5.4a Introduction to children’s health
Why do children have special health needs?
This last section of Stage 5 is dedicated to the special health needs of children and the disorders that can affect them. That children have particular health needs is reflected in the fact that in conventional medical practice the specialty of pediatrics requires further training over and above that required of a general physician. Although children may be vulnerable to many of the conditions that have already been described in this text, there is a wide range of conditions of childhood that can develop because the physiology and susceptibility of the child are different from that of the adult.
There are, of course, many conditions from which the child is protected because of its youth. These conditions are the chronic adult diseases that result from the cumulative effects of an unhealthy lifestyle and aging. For this reason, a child is usually not vulnerable to some of the most important adult diseases such as coronary heart disease, stroke, adult cancers and the degenerative diseases of old age, such as osteoarthritis and Alzheimer’s disease.
Children have special health needs for two overarching reasons: first, the physiology of the child is immature; and second, the child is in a process of rapid growth and development. These factors combine to give a third reason why children need special focus, which is that any illness becoming apparent in a growing child may cause setbacks in growth and development, which may then have lasting, even lifelong, consequences. These three reasons are now explored in more detail.
The physiology of the child is immature
Immaturity of the immune system in children means that a child may be more susceptible to conditions from which adults are relatively protected. These conditions include certain infections and allergies. Also, a child who is ill is more vulnerable to extreme fever. The small size of a child means that the child is more vulnerable to dehydration when unwell.
The immature nervous system of a child is more likely to be disturbed by fever or trauma, which can result in convulsions, confusion and loss of consciousness.
An immature digestive system is more likely to succumb to conditions such as colic, gastroenteritis and constipation.
Many of the common childhood cancers develop from the immature blast cells, which are present in developing tissue in a small child, damage to which may have even been sustained in the womb. Blast cells are the rapidly dividing fetal progenitors of adult cells.
The physical, emotional and mental faculties of a child are immature. This means that they are more vulnerable to extremes of temperature, accidents, physical abuse (non-accidental injury), and emotional and sexual abuse.
Because of the vulnerability that comes from immaturity, children require special protection from any noxious factors that might have the potential to damage their health.
The child is in a process of rapid growth and development
Growth requires a constant supply of adequate nutrients. Nutritional deficiencies in childhood can lead to lasting health problems.
Physical growth and the development of physical, mental and emotional skills also require a complex input of less measurable factors, including love, security, consistency, play, exercise, rest, access to education and a supportive social network. If any of these factors is deficient, the physical, mental and emotional health of the child may suffer, again, with long-term consequences.
Vulnerability to setbacks in growth and development
Any disturbance in health can affect growth and development. A child with a chronic childhood illness may suffer long-term consequences of impaired growth and development as a result of the illness. In particular, the impact of congenital disease can be very significant, as it can affect growth and development from the time of the birth of the child.
What are the special health needs of children?
The health needs of children are those factors that enable a child to remain healthy in the face of its immaturity and state of growth and development. Meeting these health needs is all the more important if the child has been born with a constitutional deficiency resulting from congenital disease and prematurity or if they should later develop a serious illness.
The special health needs of children include a balanced nutritious diet, protection from injury, toxins and extremes of climate, protection from infection, freedom to play and exercise, adequate rest, love, security, consistency of care and access to a social network, access to education and protection from physical, sexual or emotional abuse.
The importance of meeting these health needs at every stage in a child’s development cannot be overestimated. It is well recognized that if a child falls behind in growing and developing as might be expected, it is often very difficult for the child to catch up at a later date. Therefore, failure to meet these basic health needs during childhood can have an impact on long-term health and well-being, and so might compromise health in adult life.
The special health needs of children are considered below in detail.
A nutritious diet
Children need an adequate supply of the basic nutrients in their diet to grow and develop healthily. The basic nutrients include protein, carbohydrate, fats, and a wide range of vitamins and minerals. All these nutrients are required to enable the tissues to form at the normal rate. If there are nutritional deficiencies, the child will fail to grow and to develop as would be expected.
Nutritional deficiency can cause problems in physical growth and development, such as the small stature and vulnerability to infection that results from protein-calorie deficiency. The high infant and childhood mortality from infection in developing countries is largely a consequence of protein-calorie deficiency. Those children who have had to subsist on too little food but who do survive to adulthood are likely to be smaller than average, and to continue to be prone to infection and problems of inadequate physical development, such as later difficulties in childbirth.
