on demand through the night. But l Follow the advice given in the Back to Sleep However, Mitchell does not dispute this: as a charity whose sole remit is to reduce campaign ‘In my opinion bed sharing does increase cot death rates, we feel very strongly that l No smoking in pregnancy and around baby duration of breastfeeding, although the parents should be made aware of all the risks after birth (pregnancy is probably more effect is quite small, about two weeks longer. associated with bed sharing so that they can important) Lactation consultants, La Leche League make an informed choice.’ l The safest place for a baby to sleep is in a cot and the Baby Friendly Hospital Initiative The majority of evidence, however, points beside the parental bed. all appropriately promote breastfeeding, to bed sharing having more risks than but some members in their zeal to improve benefits. In their study, Baddock et al study Ms Bates: ‘We are reviewing our literature breastfeeding rates they – not all by any (2007) videotaped 40 infants and parents for parents and professionals and looking at means – may promote bed sharing. The other who regularly shared a bed. Evidence showed ways we can convey the risks of bed sharing, group is anthropologists who argue that close that there were 102 ‘head covering’ cases which is both proportionate and makes sense,’ proximity is how we as a species developed, observed. adding: ‘Professor Mitchell concluded that and thus it must be good. But conditions in In 22 of the cases 80% of these were due parents have the right to know about all the 2012 are very different to that of thousands of to a change in adult sleep position. Head- risks, and that sudden infant death can be years ago’. uncovering was instigated in 68% of the cases prevented if all parents follow the top pieces Ms Bates commented: ‘Non-smoking by the mother, half of these were prompted by of advice. We wholeheartedly agree with him. middle class mothers are more motivated the infant, meaning that uncovering relies on Through collaborative campaigning, and to breastfeed and some find it easier to do the mother being able to wake easily, clearly targeted interventions we have pledged to this at night if they also sleep with their mothers under the influence of alcohol are halve the number of sudden infant deaths by baby. If no other risk factors are present, likely to be impaired. 2020.’ then the risk of sudden infant death is Evidence has also shown that maternal Further advice for parents and professionals much lower. Bed sharing is dangerous if smoking can cause deficits in the arousal can be found at: www.fsid.org.uk the parents have smoked, drunk alcohol, or mechanisms of infants, meaning that the taken sleep inducing drugs and their baby infant may then fail to rouse and prompt the References was born before 37 weeks or was of low birth mother to uncover their head. Dr WE (Bill) Parish Memorial Lecture: Bed sharing weight and these are the major risks that we Mitchell has concluded that the only group with baby: Is it worth the risk?, Ed Mitchell, 2012 (Available from FSID.org) highlight. that is not at an increased risk from bed FSID: Looking after your Baby/Bedsharing: ‘Mothers can successfully breastfeed without sharing is infants aged three months and http://fsid.org.uk/looking-after-your-baby/bedsharing sleeping together with their baby in a bed. upwards, that are not preterm or of low birth FSID: http://fsid.org.uk/page.aspx?pid=1105 FSID and all infant care charities would like weight, with non-smoking parents and no DH https://www.nhs.uk/InformationServiceFor more mothers to breastfeed, because it is parental alcohol or recreational drug use. Parents/pages/home.aspx

November 2012 Volume 85 Number 11 Community Practitioner | 15 of public health nursing For many, 2012 has been synonymous with London hosting the Olympic Games; however, for health visitors it has a more important meaning. 2012 is the year that the profession marks its sesquicentenary – here’s a look back over the history of the CPHVA with our timeline, starting from its inception in 1862 until the present day ...

uch has occured over the last few years in the world of public been less welcome – namely the successful passage of the controversial Mhealth nursing, and the most significant of these events is Health and Social Care Bill. arguably the manner in which the current government has decided As always, Unite/CPHVA has campaigned throughout this period to bring the health visiting profession to the fore, pledging an extra to forge a more equitable future for NHS workers, and continues to 4 200 health visitors in post by 2015 as part of the Health Visitor do so. Implementation Plan: A Call to Action, launched in February 2011. The beginning of 2012 also saw the start of the 150 years of public The prioritisation of investment into a much neglected profession health nursing celebrations, culminating in the Unite/CPHVA has been welcomed; but there have been significant changes that have November conference 2012 – The Future of Public Health Nursing. 1862 1877 1896 1904 1907 The Ladies’ Sanitary The Sanitary Journal Seven women sanitary In April, the WSIA The Notification of Reform Association documents the workers in London establish becomes a formal Births Act 1907 passes of Manchester and appointment of six women the Women Sanitary group, with rules and in an attempt to cut down Salford is founded to health inspectors in Inspectors’ Association a written constitution. . It states promote health and Glasgow. (WSIA), which later changes Both women sanitary that newborns should sanitary conditions in poor What is to become the its name to the Health inspectors and health be registered and a local neighbourhoods, appoints ‘health visiting’ profession Visitors’ Association. It is, visitors were included medical officer of health the first health visitors. begins to gain ground and at this point, an unofficial in the organisation, informed of births as The group is founded move towards national group of women with which promoted sharing soon as possible so that upon religious ideals, with status. similar jobs and interests. knowledge between the officer can send a Christian mission women members. Like today’s trained health visitor to visiting homes to advise group, the WSIA covered the mother’s home. This residents. These women topics like infant mortality promoted the profession were employed by the and disease prevention in and fuelled its rise. lady founders to visit the home. working-class homes and give counsel on health- related issues, especially those related to infants and children.

16 | Community Practitioner November 2012 Volume 85 Number 11 1908 1915 1916 1918 1919 Royal Sanitary Association changes name College of Nursing HVA registers as trade Nurses Registration Act; Institute began to set to The Women Sanitary is established. union; WSIA formally health visiting formally examinations in health Inspectors’ and Health became a Trade Union and established as profession. visiting and extended Visitors’ Association affiliated to the Women’s Empowers Local to , who (WSIHVA). Trade Union League. Authorities to provide new came into being after Oualifications for health services like day nurseries, medical examination of visiting legally necessary; health visitors and child school children became Maternity and Child welfare clinics. mandatory in 1908, which Welfare Act enabled led to Education Act of Local Authorities to set 1907, which provided up a range of services, for the appointment including salaried health of medical officers and visitors. school nurses.

1924 1925 1927 1928 1929 First health service union Memorandum lot MCW National Gardens Specific training course The WSIHVA becomes to affiliate to the Trades Ministry of Health requests Scheme for health visitors made the Women Public Health Union Congress (TUC). that the Royal Sanitary To help raise money for compulsory. Officers’ Association Institute become sole the QNI nurses, private Institute becomes ‘The (WPHOA). Central Examining Body parties open their gardens Queen’s Institute of for the examination of to the public, charging District Nursing’. Health Visitors. The Ministry ‘a shilling a head.’ This of Health takes over money was no longer responsibility for the training needed when the National of health visitors, the RSI Health Service took continued as the designated on the District Nursing examining body, maintaining Service after WWII, but a register of those who the money was used to achieved the qualification. support retired nurses and nurse training. First issue of Association’s journal, named the The Woman Health Officer, changed to Health Visitor in 1964.

1930 1931 1948 1962 1965 Becomes ‘The Women Regular series of annual Birth of the NHS – this Health visiting becomes CETHV develops a Public Health Officers’ conferences begins. brings district nursing an exclusive nursing curriculum for a ‘new Association’. under the healthcare speciality; Council for the breed of health visitor’ umbrella, thus releasing Training of Health Visitors based on a 51-week nurses from having to raise (CTHV) established by the course. At this point, funds from patients and Health Visiting and Social a nursing qualification other activities and instead Work (Training) Act. became statutory being governmentally October – The HV requirement for entry funded. Centenary Conference in into health visitor Brighton. training, along with either April – The WPHOA registration as a midwife becomes the HVA. or, at least Part I of the midwifery training

November 2012 Volume 85 Number 11 Community Practitioner | 17 1970 1974 1977 1979 Public Health Nursing Health visiting service CETHV produces the The Nurses, Midwives becomes known as moves from local authority ‘Principles’: The search for and Health Visitors Act; provision into the NHS. health needs: Regulatory duties taken Nursing; CTHV becomes Health visitors, along ● The stimulation of an up by UKCC and four the Council for the with other public health awareness of health national boards. CETHV Education and Training of and needs disbanded, nursing Health Visitors (CETHV). staff, are transferred ● The influence on policies unified under this act; Took over from Royal from their local authority affecting health responsibility for health Sanitary Institute as employment into the ● The facilitation of visitor went to National examining body of health hospital dominated NHS. health-enhancing Boards, now requiring visitors; now the National activities registration as a nurse to Boards for Nursing, become a health visitor. Midwifery and Health Visiting. 1983 1986 1994 1997 2001 UK Central Council for Cumberlege Report Pre-registration HV The HVA becomes the Nursing and Midwifery Nursing, Midwifery and (Dept for absorbed into Community Practitioners’ Order passed; removal of Health Visiting set up – and Social Security) a post-registration nursing and Health Visitors’ title ‘health visitor’ from Known as the UKCC; on neighbourhood framework for Specialist Association (CPHVA). statute. AEEU and MSF Became the Nursing and nursing was first to Community Health Care merge to created Amicus. Midwifery Council in 2002; recommend reforms Nursing. The former 51- Abolished the CETHV. of community nursing week programme of study services; health needs was reduced to a minimum inclusive of older of 32 weeks. people, disabled people, the chronically sick, the terminally ill and preventive care. Recommended allowing community nurses to prescribe from limited list of medicines; legislation 1992. 2002 2007 2009 2011 2012 The UKCC ceases to exist, May – Amicus and the Action on Health Visiting January – First reading in Healthy lives, healthy people: with its functions taken Transport and General programme launched Commons of the Health Improving outcomes and up by the Nursing and Workers Union form to (March) – Clearly states and Social Care Bill supporting transparency Midwifery Council (NMC). created Unite the Union. the key roles of the health Feburary: Health Visitor New public health outcomes visitor and take measures Implementation Plan: A Call framework published. Facing the Future to promote reinvestment to Action established (Feb) March Inaugural CPHVA Independent report in it. awards were a celebration of on health visiting; Key aim: improve services ‘innovation, hard work and concluded it should focus and health outcomes in early dedication.’ where it can make the years for children, families greatest impact: early and local communities. Getting it right for children, intervention, prevention CPHVA run a series of free young people and families is and workshops on the subject, launched for young children and across the UK. families; requested April - HV Implementation national policy to support July – Healthy Lives, Healthy Plan Quarterly Progress recommendations. People White Paper: Update Report published and Way Forward Operational design of this November – The Future work through a series of of Public Health Nursing Public Health System Reform conference, 7&8 November Updates’. at the Brighton Centre, Brighton. 18 | Community Practitioner November 2012 Volume 85 Number 11 Bio-Oil® is a skincare oil that helps improve the appearance of scars, stretch marks and uneven skin tone. It contains natural oils, vitamins and the breakthrough ingredient PurCellin OilTM. For comprehensive product information and results of clinical trials, please visit www.bio-oilprofessional.co.uk. Bio-Oil is the No.1 selling scar and stretch mark product in 11 countries. £8.95 (60ml).

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A healthier health visiting workforce: findings from the Restorative Supervision Programme

Aims of this paper despite their key role in mental health. Sonya Wallbank This paper will describe the restorative model Those studies that have been conducted Associate Professor Child Health of supervision, which has been rolling out tend to be from outside the UK, but still South Warwickshire Foundation Trust in the West Midlands for over a year and is show that access to clinical supervision Georgina Woods being delivered in a number of other locations that remained separate to administrative or Assistant Psychologist across the UK. Results of the programme will managerial supervision was rated as significant South Warwickshire Foundation Trust be shared, in addition to their implications for to community staff. Additionally, having a the way in which community professionals use supervisor who was not the individual’s line Correspondence to: [email protected] their supervisory space. manager was also key to achieving a successful Abstract supervisor/supervisee relationship (Cutcliffe The restorative clinical supervision programme Background and Hyrkäs, 2006). This is further supported has been delivering a cascade model of What is known about clinical supervision? by Hansebo and Kihlgren, who noted that restorative clinical supervision to over 1 800 professionals across the UK. Currently, it is rolling There are vast amounts of studies covering the ‘supervision might be essentially, and most out the programme to 246 health visitors across topic of clinical supervision but as is frequently usefully, about nurturing practitioners’ the West Midlands to enable them to experience noted, the term itself is often written about (Hansebo and Kihlgren, 2004: 279). the model for themselves and to prepare them as an umbrella term with little clarity around In attempting to clarify the benefits of clinical to supervise other health visitors in the model. The programme has also been commissioned in function and purpose (Gonge and Buus, 2011) supervision the restorative element has been other trusts across the UK to reduce burnout, and with little empirical evidence of effective- regarded as an essential ingredient to increase stress and improve compassion satisfaction (the ness. Although clinical supervision is often re- job satisfaction, vitality and reduce stress pleasure one derives from doing their job) among ported as a good thing, calls for more robust and emotional exhaustion (Gonge and Buus, a range of professionals. This paper explores how clinical supervision is being delivered and implementation strategies, which use evidence- 2011). However, in the literature very few experienced by professionals within different based models as in other areas of practice are studies comment on what actually occurs in a trusts, and shares quantitative data to show how being made (Buus and Gonge, 2009; Vlachou et supervision session or what model staff were the specific restorative model used which differs al, 2011; Wallbank, 2011). The difficulty may be being exposed to (Howard, 2008). from usual clinical supervision has been significant in improving the capacity of professionals to in finding models with a robust evidence base. function at their optimum level. Clinical supervision has been identified as Supporting the health visitor able to increase nurses’ sensitivity towards The role of the contemporary health visitor Key words themselves and the families they care for means frequent exposure to demanding Health visitor, clinical supervision, staff stress, burnout, restorative supervision (Jones, 2006). It has been noted that where emotional challenges, the pace of change nurses attend clinical supervision they have within service as well as the rising demand Community Practitioner, 2012; 85(11): 20–23. an increased level of satisfaction with their from students needs as the Health Visitor psychosocial work environment through Implementation Plan (Department of Health Conflict of interest: Projected funded by NHS Midlands and East increasing job satisfaction and wellbeing (Begat (DH), 2011) moves forward are all vulnerability and Serverisson, 2006). The essential aim factors for professionals working in this area. It of clinical supervision should be to increase is important to bear in mind that where a visit the resilience of the professional ensuring has been difficult or emotionally demanding they can act on risk appropriately as well as the content of the work undertaken, especially guaranteeing and improving the quality of care within safeguarding, is not appropriate to delivered to families. be shared with colleagues, friends or family Clinical supervision is not a new concept for because of confidentiality other than in the nursing. However, the focus of much of the context of formal professional information literature is on nurses working with mental sharing. This can have an impact on the rather than physical health. This is perhaps professional feeling alone within their work following a presumption that professionals and not benefitting from the usual social working within the mental health sector are support networks, which are key protective more likely to be impacted by their work. factors (Regehr and Bober, 2005). Less scholarly consideration has been given to The Health Visitor Implementation Plan sectors of community public health nursing (DH, 2011) sets out the framework to ‘expand

