The governments of most Western nations have declared their commitment to the health and wellbeing of their communities by promoting and supporting child health initiatives. Australia and New Zealand share this commitment. Compared with children in other Organisation for Economic Co-operation and Development (OECD) countries, children in this part of the world are doing relatively well, but there are still areas for improvement. The past several years have seen declining rates of mortality related to injuries, and declining hospitalisations for asthma. There have been improved survival rates for children with leukaemia, greater immunisation coverage, and increases in the number of children meeting national physical activity guidelines and reading and numeracy standards (Australian Institute of Health and Welfare [AIHW] 2009a).

However, other benchmarks require attention, including rising rates of severe disability, diabetes and tooth decay. This indicates a need to keep up the momentum towards better health for children, promoting safety and oral health. Another challenge lies in trying to reduce the time children spend in front of a television or computer screen, and increasing their physical activity. In addition, there is a need to support parents in promoting healthy lifestyles, harmony in the home, and sustaining sufficient resources to circumvent risks to family life. As nurses and midwives, we must also remain vigilant to ensure that families at risk of injury, low socio-economic status (SES), a lack of access to services or with relationship difficulties are brought to the attention of those agencies that can help them. This also includes drawing attention to the education system and those who allocate resources to promote equity of access for rural, remote and Indigenous children.

Disadvantage among Indigenous children and their families is by far the most urgent issue for all health professionals. We have a major role to play in helping communities achieve equitable health outcomes by drawing attention to the disparities, and framing solutions in terms of primary health care (PHC). This is a major priority of government health strategies in both Australia and New Zealand (Australian Institute of Health and Welfare (AIHW), 2009a, Ministry of Health New Zealand (MOHNZ), 2001 and Ministry of Health New Zealand (MOHNZ), 2002a). It will be important for current and future generations of Indigenous children to work towards an evidence base for health policy and planning. Nursing and midwifery research can add value to this by gathering important data from our communities, showing not only the importance of an early, healthy start to life, but the local contextual strengths and constraints that impact on healthy childhoods.

At the community level, there are enormous challenges for parenting and child health from

For example, Bronfenbrenner’s (1979) theory of social ecology or ‘bioecology’ focuses on interactions between the child, parental care and features of the family’s environment. The resources a family brings to these interactions include income, time, and human, psychological and social capital (Brooks-Gunn et al., 1995 and Zubrick et al., 2000). In combination, these resources help parents build the capacity to support child health and development in the context of their community and society (Li et al 2008).

Another theory, self-efficacy theory, explains how parents make decisions about their behaviour (Bandura 1977). This perspective argues that individuals choose behaviours they believe will lead to certain outcomes, which they usually believe

they can carry out. Bandura’s self-efficacy theory suggests that when parents are provided with both information and trust in their own judgement, they will be more likely to make decisions that promote better health for their children. A third theory, Bowlby’s (1969) theory of human attachment, posits that newborn infants are predisposed to seek attachment to their caregivers in times of stress, illness or fatigue. Attachment is also important for parents. When parents have had secure attachments in their lives they will be sensitive, responsive, engaged caregivers for their own children (Olds 2002).

Children begin life with a set of predispositions, biologically embedded to respond to what lies within the sphere of their life. This ‘biological embeddedness’ provides a template for interactions between children and the array of social and environmental circumstances of their lives, as they develop. Children’s interactions with the world around them at ‘critical moments’ (times of heightened sensitivity) along their developmental pathway determine their endocrine, neurological, cardiovascular and immunological development, and how they learn to modify incoming stressors (Hertzman, 2001a, Hertzman, 2001b, Mustard, 1996 and Mustard, 1999). Critical pathway interactions are therefore instrumental to children’s development. They provide opportunities for children to embed health enhancing behaviours in the early stages of their lives, which literally helps ‘sculpt’ their developing brains to build their coping capacity for later life (Mustard 2007).

In some cases, children’s cultural, spiritual and physical environments allow them to use their biological strengths to greater advantage. In other cases, children fail to reach their potential because of socio-cultural determinants. These can include cycles of intractable poverty, or a lack of healthy policies for child support, or a lack of high-quality day care, adequate parental support or environmental protection. Instead of enhancing their coping capacity, certain combinations of these social factors may conspire to stifle a child’s ability to be nurtured in the community (Shonkoff et al 2009). This can create inequalities for children that persist into adult life in two ways. The first is by accumulating damaging adversities during sensitive developmental periods. So, for example, traumatic exposure to psychologically and physically stressful experiences during a very early sensitive period of life could establish effects that become permanently incorporated into the child’s regulatory physiological processes.