It is now recognized that the long-term effects of nutritional deficiency begin in the womb. Babies who are assessed as less well nourished at the time of birth are more likely to develop a severe chronic illness such as coronary heart disease in later life.56
Individual vitamins and minerals each play a role in the healthy development of the tissues. If there is a specific vitamin or mineral deficiency, this, too, can have a long-term bearing on health. For example, a deficiency of vitamin D in childhood can lead to the condition of rickets. Rickets leads to bony deformities, which are then set for life into the adult skeleton. Vitamin A deficiency leads to weak epithelial tissues and a vulnerability to infection, and is probably one of the most important reversible causes of infant mortality from measles in developing countries. Iron deficiency is now recognized to be common, not only in developing countries, but also in the more affluent Western nations, in which the food given to an infant may be plentiful, but unbalanced in nutrients. Inadequate iron in the diet of infants can have a lasting effect on mental development, leading to learning difficulties in later life.
Certain components of a child’s diet may be harmful if given to the child too early or if in excess. The World Health Organization (WHO) recommends that all children should be exclusively breastfed for at least the first four months, and ideally for the first six months, of life.57 It is increasingly recognized that certain nutrients may be harmful to the immature digestive system of the baby. It is possible that the early introduction of wheat, cows’ milk, egg, nut and pulse proteins may induce long-term allergies or food intolerance. It is partly for this reason that late weaning after the sixth month is recommended, and advice is given that babies should avoid cows’ milk products if possible for the first year of life. Whole foods are not considered to be so healthy for young babies and children, who may suffer from colic and diarrhea as a result of the excess dietary fiber.
An excess of fat and refined carbohydrate will lead to obesity in children. As well as affecting the ability to play and exercise, obesity in children can lead to a long-term reduction in health and well-being. Obese babies are known to be more likely to grow into obese and inactive adults. Obesity in childhood can lead to social exclusion and being bullied. Obesity is an increasing problem in children of affluent societies, and one that carries significant consequences to health in future life.
Protection from injury, toxins and extremes of climate
Many of the important health problems of childhood are preventable, as long as the child is given adequate physical protection. In affluent countries, childhood accidents, and in particular, head injuries, are the single most important cause of death in those under 14. Many of the accidents that are fatal might have been prevented by the appropriate use of car restraints, cycle helmets, smoke alarms and window locks.
Poisoning is another very common cause of illness and death in children. Contrary to popular belief, the most common poisons to cause harm in children are not wild berries and mushrooms, but those found in the home, such as alcohol, cleaning fluids and prescription medicines. Again, harm would be prevented if these substances were kept out of the reach of children.
A young child is very vulnerable to extremes of heat and cold, and also to radiation from the sun. It is now understood that sudden infant death syndrome (SIDS) can result from allowing a baby to become overheated or too cold. Children are more likely than adults to suffer from fever, dehydration, headache and confusion in very hot weather, a condition described as heat stroke.
A child’s skin is vulnerable to burning with very little exposure to the sun’s rays. Although the discomfort of sunburn may be temporary, there is a well-established link between the incidence of sunburn in children and the development of skin cancer, including melanoma, in adult life.58 Sunburn is prevented by protecting the child’s skin from direct sunlight by means of wearing long sleeves, sun hats and high-factor, ultraviolet light-blocking sun creams.
Protection from infection
Children can be protected from the serious childhood infections by the time-honored method of separating an infectious child from other children. This might mean ensuring that a child has a few days of convalescence at home during and after an illness. However, this practice is increasingly less prevalent, as the pressures on parents to return to work may oblige them to return their child to school sooner than would be advisable after an infectious illness. In such situations, medications such as paracetamol and ibuprofen are commonly used to enable a child to feel well enough to return to school, although these medications do not cure the underlying illness.
An important medical approach for managing the risk of infection is the practice of childhood vaccination. Children in the UK are currently offered immunizations to protect them against 16 strains of infectious diseases. The timing of the vaccinations in the UK immunization schedule is summarized in Table 2.4d-I.
However, vaccines are not available for many of the important childhood infections. These include the common cold, scarlet fever, tonsillitis, most forms of bronchitis and pneumonia, many forms of meningitis, herpes simplex virus (HSV), most forms of gastroenteritis, conjunctivitis and impetigo. For all these infections, exclusion of the infected child is the most important aspect of the protection of other children.
Freedom to play and exercise
A child needs to be in a stimulating environment from early babyhood. Psychological studies of babies in orphanages who were given little stimulation throughout the day indicate that the mental and physical development of these babies was delayed, despite the fact that the babies appeared contented and well nourished.59
If given a safe degree of freedom and stimulating objects, a child will naturally play, and through play will gradually develop physical and mental skills. A child will also naturally want to exercise. This tendency is apparent even in the womb. The routine ultrasound scan performed at 20 weeks of gestation demonstrates a fetus that is flexing its limbs and performing breathing movements. As well as helping to develop skills of balance and coordination, exercise stimulates muscle and bone development. It also aids the proper utilization of food and prevents obesity.