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and strengthen health visiting services’ and highlights the challenges for the professional. Restorative supervision The Universal level requires the health visitor to support families who are likely to have limited needs. The emphasis for the health visitor is using their expertise to ensure that development is progressing normally and fine Families tuning their communication skills to provide Professional Clinical work reassurance and answer questions. The Universal Plus level requires a rapid response from the health visitor meaning External that other priorities have to be managed. The Management Risk relationships interaction with a family will be in supporting them with additional needs drawn from a wide spectrum. These may be problems with Organisation the adults within the family, to issues around Health Visitor Implementation Plan – ‘Emphasis on increasing the child development and/or child behaviour. autonomy of the professional’ Those needs will have to be identified and an appropriate intervention put into place. Given Figure 1. Supervision within the wider team context the criteria families often have to meet to access other services, the health visitor is highly travelling between appointments. The increase emotional demands of staff working in these likely to be working independently with these in demand for their services, especially in child areas and support them to build resilience levels families and perhaps at the top end of their protection reviews, and poor previous numbers reducing their own stress and burnout levels. own capabilities. These are the families that has meant that health visitors are often not The results showed restorative supervision appear to distress the health visitor most as they in a resilient mindset. We know that where increased compassion satisfaction (the pleasure are often not subject to a child protection plan the emotional burden of the role is not dealt one derives from doing their job) as well and have limited support around them; they with and processed it can impair performance as reducing burnout and stress by over 40% are regarded by health visitors as providing the (Wallbank and Hatton, 2011). (Wallbank, 2010). most potential risk. Following the success of the initial pilot, The Universal Partnership level calls on the The restorative clinical supervision further restorative programmes were health visitor to offer a health perspective model commissioned working with health visitors for families who have a number of complex To deliver an effective programme of care, and school nurses who were engaged in the issues and are likely to be working with several health visitors need a constructive space to NHS West Midlands leadership programme different agencies. This involves managing the think about and process their experiences. Too (Wallbank and Hatton, 2011). The supervision relationships between the agencies and ensuring often within services the emphasis of clinical was considered important given anecdotal that access to the family is maintained, often in supervision is on the content of the work and evidence both nationally, regionally and locally difficult circumstances; for example, where it seen as a managerial function rather than in that within health visiting services morale was has been the health visitor who has made the building the resilience and autonomy of the low, retention remained a real issue for several initial referral to children’s services. professional. providers and high levels of long-term sickness The health visitor is required to work in a The model of restorative supervision being and stress were resulting in a negative impact range of settings and the demand to be thinking rolled out within the West Midlands (Wallbank, on their services (Wallbank and Hatton, 2011). about what they are about to engage with is 2007) ensures that professionals improve their Baseline results of the pilot studies showed a constant. For any professional who works in the capacity to engage with families with decreasing lack of training in the delivery of supervision, community the demands of travelling between risk. They are able to build constructive high burnout and stress scores impacting different venues, judging traffic, weather and relationships with their immediate management on the professionals’ capacity to think and other impact factors to ensure you are on time team and the wider organisation improving make decisions in practice. Qualitative results make mental demands. This is not to suggest the workplace environment and ensuring that showed participants valued the experience of that professionals are unable to cope; just that external relationships remain positive, meaning supervision and it appeared to restore their juggling these demands has an impact. the health visitor can be supported within a ability to think clearly and make decisions. In It is unlikely, before the visit, that the health wider team context (Figure 1). summary, the model of clinical supervision visitor will know what type of family they used was effective in reducing the amount are engaging with, as unlike other services Extensive piloting of stress and burnout professionals were they do not receive referrals for families who The model was initially piloted in 2007 by experiencing and would restore their capacity to meet certain criteria. The resilient health Sonya Wallbank working with midwives, think and make decisions, potentially reducing visitor moves between these environments doctors and nurses working in obstetric and risk within their organisation (Wallbank and with a swan-like grace and is often found gynaecology settings (Wallbank, 2010). The Hatton, 2011). exhausted but satisfied at the end of long day pilot programme was designed to address the Staff participation in the development

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and piloting of the model meant that we team has also attracted a number of other staff Participants had developed a programme of restorative who work on a consultancy basis to deliver the The programme participants are selected supervision which contained the key programme in their areas. The team also has a differently by trusts. Some have expressed ingredients to a resilient and effective member full time assistant psychologist to support the their own interest in being trained, others of staff. research of the programme. have been nominated by their managers with A model of development that occurs within the final group responding to a global trust What has been developed the supervisory session has been developed invitation. The model uses the Solihull Approach, (Figure 2). This has been widely accepted motivational interviewing and leadership (Wallbank, 2011) to provide a coherent Methodology concepts, among others, to support understanding of why restorative supervision is The questionnaire used to evaluate the professionals working with complex families. needed when working with complex families. It restorative programme consists of the The emphasis of the model is on the resilience shows how the professional moves between the Professional Quality of Life Scale (PROQOL) of the professional, improving their own health anxiety of managing the risk and supporting (Stamm, 2009). The ProQol comprises three and wellbeing and supporting their capacity to complex families, being able to think about discrete scales that measure: think and make complex clinical decisions. themselves and their own learning needs and l Compassion satisfaction – the pleasure that Following investment from the NHS West then becoming creative and energetic enough one derives from being an effective caregiver Midlands leadership programme, a one-day to think about developing their service. Once l Burnout – feelings of hopelessness, difficul- training programme was developed. The day participants have been through the programme ties in dealing with work or carrying out the covers a range of topics, including the theoretical of supervision they are much more likely to work effectively basis for supervision, an outline of the model spend a consistent amount of time in the l Compassion fatigue – psycopathological and how the participant can use the model to creative zone than the anxiety one as they are symptoms associated with secondary expo- support them in their work. The programme more resilient. sure to stressful events. Stress was meas- is supported by a comprehensive manual to Traditional models of supervision tend to ured using the Impact of Event Scale (IES) support learning beyond the training. emphasise the content of the work being (Horowitz, 1982). The IES has 15 items, The second aspect of the training programme undertaken rather than on the professional seven of which measure intrusive symp- was for the professional to receive six sessions of delivering the care. This often means a toms (thoughts, nightmares, feelings and supervision from a member of the supervisory managerial approach is taken through the use imagery) and eight that identify avoidance team. Participants are then supported to of checklists and targets for the supervisory symptoms (numbing of responsiveness, cascade the model to no more than four of space and the professional suspends their own avoidance of feelings, situations and ideas), their colleagues using a supervisor readiness autonomous decision making. This model of and these are combined to provide a total scale (Wallbank, 2011). This ensures that restorative supervision focuses the professional subjective stress score. participants have gained the skills they need on their own capacity to think and make Before the training day staff are given to deliver the model of supervision and that decisions. It helps the professional reflect on information about the restorative programme they are ready to do so; and that they are not their own contribution to the situations they and the evaluation elements to allow them overwhelmed by the demand of taking on too find themselves faced with and aids clarity to give consent to their participation. many supervisees. This form of training also of thought. During the training day they are asked to ensures that commissioning organisations are complete a baseline questionnaire which takes left with a sustainable model to work with. Current programme activity approximately five minutes to complete. This The training team comprises the programme The programme is currently being delivered is completed again at the end of the sixth lead, clinical psychologist, nurse consultant to 249 staff across 13 trusts within the West session. The questionnaire data do not contain and a group of clinical supervisors who have Midlands. This brings the total number of any identifying features and data are processed health visitor backgrounds. The programme professionals to have been trained in the model anonymously by the programme researcher across the UK to over 1 800. The programme who analyses the results. has been recommended in the DH service level agreement to strategic health authorities Programme results Creative, energy, and the Early Implementer site leads are all Compassion satisfaction solution focused receiving training in the model from the The average score is 37 (SD=7; alpha scale Identification of programme lead. reliability=0.87). About 25% of people score learning/develop- higher than 42 and about 25% of people ment needs Supervisors score below 33. The average score on the The programme is overseen by a consultant burnout scale is 22 (SD=6.0; alpha scale Anxiety clinical psychologist. The clinical supervision reliability=0.72). About 25% of people score is delivered by senior health visitors who above 27 and about 25% of people score below have varied backgrounds, including specialist 18 (Stamm, 2009). clinical roles, team management, professional The IES measure can be also used to identify Figure 2. Model of development of lead role and safeguarding. levels of clinical concern, with Horowitz supervisees (Wallbank, 2011) (1982) proposing low, medium and high

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symptom levels based on the IES total score: Table 1. Latest programme results (n=1805) low=<8.5; medium=7.6–19.0; and high=>19 Scale measure Regional Regional post (Horowitz, 1982). baseline supervision The results show that the restorative (standard deviation) (standard deviation) supervision model (Wallbank, 2010) has Compassion satisfaction 44.20 44.72 been successful in maintaining compassion (4.18) (4.17) satisfaction, even suggesting a slight increase Burnout 42.81 24.71 in this area. (4.23) (5.13) Compassion satisfaction is a protective Stress 43.35 16.86 factor against stress and burnout; we know (4.12) (4.02) that when we gain pleasure from an activity, Key: l 22 or less Low l 23-31 Average l 31+ High even if it is stressful, we cope better. Burnout has reduced by 43% and stress by 62%; this Key points will mean a calmer workforce who are able to l Clinical supervision is recognised as a helpful tool for professionals working within think more clearly. clinically demanding roles l Less is known about the key ingredients for a positive supervision experience for health Learning from the programme so far visitors The effectiveness of the model is inextricably l The Restorative Clinical Supervision programme has evidenced a reduction in stress, linked to the approach that organisations burnout and increasing compassion satisfaction for 1800 participants have taken in developing a more reciprocal l Training professionals to offer restorative supervision improves the capacity of relationship with their staff teams. Where staff supervisees to think and function at their best an essential requirement given the current perceive that they are being supported by the demands on the health visiting profession introduction of this model of supervision they are more able to build productive rather than Midlands and beyond. We are looking at how supervision in psychiatric nursing: A systematic literature review and methodological critique. Int J Mental Health adversarial relationships even where times the model has impacted upon the relationship Nurs 18: 250–64. are difficult. between the professional and the family using Cutcliffe J, Hyrkäs K. (2006) Multidisciplinary attitudinal Changes to fundamental elements of how a web-based questionnaire and formalising the positions regarding clinical supervision: a cross-sectional professionals deliver their programme of care anecdotal evidence of the impact for the wider study. J Nurs Manag 14(8): 617–27. matter deeply to staff. Changes of base or where organisation. This will form part of our final Department of Health (DH). (2011) Heath Visitor Implementation Plan 2011–15: A Call to Action. London: a member of staff completes their clinical impact evaluation. DH. Available from: www.dh.gov.uk/prod_consum_ work from; have a largely negative impact on One of the inadvertent benefits of the dh/groups/dh_digitalassets/documents/digitalasset/ staff productivity. This may be as a result of programme is the professional being able dh_124208.pdf [Accessed March 2012]. change fatigue within health visiting but needs to focus on their own health and wellbeing. Gonge H, Buss N. (2011). Model for investigating the benefits of clinical supervision in psychiatric nursing: a to be thought about wisely to ensure that an Anecdotal evidence identified by supervisors survey study. Int J Ment Health Nurs 20(2): 102–11. appropriate balance between service need and suggests that professionals appear able to Hansebo G, Kihlgren M. (2004) Nursing home care: staff wellbeing are weighed up. Often, changes think about how they are functioning and changes after supervision. J Adv Nurs 45(3): 269–79. are not essential and the status quo can be spend more time thinking about what they Horowitz M. (1982) Stress response syndromes and their preserved to avoid unnecessary conflict. Where treatment. In: Goldberger L, Breznitz S (eds). Handbook of eat and how they exercise, which is having a stress: theoretical and clinical aspects. New York: Free Press. changes need to be made to meet service positive benefit to their health. The second Howard F. (2008) Managing stress or enhancing wellbeing? productivity levels, having a staff team who are phase of the programme research is, therefore, Positive psychology’s contributions to clinical supervision. on board with changes is crucial. looking at measuring health behaviours with Australian Psychologist 43(2): 105–13. There are numerous pockets of good a questionnaire, cortisol, heart rate and blood Jones A. (2006) Clinical supervision: what do we know and practice occurring across the profession what do we need to know? A review and commentary. J pressure to determine the programmes impact Nurs Manag 14(8): 577–85. and the motivation to support families and on the physiology of the participant. Regehr C, Bober T (2005). In the line of fire: trauma in the children is very high. Developing a model of emergency services. Oxford: Oxford University Press. service promotion and sharing good practice Acknowledgements Stamm BH. (2009) The concise ProQOL manual. Pocatello, are fundamental if the benefits of the Health The author wishes to thank all of the Idaho: ProQOL.org Visitor Implementation Plan are to be sustained professionals and organisations who continue to Vlachou E, Plagisou L. (2011) Clinical supervision as a support tool for nurses. Nosileftiki 50(3): 279–87. beyond 2015. Raising the profile of individuals be instrumental in support of the development and celebrating the success of a service appears Wallbank S. (2010) Effectiveness of individual clinical of the programme; with a special thanks to Sue supervision for midwives and doctors in stress reduction: unusual within health visiting services, and Hatton and Jane Williams. findings from a pilot study. Evidence-based Midwifery 8: this requires strong leadership to change 28–34. the culture. References Wallbank S, Hatton S. (2011) Evaluation of Clinical Begat I, Severinsson E. (2006) Reflection on how clinical Supervision delivered to health visitors and school nurses. nursing supervision enhances nurses’ experiences Comm Pract 84(7): 21–5. Future research of wellbeing related to their psychosocial work Wallbank S. (2011) Restorative Supervision Manual. environment. J Nurs Manag 14(8): 610–16. The programme will continue to research the NHS Midlands and East Restorative Clinical Supervision impact of the investment within the West Buus N, Gonge H. (2009) Empirical studies of clinical Programme.