Current research has found that these physiological mechanisms can lead to coronary artery disease, cancers, alcoholism, depression and substance abuse, as well as being linked to obesity, physical inactivity and smoking (Shonkoff et al 2009). For this reason, interventions to deal with these diseases in adulthood are nowhere near as effective as ensuring a healthy childhood relatively free from stress. An alternative explanation to why childhood stress leads to adult diseases is called ‘weathering’ of the body, which occurs under persistent adversity (Shonkoff et al 2009). In this situation, the increased wear and tear induced by too many stressful experiences deregulate and overuse the pathways that were originally designed for an individual’s adaptation to stress. This accelerates the ageing processes. Cumulative exposure to stress creates an ‘allostatic load’ which activates stress management systems in the brain to the extent that they become pathogenic instead of adaptive (Shonkoff et al 2009).

Pathogenic effects can be created when children live in impoverished families, where they can be exposed to numerous stressors. These stressors include such things as maltreatment, traumatic fear, family conflict and/or chaos, inadequate nutrition, recurrent infections, having mentally unstable or absent parents, punitive parental behaviour, neighbourhood violence and dysfunctional schools (Shonkoff et al., 2009 and Waldegrave and Waldegrave, 2009). Research shows that these social stressors affect many children from lower SES backgrounds through heightened activation of their stress-responsive systems (Shonkoff et al., 2009 and Waldegrave and Waldegrave, 2009). Because of this burden of stress it may be impossible to completely reverse the neurobiological and health consequences of growing up poor. On the other hand, an emerging body of research is showing that positive parent–child interactions, exposure to a new vocabulary and stability of parental responsiveness can actually alter a child’s physiological responses (Hackman & Farah 2009). Parental social support, especially from family members, and having the support of services and schools can help moderate the impact of adverse circumstances for children (Zubrick et al 2008). Stress in children can therefore be buffered by stable and supportive relationships at the family, community and societal levels (Shonkoff et al., 2009 and Zubrick et al., 2008). This is cause for optimism in promoting child and family health.

As mentioned in the previous chapter, the quality of the parental relationship is a significant influence that can lead to either sensitive parenting or disruptive relationships between parents and their children (Finger et al 2009). This reflects the importance of focusing on intergenerational health. Where the community and society provide supportive environments for families, there is a greater likelihood that parents will make healthy choices for parenting practices, and personally, modify any risky behaviours that leave them vulnerable to ill health. This, in turn, affects the likelihood of their children leading healthy lifestyles.

Clearly, investing in children and their parents should be the major priority for ensuring good health across the life course and across the population (Shonkoff et al 2009). This is illustrated in Figure 6.1.

The health of the world’s children is of concern to everyone who claims global citizenship. Most children in the world are cared for and loved, but other children suffer from violence, exploitation and abuse. Approximately 200 million children globally are not achieving their full development potential (Commission on the Social Determinants of Health [CSDH] 2008). Every day, more than 2000 die from an injury (World Health Organization [WHO] 2008b). In some regions, children are sexually abused or forced into child marriages, while others may be trafficked into exploitative conditions of work. Just over one billion children under the age of 5 live in the midst of armed conflict (United Nations Childrens Fund [UNICEF] 2009). Infant mortality is improving in some countries, but in the African countries, rates have either stagnated or lost ground, primarily due to poor access to health care (WHO 2008a). Although there have been some improvements in countries where there has been greater access to water, sanitation, drugs and antenatal care, globally, there are still nearly 10 million child deaths per year (WHO 2008a).