It is clear that children in affluent societies exercise far less than their parents did, and even less than their grandparents did as children. The reasons for this are multiple, and include the increased use of the car, a reduction in allocated time for physical activity in school curricula (many children in the UK are obliged to attend less than half an hour of physical education per week) and the almost universal availability of habit-forming and sedentary methods of entertainment such as television and computer games. The impact that this decline in physical activity in today’s children will have is likely to be significant. It is well recognized that children who do not exercise are even less likely to exercise when they become adults.60 The habit of exercise is apparently one that is most easily formed when young. Lack of activity in childhood may, therefore, contribute to problems such as heart disease, obesity and osteoporosis in adulthood.
The value of adequate rest for children is emphasized in conventional guides to childcare. Overstimulation and lack of sleep in a child will lead to poor concentration and irritability in the day. It is conventionally recognized that the development of a child can be adversely affected as a result of inadequate rest alone.61
Love, security, consistency of care and access to a social network
Although very difficult to measure, it is also known that interpersonal factors, including love, a sense of security, consistency of care and access to a social network, are extremely important in the healthy mental, emotional and physical development of a child. Although it may make sense that the emotional development of a child deprived of one or more of these factors might be adversely affected, it may come as a surprise that mental and physical development can also be impaired by emotional deprivation. The effect of emotional deprivation can be so marked that the term psychosocial short stature has been coined to describe the phenomenon of otherwise unexplained stunted growth in children in whom there is evidence of emotional deprivation.62 The conventional explanation for this phenomenon is that, through the effect of emotional deprivation on the brain, the release of the hormones that stimulate growth and the development of the brain in children (including growth hormone, the thyroid hormones, insulin and, after puberty, the sex hormones) is inhibited.
Access to education
The definition of what constitutes appropriate education will vary according to the society in which the child grows up. At the very least, education should allow a child to develop skills and the confidence to be able to function as an independent adult in their society. At best, education should also enable a child to develop the skills to continue to learn and develop throughout adult life.
Theories abound about when is the best time to begin to acquire skills such as reading, playing the violin or driving a car. What is generally understood is that there is an optimum time period in the life of a child during which a skill, such as learning to read, can be acquired. It is also believed that most children require a foundation of basic skills before they can progress on to learning more complex skills. For example, for most children reading will follow only after the skill of letter recognition has been mastered. A good educational system, whether it is at school or at home, will enable the child to concentrate on the skills that are most important to develop according to the child’s particular stage in development. If the window of opportunity in childhood for learning a particular skill is missed, and reading is a good example, it may be very difficult for the adult ever to acquire the skill with proficiency. A child may miss out on an important stage in educational development because of a long period of poor health, because of an unstable social setting or because of lack of parental support and encouragement.
Education has a significant impact on health. Not only can it enable the child to develop the skills and confidence to follow a healthy lifestyle as an adult, it also opens the door to a choice of professions. There is now no doubt that there is a strong correlation between professional status (by which the five socio-economic classes are defined) and health. For a wide range of diverse diseases, including most forms of cancer, heart disease, childhood asthma, pneumonia and type 2 diabetes, there is a very striking correlation between the incidence of the disease and socio-economic class (of the child or parent). A person who is classified by profession into a high socio-economic class (e.g. a judge would be classified as Class I) is more likely to enjoy better health and a longer life than someone who is classified by profession into a low socio-economic class. This correlation cannot be completely attributed to differences in lifestyle between people from different socio-economic groups. So it seems that, over and above the advantages an education might offer in terms of learning about healthy living (or possibly the wealth and security that tend to accompany it), it also appears to protect against disease in its own right.63
Protection from physical, sexual or emotional abuse
The deleterious effects that any form of abuse may have on a child are obvious. If the abuse is severe or occurs on a long-term basis, the child’s growth and development will be affected adversely, probably by a similar mechanism as results from emotional neglect.
Physical abuse is also termed non-accidental injury (NAI). NAI may manifest as bruises, lacerations, cigarette burns or fractures. In some cases, NAI results in wounds or fractures that would be very unlikely to occur by accident (e.g. bruising within the pinna of the ear), and so should alert the examining doctor to the possibility of abuse. Rarely, a child may be deliberately poisoned by his or her parents with alcohol or prescription medicines. Munchausen syndrome by proxy is a very rare syndrome in which the parent or caregiver causes or feigns illness in the child as an indirect form of attention seeking.
Physical neglect is also a form of physical abuse, and may manifest in the child as failure to gain weight, inadequate hygiene with skin infections and infestations, poor speech development and failure to attend health check-ups.
Emotional abuse includes emotional neglect and withdrawal of love, but also malicious criticism, threats and scapegoating. The child may appear withdrawn and may have speech difficulties and other features of developmental delay.