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Parent and group leader reflections on a group-based programme for parents and babies

Introduction sensitivity to their babies’ cues, encourage the Catrin H Jones There is increasing interest in evidence-based early development of parent support networks and PhD Student intervention programmes that aim to establish highlight safety issues. Parents and their babies firm foundations for positive parent-infant meet weekly with two trained leaders for two- Judy Hutchings Director DClinPsych FBPsS OBE relationships and encourage child development. hour sessions. Updates on their infants’ activities Centre for Evidence Based Early Intervention (CEBEI) A recent government-commissioned report on and development are shared in a safe and Early Intervention stated that ‘What parents do is supportive environment. Parents are encouraged Mihela Erjavec BSc(Hons) PhD more important than who they are’ (Allan, 2011: to implement the programme strategies in their Lecturer in Developmental Psychology and Senior xiv). The report emphasised the importance of daily activities at home. If parents miss meetings, Researcher Food Dudes Health investing support for families at disadvantage leaders try to visit or call them to update them

J Carl Hughes PhD BCBA-D at an early age before behavioural and social and encourage their continued participation Senior Lecturer and Consultant Behaviour Analyst problems become entrenched and more in the group. Weekly phone calls to the parents School of Psychology, Bangor University expensive to tackle. A longitudinal evaluation of provide an opportunity for leaders to support individual family interventions with parents and parents. Parental participation is also rewarded Abstract babies (Olds et al, 1998) has shown substantial with token gifts and a shared meal/snack at each There is growing interest in supporting families during children’s early years to encourage optimal reductions in welfare and criminal justice meeting. Leaders follow a detailed manual with infant development. The data were collected expenditures, higher tax revenues in addition to weekly process checklist to ensure the programme from an evaluation of the Incredible Years (IY) improved physical and mental health. However, is delivered with fidelity in accordance with the eight-week parenting group for parents and their the high staffing costs associated with intensive programme developer. babies. Feedback obtained from parents (n= 34) individual home visiting programmes may still and leaders (n= 13) was positive. Retention and attendance rates were high. A detailed costing be prohibitive in terms of a preventative strategy Parenting groups: existing for the groups indicated that this programme for all high-risk children. An alternative method cost evaluations can be delivered for a reasonable cost to meet of support may be attending a group based A recent review by Charles et al (2011) concluded health visitor objectives with families in the first parenting programme. there is a paucity of research on the cost postpartum months and provides an opportunity The Incredible Years (IY) programmes for effectiveness of parenting programmes tackling to inform parents about resources and other support available for them and their infants. parents of pre-school and school aged children conduct disorder in children. Reviews based on (aged three to 12) have good evidence for programmes for parents with older children Key words reducing conduct disorder behaviour in children report variable delivery costs per child from £629 Infant; parenting; intervention; costing; Incredible and increasing the use of effective parenting to £3 893 (Dretzke et al, 2005), £282 to £1 486 Years strategies (Hutchings et al, 2004, Webster- (Bonin et al, 2011) and Edwards et al (2007) Community Practitioner, 2012; 85(11): 26–29. Stratton, 2011). IY parenting programmes reported that the 12-week basic IY programme use DVD based modelling and group practice delivered to eight families cost £1 595 per family. No potential competing interests declared to encourage effective parenting skills. The The information on the costs savings of programme emphasises the importance of providing parenting support for parents of parents and leaders to working collaboratively to babies is limited. McIntosh et al (2009) reported recognise important principles demonstrated in that individual home visiting of parents the programme DVD clips. and their infants by HVs trained to deliver a New IY programmes for parents of toddlers programme to improve parenting cost £3 874 and babies were recently developed in Seattle per intervention family compared to the societal (Webster-Stratton, 2008). The 12-week toddler cost of £7 120 from control families. The Elmira parenting programme has been the subject of Prenatal/Early Infancy project involved first time a Welsh Government (WG) funded separate mothers receiving 32 home visits during the late evaluation (see Griffith, 2011). The WG has pregnancy and first two years with long-term also funded training for 475 leaders across benefits for ‘high-risk’ families (unmarried, low Wales to deliver the IY babies programme. The socio economic status and/or mothers that were eight-week programme discusses appropriate younger than 19). The intervention families stimulation and aims to increase parental reported reduced maternal criminal activity

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and behaviour impairments, fewer subsequent Table 1. Baseline parent demographics (n=40) pregnancies and 33% less months receiving welfare benefits; the children also had fewer arrests Demographic data Numbers of families % by their 15-year follow-up, contributing to overall Index infant age weeks M=12.27 (4.96) savings four times the cost of the programme Sex of index child Male 19 47.5 (Olds et al, 1998; Karoly et al, 1998). Research Birth order First born 20 50 by Cunningham et al (1995) compared the cost Parent age at first birth M=22.58 (5.80) of providing individual/clinic based and large community based parent training programmes. Teen pregnancy 16 17.5 The group format became cost-efficient relative Parent age at baseline M=26.38 (6.23) to individual therapy once group sizes exceeded Relationship status Single/living apart 11 27.5 three families. Cohabit/married 29 72.5 Household in poverty Yes 35 85 Study purpose and scope Working household Neither parent 9 22.5 The purpose of this paper is to report on the experiences of parents and leaders involved in One parent 10 25.0 the IY parents and babies programme in north Both in work 21 52.5 and mid-Wales. The cost evaluation should give the services considering offering the programme costing diaries. This paper reports on the data Full measures collected from an understanding of the required commitment parents before groups started from five of the nine groups in which both leaders in time and costs involved in leaders that have (n=54) submitted a cost diary (n=10 leaders). been trained on certified courses delivering the programme with fidelity to the IY parents and 9 group delivered Group delivery method babies programme. by 18 leaders Sept Nine parents and babies groups were delivered 2010-March 2011 between September 2010 and March 2011 with Methods a total of 17 different group leaders working in Full costs diaries form both leaders Ethical approval (n=5 groups) pairs (one leader delivered two groups). The The evaluation received ethical approval by leaders were mainly HVs; other leaders were Bangor University School of Psychology and NHS family centre managers, specialist behaviour Research Ethics Committee (ref: 10/WNo01/40). Families withdrew before first group meeting (n=14) practitioners, parenting workers, educational and Parent infant dyads attended the group (n=40) clinical psychologists. The majority of the leaders Recruiting services and parents (n=14, 82%) were delivering the programme for Service managers in north and mid Wales Completed end programme questionnaire the first time and five (29%) had not delivered were contacted to explain the research plan, (n=34) any IY parent programmes prior to this study. gather information on birth rates and planned Figure 1. Flow chart of the numbers of Group locations for meetings varied from service delivery. Managers who committed to parents recruited and retained in groups well-resourced family centres (5), clinic rooms delivering the infant programme within their and leader data (2), and community halls (2). Family centres area, and agreed to release at least one of the had the advantage of on-site equipment and group leaders to attend weekly supervision, of the mothers lived with the babies’ father | facilities for parents and their infants within were invited to be part of the evaluation. at baseline. the building. Clinics and halls required leaders Further meetings were arranged to brief group This paper reports on families that attended to transport the programme and associated leaders in each area to explain the inclusion the IY babies and parents programme. The equipment for the babies to the venue each criteria and research process. Parent feedback was obtained using an end of week. Room hire arrangements also influenced HVs and other group leaders referred parents programme parent questionnaire included in the the scope for informal gathering before/after for the trial using the study inclusion criteria; IY manual (n=34); the results are summarised the group for a meal/snack. Overall, the groups parents had infants younger than 26 weeks in Table 2. Group leaders that attended the last spent £21.27 per family on refreshments during (mean age at baseline=12.27 weeks; SD=4.96) weekly supervision also completed an end of the programme. and were considered to be living in poverty, programme feedback form (n=11) and discussed calculated using the Families and Children the experience in a focus group (n=13) led by the Supervision Study criteria (Philo et al, 2009). first author. Leaders were asked a series of open Weekly supervision was provided by IY The first author conducted home visits to questions and discussions of their experiences accredited mentors to support the leaders to interested parents to explain the study and were recorded on the flipchart by the first author. deliver the programme with high degree of gain informed consent. A summary of the The questions used in the focus group related to fidelity. Recordings of previous group sessions demographic characteristics of all intervention the leaders’ overall impressions, perceived benefits were reviewed and leaders planned the following parents is presented in Table 1. The mean of providing the group, any specific difficulties group session. The first author also recorded the maternal age was 26.38 years (SD=6.23); 20 and suggested improvements to the programme. main issues discussed by each group at the weekly (50%) were first time parents and 29 (72.5%) Finally, leaders were asked to complete detailed supervisory meetings.

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section of the programme (n=4). Book bags, Table 2. Parents end of programme questionnaire feedback (n=34) treasure baskets, portion guides, toothbrushes Questionnaire statements Parent responses % and baby-led weaning information were shared What part of the programme Information on baby’s 35.3 within the groups (n=6) and leaders (n=2) also was most helpful? development 12 signposted parents to other activities. Group discussions 10 29.4 The group leaders (n=11) stated that the Social aspect 7 20.6 weekly supervision meetings were either helpful All of the programme 5 14.7 or very helpful. Overall one issue was shared and What did you like most Social interaction 13 38.2 problem solved at each supervisory meeting. about the programme? Developing new skills 8 23.5 Issues included dealing with negative or off- Support from group/ leaders 8 23.5 Everything 14.7 task members, how to encourage an inclusive What did you like the least DVD clips 6 17.7 group environment, striving for a balance about the programme? Paperwork 2 5.9 between delivering the programme content and Nothing 12 35.3 encouraging parents to observe and practice No comments 12 35.3 skills with their infants in the group setting (when Unrealistic expectations 1 2.9 the infants were awake). Some leaders (n=5) Journey to group 1 2.9 suggested changing the format to introduce How could the programme be Longer programme 6 17.7 infant developmental milestones before weaning improved to help you more? Started at a younger age 1 2.9 and others (n=5) described the last session Number hand-outs 1 2.9 as repetitive. Updated videos 1 2.9 Better chairs 1 2.9 Examples of mother sharing 2.9 Challenges time between children 1 Some leaders (n=4, 36%) reported having Could not be improved 7 20.6 difficulty in getting members to join the group. No comments 15 44.1 This may have been due to the programme being new to the leaders and parents. The method of Results valued herself as a mum after the group and that recruiting families varied according to location. Parental attendance at the groups it had given her the confidence to join a training HVs that contacted families during pregnancy Following baseline visits, 14 parents (26%) who programme. Parents also reported developing (n=2 groups) were able to recruit and more were offered a place on the programme declined effective routines and learning coping strategies importantly retain interested parents, while to attend. A telephone survey of these parents as they attended the group. those that relied on referrals from colleagues yielded the following reasons: illness (4), return in neighbouring areas lacked vital information to work (3), family issues (2), lack of child care Group leader feedback required for planning adequate resources for for older sibling (1), move (1), transport (1), clash The programme was rated positively with the interested parents. with other group (1) and no response (1). These overwhelming majority (72.7%) of the leaders The amount of time leaders reported on visits parents were thanked for their involvement and very likely and 27.3% of the leaders likely to and preparation before the first meeting varied interest and released from further follow-ups. deliver the groups in the future. One leader considerably between the five groups (mean Of the remaining 40 that attended the babies described the programme as the ‘bread and time=10.80 hours; SD=6.72). The two groups programme, the retention rate was high with butter of health visiting’. with the least amount of invested time specifically 34 (85%) attending six or more sessions (75% Group leaders described delivering the by the group leaders before the groups started of the programme) and receiving IY certificates programme as a rewarding and very enjoyable (three and five hours collectively per group) for successful completion of the programme. part of their work. They saw positive changes had the highest drop out of parents that agreed The mean attendance was high at 6.85 sessions in parental skills and the development of to attend (24.43% and 35%). Overall, the hours (SD= 1.86). attachment between parents and infants during spent collectively by both group leaders before the the programme. One leader commented that, groups’ first meeting correlated highly with the Parent feedback irrespective of family difficulties, by the end of the mean attendance in their group (r=.80), but this Parents were asked a series of questions about programme mothers were observing their babies failed to reach statistical significance (p=0.104), their overall impression of the programme, the more. The collaborative format enabled leaders probably due to small sample size (five groups). teaching format, which part of the programme to build trusting relationships with parents Some HVs (n=5) saw the group as an efficient was most helpful, what they liked or disliked most and ensure that issues such as safety could be use of their time as they were establishing a about the programme and any suggestions for discussed in a supportive environment. Leaders weekly contact within the group environments. improvements. Parents enjoyed learning how to stated that parents showed increased confidence However, group leaders (n=8) stated that they felt encourage their babies’ developments (35.29%), and expanded social networks with reports of that lack of time within their current workload group discussions (29.41%) and meeting other mothers meeting outside of the group. was a barrier to delivering the programme. They mothers (20.59%). Table 2 demonstrates parents’ Some groups invited other agencies such as commented that the preparation and assignment responses to the programme. One parent said that bilingual promotion officers and language and feedback to parents was completed in their before attending the group she felt suicidal, but play workers to join the group for the appropriate own time.

