Healthy Birth and Early Years

Why a Healthy Birth and the Early Years are important

A child’s earliest years, from their birth to the time they reach statutory school age, are crucial. All the research shows that this stage of learning and development matters more than any other.
Unknown children – destined for disadvantage?[1]

Families are the most important influence on a child – particularly in the early years – and identifying those families who need help as early as possible opens opportunities to offer evidence-based interventions. Several related protective factors can be optimised to support a healthy birth and the early years including:[2]

  • Authoritative parenting combined with warmth, with an affectionate bond of attachment being built between the child and the primary care-giver from infancy
  • Parental involvement in learning
  • Protective health behaviours e.g. stopping smoking
  • Psychological resources including self-esteem
  • Breastfeeding

The local picture

The most recently compiled and published data is compared with other local authorities of similar deprivation, unless stated otherwise, as of April 2023.

Table 1: Healthy Birth and Early Years in Bedford Borough

Table depicting the key for the table that follows
A red circle followed by text saying significantly worse than comparator
A yellow circle followed by text saying Not significantly different from comparator
A green circle followed by text saying Significantly better than comparator
A white/clear circle followed by text saying No IMD comparator.
Healthy Birth and Early Years IndicatorPrevious Period
[Comparator IMD 2019]
(Date)
Most recent available period
[Comparator IMD 2019 or England]
(Date)
Baby’s first feed breastmilk (%)
79.7%
[NA]
(2016/17)
72.7%
[NA]
(2020/21)
Breastfeeding at 6-8 weeks (%)
52.0%
[England, 52.0%]
(2021/22)
56.0%
[England 49.2%]
(2022/23)
A&E attendances aged 0-4 years (Rate per 1,000)
437.5
[576.4]
(2018/19) 
526.5
[665.8]
(2021/222)
Low birth weight of all babies (%)
7.6%
[6.3%]
(2020)
7.6 %
[5.9%]
(2021)
Admissions for gastroenteritis in infants aged 1 year
(Rate per 10,000)
63.7
[87.6]
(2019/20)
188.2
[101]
(2021/22)
Admissions for lower respiratory tract infections in infants
aged under 1 year (Rate per 10,000)
571
[739]
(2019/20)
442.3
[728.4]
(2021/22)
Infant immunisations – MMR one dose at 24 months
(%)
91.4%
[91.8%*)
(2021/22)
91.7%
[92.0*]
(2022/23)
Infant immunisations – MMR two doses at 5 years old (%)
[Benchmarked against national target of 90%]
89.5%
[88.4%]
(2021/22)
90.4%
[87.7%]
(2022/23)
Domestic abuse incidents (Rate per 1,000)
26.2
[NA]
(2021/22)
25.4
[NA]
(2022/23)
Early Years Foundation Stage: good level of development
at age 5 (%)
Note new wording for measure from 2021/22:
School readiness: children achieving a good level of
development at the end of reception
63.8%
[England 65.2]
2021/22
66.9%
[England 67.2]
2022/23
Hospital admissions for dental caries (0-5 years)
(Rate per 100,000)
24.2
[196.3]
(2017/18-19/20)
24.1
[135.3*]
(2018/19-20/21)

Bedford Borough’s overall score for deprivation (using the 2019 Index of Multiple Deprivation) relative to all other local authorities in England, puts it in the 4th least deprived decile. Throughout this report, Bedford Borough’s performance is compared to other areas of similar deprivation where possible. For comparison to other local authorities of similar deprivation (IMD 2015), please refer to the reference. [3]
* Aggregated from all known lower geography values

