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Editor,—I am worried by the article by John Dearlove and Su Illingworth.1 The topic is interesting for community paediatricians when many believe the routine checks of the child health surveillance (CHS) programme need justification if they are to continue. Good research to answer the question of whether parental concern is as good as regular professional contact in identifying abnormalities is urgently needed.
This study sample of 538 babies is small. Babies were randomised by practice, making this a cluster randomised trial. The sample size needed to give enough power to detect true differences between the groups runs into several thousands. In addition, 234 mothers (43% of the initial sample) were lost by the end of the first year. The numbers randomised to each group at the outset are not given. It is clear however that the study intervention was implemented in only 45 cases, 8% of the original sample.
Neither mothers nor health visitors were keen on mothers making their own appointments. Those mothers who did not comply with the intervention said they found routine appointments more convenient. Anecdotal evidence suggests that health visitors undermined the intervention. It would have been prudent to seek health visitors' views formally as part of the study.
A small study in Northampton (unpublished data) suggests that the CHS programme leads to identification of complex developmental problems in two ways. In a third of cases, the professional alone identifies the abnormality. In another third, the parent identifies it. In half those cases parents used the routine CHS check to raise their concern. In the other half, they raised concern outside the routine programme.
This paper's conclusion is not proven because of small sample size and failure to implement the study intervention. Mothers and health visitors appear to value routine professional contact within a CHS programme. Our local evidence supports that view. More research is needed.
Dr Dearlove and Mrs Illingworth comment:
Your correspondent is wrong in thinking that 43% of our sample was lost to follow up. They just did not turn up for their clinic appointments. However, what happened to them is as follows: of the 116 mother/child pairs in our parent initiated surveillance group who did not turn up for their clinic appointments, three possible abnormalities were missed when reviewing their hospital notes at the age of about 3. None of these screening abnormalities needed treatment. In the 118 controls who did not turn up for their appointments, two orthoptic abnormalities were missed (again neither needing treatment).
By the age of 5, two children from each group of non-attenders needed educational psychology involvement at school. This compares to 10 of 163 in the parent initiated group and three of 107 in the control group.
These results suggest that your correspondent is correct in as much as parents voice their concerns to health visitors, not because of a structured child health surveillance programme but probably because the health visitor, speech therapist, or even the occasional GP, are available to listen. As to who identifies complex disabilities, our results1-1 are different from those suggested by your correspondent. However the point of our paper was not to deprecate child health surveillance, which may well be very popular with some parents, but rather to illustrate how hard it is to change entrenched views; and secondly to try to measure the value of routine professional contact within the child health surveillance programme. The major effect of the latter was to disempower parents.