In addition to these poor morbidity and mortality rates, global and national inequities are not being resolved, especially in developing nations. Approximately 51 million children are not registered at birth, leaving them without the protection they should have from social institutions (UNICEF 2009). In 33 countries, less than half of all births are attended by health professionals (WHO 2008a). More than one-third of young women in developing countries were married as children (UNICEF 2009). More than 70 million girls have undergone female genital mutilation, and 150 million children aged 5–14 are engaged in child labour. Others are trafficked into prostitution or other forms of exploitation (UNICEF 2009). Child poverty is also persistent. Despite worldwide attention to child poverty throughout the past 100 years, about 600 million children continue to live in absolute poverty, trying to survive on less than $US1 per day (UNICEF 2007). The main problem in many of these countries is an actual expansion of disparities between the wealthy and the poor, which leaves many poor children with little hope for the future (WHO 2008a).

In the countries of the West, relative child poverty continues to be a major problem. Relative poverty refers to those children living in homes receiving less than 50% of the median national income, and this affects approximately 15% of children in Australia and New Zealand (Emerson 2009). The effects of living in relative poverty have been demonstrated in a wide-ranging body of research (Emerson 2009), summarised in Box 6.1.

An interesting analysis of young people’s perspectives on poverty was conducted in the United kingdom (UK) to see how the children themselves experienced disadvantage (Redmond 2008). A review of nine studies where children’s views were sought found that children living in relative poverty were not as concerned about the lack of resources as they were about family relationships and being excluded from activities that their peers can access (Redmond 2008). Social exclusion therefore had the most profound impact on their lives as a result of relative poverty. This was experienced in not being able to access the tools of virtual communication (phones, computers) to connect with their peers. The children coped with this type of social exclusion by relying heavily on family life to help them cope. For children who live in rural and remote areas, these effects are even more intense. Some children adapt to these difficulties with resourcefulness and optimism, while others experience anxiety, pessimism and reduced aspirations for the future (Redmond 2008).

At the extreme end of poverty, a growing number of children are rendered homeless, even in the wealthiest countries. Homelessness is a source of grave concern in the United States, where in a CNN poll found that 1 in 50 American children faced homelessness in 2005–06 (Online. Available: www.cnn.com/2009/US/03/10/homeless.children [accessed 14 October 2009]). In Australia during the financial crisis of 2008–09, homeless families with children accounted for one-quarter of the homeless population of nearly 79000 (AIHW 2009b). In New Zealand, homelessness is a largely invisible problem, with some imprecision in the number of homeless. Although Statistics New Zealand released a formal definition of homelessness in 2009 (Statistics New Zealand 2009), there are also cases of ‘concealed homelessness’, a situation where people have no other option but to share someone else’s accommodation. This is a growing concern.

In addition to having a lack of housing, there has been a growing trend towards women and children using women’s refuge services as temporary safe housing (National Collective of Women’s Refuges 2007). The negative health and social impact of this situation is an immediate problem, as these children are prone to injury, violence and behavioural problems. It is a social tragedy in wealthy countries. Although some cases of homelessness are a result of families becoming victims of changing socio-economic circumstances, other cases of child homelessness reflect parental neglect or abuse. Children who have been neglected or abused have the same types of negative developmental outcomes as mentioned opposite in Box 6.1, particularly lower social competence, poor school performance and impaired language ability (AIHW 2009a; Waldegrave & Waldegrave 2009). In addition, child victims of maltreatment or abuse do not acquire the skills to be self-regulating, which interferes with their ability to control emotions and behaviour. This impedes the development of independence and self-sufficiency later in life (Schatz et al 2008). A longitudinal study of New Zealand children found that children with severely disturbed childhood behaviours have a number of risks in later life, including the risk of committing violent offences, attempting suicide and becoming teenage parents (Fergusson et al, in WHO 2009a). As others have found, the residual effects of child abuse often last throughout the child’s life, especially among those who have been sexually abused, and those who do not disclose the abuse (Ming Foynes et al 2009; Pereda et al 2009). As we mentioned in Chapter 5, some victims of abuse grow up to become perpetrators of abuse themselves (AIHW 2008).

A comprehensive report on child health in Australia in 2009, indicates where progress has been made in reducing risk and increasing protective factors, and identifies health issues that continue to be problematic (AIHW 2009a). No similar barometer of child health has been reported for New Zealand children, although a monitoring framework provides the basis for key indicators of child health (Craig et al 2007). What we do know from recent comparative data is that New Zealand lags behind Australia in a number of international child health indicators, including infant mortality rates, immunisation, deaths from accidents and injury, relative income poverty of children and material wellbeing of children (UNICEF 2007).