28 | Community Practitioner November 2012 Volume 85 Number 11 PROFESSIONAL AND RESEARCH: PEER REVIEWED

Technical difficulties with unfamiliar Key points equipment used to deliver the DVDs were reported by six of the nine groups and this also l Parent feedback was very positive with 85.3 to 97.1% of parents responding positively in serves to highlight the need for leaders to have the end of programme evaluation. Parents stated that they had learned new skills and time to plan and learn about equipment prior to particularly appreciated the support from the group format l starting the group. Group leaders reported that delivering the programme was rewarding for them professionally and for the group members l The collaborative format facilitates leaders and parents to build trusting relationships and Cost evaluation enables issues to be discussed in a supportive environment The leaders that submitted detailed costs l Service managers and group leaders need to allocate sufficient time for leaders to recruit include seven HVs, one family centre manager, and deliver the programme one specialist behaviour practitioner and one parenting worker (mean annual salary=£28 427, SD=6,71). Across all nine groups the mean annual Limitations supported by a KESS (PhD) studentship awarded salary was £31 158 (SD=7,98). The feedback should be interpreted with some to Catrin Hedd Jones (BU Maxi 017). The costs reported in this paper also include caution. Participant response bias may have an additional 50% on top of the mean salary for increased the level of positive feedback from References the group leaders to account for additional costs parents completing their end of programme Bonin E, Stevens M, Beecham J, Byford S, Parsonage M. (2011) Costs and longer-term savings of parenting of employment pension, employers NI and other questionnaires due to completing in the presence programmes for the prevention of persistent conduct general overheads, as was used in the evaluation and handing them to the leaders. Missing feedback disorder: a modelling story. BMC Public Health 11: 803. by Edwards et al (2007). from parents (n=6) and leaders (n=4) was due to Charles JM, Bywater T, Edwards RT. (2011) Parenting Based on a group of six parents attending with their absence at the last group session. interventions: a systematic review of economic evidence. Child Care Health Dev 37(4): 462–74. their infant, an initial group would cost £1 391.20 Another limitation is the small sample size in Cunningham CE, Bremner R, Boyle M. (1995) Large group per parent. This includes the initial investments in this study. All the groups were scheduled for the community-based parenting programmes for families of purchasing the programme, training two leaders daytime and this may have limited the scope for preschoolers at risk for disruptive behaviour disorders: and allowing the leaders to attend supervision some parents to attend; offering the programme utilization, cost-effectiveness and outcome. J Child Psychol Psychiatry 36(7): 1141–59. during the first group. This is comparable to other in the evenings may have appealed to fathers as Dretzke J, Frew E, Davenport, C et al. (2005) The effectiveness group based parenting programmes (Dretzke et 70% in this study were in employment. Larger and cost-effectiveness of parent training/education al. 2005; Edwards et al. 2007). As leaders become studies with leaders that were more experienced programmes for the treatment of conduct disorder, including experienced in delivering the programme, locally in the programme would be needed to evaluate oppositional defiant disorder in children. Health Technol Assess 9(1): 1–233. based peer supervision would replace the need for the programme further. Edwards RT, Céilleachair AJ, Bywater T, Hughes DA, leaders to invest additional time in traveling to Hutchings J. (2007) Parenting programme for parents receive supervision. Conclusion of children at risk of developing conduct disorder: cost- effectiveness analysis. BMJ 334(7595): 682. Subsequent groups with six parents could be Leaders need to invest time in visiting potential delivered at a greatly reduced cost of £424.68 families before the group starts to ensure Griffith N. (2011) Evaluating the Incredible Years Toddler programme for disadvantaged areas of Wales. PhD Thesis, per parent as the programme materials could be sufficient attendance rates. Additional support in Bangor University. used again and leaders would be familiar with the form of supervision for newly trained leaders Hutchings J, Lane E, Kelly J. (2004) Comparison of two the programme so external supervision could is important in ensuring the programme is treatments for children with severely disruptive behaviours: A be replaced with in house peer group support. four-year follow-up. Behavioural and Cognitive Psychotherapy delivered effectively. The cost of delivery compares 32: 15–30. Leaders that recruited and delivered larger groups, very favourably with other interventions and we Karoly LA, Greenwood PW, Everingham SS et al. (1998) based on the manual recommended size of 10 will shortly report further outcomes. Investing in our children: what we know and don’t know parents per group, would decrease the cost per The programme was well received by about the costs and benefits of early childhood interventions. Washington DC: RAND publications. parent to £834.72 at the first group and £254.81 the parents and leaders, enabling HVs and for future groups. other group leaders to build relationships McIntosh E, Barlow J, Davis H, Stewart-Brown S. (2011) Economic evaluation of an intensive home visiting with families and meet families in a positive programme for vulnerable families: a cost-effectiveness Discussion environment. The programme also has the analysis of a public health intervention. J Public Health 31(3): 423–33. Leaders and parents were positive about the group potential to ensure more families benefit from Olds D, Henderson CRJ, Cole R et al. 1998, Long-term effects experience. The cost evaluation suggests that this the range of support available at this crucial of nurse home visitation on children’s criminal and antisocial can be an efficient use of HV time in delivering period in their child’s development. behavior: 15-year follow-up of a randomized controlled trial. services to parents on their caseload within the JAMA 280(14): 1238–44. group and can integrate/promote efficient use of Acknowledgements Philo D, Maplethorpe N, Conolly A, Toomse M. (2009) Families with children in Britain: findings from the 2007 other family services. The authors would like to thank all the parents Families and Children Study (FACS). London: Department of The results show the importance of investing that agreed to be part of this evaluation and Work and Pensions. time before the group starts in meeting potential the dedicated group leaders who delivered the Webster-Stratton C. (2011) The Incredible Years. Parents, families to explain the format for the groups, plan programme with enthusiasm and often went the teachers and children’s training series. Program content, methods, research and dissemination, 1st edn. Seattle: Incredible Years. for any requirements as issues such as providing extra mile for their families. The quality of delivery Webster-Stratton C. (2008) The Incredible Years Parents, childcare for older pre-school siblings and timing was also ensured with the mentoring and support Babies and Toddlers series. Leader guide manual, 1st edn. the group to coincide with public transport. provided by the team at CEBEI. This work was Seattle: Incredible Years.

November 2012 Volume 85 Number 11 Community Practitioner | 29 PROFESSIONAL AND RESEARCH: PEER REVIEWED

Standardising school nursing practice: developing and implementing a care pathways package

Introduction lead to inequality of service provision. This paper Nicy Turney RN RM HV(Dip) CPT BA(Hons) The NHS has a longstanding relationship with describes the development and implementation Senior Nurse/Professional Lead care pathways for managing clinical processes of a package of care pathways in community and patient outcomes. At a time when the children’s health services. In this example the Maggie Clarke RN(CB) SCPHN BA(Hons) Senior Nurse (Professional Lead School Nursing)/ NHS is under extreme financial pressure, care conceptualisation of a care pathway is not Clinical Team Leader pathways are increasingly being positioned by one of a planned trajectory of care but rather policy makers and commissioners as agents of a means to define best practice and to help Emily Steventon BSc(Hons) MSc(Hons) service improvement (Allen, 2009). implement evidence-based practice. Comprehensive Local Research Network (CLRN) Research Facilitator Care pathways are in use in most healthcare Leicestershire Partnership NHS Trust systems and are purported to improve the Methodology efficiency and effectiveness of care, improve Developing care pathways in children’s Correspondence: [email protected] the quality of care and to ensure care is based services on current research and evidence (Vanhaecht The development and implementation of care Abstract The NHS has a longstanding relationship with et al, 2006). Care pathways, in generic terms, pathways could play a vital role in ensuring that care pathways for managing clinical processes enable the smooth implementation of national children’s services, such as school nursing, are and patient outcomes. Care pathways are an guidelines, local policy and research evidence. more focused on the needs of children, young effective mechanism to improve the delivery of The benefits of using care pathways include: people and families. The pathways, and their services in managing children’s health. However, l Ensuring care and treatment is evidence- associated guidelines in this best practice example few individual NHS trusts have successfully developed and implemented local pathways. based (including local/national guidelines were designed to support the services provided by This paper describes the development and and research evidence) healthcare professionals to families, young people implementation of a comprehensive care l Improving quality, consistency and continuity and children across community care in the East pathways package for school nursing in a of care Midlands. The project was instigated by two key community health services trust in the East l Reducing variation in assessment, care children’s health professionals and has had input Midlands. and treatment and support from the Senior Management Team Key words l Increasing communication between health within Families, Young People’s and Children’s School nursing, care pathway, evidence based, professionals, teams and stakeholders Service (FYPCS), members of a School Nurse children, standards l Identifying and addressing gaps in service Reference Group, educational and operational provision. leads from community locality teams, locality Community Practitioner, 2012; 85(11): 30–32. managers and a Child and Adolescent Mental No potential competing interests declared A care pathway usually ‘determines locally Health Service (CAMHS) team. agreed multidisciplinary and multi-agency The launch of a local health visitor’s Standard practice based on guidelines and evidence … for Operating Procedure (SOP) acted as the driver a specific patient/client group’ (Overill, 1998: for the development and implementation of 10). They are commonly conceptualised as a a comprehensive package of care pathways, device to map the expected course of a health highlighting the need in the allied school condition and appropriate interventions. nursing service for an evidence-based tool to Care pathways are an effective mechanism to support practice and to respond to the Healthy improve the delivery of services in managing Child Programme 5–19 years (DH, 2009a). children’s health. The Department of Health (DH) Unlike the specific universal contact points set has published several national care pathways and out in the Healthy Child Programme 0–5 years the National Institute of Health and Clinical (DH, 2009b), school nurses do not have defined Excellence (NICE) has published guidelines contacts with the children, young people and on numerous child health issues. However, few families accessing their service. However, for those individual NHS trusts have successfully developed accessing school nursing services – whether it be and implemented local pathways. In particular, through a universal service (delivery of the Healthy the field of school nursing suffers from a lack of Child Programme 5–19 in the local population), standardised frameworks for practice, which may universal plus (delivery of specific expert help and

30 | Community Practitioner November 2012 Volume 85 Number 11 PROFESSIONAL AND RESEARCH: PEER REVIEWED

support in response to additional health needs), universal partnership plus (ongoing additional support for vulnerable children, young people and families) or through a community model (the development and provision of a range of health services in the local community) (DH, 2012) – core principles of practice are still required to ensure high standards of equitable care, in line with best practice guidelines (eg, NICE guidelines). In the former Leicestershire County and Rutland Community Health Services NHS Trust this was achieved through a school nursing core offer, setting out the essential services school nurses would provide to local schools and the associated service users. Leicestershire County and Rutland Community Health Services NHS Trust merged with Leicestershire Partnership NHS Trust in April 2011 as a result of the Transforming Community Services agenda. Figure 1. Snapshot of the HNA care pathway As part of the Transforming Community Services agenda, which has as its central tenant This reference group was tasked initially with the health issues of local communities, leading innovation and improvement of services and prioritising the top 10 areas of practice that to agreed priorities that improve health and supporting high-quality care to service users, the were undertaken by school nurses. This was a reduce inequalities. Locally, it was felt that development and implementation of a package consultative process, involving all the school nurses school nurses had an obligation to carry out of care pathways was identified as an approach in the organisation, asking them to identify where a HNA to promote their services and secure which would ensure high-quality, evidence-based they spent their time, knowledge and skills. This agreements with commissioners regarding local care to school nursing service users (DH, 2009c). resulted in 10 areas of practice being identified: needs. Additionally, this allowed school nurses Seizing the opportunity to shape school 1. Health needs assessment to prioritise and plan their workloads as well nursing into a robust, streamlined, fit-for- 2. Safeguarding as clarifying their role. Therefore, a pathway purpose service, the decision to develop and 3. describing the way that a health needs assessment implement a comprehensive package of care 4. Immunisations was undertaken was the first to be addressed. pathways identified the following project aims: 5. Behaviour The three components that the school nurse l To outline and set high standards of equitable 6. Self-harm team already use as part of their assessment; the care across the county, in line with best 7. Long-term conditions school entry questionnaire (a locally-devised data practice guidelines 8. Sexual health collection tool to capture parental awareness/ l To improve the confidence and competence 9. Continence priorities of their child’s health before school of, and support to practitioners 10. Healthy weight management. entry), the individual school profile (a locally- l To raise the standard of care given to young devised data collection tool to capture individual people and their families/carers Of the 10 topics identified, three (safeguarding, school’s awareness/priorities of health issues) l To market the strengths of practitioners and immunisations and smoking) already had and the information from health improvement the organisation clear local pathways and strategies in place. specialists and local population data were l To clarify the diverse role of the school nurse. The remaining seven key topics went on to brought together in the HNA care pathway. A local school nurse reference group (membership be developed into the pathways to form the An innovative approach was selected to develop comprising a minimum of two school nurses, a comprehensive care pathways package. the HNA pathway into an electronic document senior nurse, practice educator, locality manager, At this point the trust’s research facilitator using Microsoft® VISIO software which is a clinical lead and a health improvement specialist) became involved and was instrumental in diagrammatic, interactive, user friendly package were given responsibility for taking the pathway ensuring that the project and its constituent parts which enables content to be instantly updated. project forward as it fell within their terms of were supported by research evidence, national Guidelines, policies and research evidence reference, which were: guidelines and local policies. A consensus decision documents were embedded into each electronic l To provide a forum for the review of the was reached by a team of multidisciplinary pathway to assist the practitioner and provide school nursing agenda and priorities, both at professionals to focus on the Health Needs clarification at each stage. a local and national level Assessment (HNA) pathway to kick-start the Following the development of the HNA pathway l To provide standards of practice to the project. The driver to create the HNA pathway and greater familiarity with the Microsoft® locality teams first was the need to ensure that firm foundations VISIO software, the further six pathways were l To review clinical policies and setting up for school nursing practice were established and developed in partnership with other agencies and implementation systems to the locality school associated interventions were evidence-based. professionals. Some pathways, where appropriate, nursing teams. A HNA is a systematic approach for reviewing were divided into age groups and can be used

November 2012 Volume 85 Number 11 Community Practitioner | 31 PROFESSIONAL AND RESEARCH: PEER REVIEWED