Table Sources:
Public Health Profiles Available at:  Child and Maternal Health – OHID (phe.org.ukBedford Borough’s overall score for deprivation (using the 2019 Index of Multiple Deprivation) relative to all other local authorities in England, puts it in the 4th least deprived decile. Throughout this report, Bedford Borough’s performance is compared to other areas of similar deprivation where possible. For comparison to other local authorities of similar deprivation (IMD 2015), please refer to the reference.[1]
*Aggregated from all known lower geography values
**  Note new wording for measure for 2021/2: School readiness: children achieving a good level of development at the end of reception
Table Sources:
Public Health Outcomes Framework: CYP JSNA – Section 2 (IMD 2021)  https://fingertips.phe.org.uk/profile/child-health-profiles/data#page/1/gid/1938133228/pat/6/par/E12000006/ati/402/are/E06000055/iid/92196/age/2/sex/4/cat/-1/ctp/-1/yrr/3/nn/nn-11-E06000055/cid/4/tbm/1 [Accessed 3 May 2023]
 
Public Health Outcomes Framework: CYP JSNA – Section 2 (IMD 2019): https://fingertips.phe.org.uk/indicator-list/view/wGGsClEvSk#page/4/gid/1/pat/10113/ati/302/are/E06000055/iid/93580/age/309/sex/4/cid/4/tbm/1 [Accessed 1 April 2021].
 
Public Health Outcomes Framework: CYP JSNA – Section 2 (IMD 2015): https://fingertips.phe.org.uk/indicator-list/view/wGGsClEvSk#page/4/gid/1/pat/10105/ati/302/are/E06000055/iid/93580/age/309/sex/4/cid/4/tbm/1 [Accessed 11 July 2021].

For the latest data in key indicators, please see the Dashboard

Overall, Bedford Borough data is broadly similar to other local authorities in the same deprivation decile, with better levels than comparator local authorities (2021/22) for the following indicators:

  • A&E admissions (age 4 and under), although it is useful to note that these admission rates remain higher than pre-pandemic rates
  • Hospital admissions for dental caries (0-4 yrs), although there are other areas of oral health where Bedford is performing less well than comparator areas (see oral health section)
  • Hospital admissions for lower respiratory tract infections in infants aged under 1 year. This may be partly attributable to measures to control Covid-19 which also reduced transmission of other infectious diseases in children (BMJ 2022 Covid-19 control measures and common paediatric infections p.336).

Bedford has a lower rate of children reaching a good level of development at 5 years old. This has been the case over the longer term, although changes to the EYFSP new curriculum framework in 2021-22 mean that latest results are not directly comparable to previous years. The reduction in levels of children reaching a good level of development between 2018/19 and 2021/22 reflects the national trend and is attributed to lower starting points of children due to the pandemic (data was not collected during the pandemic 2019/20 or 2020-21).

Bedford also has a high rate of hospital admissions for gastroenteritis in infants aged 1 year, which may be attributable to poor access to GPs and/or small outbreaks. The MMR Vaccination rate for two doses at age 5 is lower than national targets due to the ongoing impact of Covid-19 which disrupted vaccination programmes. 

A healthy childhood

We are aiming for parents and carers to feel supported to make decisions to improve their child’s health outcomes and life chances, be their child’s first educator, and feel confident to manage their child’s minor illnesses and health issues.

The 0–5-year-olds element of the Healthy Child Programme[4]is led by the Health Visiting Service, and involves integrated working with all partners across the system, including maternity services, children’s centres, Early Years settings, children’s social care, and GPs. It offers a programme of screening tests, developmental reviews, immunisations and guidance to support parenting and healthy choices until the child reaches statutory school age. In addition to universal services, the Healthy Child Programme provides additional support to families where it will reduce the risk of adverse outcomes for the child. The pressures of the dramatic increase in vulnerable families through the Covid-19 pandemic, coupled with ongoing staffing capacity has led to a reduced universal offer within the Healthy Child Programme.

Bedford has an active and supportive Parent Carer Panel for families with SEND, comprising around 1400 families. The panel provides a range of support for parents, including advice and support sessions for families online and drop ins. It advocates on behalf of families to improve information and support for families with children with SEND and has strong relationships with statutory and voluntary services. The numbers of children and young people with SEND have increased significantly between 2019-2023 and it is anticipated that this will continue over the coming years, particularly as children currently on Education, Health and Care Plans (ECHPs) transition to young people[5].