The main health issues for children in Australia are mental disorders, chronic respiratory conditions such as asthma, and neonatal conditions. As in other Western nations, injuries are the leading cause of death in children aged 1–14, with 10–14-year-old boys having 2.5 times the rate of injuries for girls in this age group. For all Australian children the leading causes of injuries are falls, land transport accidents, accidental poisoning, burns, scalds and assault. The other most prevalent conditions causing childhood deaths are cancers and diseases of the nervous system (AIHW 2009a). Injury deaths have been reduced over the past decade because of fewer land transport accidents, accidental drowning and submersions. Infants have the highest rates of injury death of all children’s age groups, although infant mortality can be due to factors related to pregnancy. The mortality rate among infants and young children have steadily declined as a result of adequate neonatal intensive care units, increased community awareness of risk factors for sudden infant death syndrome (SIDS) and the rate of childhood immunisation, which covers 93% of Australian 2-year-olds. The rate of Australian infant mortality and childhood deaths compares favourably with other OECD countries in ranking, just above the median level, but only for non-Indigenous children.

New Zealand children are most likely to be acutely hospitalised for injuries/poisoning, gastro-enteritis and asthma. Arranged admissions to hospital are most often for cancer/chemotherapy and dental conditions, with the most common reason for children’s hospital admissions in 2004 being insertion of grommets (Craig et al 2007). In the same year, SIDS (now often referred to in New Zealand as sudden unexpected death in infancy or SUDI), was the most common cause of mortality for children aged under 1 year, with injuries the most common cause for children over the age of one. As is the case for Australian children, the leading causes of injury among children were motor vehicle accidents and falls. Drowning also figured highly among causes of death among New Zealand children (Craig et al 2007).

Although infant mortality has halved in the years 1986–1998 in Australia, since 2006 it has been comparatively stable in Indigenous children (AIHW 2009a). Aboriginal and Torres Strait Islander (ATSI) children experience a significantly higher rate of under 5 mortality than non-Indigenous children, including three times higher infant mortality, and three times as many childhood injuries. Half of all Indigenous infant deaths are due to perinatal problems; low birth weight and complications of pregnancy, with congenital conditions and diseases like SIDS being responsible for the remainder. Indigenous children are nearly five times more likely to die of SIDS. They are also eight times more likely than non-Indigenous children to be the subject of child protection orders for child abuse, neglect and maltreatment. Injury deaths are also more than four times greater in remote areas, where many Indigenous children live.

New Zealand’s Indigenous children are also at greater risk of poor health outcomes than non-Indigenous children. When Maori children in New Zealand are born, they are more likely than European children to have a low birth weight, die in infancy, enter primary school with poorer hearing, have oral health problems, have experienced respiratory issues, and be at greater risk of unintentional injuries (Dyall 2007). Maori children are also more likely to be exposed to domestic, sexual and criminal violence in the home (Dyall 2007).

The chronic conditions of asthma, diabetes and cancer are increasing in Australian children, with 40% experiencing at least one condition of 6 months or more duration, and boys suffering disproportionately (55%). Indigenous children have a greater prevalence of chronic conditions and hospitalisation rates than non-Indigenous children as well as a 30% greater prevalence of disabilities (AIHW 2009a). Among all Australian children, there has been a significant increase in type 2 diabetes over the past decade, more so for girls. The incidence of cancers among children has remained relatively stable over this time, with improved survival because of advanced treatments, and a decline in mortality. Cancer prevalence is greater in boys than girls (55%). The proportion of Australian children having allergies and asthma is equal highest (with Costa Rica) among OECD countries, whereas the prevalence of other chronic conditions is relatively similar to the other countries.

Children in New Zealand experience similar chronic conditions to Australian children. New Zealand has one of the highest reported occurrences of asthma in the world, with 25% of children reporting asthma symptoms (Howden-Chapman et al 2008). Although overall hospital admissions for asthma have declined over the past decade, ethnic disparities persist with higher rates for Maori and Pacific children than for European children (Craig et al 2007). While it is acknowledged that childhood obesity and associated type 2 diabetes are increasing in prevalence among New Zealand children, figures are not readily available. However, it is known that, like other conditions, Maori and Pacific children are over-represented in obesity and diabetes statistics (Kedgley 2007).