across the 0–19 age range giving a seamless service Evaluating the impact of the is that we are using the same resources, guidance to children, young people and families. This led to comprehensive package of care pathways and training so that all agencies know their roles, a comprehensive package of electronic pathways. So far, feedback from practitioners about the responsibilities and accountabilities. Future steps Rather than use paper documents, which comprehensive package of care pathways has been will be to translate the pathways into service user- have the potential to become outdated, the care very positive. Anecdotal evidence suggests that the friendly versions to maximise the engagement of pathways were real-time, providing access to package provides practitioners with long-awaited children, young people and families with the local the most up to date and current practice. Each support tools, which they have indicated will assist health priorities. pathway instantly linked the practitioner to them to more efficiently perform their role. professional and credible websites relevant to Evaluation should be an integral part of Conclusion that sphere of practice – such as Asthma UK – development work in the health service and yet it This pathway project was the first of its kind in and can be accessed live on the trust’s intranet. often seems to be an afterthought. The intention the trust, where previously very little work had The pathways can only be appreciated when used moving forward is to undertake a comprehensive been undertaken to identify the evidence base as a live document where the hyperlinks direct evaluation of the care pathways package, for many of the common processes performed you immediately to government documents, which will involve an audit of a health records in children’s services. The pathways are in their local policies and best practice documents. database (SystmOne) to measure the use and infancy and the maintenance and updating effectiveness of the pathways in the organisation. of content will be an ongoing process but Implementing care pathways in To complement the objective assessment of initial feedback from practitioners about the children’s services pathway use (including, for example, analysis of accessibility and application of the pathways in In April 2012 the comprehensive package of care data on referral rates to support services via the day-to-day practice has been very positive. At a pathways was launched in conjunction with the care pathways), a qualitative element will also be time when innovation is key and transforming trust’s new school nursing standard operating included in the evaluation to seek the views of services to be more streamlined and efficient, procedures. Together, these give school nurses the practitioners using the pathways. pathways have been demonstrated as integral within the organisation clear standards for A well conducted evaluation may serve to to this work in one trust. practice and identify their responsibilities at reassure commissioners and NHS managers that It is hoped that the future evaluation of the each contact. For example, the behaviour and the school nursing service provides value for pathways in this project will demonstrate that continence care pathways outline the number of money through better and more consistent use of the school nursing service is providing value for contacts that a school nurse should be offering services. In contrast, results might identify gaps money through better and more consistent use children and young people and illustrates the in service provision or staff training needs which, of services, paving the way to the delivery of the process from initial assessment, the package of although would ultimately mean benefits for the public health agenda and ensuring a seamless, care to re-assessment, then discharge or referral. service, would have financial implications. With transparent journey for children, young people Early indications are that the pathways have been financial aspects of health service provision at the and families. readily adopted by practitioners and that they are forefront of commissioning decisions, projects in use in their day-to-day practice. The pathways such as this may also serve to identify misuse of Acknowledgements provide assurances of what can be delivered by resources and thus lead to cost savings. Des Anderton, Andrea Fiford, Sharon Gregory, the school nursing service and if applicable when Amy Roberts, Deborah Hockett, Jo Chessman to refer children, young people and families on to Key outcomes and lessons learned and School Nurse Reference Group. other services. In conjunction with the pathways, The pathway project has enabled us to demonstrate training needs have been identified and standards both to our commissioners and our partners the References have been set. The pathways can be accessed key areas of school nursing practice. It has also been Allen D. (2009) From boundary concept to boundary object: The practice and politics of care pathway through the staff intranet and linking them in to an opportunity to work more closely with allied development. Social Science and Medicine 69(3): the system (SystmOne) services, particularly with regard to the self-harm 354–61. is a future priority. pathway and long term conditions pathway, where Vanhaecht K, Bollmann M, Bower, K et al. (2006) The process of embedding the packages into the developing the tools was done in collaboration with Prevalence and use of clinical pathways in 23 countries – an international survey by European Pathway Association nursing service and other allied children’s services, the Child and Adolescent Mental Health Service E-P-A.org. Journal of Integrated Care Pathways 10(2): is a continued focus and the next step following (CAMHS) and specialist nurses in a neighbouring 8–34. implementation is to evaluate their impact. acute NHS trust. One of the great benefits of this Overill S. (1998) A practical guide to care pathways. Journal of Integrated Care 2: 93–8. Key points Department of Health (DH). (2009) Healthy Child Programme from 5–19 Years. London: DH. l School nursing suffers from a lack of standardised framework for practice, which may lead DH. (2009) Healthy Child Programme: Pregnancy and to inequality in service provision the first five years of life. London: DH. l National care pathways are available for children’s health but few NHS trusts have  DH. (2012) Getting it right for children and young people. successfully developed and implemented local pathways that translate national London: DH. guidelines to the needs of the local population DH. (2009) Transforming Community Services: Ambition, l Locally-driven care pathways could play a vital role in ensuring community children’s Action, Achievement. Transforming Services for Children, health services such as school nursing are focussed on the needs of families, children and Young People and Families. London: DH. young people National Institute of Health and Clinical Excellence (NICE). (2006) Health Needs Assessment: A Practical Guide. London: NICE.

32 | Community Practitioner November 2012 Volume 85 Number 11 BREASTFEEDING IS BEST FOR BABIES* With expert advice… Infants with Cow’s Milk Allergy don’t have to miss out A new series of parent information booklets by two leading paediatric dietitians

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Return to health visiting? You must be mad! Going back to a career in health visiting was not part of Algar Goredema-Braid’s plan – but rejoining the profession has revitalised her life and changed the course of her future

Algar Goredema-Braid (right) at work in Birmingham

34 | Community Practitioner November 2012 Volume 85 Number 11 First person

Algar Goredema-Braid GDL MBA MA SCPHN PE RN Health Visitor, Birmingham Community Healthcare NHS Trust

y career in the NHS started as a cadet Mnurse over 30 years ago. The learning foundations and the nursing values instilled in me at the time anchored a career journey that afforded me opportunities to work as a nurse, midwife, health visitor, fieldwork teacher and team leader and in senior jobs at various levels in commissioning and general management. So – why am I back working as a health visitor? My last job in the local authority became redundant and this enforced vehicle for doing this. It states that ‘effective Capacity Programme. In working with career break became an opportunity to leadership is required to ensure that various identified communities to assess their travel, get involved in voluntary work and practitioners contributing to the Healthy health and wellbeing needs and plan for spend time with my grandchildren. It Child Programme communicate with one improvement, I have, in partnership with one was also an opportunity to reflect on my another and provide a holistic, co-ordinated of our children’s centres, started exploring past employment and my time in health service tailored to local needs’ (DH, 2009: 65). this in relation to speech, language and visiting stood out as the most enjoyable and Having successfully completed my return communication. successful of my career. to practice training, which required a When, finally, the time came to return minimum of 300 hours, I chose to work in a Passion to work, I was enticed by an advert for multicultural area of Birmingham with over I am even more passionate about health visitor vacancies in Birmingham. 73% black and minority ethnic communities, preventive health and believe strongly in I was excited when I found out about the predominantly Pakistani (2007 ONS the effectiveness of integrated services and Department of Health’s new health visiting estimates). effective multi-agency partnerships. Drawing service vision, which is backed up by the Infant mortality is 14.3 per 1 000 births on the skills and experience I have gained national Health Visitor Implementation Plan (2007/9) in one council ward compared to 7.7 over the years, I am hitting the ground (DH, 2011). per 1 000 births for Birmingham as a whole. running and working hard to establish local Not only were 4 200 more health visitors knowledge and building the relationships going to be recruited nationally, but there Health needs that are fundamentally essential to making was also the greatest opportunity I had ever I work in a beautiful, modern building with sure we make the most of increasing known to address health inequalities and a skill-mixed dedicated team of colleagues resources in health visiting and joined-up undertake preventive initiatives in a joined- that reflects the multicultural community working to make a real difference. up and focused way. we serve. Some have worked in the area for I would urge other people thinking of many years and some live within the local returning to health visiting to do it. Come Making a difference community and speak the local community back to the profession and don’t be put off I am passionate about making a difference. I languages. There are high health needs, and by people saying that the challenges we face believe we can achieve our goals by engaging a lot to learn and do. are too big – the journey of 1 000 miles starts in prevention and early intervention, I can understand, why on the face of it, with just one step. And with each step taken, integrating services and effective partnership some people thought I was mad to return. you can make a lasting difference to a young working. There remain shortages of health visitors child’s life. The chance to work with parents, in many areas and the demands of child communities, GPs, children’s centres and protection work have meant implementation References other stakeholders with the same targets, of the new service model will be incremental. Department of Health (DH). (2011). Health visitor implementation plan 2011-15: a call to action. Available priorities and goals was enticing. The Healthy However, I have always been one for seizing from: http://www.dh.gov.uk/en/Publicationsandsta- Child Programme, a clinical and public opportunities. One that has come my way, tistics/Publications/PublicationsPolicyAndGuidance/ DH_124202 [Accessed October 2012]. health programme led by, and dependent and I guess your way too, as this initiative DH. (2009) Healthy Child Programme: pregnancy and on, health professionals is an important is national, is the Building Community the first five years of life. London: DH.

November 2012 Volume 85 Number 11 Community Practitioner | 35 ADVERTISEMENT Multiple childhood ailments: Multiple treatment options from the CALPOL® Range The makers of CALPOL® understand that when a child is ill, parents want to do all they can to get them back to normal. But when their child is suffering with more than one ailment at a time, some parents may be confused or anxious about making a mistake when giving their child medicine at home.1 To help support parents, the makers of CALPOL® have a range of products that have been designed specifically to be used alongside CALPOL® Infant Suspension (paracetamol) to provide additional, effective relief from most common childhood ailments. The guide below aims to provide clear and accurate guidance about which medicines from the CALPOL® range can be used together to ensure parents have the confidence they need to treat their children safely at home.

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CALCOUGH® Infant Syrup CALPOL® Soothe and Care Saline Nasal CALGEL® Teething Gel (glycerol) which can be used Spray* or NEW FORMAT CALPOL® Soothe (lidocaine hydrochloride and from three months and Care Saline cetylpyridinium chloride). to coat throats to Drops* soothe coughs, It can be used from three months to: Helps unblock noses while allowing 2 • quickly numb sore gums natural sleep in just 5-10 minutes and can be used from • provide rapid soothing relief from birth to provide natural teething pain relief from congestion caused by: • Cold and flu • Sinusitis • Allergy including hayfever

* This is not a medicine CALPOL® is the UK’s best-selling children’s pain and fever relief medicine2, trusted by parents and healthcare professionals for over 45 years. The makers of CALPOL® have a range of medicines that are specifically designed for children – with more mums trusting, using and recommending CALPOL® than any other children’s pain and fever relief brand.3 For more information on the CALPOL® range, visit: www.calpol.co.uk or contact McNeil Healthcare (UK) Ltd. Care Line on 01344 864042.

Calpol Infant and Sugar-free Infant Suspension Product Information: insufficiency should not take this medicine. Maltitol may have a mild laxative Precautions: Do not exceed stated dose. Avoid in patients with rare fructose Presentation: Suspension containing 120mg Paracetamol per 5ml Uses: effect (Sugar-Free only). Parahydroxybenzoates and carmoisine may cause intolerance. Pregnancy and lactation: Not applicable. Side effects: Rarely Treatment of mild to moderate pain and as an antipyretic. Can be used in many allergic reactions. Fertility, pregnancy and lactation: Consult doctor before use. hypersensitivity reactions or allergic reactions. RRP (ex-VAT): 10g: £2.17. Legal conditions including headache, toothache, earache, teething, sore throat, colds Side effects: Very rarely hypersensitivity and anaphylactic reactions including category: GSL. PL holder: McNeil Products Ltd, Foundation Park, Maidenhead, and influenza, aches and pains and post immunisation fever.Dosage for Children skin rash. Blood dyscrasias, chronic hepatic necrosis and papillary necrosis have Berkshire, SL6 3UG. PL number: 15513/0015. Date of preparation: May 2008 over 3 months: Do not give more than 4 doses in 24 hours and leave at least 4 been reported. RRP (ex-VAT): 100ml bottle: £2.60; 200ml bottle: £4.36; 12 x hours between doses. Children 4 to 6 years: 10ml. Children 2 years to 4 years: 5ml sachets: £2.87 ; 20 x 5ml sachets (sugar free only): £4.62. Legal category: Calcough Infant Syrup Product Information: Presentation: Syrup containing 7.5 ml. Children 6 to 24 months: 5 ml. Children 3 to 6 months: 2.5 ml. Dosage 200ml bottle: P; 100ml bottle: GSL; Sachets: GSL. PL holder: McNeil Products 0.75ml Glycerol per 5ml (15%v/v). Uses: Relief of dry tickly coughs. Dosage: for Infants 2-3 months: Post –vaccination fever at 2 months: 2.5ml, and a Ltd, Maidenhead, Berkshire, SL6 3UG. PL numbers: Calpol Infant suspension: Children aged 1 – 5 years: 10ml 3 to 4 times daily; Children 3 months – 1 second dose, if necessary, after 4-6 hours. The same two doses can be given for 100ml bottle: 15513/0122; 200ml bottle: 15513/0004; Sachets: 15513/0154. year: 5ml 3 to 4 times daily; Children under 3 months: not recommended. the treatment of mild to moderate pain and as an antipyretic in infants weighing Calpol Sugar-free Infant Suspension: 100ml bottle: 15513/0123; 200ml bottle: Contraindications: Hypersensitivity to ingredients; fructose intolerance. over 4kg and not born before 37 weeks. Contraindications: Hypersensitivity 15513/0006; Sachets:15513/0155. Date of preparation: March 2012. Precautions: If symptoms persist for more than 3 days consult doctor. to paracetamol or other ingredients. Precautions: Caution in severe hepatic Pregnancy and Lactation: Not applicable. Side Effects: Possible mild laxative or renal impairment. Interactions with domperidone, metoclopramide, Calgel Teething Gel Product Information: Presentation: Topical gel effect. RRP (ex-VAT): 125ml £2.85 Legal category: GSL. PL Holder: McNeil colestyramine, anticoagulants, alcohol, anticonvulsants and oral contraceptives. containing Lidocaine hydrochloride 0.33% w/w and Cetylpyridinium chloride Products Ltd, Foundation Park, Roxborough Way, Maidenhead. SL6 3UG. PL No: Patients with rare hereditary problems of fructose intolerance should not take this 0.1% w/w. Uses: Relief of teething pain. Dosage: Children over 3 months: rub 15513/0168. Date of prep: Jan 2010 medicine. Due to the presence of sucrose and sorbital in the Infant Suspension, 1/3rd inch (7.5mm) of gel onto affected area of gum up to 6 times a day. Do patients with glucose-galactose malabsorption or sucrose-isomaltase not reapply within 20 minutes. Contraindications: Hypersensitivity to ingredients.