FACES is a well-established local charity offering practical and emotional support to families and children who are experiencing difficulties and find it hard to use universal services. This includes families experiencing domestic abuse or families with poor mental and/or physical health, children with SEND, children with difficult behaviour and children exposed to (or at risk of) exploitation. At different times in their parenting journey, families can be referred to – or refer themselves – to FACES. The small staff team and over 40 trained volunteers offer quality-tested services through one-to-one and group support, including specific support for dads as well as working with schools to support children with emotional literacy.

Breastfeeding

The longer breastfeeding continues, the longer the protection lasts and the greater the benefits. Breastfeeding increases the level of attachment and the bond between mothers and their babies, as well as having health benefits for both the mother and child. The World Health Organization and the Department of Health recommend exclusive breastfeeding for the first 6 months of life.

Breastfed babies have lower rates of gastroenteritis, respiratory infections, sudden infant death syndrome, obesity and allergies. The health benefits for the mother include lower risks of breast and ovarian cancers, cardiovascular disease, osteoporosis and type 2 diabetes in later life. National research suggests that breastfeeding is influenced by a complex set of factors, including age, religion, culture and deprivation[6].

In Bedford, 73% of babies received breastmilk as their first milk in 2020-21 and the breastfeeding rate at 6-8 weeks was 52% for 2022-23. Breastfeeding rates have increased in Bedford Borough over recent years and are above national rates. However, there is still work to do particularly in hospital and the first 10 days where there is an early opportunity to provide advice and resolve feeding misinformation, concerns or issues. There is variation across Bedford Borough – with most drop off after 6-8 weeks in Kempston.

In Bedford, midwives encourage and support breastfeeding and there is a breastfeeding specialist midwife based at Bedford hospital who also provides a tongue tie clinic. Maternity support workers and volunteer breastfeeding buddies are trained in providing breastfeeding support and women are encouraged to ask for support when required.

Regular ‘Baby Brasseries’ take place in Bedford’s Children’s Centres where parents can access infant feeding support. The Baby-Friendly Support team are also continuing to encourage and support mothers in breast-feeding through virtual consultations. This has encouraged an increase in breastfeeding rates. Family hubs will provide additional capacity within the team to support this approach. Bedford is gold standard accredited in the community for the UNICEF Baby Friendly Initiative, with Bedford hospital working towards full accreditation which includes all midwifery staff being trained in Breastfeeding and Relationship Building[7]

Preventable childhood diseases

Antenatal and newborn screening goes from pre-conception to 8 weeks after birth and is part of the routine maternity care pathway.[8]Through the robust programme provided locally, it could help prevent infection of the newborn child and ensure appropriate care is made available.

Vaccination is recognised as one of the most effective public health interventions in the world, with the UK having one of the best immunisation programmes. High coverage protects the whole community, not just those vaccinated, by reducing the likelihood of infectious diseases being able to spread. National research shows that children under the age of 5 years have the highest rate of hospital admissions of any age group. The purpose of the childhood vaccination programme is to help protect children against preventable diseases including measles, mumps and rubella. The annual flu vaccination programme includes children; this helps to protect them from catching flu and to prevent spreading infection to their families and the wider community.

Figure 1: Vaccination Programme for children and young people

In Bedford borough (2022-23), the 12-month indicators of Diphtheria/tetanus/Pertussis/Polio/Hib Influenza/Hepatitis B, Rotavirus, Pneumococcal and Meningitis B vaccines, were all above the England and East of England average. Most vaccine types, other than Rotavirus, have sat consistently close to or above the national COVER target of 95%, even within the constraints of the COVID-19 pandemic. Sustaining uptake during this period was attributed to the work of both General Practice and the support of the redeployed Community and School Age Immunisation team.