Cancer is relatively rare among New Zealand children, with leukaemia accounting for approximately one-third of all cases (Craig et al 2007). Cancer prevalence is, however, increasing across all types, but with a corresponding decrease in mortality, which is expected to continue into the foreseeable future (Craig et al 2007).

Approximately 8% of Australian children and 11% of New Zealand children have disabilities that interrupt their interactions and effective participation in society, with physical disabilities more common in girls, and intellectual disabilities more common in boys. Disabling conditions among children range from moderate impairments for home and school life to those that severely limit core activities of development and require lifelong support (AIHW 2009a; Craig et al 2007).

Other indicators of child health and wellbeing include having good dental health, physical activity and nutrition, and being breastfed from birth (AIHW 2009a). Internationally, dental health is improving due to better public health programs, water fluoridation, and improved oral hygiene and disease management (AIHW 2009a). Figures on the oral health of Australian children are not current, but it appears that they are above the OECD standard on the number of tooth decays. In New Zealand, however, the figures are concerning, with no improvement in the rate of dental caries since the early 1990s. Only 50.7% of 5-year-olds in New Zealand live in communities with fluoridated water supplies (Craig et al 2007).

In terms of nutrition and physical activity, most Australian and New Zealand children meet the national guidelines of 60 minutes of activity every day, but very few meet the nutrition standard for fruit and vegetable consumption (AIHW 2009a; Craig et al 2007). In addition, only one-third report that they conform to the ‘screen guidelines’, which recommend no more than 2 hours of non-educational screen time (computers, video, TV) per day. These guidelines are based on the fact that children who engage in more than 2 hours of screen time per day are more likely to be overweight; be less physically active; drink more sugary drinks; snack on foods high in sugar, salt and fat; and have fewer social interactions (Commonwealth Scientific and Industrial Research Organisation [CSIRO] 2009).

Although most Australian and New Zealand children are within a normal weight range, approximately one-fifth of Australian children and one-tenth of New Zealand children are overweight or obese (Australian Institute of Health and Welfare (AIHW), 2009a and Ministry of Health New Zealand (MOHNZ), 2008a). Those who are disadvantaged socially, economically and geographically are at increased risk of becoming overweight due to a lack of available, accessible and affordable fresh fruit and vegetables and opportunities for exercise. Pacific children in New Zealand are 2.5 times, and Maori children are 1.5 times more likely to be obese than other children (MOHNZ 2008a). The majority of children are also active, meeting the standard of 60 minutes a day of some kind of physical activity, but nearly one-quarter do not meet this benchmark (AIHW 2009a). Children’s nutrition and physical activity patterns have attracted worldwide attention because of the ‘obesity epidemic’ in many nations. The obesity epidemic has attracted widespread attention because it is commonly understood that the most prevalent cause of morbidity and mortality in adults in the 21st century are non-communicable cardiovascular and metabolic diseases (WHO 2008a). The most useful way to analyse these disease patterns and their causes in the population should begin with an examination of children’s health, and the critical events that occur along the pathway to adulthood that instigate and perpetuate these diseases in epidemic proportion. A significant element of this type of analysis lies in analysing the social determinants of poor eating behaviours and inactivity patterns and the way these may be contributing to the obesity epidemic.

Many researchers into obesity have focused on genetics, physiology, race/ethnicity, personal responsibility and freedom of choice, effectively creating the impression that inappropriate diets are either destiny or unwise choices (Drewnowski 2009). However, increased attention has been drawn to obesogenic food environments and the importance of economic factors as social determinants of poor eating habits (Drewnowski 2009). For example, low-income neighbourhoods tend to have many fast-food outlets and convenience stores, which encourages consumption of inexpensive foods with refined grains and high sugar and fat content. On the other hand, people living in affluent neighbourhoods have the wealth and access to healthy, low-fat foods. This difference in access illustrates the role of social inequality in dietary behaviour (Drewnowski 2009). Other studies take a more socio-cultural approach, arguing that poor dietary habits are environmental and intergenerational, the result of how the family environment socialises and controls a child’s eating habits (Kime 2008). This perspective contends that the lack of structure in contemporary family life creates a more haphazard and less ordered way of eating that is sometimes chaotic, and can lead to less nutritious patterns of food consumption (Kime 2008). The other critical issue relevant to good nutrition is breastfeeding.