References: 1. Medicines for Children, Royal College of Paediatrics and Child Health, http://www.medicinesforchildren.org.uk/what-we-do/why-we-produce-leaflets/ Last accessed August 2012 2. Source: IRI Volume sales 13 w/e 28 July 2012 3. Data on File. Millward Brown Equity Tracking 2012 UK/CA/12-0655a

15303 J&J CalAdv CP 297x210.indd 1 12/10/2012 09:02 PRACTICE: PEER REVIEWED

Getting to the bottom of nappy rash

Introduction diarrhoea and then a cold. Heather Morris RGN SCM l Medical Writer Nappy rash describes a range of inflammatory Teething – 56% reactions of the skin in the nappy area. The l Diarrhoea – 42% Abstract key presenting feature is a pink or red rash l A cold – 35% Most babies are likely to get nappy rash at around the nappy area, which may be a series l First sleeping through the night – 29% some time. It’s usually a mild condition which l can easily be treated, but understandably is of small spots or blotches. In mild cases, apart Weaning onto solid foods – 25% a cause for concern to parents. Community from the rash, the baby will otherwise appear l Antibiotic use – 21% healthcare professionals are likely to be asked to be well. l Changing from breast to formula milk – for advice and this article aims to give a It is a common problem and is thought to 12% (GFK, 2012). practical overview of managing mild cases of nappy rash. affect around a third of nappy-wearing infants at any one time (NHS Clinical Knowledge Teething Key words Summaries (CKS), 2009). Boys and girls, Overall, 56% of parents whose infant had had Nappy rash, ammonia, teething, skin, and infants of all racial groups, are equally nappy rash reported a link between nappy inflammatory affected (CKS, 2009). The fact that nappy rash rash and teething. Comments from popular Community Practitioner, 2012; 85(11): 37–38. is so common should help to reassure anxious parenting discussion sites consistently claim parents. a link with posts such as the two below, being No competing interests declared typical examples of the numerous discussions Causes about nappy rash taking place on a daily basis Ammonia between parents. When a baby soils or wets itself, the nappy ‘Daughter used to get a shocking bum when cannot always absorb the waste products. This teething. Only time we’ve ever had nappy rash means that the child’s delicate skin will come really.’ (Mumsnet (www.mumsnet.com), into contact with urine and faeces. When a 2012) nappy is left on for a long time, the urine and ‘Son is nine months and has got seven teeth faeces can turn into the chemical ammonia which have come one at a time since he was which can irritate the baby’s skin, causing it to seven months constantly, so he’s had a red, sore become sore and inflamed. bottom for ages – and dirty nappies five times a day. Health visitor said it was due to his teeth.’ Fungal infection (Mumsnet, 2012) Nappy rash can also be caused by a fungal A literature search showed that irritability, infection. If the baby’s skin is warm and damp increased salivation, runny nose, loss of for long periods of time, it can cause a fungus, appetite, diarrhoea, rash, and sleep disturbance known as candida, to grow. Like ammonia, are associated with primary tooth eruption. candida can irritate the baby’s skin. Sometimes, (Ramos-Jorge et al, 2011). It is likely that these the baby’s rash starts as a reaction to the factors could contribute towards the more ammonia, which is further complicated by a frequent occurrence of nappy rash when an fungal infection. infant is teething. There are a number of times when infants seem to be particularly prone to nappy rash. Diarrhoea A recent survey of parents identified seven key ‘Son (17 months) has had diarrhoea for about times when parents believed their child was 24 hours - needs a nappy change every two hours more prone to nappy rash. These included or so. He’s been left with really bad nappy rash, during and after antibiotic use, an episode so bad that he howls every time I clean him.’ of diarrhoea, teething, weaning, switching (Mumsnet, 2012) from breast to formula milk and during mild An episode of diarrhoea was the second most infections like colds (GFK, 2012). common link to nappy rash. There is evidence The most frequently cited link was between to support this link and a high incidence of nappy rash and teething, followed by a bout of irritant nappy rash has been observed in babies

November 2012 Volume 85 Number 11 Community Practitioner | 37 PRACTICE: PEER REVIEWED

who have had diarrhoea in the previous 48 Key points hours (Kazzi, 2006). Nappy rash usually begins with prolonged l Nappy rash is estimated to affect around one third of nappy wearing infants at any exposure to moisture and the contents of the one time nappy ie, urine and faeces. l The peak incidence tends to be between 9 –12 months with girls and boys equally affected l A cold A good skincare routine and appropriate barrier ointment form the basis for management ‘My 11 month old daughter has a cold and has in most mild cases really bad nappy rash!!’ (Mumsnet, 2012) ‘I was up most of the night with my little one he by the evening had a nappy rash.’ (Mumsnet, has a valuable role to play in advising parents has a cold and was so stuffed up in the night he 2012) about skincare routines to help treat and couldn’t sleep. Now he has a sore bum to top it all Weaning onto solid foods was given as a prevent nappy rash, as well as prescribing off.’ (Mumsnet, 2012) link to nappy rash by 25% of parents and or recommending an appropriate barrier A total of 35% of parents reported a link changing from breast to formula milk by ointment. between a baby having a cold and developing 12%. It is possible that dietary changes in an nappy rash. This could be caused by the child infant may lead to the production of more References experiencing diarrhoea or looser and more frequent, looser or watery stools, potentially Atherton DJ. (2004) A review of the pathophysiology, prevention and treatment of irritant diaper dermatitis. frequent stools while suffering a cold; the link leading to an increased likelihood of Curr Med Res Opin 20(5): 645. between diarrhoea and nappy rash is well nappy rash. GFK NOP. Nappy Rash Survey, March 2012. documented. Gupta AK, Skinner AR. (2004) Management of diaper Skincare advice dermatitis. Int J Dermatol 43(11): 830–4. First sleeping through the night Good skincare advice has a key role to play Hoberman A, Paradise JL, Rockette HE et al. (2011) ‘I feel that changing his nappy wakes him in both treating and preventing nappy rash. Treatment of acute otitis media in children under 2 years of age. N Engl J Med 364(2): 105–15. quite a bit, so I let him sleep through the night. Healthcare professionals are well placed to Honig PJ, Gribetz B, Leyden JJ, McGinley KJ, Burke LA. The downside was he developed nappy rash.’ give this advice. Key points about infant (1988) Amoxicillin and diaper dermatitis. J Am Acad (Mumsnet, 2012) skincare routines are listed below: Dermatol 19(2): 275–9. Although 29% of parents linked nappy rash l Leave the nappy off for a long as possible Jordan WE, Lawson KD, Berg RW, Franxman JJ, Marrer with their baby first sleeping through the night, l Change the nappy regularly AM. (1986) Diaper dermatitis: frequency and severity among a general infant population. Pediatr Dermatol the underlying cause is more likely to be the l Use only water or alcohol-free /fragrance- 3(3): 198–207. delayed nappy changes rather than the baby free baby wipes Kazzi A. (2006) Diaper rash. Available from: http:// sleeping for longer. The delayed changing of l Avoid soap, bubble baths and lotions emedicine.medscape.com/article/801222-overview nappies has a considerable effect on causing l Avoid using tight-fitting plastic pants over NHS Choices. Nappy rash. Available from: www.nhs.uk/ nappy rash, due to the link between nappy rash nappies conditions/Nappy-rash/Pages/Introduction.aspx#close [Accessed September 2012]. and prolonged contact time with faeces and l Avoid the use of talcum powder NHS Clinical Knowledge Summaries. (CKS) (2009) urine (Philipp, 1997). l Pat rather than rub the baby’s bottom dry Nappy rash. Available from: www.cks.nhs.uk/nappy_rash l Use a suitable barrier ointment at each [Accessed September 2012]. Antibiotic use nappy change. Philipp R, Hughes A, Golding J. (1997) Getting to the ‘First son always got nappy rash when on bottom of nappy rash. Br J Gen Pract 47(421): 493–7. antibiotics. Now the antibiotics seem to be giving Treatment Ramos-Jorge J, Pordeus IA, Ramos-Jorge ML, Paiva SM. (2011) Prospective longitudinal study of signs and my second son an upset tummy and nappy rash.’ Mild cases of nappy rash can usually be easily symptoms associated with primary tooth eruption. (Mumsnet, 2012) treated with a combination of the simple Paediatrics 128(3): 471–7. There is a strong link between nappy rash routine above and the use of an appropriate Wake M, Hesketh K. (2002) Teething symptoms: cross sectional survey of five groups of child health and the use of antibiotics. A recent study of barrier ointment. NHS Choices recommends professionals. BMJ 325: 814. children under two who were treated with that the best way to prevent nappy rash is amoxicillin-clavulanate demonstrated an to follow a good skin care routine, which increased incidence of diarrhoea and nappy includes ‘applying a barrier cream after each related dermatitis (Hoberman, 2011). nappy change’. Antibiotics are known to disrupt the normally Zinc ointment BP, zinc and castor oil are Although 29% of parents protective barrier of intestinal microflora all recommended (CKS, 2010). Ointments linked nappy rash with which can lead to diarrhoea. are generally more effective than creams and their baby first sleeping lotions, as they provide a better moisture through the night, the Dietary changes barrier (Atherton, 2004). ‘Daughter of 16 months started weaning a couple underlying cause is more of weeks or so ago with rice which she loves Conclusion likely to be the delayed and now sweet potato – also loves it and kept Most cases of nappy rash only cause mild nappy changes wanting more – then pooed all afternoon and symptoms and the community practitioner

38 | Community Practitioner November 2012 Volume 85 Number 11 The Range We’ve got babies’ bottoms covered

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Product Information Metanium Nappy Rash Ointment Presentation: Ointment for topical administration. Indications: treatment for nappy rash Dosage and administration: Children: Dab a small amount of Metanium over the sore area. Spread the ointment thinly so the skin texture can be clearly seen through it. Repeat at each nappy change. Contraindications: Hypersensitivity to any of the ingredients. Precautions and Warnings: If no response occurs, or the condition worsens, consult your doctor. For external use only. Side Effects: Rarely: skin irritations. Product Licence Holder: Thornton & Ross Ltd Legal Category: GSL Price 30g: (MRRP ex VAT) £2.92. Trade £2.06 Product Licence No: PL00240/0366 Date of preparation: June 2011 Metanium Everyday Barrier Ointment Abbreviated prescribing information Presentation: A greasy pale white/off-white ointment. Each pack contains titanium dioxide, white soft paraffin, liquid paraffin and dimethicone 350. Indications: For use as a skin barrier to help protect the skin from external irritants. Dosage and Administration: Infants: Use daily at every nappy change on clean dry skin, using clean dry hands. Apply a pea size amount to the skin, gently spreading the barrier ointment evenly to form a thin protective layer. Contraindications: Allergy to any of the ingredients. Precautions: For external use only. Avoid contact with eyes. If accidently swallowed, seek medical advice immediately. Do not use if the skin is broken, badly cracked, infected or bleeding. May stain dark materials white. Pregnancy: No restrictions. Interactions: None known. Side effects: Rarely, mild skin irritation may occur. Pack size: 40g & 80g. (MRRP ex VAT 40g is £2.39 and 80g is £4.39) Trade Price: 40g is £1.67 and 80g is £3.07 Medical Device: Class I. Manufacturer: Thornton & Ross Limited, Huddersfield. HD7 5QH. Date of preparation: March 2012.

5162•Metanium Range Ad_210x297_CP.indd 1 20/09/2012 10:03 AWARDS 2013 A celebration of professionalism The CPHVA and Community Practitioner are proud to announce the second CPHVA Awards, to recognise and celebrate the achievements and vital hard work of community nursing practitioners across the UK, each and every day

The CPHVA is immensely proud of the professionalism, You need to make sure your nominations are submitted online no passion and creativity that community practitioners and health later than 20 December 2012. visitors undertake daily, across a diverse landscape of practice Your entries will be assessed by a CPHVA judging panel environments. throughout January 2013. This work continues to be undertaken in extremely difficult The judging panel will release a short-list of finalists, no later than times, often with little or no recognition or appreciation. Launched 31 January, with no more than five finalists in each category. in 2011 to counter the lack of appreciation for the professional All those shortlisted will be invited to attend the awards ceremony, achievements of members, the CPHVA Awards acknowledge the when the winners will be announced. extraordinary work that members carry out every day with huge Profiles on the finalists and winners will be published in dedication, and without complaint. Community Practitioner journal.

A date for the diary Nomination criteria The CPHVA Awards will take place in the stunning setting You will need to visit the Community Practitioner journal website of Savoy Place, London on Wednesday 13th March 2013, at a (www.commprac.com) to enter your nomination(s) online. lunchtime ceremony that is the annual opportunity to recognise the You may nominate any colleague or team demonstrating achievements of the profession at your own national awards. exceptional work performance. Self-nominations are permitted, but The occasion will begin with a reception at 12pm, to which those shortlisted for each award will be invited to attend and enjoy meeting and mixing informally with their peers, our key partners and invited guests. After lunch, the presentation of the awards will form the highlight of a wonderful day. Now, the moment has come for you to nominate or be nominated for the awards – your awards – to celebrate you, your colleagues, your teams, and the positive work they accomplish.

How to get involved First, study the categories and list anyone you believe should be nominated for their outstanding professional contribution.

Next, prepare your nomination(s) From 1 October you will be able to complete the online entry form at the website and upload the information about your nominated person or team. 2013 Award Categories Community Practitioner of the year Community Practitioner Team of the year Health Visitor of the year Community Nursery Nurse of the year School Nurse of the year you must provide a supporting endorsement from a senior officer, Community Practitioner/Health Visiting team leader of the senior employer’s representative, or college lecturer. year You need to briefly describe the nominee’s activities, achievements, or contributions that you believe qualify them for an CPHVA Student of the year Award. Please limit this description to 500 words. Healthcare Assistant of the year These guidelines are intended to help focus your thinking when completing the nomination form. They are not all-inclusive nor are CPHVA Advocate of the year they intended as categories. CPHVA Trust Overseas Travel Bursary Nominations should describe the qualities nominees have displayed in their chosen area of professional practice. Make your nomination online at www.commprac.com

They could demonstrate: l outstanding care within their practice setting l an ability to be an advocate and professional role model l an ability to instigate, develop, coordinate and/or participate in projects and programmes that have a positive outcome for the health and wellbeing of the community l active participation in professional and/or community organisations that foster and advance the health and wellbeing of the community l a willingness to share their personal philosophy of community and public health nursing practice l a vision for community practice l a commitment to safety and quality l a personal commitment to continuing education for themselves and/or others.