The rate of 2nd MMR dose at age 5, however has not reached the 95% target (although Bedford is performing slightly better than comparator areas). Uptake was at 90.4% for 2022/23.  Strategies are in place with the Integrated Care System (ICS), NHS England (NHSE) and the Child Health Information Service, to improve uptake through targeted work, at practice level, for all children with outstanding MMR vaccinations. Full uptake figures can be found in the COVER programme, 2021-22.[9]

The annual flu vaccination programme now includes children; this helps to protect them from catching flu and helps to prevent them spreading infection to their families and the wider community. Reporting as Bedfordshire CCG, flu vaccination uptake in 2020/21 for the 2 & 3 year olds was above both the England and East of England uptake and a significant improvement on 2019/20.

The NHSE Screening & Immunisation Team continue to update all members of the wider team, in partnership with Public Health, including 0-19 teams including Looked After Children teams, General Practice staff both clinical and non-clinical, pharmacists, Foster carers, Childminders and Early Staff on the changes in the UK Routine Vaccination Schedule, strategies on improving uptake, the role of Child Health Information Service and reducing inequalities.

Ensuring children are ready to learn

As part of the Healthy Child Programme, children are normally offered a developmental review at 2-2.5 years old. The focus of this is to optimise child development and emotional wellbeing and reduce inequalities in outcome. Collaboration between Health Visiting and Early Years professionals ensures high quality and comprehensive assessment of need that includes the child, their family, and the wider context. The review provides an opportunity to discuss and assess a child’s health, wellbeing and development and to identify those children and families who may need additional support.

As a pilot, Bedford Borough has been testing the effect of conducting the Integrated Education and Health Review at the age of 3 years and 3 months (whilst still offering the developmental review at 2 to 2.5 years old where there are developmental concerns).  Further to an academic review, the integrated health and development review will revert to taking place at 2.5 years old later in 2023. As a result of the pilot, Bedford developmental data at 2-2.5 years old is lower than national levels[10].

Parenting and the home learning environment is a priority element of the family hubs programme. During the Covid-19 pandemic, the lack of opportunities to socialise babies alongside changes to service delivery has increased need for speech, language and communication support (SLT). SLT Support at different levels of need is commissioned through the Cambridgeshire Community NHS Trust including:

  • The Early Communication Support team that provides early support for families with pre-school children through virtual consultations, home visits and group support in partnership with children’s centres. The team also provides training and support with childcare settings to build their capacity to enable early identification of needs and to provide appropriate support.
  • The Community SLT team is based in Health Centres across Bedford and provides access via a referral for pre-school children and all ages above. They treat children with disordered speech and language development.  
  • The Special Needs Team (based at the Child Development Centre, Kempston) provide a service to Early Years children with complex needs and to children who have identified Speech, Language, and Communication Needs and/or eating or swallowing difficulties as part of their Education, Health, and Care Plan.

Although there are long waiting lists for assessment for community and specialist services, families can access information, advice and support from children’s centres, the Early Communication Team, the SEND Parent Carer Forum (PCF) and FACES whilst they are waiting for assessment.

To support parents and carers in their crucial role as their child’s first educator, evidence-based parenting programmes such as Parents as First Teachers[11] and the Triple P Positive Parenting Programme[12] are offered online and face to face through children’s centres. FACES provide one to one and group parenting support for parents in children’s centres for those who can find it difficult to join universal groups.

Development by 5 years

A child’s development and a gauge of their readiness for school is next measured at age 5, using the Early Years Foundation Stage profile (EYFSP).[13] Improving the number of children who achieve a good level of development when starting school remains a priority for Bedford Borough because Bedford has a lower rate than comparator local authority areas. Analysis of the 2021-22 EYFSP data suggests that underperformance is more pronounced in the literacy domain and for Black children.

Adverse childhood experiences and trauma

Adverse Childhood experiences (ACEs) and trauma,[14] are highly stressful, and potentially traumatic, events or situations that occur during childhood or adolescence. These can be a single event, or prolonged threats to, and breaches of, a young person’s safety, security, trust or bodily integrity. These experiences directly affect the young person and their environment, and require significant social, emotional, neurobiological, psychological or behavioural adaptation.