Sexual abuse may result in the features of emotional abuse and also in precocious sexual awareness or behavior in a young child. Both physical and sexual abuse may cause the child to become vigilant and still when close to adults, a response described as “frozen watchfulness.” A sexually abused child may present with the symptoms of a sexually transmitted disease, or may fall pregnant. There are some characteristic signs that may be found on examination of the genitalia of a sexually abused child, but the finding of these signs is not always conclusive.
Commonly, two or more of the forms of abuse may coexist. Apart from causing developmental delay, the long-term effects of child abuse on the individual’s future relationships and care of future children may be serious and very difficult to remedy. It is recognized that abused children are more likely to abuse others in adulthood. Children who have been victims of sexual abuse are at great risk of suffering from psychiatric disorders and sexual dysfunction in adulthood.
The concept that parents or carers might abuse their children only began to be noted as a possible widespread problem in the 1950s. In recent years there has been an increased awareness that abuse may underlie the health problems of a child, and conventional health professionals are now given specific training in recognizing the warning features of abuse in a child.
If there is good reason to suspect the abuse of a child, a conventional health practitioner in the UK is expected to report the matter to the local children’s social care team or to the police if urgent. In the first instance, after a report has been made, an assessment has to be made about the degree of risk. This assessment will involve a social worker interviewing the family and associated professionals such as teachers and medical staff. If the child seems to be at high risk, a decision may be made about whether the child should be separated straight away from the suspected abuser, either by admission to hospital or by placing the child into the care of a foster parent or children’s home. Whether or not this is done, a multidisciplinary case conference is convened, which will have representation from a wide range of relevant professionals, including social workers, health visitors, the general practitioner (GP), hospital doctors and nurses, police officers, teachers and lawyers. The evidence relevant to the case will be discussed and a decision will be made about:
•whether to place the child on the Child Protection Register, so that the child continues to remain at home while under the surveillance of health visitors and social services
•whether to apply to the court for long-term protection of the child and prosecution of the possible abuser
•what sort of follow-up is required.
If, as a practitioner of acupuncture, there are any concerns about possible abuse of a child, it is necessary to seek further advice. In the UK it would be appropriate to contact either the NSPCC or local children’s social care services64 for advice. This is an example of a situation when it may be appropriate to breach the professional code of confidentiality.
Information box 5.4a-I
Children’s health: comments from a Chinese medicine perspective
In Chinese medicine, children are recognized as energetically different in nature from adults, and these differences become gradually less marked as the child grows older. Scott and Barlow (1999) expand on the principal differences that are summarized succinctly by seven aphorisms from Chinese medical pediatrics.65 These are as follows:
“Children’s Spleen is often insufficient”
This refers to the fact that the digestive system of a child has to work full time to ensure adequate growth and health of the Organs. For this reason, a young child is particularly vulnerable to digestive disorders. Late weaning and a balanced and regular diet consisting largely of Warm foods are extremely important for the health of the child. Accumulation Disorder (akin to the adult syndrome Retention of Food in the Stomach) and Spleen Qi Deficiency are syndromes very commonly found in young children.
“Children’s Yin is often insufficient”
Although the nature of children is very Yang, the Yin is immature. This can result in the tendency to high fevers and dehydration that are characteristic of children. Scott and Barlow (1999)66 suggest that the reason why Yin Deficiency is not seen more often in Western children is that their Heat symptoms have been treated too readily with antibiotics, which are, by nature, cooling and damaging to the Yang.
“Organs are fragile and soft; Qi easily leaves its path” and “Children easily become ill: their illnesses easily become serious”
These statements both refer to the fact that a slight insult from a Pathogenic Factor (such as the Heat of a hot day, or Damp Heat from over-rich food) can easily disturb the Qi and so cause illness. This can easily progress to a disturbance of the Qi of the whole body, and so lead rapidly to serious illness. Likewise, emotional disturbances can also lead to health imbalances, which can escalate into serious conditions.
“Yin and Yang Organs are clear and spirited. They easily and quickly regain their health”
As a counterpoint to the preceding maxims, despite the vulnerability that arises from immaturity of the organs, the clarity of the Spirit of the child’s Organs means that, in many cases, a child can return very rapidly to good health even after a major illness. Also, emotional disturbance in a child is often very short-lived, as long as the stress that has caused the disturbance is not maintained for a long time.
“Liver often has illness”
This statement refers to the tendency of children to succumb to Liver Wind and so to suffer from convulsions. However, health problems that result from Stagnation of Liver Qi are not so prominent in children, presumably because small children in general have not learned the tendency to restrain their emotions.
“Treat the mother to treat the child”
Health and emotional imbalances in the mother may readily be transmitted to the child, and so treatment of the mother may be important in the management of a child health problem. Conversely, a mother may become unwell in response to the health problem of her child, and her condition may only get better when the health of the child starts to improve.