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Developmental dysplasia of the hip

Introduction Daniel Westacott MBBS MRCS Community practitioners have a unique role Specialist Registrar in Trauma and Orthopaedic Surgery working with families and young children, and can prove vital in preventing problems Giles Pattison MBBS MSc(Med Ed) FRCSEd associated with developmental hip dysplasia FRCSEd(Tr&Orth) FHEA (DDH), which may affect a child for the rest Consultant Paediatric Orthopaedic Surgeon of its life. This might be through preventing Stephen Cooke MBChB FRCS(Tr & Orth) the condition by educating parents on safe Consultant Paediatric Orthopaedic Surgeon swaddling, supporting a young mother struggling to adapt to her baby wearing a Warwick Orthopaedics, University Hospital of Coventry and Warwickshire harness, or even by detecting a case that was not picked up through the current screening Figure 1. Barlow’s Test Correspondence: [email protected] programme. In this article, we hope to empower Abstract The close interaction between community community practitioners by providing some practitioners and young families provides facts and tips relevant to DDH so that they an invaluable opportunity for prevention, can provide support and education to parents education, support and even diagnosis in cases going through a potentially difficult process. of developmental hip dysplasia. This article provides a brief overview of the condition, DDH is a condition characterised by including clinical findings, screening protocols, incomplete formation of the ball and socket ‘hip safe’ practices, and common treatments of the hip joint during a child’s growth, both that may be encountered in the community. before and after birth. DDH encompasses Key words a range of pathologies, from a congruent Developmental hip dysplasia; examination; hip joint with a shallow socket, through hip screening; swaddling instability, to complete dislocation of one or Figure 2. Ortolani’s Test, flexion then both hips (Dezateux and Rosendahl, 2007). Community Practitioner, 2012; 85(11): 42–44. abduction (a positive test elicits a ‘clunk’) In Caucasians, around one child in 1 000 is No potential competing interests declared born with a dislocated hip, and one in 100 first-degree relative, female sex, first born, has a dysplastic hip at birth. It is believed multiple pregnancy, high birth weight to be caused by a combination of genetic and oligohydramnios. It is associated with factors and positional moulding in the congenital abnormalities such as metatarsus womb. If undetected, it can cause chronic adductus (pigeon toe), torticollis (wry neck), disability and necessitate hip replacement at infantile spina bifida and talipes equinovarus a comparably young age. Thirty per cent of (club foot). hip replacements performed under the age of 60 are thought to be due to DDH (Engesaeter Identifying DDH et al, 2008). The most reliable clinical signs in DDH If detected in the first few months of are restricted abduction and leg length life conservative interventions can have discrepancy. Asymmetry of the buttock and good results, although some established thigh creases is also suggestive of DDH but it dislocations still require surgical intervention must be remembered that this is only the case (Suzuki, 1993). DDH was previously referred if it is associated with leg length discrepancy. to as congenital hip dysplasia but this has In DDH, crease asymmetry occurs because of been largely replaced in recognition of the bunching of the soft tissues due to shortening facts that not all abnormalities are present at of the leg caused by a dislocated hip. Crease birth and that some dysplasia and instability asymmetry without leg length discrepancy is, normalises naturally during the first weeks therefore, unrelated to DDH. of life (Kocher, 2000). Recognised risk Ortolani’s and Barlow’s test are also factors include breech position, an affected commonly used. Barlow’s test (posterior

42 | Community Practitioner November 2012 Volume 85 Number 11 PRACTICE: PEER REVIEWED

pressure on a flexed and adducted hip) universal ultrasound screening is not the should detect an unstable or dislocatable hip perfect solution as it can lead to over- (Figure 1), while Ortolani’s test (flexion and treatment of hips that would normalise abduction) should demonstrate the reduction naturally as the child grows (Rosendahl of a dislocated hip (Figure 2). Unfortunately, et al, 1994) and doubts exist as to its cost- Barlow’s and Ortolani’s tests have been shown effectiveness (Rosendahl et al, 1995). Recent to have low diagnostic accuracy (Dogruel systematic reviews have been unable to et al, 2008). They are difficult to perform recommend universal screening (Woolacott correctly and their value depends greatly on et al, 2005; Shorter et al, 2011). the experience of the examiner. Figure 3. Swaddling that is not ‘hip healthy’ Guidance for parents on swaddling Screening The practice of swaddling babies has been It has long been common practice for babies growing in popularity recently as it is thought to undergo screening for DDH at birth and at to improve sleep and reduce crying (Meyer six weeks with clinical examination; but due and Erler, 2011). There is a high incidence to the low diagnostic accuracy of physical of DDH in cultures in which babies are examination, it is widely accepted that some swaddled with the hips extended and legs form of radiological screening programme together (Kutlu et al, 1992). This type of should be in place for the infant population swaddling during infancy has been shown (Morrissy and Cowie, 1987). to be the most significant risk factor for hip Ultrasound is a widely used and effective dysplasia in such cultures (Dogruel et al, test for detecting DDH. It is a relatively cheap, 2008). Keeping the legs in this position holds safe, accessible and acceptable screening tool the ball in an unnatural position within the but requires a skilled practitioner to perform socket, preventing normal maturation of the and interpret (Terjesen, 1996). X-ray is less joint (Figure 3). In contrast, cultures that reliable as the infant hip joint is largely made carry their children in the straddle or ‘jockey’ of cartilage so is not well demonstrated on position have very low rates of DDH (Figure plain radiographs and is unfavourable as it 4) (Salter, 1968). involves radiation exposure. If swaddling is to be performed, the arms In a number of countries in Europe, universal may be tightly wrapped but the legs should screening programmes are in place where Figure 4. The hip-safe straddle technique have room to move freely, with the hips able every newborn has an ultrasound scan. This to bend up and out. The International Hip is not the case in the UK, Scandinavia, or the per 1 000 live births (Clarke et al, 2012). This Dysplasia Institute has released guidance USA, due primarily to a lack of clear financial does, however, mean that a large centre can on ‘hip-healthy swaddling’ (see: http:// benefits (Rosendahl et al, 1995; Clegg et al, still expect to see up to four children a year hipdysplasia.org). 1999) and because some abnormalities picked that present at a later stage, often requiring up soon after birth resolve spontaneously major surgery to correct a deformity that Conservative management with normal growth (Shipman et al, 2006). may have been amenable to non-operative If diagnosed before six months of age, the Until recently, practice varied in the UK treatment if detected earlier (Lotito et first line of treatment for most children will between primary care trusts. It has now been al, 2007). be an orthosis. The most commonly used in standardised and the NHS Newborn and In general, the earlier DDH is detected, the UK is the Pavlik harness. This is a flexion- Infant Physical Examination Programme the easier it is to treat. Health visitors and abduction orthosis, consisting of an anterior (NIPE) recommends that babies with an community nurses may be the first health flexion strap and a posterior abduction strap abnormal physical examination at birth professionals to be alerted to a missed case for each leg, a chest strap, and two shoulder undergo ultrasound within two weeks and of DDH. Through a high index of suspicion straps. If employed before six months, it is those with a significant risk factor (breech and appropriate referral, a community successful in over 90% of cases (Grill et al, presentation or an affected first degree practitioner can save a child from a lifetime 1988). It is the authors’ practice to review the relative) are scanned within six weeks of birth of hip problems, potentially involving child weekly while wearing the harness, with (NHS Choices, 2012). numerous major surgeries. DDH should an ultrasound scan to ensure the hip is in joint This targeted screening programme means be suspected in the presence of any of the and developing well. These review clinics can that some cases may be missed, as over 60% of physical findings previously mentioned, or in be very busy, so parents may find they have cases of DDH have no recognisable risk factor a child with an uneven gait or a painless limp. unanswered questions or concerns that can (Standing Medical Advisory Committee, 1986) If there is any clinical suspicion, expedient be addressed later in the community. and the sensitivity of clinical examination is referral for ultrasound (or X-ray if older than Treatment is usually continued until three low (Dogruel et al, 2008). six months) can quickly confirm or rule out consecutive ultrasound scans are normal. Fortunately, targeted screening has been able the diagnosis. The harness is then weaned over a four week to reduce the rate of late presentations to 0.34 However, it should be remembered that period. However, treatment protocols do vary

November 2012 Volume 85 Number 11 Community Practitioner | 43 PRACTICE: PEER REVIEWED

a small surgical procedure to release a tight Kutlu A, Memik R, Mutlu M, Kutlu R, Arslan A. (1992) tendon, particularly on the inside of the hip Congenital dislocation of the hip and its relation to swaddling used in Turkey. J Pediatr Orthop 12(5): (an adductor tenotomy). 598–602. If closed reduction is unsuccessful, an open Lotito FM, Sadile F, Cigala F. (2007) Surgical treatment reduction is performed, which involves more of hip dislocation in early inf ancy. Hip Int 17(Suppl extensive surgery. This is often combined 5): S35–43. with procedures in which the bones are cut Meyer LE, Erler T. (2011) Swaddling: a traditional care method rediscovered. World J Pediatr 7(2): 155–60. to realign the femur and the pelvis in order to keep the hip in joint. Mooney JF 3rd, Kasser JR. (1994) Brachial plexus palsy as a complication of Pavlik harness use. J Pediatr Orthop 14(5): 677–9. Summary Morrissy RT, Cowie GH. (1987) Congenital dislocation Although a rigorous screening programme of the hip. Early detection and prevention of late Figure 5. A child in a Pavlik harness exists throughout the UK, community health complications. Clin Orthop Relat Res (222): 79–84. professionals should remain vigilant for Murnaghan ML, Browne RH, Sucato DJ, Birch J. (2011) missed cases of DDH, as the earlier treatment Femoral nerve palsy in Pavlik harness treatment for developmental dysplasia of the hip. J Bone Joint Surg is initiated, the simpler and less invasive it is Am 93(5): 493–9. likely to be. Any doubt regarding an infant’s NHS Choices. Change to guidance on ultrasound hips can be easily and safely allayed with examination of the hips in screening for developmental ultrasound scanning. dysplasia of the hips (DDH). Available from: http:// newbornphysical.screening.nhs.uk/standards Evidence does not exist to support ultrasound [Accessed October 2012]. screening of all infants. Tight swaddling with Rosendahl K, Markestad T, Lie RT. (1994) Ultrasound the legs together increases the risk of DDH screening for developmental dysplasia of the hip in the and should be avoided. The Pavlik harness is neonate: the effect on treatment rate and prevalence of a commonly used treatment which may be late cases. Pediatrics 94(1): 47–52. encountered in the community. Although Rosendahl K, Markestad T, Lie RT, Sudmann E, Geitung JT. (1995) Cost-effectiveness of alternative Figure 6. A child in a hip spica cast complications are rare, some may require screening strategies for developmental dysplasia of the urgent review by the treating surgeon. hip. Arch Pediatr Adolesc Med 149(6): 643–8. between centres, particularly regarding to the Salter RB. (1968) Etiology, pathogenesis and possible weaning process, with some surgeons electing References prevention of congenital dislocation of the hip. Can Med Assoc J 98(20): 933–45. not to wean at all. Clarke NM, Reading IC, Corbin C, Taylor CC, There is currently no evidence or guidance Bochmann T. (2012) Twenty years experience of Shipman SA, Helfand M, Moyer VA, Yawn BP. (2006) as to which method works better. Skin selective secondary ultrasound screening for congenital Screening for developmental dysplasia of the hip: a dislocation of the hip. Arch Dis Child 97(5): 423–9. systematic literature review for the US Preventive problems in the groin crease may occur and Clegg J, Bache CE, Raut VV. (1999) Financial Services Task Force. Pediatrics 117(3): 557–76. can be treated with hydrocolloid dressings. justification for routine ultrasound screening of the Shorter D, Hong T, Osborn DA. (2011) Screening The harness can, rarely, put pressure on the neonatal hip. J Bone Joint Surg Br 81(5): 852–7. programmes for developmental dysplasia of the hip brachial plexus at the shoulder or the femoral Dezateux C, Rosendahl K. (2007) Developmental in newborn infants. Cochrane Database Syst Rev 7(9): CD004595. nerve in the groin (Mooney and Kasser, 1994; dysplasia of the hip. Lancet 369(9572): 1541–52. Murnaghan et al, 2011). Any child that stops Dogruel H, Atalar H, Yavuz OY, Sayli U. (2008) Clinical Standing Medical Advisory Committee (1986) examination versus ultrasonography in detecting Screening for the detection of congenital dislocation moving an arm or leg while in the harness developmental dysplasia of the hip. Int Orthop 32(3): of the hip. Arch Dis Child 61(9): 921–6. 415–19. should therefore be urgently reviewed by the Suzuki S. (1993) Ultrasound and the Pavlik harness in treating orthopaedic surgeon. Grill F, Bensahel H, Canadell J, Dungl P, Matasovic T, CDH. J Bone Joint Surg Br 75(3): 483–7. If conservative treatment is successful, the Vizkelety T. (1988) The Pavlik harness in the treatment of congenital dislocating hip: report on a multicenter Terjesen T. (1996) Ultrasound as the primary imaging child will normally be followed up closely study of the European Paediatric Orthopaedic Society. method in the diagnosis of hip dysplasia in children with periodic ultrasound scans until six J Pediatr Orthop 8(1): 1–8. aged <2 years. J Pediatr Orthop B 5(2): 123–8. months of age and X-rays beyond that, Kocher MS. (2000). Ultrasonographic screening for Woolacott NF, Puhan MA, Steurer J, Kleijnen J. (2005) developmental dysplasia of the hip: an epidemiologic Ultrasonography in screening for developmental to ensure the hips continue to grow and analysis (Part I). Am J Orthop (Belle Mead NJ) 29(12): dysplasia of the hip in newborns: systematic review. mature normally. 929–33. BMJ 330(7505): 1413.

Surgical treatment Key points If conservative treatment fails to relocate l Only children with a significant risk factor now receive routine ultrasound screening in the the hip, or the child presents at an older age, UK, meaning some cases can be missed surgery may be necessary. In the first instance, l The later the diagnosis is made, the harder the condition is to treat this involves a closed reduction under general l Community practitioners can play a key role in the diagnosis of the condition and in anaesthetic. The hip is manipulated back supporting and educating parents into joint and held with an orthosis or a hip l Swaddling must be performed safely in order for the hips to develop normally spica plaster cast. This may be combined with

44 | Community Practitioner November 2012 Volume 85 Number 11

PRACTICE: PEER REVIEWED

Identifying gastro- oesophageal reflux disease in infants

Introduction by Vakil et al (2006), meaning symptoms that Sara Patience MSc RNutr RHV RN affect quality of life. Sherman et al (2009) Nutritionist and Health Visitor Parents or professionals may be concerned that a baby has gastro-oesophageal reflux disease acknowledge that while ‘troublesome’ can be (GORD), particularly if their baby cries more defined by adults and children with the ability Abstract than parents think is acceptable, is unsettled, to describe their symptoms independently (they This article will look at the similarities suggest those over eight years old) it becomes between normal baby behaviours, and normal appears to be in pain/discomfort or brings physiological gastro-oesophageal reflux (GOR) back milk. problematic for paediatric practitioners who and GORD, giving the practitioner evidence- Although this article does not look at the need to ensure that symptoms described by based information to offer reassurance to pharmacological treatment of GORD, it is parents/carer are those that are ‘troublesome’ parents. It will also look at conservative to the child, and not the parent/caregiver. The management of the common symptoms worth noting that in a placebo-controlled, of GOR, and try to identify why this double-blind study of the efficacy of proton identification of what is ‘troublesome’ to a baby condition can cause confusion among health pump inhibitors (PPIs) in infants aged one is harder to ascertain than what is ‘troublesome’ professionals and parents. year to 12 months, PPIs were found to be no to an adult. Key words more effective than placebo. The authors note Gastro-oesophageal reflux, gastro-oesophageal that, although there was an inclusion/exclusion Rationale for treatment reflux disease, health visitor, cows’ milk protein criteria for the study, the difficulty of accurately The aim of treatment for GORD is to reduce allergy, proton pump inhibitor diagnosis GORD may have gone some way to ‘troublesome’ symptoms, promote growth, contributing to the lack of efficacy found in prevent or treat oesophagitis and prevent Community Practitioner, 2012; 85(11): 46–48. this trial (Orenstien et al, 2009). complications (Rudolph et al, 2001). No potential competing interests declared Two papers exist that have agreed evidence- based consensus for the definition (Sherman et Symptoms and diagnosis al, 2009) and recommendations for treatment Signs and symptoms such as regurgitation, (Vandenplas, 2009) and these are accepted as crying, irritability and vomiting are commonly current and best evidence for this article. associated with reflux and are included in the ‘troublesome symptoms’ described Definitions of reflux above; however, they are also common baby GOR refers to the normal physiological behaviours, or may indicate GOR as well as process of some stomach contents rising back GORD and health visitors and team members into the oesophagus due to relaxation in the need to be able to knowledgably discuss these lower oesophageal sphincter. This occurs in symptoms with parents, helping them identify infants, children and adults, usually without what is normal and what may indicate a symptoms. In infants some regurgitation problem. may occur (Vandenplas et al, 2005; Van Howe Vandenplas et al (2005) state that et al, 2010). regurgitation will be present in the majority GORD occurs when GOR is accompanied by of infants with GORD but equally may be a additional and ‘troublesome’ symptoms, such as normal physiological event, however, when frequent regurgitation, irritability, crying, sleep accompanied by other symptoms he has disturbances, back arching or refusing to feed. classified as ‘very common’ such as crying/ This definition is accepted by NHS Evidence irritability, or ‘common’ such as: vomiting, Clinical Knowledge Summaries and is taken back arching, refusal to feed, persistent from Sherman et al (2009), who developed a hiccups, oesophagitis, impaired quality of global consensus of the definition of GORD life or failure to thrive then GORD should be in paediatric patients. The word ‘troublesome’ suspected. Sleep difficulties, haematemesis, was adopted from adult guidelines developed and respiratory symptoms are classified as