Adaptations are children and young people’s attempts to:

  • Survive in their immediate environment
  • Find ways of mitigating or toleration the adversity by using available resources
  • Establish a sense of safety or control
  • Make sense of the experiences they have had

What kinds of experiences are adverse?

  1. Maltreatment: including physical, sexual, emotional and financial abuse and neglect
  2. Violence and Coercion: including experiencing, or directly witnessing, domestic abuse, assault, harassment or violence, sexual exploitation, sexually harmful behaviour, being the victim of crime or terrorism, experience of armed conflict, gang or cult membership and bullying.
  3. Adjustment: including moving to a new area where there are no social bonds, migrating, seeking and gaining refuge or asylum and the ending of a socially significant or emotionally important relationship.
  4. Prejudice: including discrimination, victimisation, hate incidents and crime, other attitudes, chronic exposure to behaviours and institutional processes driven by LGBT+ prejudice, sexism, racism or disablism.
  5. Household or family adversity: including living in a household with adults or adolescents who misuse substances, engage in criminal activities, are not supported to manage their mental ill health, making sense of intergenerational trauma (e.g. experiences of genocide). It also includes living in poverty, destitution or facing significant social, material and emotional deprivation. It also includes being looked after, leaving care, being detained in a secure children’s service (e.g. young offender institution) and family or placement breakdown
  6. Inhumane treatment: including torture, forcible imprisonment, confinement or institutionalisation, non-consensual and coercive scarification and genital mutilation.
  7. Adult responsibilities: including being the primary carer of adults or siblings in the family, taking on financial responsibility for adults in the household and engaging in child labour.
  8. Bereavement and survivorship: including death of care-giver or sibling (including through suicide or homicide), miscarriage, acquiring or surviving an illness or injury, and surviving a natural disaster, terrorism or accident.

Often risk factors occur together; particularly for children living in a family affected by the ‘toxic trio’ of parental mental illness, substance misuse and domestic violence. Over a quarter (26%) of babies in the UK have a parent affected by at least one of these issues.[15]  If we apply this prevalence data to Bedford, this equates to around 570 babies per year where one parent is affected by an ACE.

Children and young people who witness and live with these stressful incidents are more likely to have low self-esteem, attachment issues and difficulties managing their emotions.

Individuals who experienced four or more adverse childhood experiences or traumatic events have an increased risk of high-risk behaviours and poorer outcomes as adults, as shown in the graphic.[16]

Figure 2: Increased adult risks associated with having had four or more adverse childhood experiences

Emergency hospital attendances and admissions

The main causes of Accident and Emergency (A&E) attendances and admissions amongst children and young people are acute illnesses, such as gastroenteritis and upper respiratory tract infections, and injuries caused by accidents in the home. Unintentional injuries are the main cause of death in children and young people nationally.

Bedford had a higher rate of hospital admissions caused by unintentional and deliberate injuries in children (aged 0 to 4 years) than comparator local authorities (130.9 per 10,000 compared to 98.4 per 10,000 in 2021-22)[17].

Oral Health

Poor oral health can affect children’s ability to speak, eat, sleep, play, socialise, and can negatively impact on a child’s school attendance and wellbeing. In the UK, tooth decay is still the commonest cause of admission to hospital in 5-19 year olds. Although Bedford has a low rate of hospital admissions for caries in 5 year olds (in comparison to UK and comparator LAs), the percentage of five year olds with incisor decay is higher than the England average. This is often linked with particular drinking practises, such as prolonged bottle use and drinking sugary drinks from a teated bottle/cup (England: 6.6; Bedford: 7.8 )[18]

In addition, 2022 data for 5 year-olds shows that the mean number of teeth that are decayed, missing or filled in Bedford is higher than the England average (England: 3.5 teeth per mouth; Bedford: 4.6 teeth per mouth)[19].