46 | Community Practitioner November 2012 Volume 85 Number 11 PRACTICE: PEER REVIEWED

‘possible’ GORD symptoms by Vandenplas Excessive crying and irritability or alginate products can be beneficial in (2005). Excessive crying is often considered to be GOR, but these are not easy to administer Although GORD can also be associated with a common symptom of GOR/D, although, to breastfeeding babies. In an investigation non-digestive symptoms, such as respiratory in reality, it is not a specific symptom of of 128 mother and baby pairs, Van Howe disease or apnoea, it should be noted that GORD, and GORD is not a common cause et al (2010) found no difference in the both conditions require expert investigation to of crying (Vandenplas, 2005; 2009). Crying incidence of reflux in breast or formula-fed rule out serious or potentially life-threatening as normal behaviour appears overlooked. In babies and their method of feeding should disorders. Hassall (2011) cautions that in recent 1962, Brazelton described how crying peaks be maintained, except for in the case of food years regurgitation and crying together have at around six weeks and then begins to decline allergy or intolerance. come to equate with a diagnosis of GORD, yet after three months; this pattern is described by The use of formulas specific for CMPA or argues that this is often not the case. Barr (1990) as the ‘crying curve’. removing cow’s milk from a breastfeeding Regurgitation and crying/irritability are Barr (2006) describes this normal early mother’s diet can be effective due to the among the most common concerns of crying as a behaviour that can be unpredictable crossover between GORD and CMPA which new parents, and each can be managed and not related to any specific event. The baby has long been recognised. conservatively in the first instance. It is worth can be difficult to console and may appear to In a prospective study by Iacono et al (1996) remembering that some symptoms may also be be in pain (although it is not) – crying from 85/204 infants diagnosed with GORD were indicative of other underlying health concerns 35 minutes to two hours. Hassall (2011) found to have CMPA demonstrated through and these should be ruled out. suggests that there needs to be a return to a cow’s milk-free diet and blind challenge. promoting suggestions to parents to manage CMPA, and other allergies or intolerances Regurgitation crying through parental actions, rather than can present with the same set of symptoms Often referred to as ‘possetting’ or ‘spitting associating it with gastrointestinal problems. as GORD, such as regurgitation, vomiting, up’, regurgitation is considered to be a very Vandenplas et al (2009) state that numerous crying, irritability, food refusal (Sherman et common symptom of GOR in infants, studies have demonstrated no relationship al, 2009). primarily due to the quantity of liquid diet and between crying and GORD as determined These should be considered in infants small size of a baby’s oesophagus (Vandenplas by pH testing or presence of oesophagitis. resistant to treatment for GORD. A change of et al, 2005). However, regurgitation alone is Again, when crying is accompanied by other formula or changes in a breastfeeding mother’s not be sufficient evidence for a diagnosis of symptoms, GORD or other conditions should diet should be maintained for two weeks. If a GORD (Sherman et al, 2009). Regurgitation be considered. woman removes dairy from her diet for any tends to resolve by the time the infant is length of time she will need to see a GP to between one year and 18 months of age Management of GOR/D discuss calcium supplementation. (Vandenplas, 2009). North American Society for Pediatric For parents, hearing their baby If regurgitation occurs with poor weight Gastroenterology, Hepatology, and Nutrition cry inconsolably is very distressing. gain, further investigation is warranted (NASPGHAN) and European Society for They may feel concerned that and this scenario should not be considered Pediatric Gastroenterology, Hepatology, something is wrong with their baby or typical of GOR (Vandenplas et al, 2009). If and Nutrition (ESPGHAN) (Vandenplas, powerless to stop their baby crying, and regurgitation is accompanied by one of the 2009) guidance states that parental parents who are tired or distressed may symptoms listed above, GORD should be education, advice and support are adequate argue about the best action to take. considered. to manage physiological GOR and that Parents do sometimes need to be reminded Vomiting differs from regurgitation and education and management of parental that some babies cry more than others, can can be distinguished through its forceful expectation is firstline management of simple be difficult to console and crying tends to discharge of gastric contents from the regurgitation. This helps parents understand diminish after six weeks of age (Barr, 2006). mouth. Vomiting can occur in GOR, that regurgitation associated with physiological Hassall (2011) calls for the return of basic triggered by regurgitation. Ornstein et al GOR is normal in some babies. Vandenplas behavioural management of crying, such as (1999) estimate that vomiting more than (2009) states that up to 50% of healthy babies rocking, patting, taking baby for a walk or ride twice in 24 hours is normal in nearly half of regurgitate once a day with no difference found in the car as first line conservative management all healthy babies; however, if parents report between formula or breastfed babies. in babies with no other worrying symptoms. vomiting in their infant, acute illness needs Regurgitation can be exacerbated by to be discounted. Vandenplas et al (2009) list overfeeding; so smaller, more frequent feeds Conclusion potential differential diagnosis of vomiting can be suggested, as long as the baby is still GORD is a condition requiring treatment; in infants and children to include a range of meeting his or her calorie requirements. however, some signs and symptoms may be gastrointestinal obstructions or disorders, Positioning does not always have an effect and indistinguishable from normal baby behaviour, such as pyloric stenosis, Hirschsprung disease, putting the baby in a sitting position, such as normal physiological GOR or CMPA, at other food allergy, gastroenteritis, or neurological, a car seat, is unlikely to help GOR as it will times more worrying conditions need to be infectious or metabolic disorders among increase abdominal pressure. excluded. Some common symptoms in babies others and any potentially serious or life Prone positioning is known to relieve can initially be managed conservatively, which threatening disorder should be excluded by regurgitation, but should not be recommended empowers parents to care confidently for their the GP. due to the risk of SIDS. Using feed thickeners baby.

November 2012 Volume 85 Number 11 Community Practitioner | 47 PRACTICE: PEER REVIEWED

References Brazelton TB. (1962) Crying in infancy. Pediatrics 29: Key points 579–88. l GORD is a condition which requires treatment, however some symptoms such as Barr RG. (1990) The normal crying curve: what do we regurgitation, vomiting, crying and irritability are also associated with ‘normal’ baby really know? Dev Med Child Neurol 32(4): 356–62. behaviours Barr RG. (2006) Crying behaviour and its importance l Regurgitation associated with physiological GOR is normal for some babies for psychosocial development in children. Available from: www.child-encyclopedia.com/pages/PDF/BarrANGxp. l Smaller, more frequent feeds can lessen the chances of regurgitation pdf [Accessed September 2012]. l Common symptoms of GORD can be managed conservatively by parents Hassall E. (2011) Over-prescription of acid-suppressing medication in infants: how it came about, why it’s wrong, Orenstein S, Hassall E, Furmaga-Jablonska W, Atkinson Vandenplas Y, Salvatore S, Hauser B. (2005) The and what to do about it. J Pediatr 160(2): 193–8. S, Raanan M. (2009) Multicenter, double-blind, diagnosis and management of gastro-oesophageal reflux randomized, placebo-controlled trial assessing the in infants. Early Hum Dev 81(12): 1011–24. Iacono G, Carroccio A, Cavataio F et al. (1996) efficacy and safety of proton pump inhibitor lansoprazole Vandenplas Y, Rudolph C, Lorenzo C et al. (2009) Pediatric Gastroesophageal reflux and cow’s milk allergy in infants: in infants with symptoms of gastroesophageal reflux gastroesophageal reflux clinical practice guidelines: joint a prospective study. J Allergy Clin Immunol 97(3): 822–7. disease. J Pediatr 154(4) 514–20. recommendations of the North American Society for Rudolph CD, Mazur LJ, Liptak GS et al. (2001) Guidelines Sherman PM, Hassall E, Fagundes-Neto U et al. (2009) Pediatric Gastroenterology, Hepatology, and Nutrition for evaluation and treatment of gastroesophageal reflux A global, evidence-based consensus on the definition and the European Society for Pediatric Gastroenterology, in infants and children: recommendations of the North of gastroesophageal reflux disease in the pediatric Hepatology, and Nutrition. J Pediatr Gastroenterol Nutr American Society for Pediatric Gastroenterology and population. Am J Gastroenterol 104(5): 1278–95. 49(4): 498–547. Nutrition. J Pediatr Gastroenterol Nutr 32(Suppl 2): S1–31. Vakil N, van Zanten S, Kahrilas P, Dent J, Jones R, Global Van Howe R, Storms M. (2010) Gastroesophageal reflux Consensus Group. (2006) The Montreal definition and symptoms in infants in a rural population, longitudinal Orenstein S, Izadina F, Khan S. (1999) Gastroesosphageal classification of gastroesophageal reflux disease: a global data over the first six months. BMC Pediatr 10: 7. reflux disease in children. Gastroenterol Clin North Am evidence-based consensus. Am J Gastroenterol 101(8): 28(4): 947–69. 1900–20.

CP Continuing Professional Development modules Community Practitioner introduces a new web-based resource for continuing professional development. Just visit the website and answer the questions below. Print out the certificate and add it to your portfolio - easy!

1. Gastro-oesphageal reflux (GOR) is: 6. Parents attend clinic and say their baby cries and sometimes isn’t a. A condition common in babies, requiring intervention to prevent consolable. There are no other worrying symptoms. You inform oesophagitis them: b. A normal physiological condition in which stomach a. Their baby is likely to have GORD contents rise back into the oesophagus due to relaxation of the b. Some crying is normal, it can be unpredictable, it does not always lower oesophageal sphincter indicate gastrointestinal problems and discuss ways to cope c. A set of symptoms including frequent regurgitation, c. That babies do not cry without reason and they can work it out crying and back-arching by trying different things

2. If a baby is bringing up some milk after feeds, but has no other 7. Van-Howe et al (2010) suggest GORD is more common in: symptoms it is: a. Formula feeding a. Always indicative of reflux and worth suggesting medication b. Breastfeeding b. Most likely to indicate an underlying health problem and you c. Neither, it is not associated with feeding type would suggest the baby needs to see the GP c. Quite possibly a normal physiological event, but worth exploring 8. ‘Troublesome symptoms’ present in GORD do not include: further with the parents a. Crying or regurgitation b. Back-arching or refusal to feed 3. GORD is defined by: c. Rash and high temperature a. Possetting occurring more than three times in 24 hours b. Excessive crying where the baby appears inconsolable 9. Infants with GORD symptoms, who are not responding to treatment c. GOR accompanied by troublesome symptoms including regurgi- may: tation, irritability, back arching, or food refusal a. Need investigation for allergy, such as cow’s milk protein allergy b. Need hungry baby formula 4. When parents report signs of GOR in their babies they should: c. Have parents who are just not coping a. Receive advice and support to help them manage their baby’s symptoms conservatively, such as smaller more frequent feeds, 10. Advising parents to sit their baby in a car seat or on their lap for 10 and positioning minutes after feeding to help regurgitation: b. Be prescribed appropriate medication for their baby in the first a. May make regurgitation worse due to increased abdominal pres- instance sure c. Ask their GP for a paediatric referral b. Has no evidence base c. Will improve regurgitation by keeping the baby in an upright 5. A parent reports that their baby, who has GORD regularly has respi- position ratory symptoms, you should: a. Tell them not to worry as it is common for babies with GORD to have respiratory symptoms b. Advise them to see their GP to ensure the baby does not have another health concern To take this CPD module, please visit Commuity Practitioner online c. Suggest they clear their baby’s nose with saline drops at: www.commprac.com

48 | Community Practitioner November 2012 Volume 85 Number 11

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52 | Community Practitioner November 2012 Volume 85 Number 11 Protected skin. Joining in.

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Diprobase Prescribing Information Uses: Diprobase Cream and Ointment are emollients, with moisturising and protective Contra-indications: Hypersensitivity to any of the ingredients. Side-effects: Skin properties, indicated for follow-up treatment with topical steroids or in spacing such reactions including pruritus, rash, erythema, skin exfoliation, burning sensation, treatments. They may also be used as diluents for topical steroids. Diprobase products hypersensitivity, pain, dry skin and bullous dermatitis have been reported with are recommended for the symptomatic relief of red, inflamed, damaged, dry or product use. Package Quantities: Cream: 50g tubes, 500g pump dispensers; chapped skin, the protection of raw skin areas and as a pre-bathing emollient for Ointment: 50g tubes, 500g jar. Basic NHS Costs: Cream: £1.28 (50g), £6.32 dry/eczematous skin to alleviate drying effects. Dosage: The cream or ointment (500g); Ointment: £1.28 (50g), £5.99 (500g). Legal Category: GSL. Marketing should be thinly applied to cover the affected area completely, massaging gently Authorisation Numbers: Cream: PL 00025/0575; Ointment: PL 00025/0574. and thoroughly into the skin. Frequency of application should be established by the Marketing Authorisation Holder: Merck Sharp & Dohme Limited, Hertford Road, physician. Generally, Diprobase Cream and Ointment can be used as often as required. Hoddesdon, Hertfordshire, EN11 9BU, UK. Date of Revision: February 2012.

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