3 year old data reflects a similar trend[20] – in Bedford 12.2% have decay experience compared to 10.7% in England with decay experience.

Through the locally commissioned Oral Health Promotion (OHP) Service, health education advice, information and training is provided in various settings, to a range of groups in Bedford Borough, which includes:

  1. Nursery Schools
  2. Pre-Schools
  3. Foster carers
  4. Other groups by request

The team, who are part of Cambridgeshire Community Services (CCS), also provide training to other CCS children’s teams including the 0-19 HCP Service, specialist school nurses and the looked after children (LAC) health team. Oral health is discussed by the HCP team in all 0-5 mandated contacts, with staff using activities and materials provided by the OHP team. The training delivered to 5-19 teams covers specific areas – i.e., interdental cleaning, HPV awareness, piercings etc.

Professionals in oral health promotion offer health protection messages for families to promote the importance of good oral health using a range of evidence based approaches such as: apps and websites through Start4Life and Change4Life; encouraging children and their families to register and attend a dentist if they have not done so already; making every contact count by delivering brief intervention and advice to parents/carers including making the link between healthy eating (low sugar diet/drinks) and good oral health; promoting good oral health practices such as effective tooth brushing, and the use of fluoride paste.[21]

The OHP team also deliver the ‘mysmile’ accredited programme for early years settings, children’s centres, special schools and primary schools in greatest areas of need. The programme guides settings in the application of the 4-step approach to providing a tooth-friendly environment for children within their care, including a supervised tooth-brushing programme. The ‘my smile’ accreditation is given to settings that can demonstrate to the ‘my smile’ team that all 4 steps are in fully in place and are being implemented effectively.

COVID-19 Recovery

The pandemic has influenced the development and well-being of children and young people. The largest impact is likely to fall on children from the poorest families or those with vulnerabilities and additional or particular needs.[22] The extent of the impact on outcomes for children is still emerging.

0-5 services are continuing to work together to re-engage families and support healthy births and child development. Many services are being delivered face to face again alongside virtual support where this proven effective. Workforce recruitment remains challenging within most key statutory services.

Continued areas of priority focus

  1. Develop and retain our highly skilled and motivated 0-5 workforce across the system supporting integrated working across health, social care and education.
  2. Provide training for all professionals working with children and families to: recognise key risk factors (including adverse childhood experiences and trauma), improve information sharing, intervene early and refer to appropriate services.
  3. Support parents and carers to ensure their children are ready to learn. This includes raising parental awareness of children’s centres, how to nurture their child, increasing uptake of the integrated health and education review at 2-2.5 years old and free nursery places at ages 2 and 3 where applicable.
  4. Ensure consistent messages across all health and early years providers to continue to promote and support responsive breastfeeding, responsive bottle-feeding and smoke-free environments.
  5. Reduce unintentional injuries in under 5s.

Priority actions to deliver better outcomes

  1. The ICS/Public Health/NHSE and all key stakeholders in delivering vaccination to children and young people to work together to continually raise the profile of immunisation, monitor activity and identify and address issues such as increased vaccine hesitancy in certain communities, in a timely manner.
  2. Support with effective positive messages around immunisations to parents and young people.
  3. Using the most appropriate and effective means to communicate messages, for instance, social media and trusted voices.
  4. Support with access to appropriate community vaccination venues to provide easy access for all children who have not been vaccinated in a school setting.
  5. Population awareness of choice of vaccine for the healthy children’s flu programme to include non-porcine vaccine.
  6. Responsive 7-day services to cater to the needs of children and young people and carers to ensure children get care close to home at the right place at the right time 7 days a week.

References

[1] Ofsted. 2016. Unknown children – destined for disadvantage? Available at: https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/541394/Unknown_children_destined_for_disadvantage.pdf [Accessed 28 April 2020].[Accessed 2 June 2023]

[2] Public Health England (2015). Promoting Children and Young People’s Emotional Health and Wellbeing. Updated September 2021 Available at: https://www.gov.uk/government/publications/promoting-children-and-young-peoples-emotional-health-and-wellbeing [Accessed 2 May 2023].

[3] Public Health Outcomes Framework: CYP JSNA – Section 2 (IMD 2015). Available at: https://fingertips.phe.org.uk/indicator-list/view/wGGsClEvSk#page/4/gid/1/pat/10105/ati/302/are/E06000055/iid/93580/age/309/sex/4/cid/4/tbm/1 [Accessed 27 December 2023].

[4] Department of Health (2009) The Healthy Child Programme. Available at: https://www.gov.uk/government/publications/healthy-child-programme-pregnancy-and-the-first-5-years-of-life [Accessed 13 January 2021].

[5] Bedford Borough Council SEND JSNA 2023 [unpublished]

[6] Oakley LL, Renfrew MJ, Kurinczuk JJ, et al; Factors associated with breastfeeding in England: an analysis by primary care trustBMJ Open 2013;3:e002765. doi: 10.1136/bmjopen-2013-002765 [Accessed online June 6 2023]

[7] Unicef BFI Courses – Baby Friendly Initiative (unicef.org.uk) [Accessed June 6 2023]

[8] Public Health England. 2020. Antenatal and newborn screening timeline – optimum times for testing. Available at: assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/768805/ANNB_Timeline_v8.4.pdf [Accessed 16 December 2020].

[9] Cover of vaccination evaluated rapidly (COVER) programme: annual data. (digital.nhs.uk) Available at: Childhood Vaccination Coverage Statistics- England, 2021-22 – NDRS [Accessed 23rd May 2023]

[10] OHID Child Health Profile March 2023 Child Health Profiles (phe.org.uk) [Accessed 6 June 2023]

[11] Parents as First Teachers. 2016. Available at: parentsasfirstteachers.org [Accessed 16 December 2020].

[12] Triple P Positive Parenting Programme. Available at: www.TripleP.uk.net/uken/home [Accessed 16 December 2020].

[13] Department of Education. Early years foundation stage profile handbook. Available at: https://www.gov.uk/government/publications/early-years-foundation-stage-profile-handbook [Accessed 12 May 2021].

[14] Young Minds Addressing Adversity: Prioritising adversity and trauma-informed care for children and young people in England. Funded by Health Education England 2018. Available at:https://youngminds.org.uk/media/2142/ym-addressing-adversity-book-web.pdf [Accessed 25 January 2021].

[15] Wave Trust (2015). 1001 Critical Days. The Importance of the Conception to Age Two Period. Available at: https://www.wavetrust.org/1001-critical-days-the-importance-of-the-conception-to-age-two-period [Accessed 16 December 2020].

[16] Young Minds 2020. Addressing Childhood Adversity and Trauma. Available at: https://youngminds.org.uk/media/2141/ym-addressing-adversity-infographic-poster-web.pdf [Accessed 16 December 2020].

[17] PHE health profiles Public health profiles – OHID (phe.org.uk) [Accessed 6th June 2023]

[18] Source: https://www.gov.uk/government/statistics/oral-health-survey-of-5-year-old-children-2022/national-dental-epidemiology-programme-ndep-for-england-oral-health-survey-of-5-year-old-children-2022

[19] Source: https://www.gov.uk/government/statistics/oral-health-survey-of-5-year-old-children-2022/national-dental-epidemiology-programme-ndep-for-england-oral-health-survey-of-5-year-old-children-2022

[20]Source: https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/987179/NDEP_for_England_OH_Survey_3yr_2020_v2.0.pdf

[21] Local.gov.uk. 2016. Tackling poor oral health in children. Available at: https://www.local.gov.uk/sites/default/files/documents/tackling-poor-oral-health-d84.pdf [Accessed 3 May 2023].

[22] Sutton Trust. 2020. COVID-19 Impacts: Early Years – Sutton Trust. Available at: https://www.suttontrust.com/our-research/coronavirus-impacts-early-years [Accessed 16 December 2020].