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The Parliamentary Under-Secretary of State for Health (Dr. Stephen Ladyman):
I congratulate my hon. Friend the Member for Derby, North (Mr. Laxton) on raising this important subject, in which he has taken a considerable interest for a long time. I hope to be able to reassure him that the Government take it as seriously as he does.
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Nutritional anaemia is the most common type of anaemia in children. As my hon. Friend said, it can be caused by deficiency of iron, vitamin B12 or folate, although iron deficiency appears to be the most important cause of the condition. Its effect is to limit a child's ability to be physically active. Prevention of iron deficiency is important, because the condition can affect intellectual development and behaviour in the longer term, and it is also associated with deficits in a variety of developmental and behavioural measures. The Department of Health and the Food Standards Agency undertake regular surveys to monitor the diet and health of children. My hon. Friend mentioned the national diet and nutrition survey, and the last survey in 2000 indicated that the reported prevalence of anaemia varies markedly in different age groups and that younger children and teenagers are both prone to iron deficiency. It showed that 3 per cent. of boys aged two to six years were anaemic, compared with 1 per cent. of boys aged seven to 18 years. Eight per cent. of girls aged four to six years, 4 per cent. of girls aged seven to 10 years, and 9 per cent. of 15 to 18-year-olds were anaemic. In addition, lower intakes of both iron and vitamin C, which helps in the absorption of iron, are more common among manual worker social classes.
My hon. Friend rightly mentioned concerns that iron-deficiency anaemia is much more common among certain ethnic groups, including people from south Asian and Afro-Caribbean backgrounds. One survey, as he suggested, showed very high levels of deficiency. For example, 29 per cent. of Pakistani children, 25 per cent. of Bangladeshi children, and 20 per cent. of Indian children aged about two years were anaemic. Also of concern is the fact that iron intakes are considerably lower in young women, with 50 per cent. of 15 to 18-year-olds having intakes well below the recommended amounts, which can put them at risk of iron-deficiency anaemia. My hon. Friend raised the possibility of screening and early detection of anaemia. I can understand why he has come to that conclusion, but we must consider all the available evidence before deciding on such a course.
The UK national screening committeethe NSCadvises the Government about all aspects of screening policy, drawing on the latest research evidence and the skills of a specially convened multidisciplinary expert group. While screening has the potential to save lives or improve the quality of life through early diagnosis of serious conditions, it can never be 100 per cent. accurate. The NSC is increasingly presenting screening in a risk reduction context to emphasise that point. Its child health sub-group has advised that there is currently insufficient evidence to introduce a national screening programme for iron deficiency anaemia, and that the emphasis should be on primary prevention through good nutritional advice until further evidence is available.
The child health sub-group is a specialist sub-group of the NSC consisting of representatives of the royal colleges, paediatricians, researchers, health visitors and consumer interests. They weighed in the balance a number of arguments against screening when arriving at their recommendations. The test requires a blood sample, which some parents might regard as an unwelcome intrusion. Although haemoglobinometers are simple to use, a meticulous technique in collecting
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the sample and using the instrument is essential. The instruments available in community settings have a higher measurement error than those used in laboratories, and little is known about the accuracy of the measurements carried out in the primary care setting. Severe iron-deficiency anaemia would probably be identified without difficulty, but detection of the mild cases that would form the bulk of the screening could be less reliable.
The timing of a screening test would present problems. Many children who would have the screening test at the age of 12 or 18 months would become iron- deficient in their third year. Conversely, some children who are iron-deficient in their second year recover as they eat a more varied diet in the third or fourth year of life. We do not think, therefore, that the evidence currently supports the extension of whole-population screening programmes. Iron deficiency is preventable, and resources need to be directed at primary prevention rather than screening. I realise that my hon. Friend may not agree with that recommendation, but if it is of any reassurance to him, the UK national screening committee always keeps its policies under close review, and I will draw its attention to the issues that he has raised today.
What are we doing about childhood anaemia? I took part of my hon. Friend's speech as an indication that he does not believe that our emphasis should be on improved nutrition. However, I believe that is exactly where it should be. The Government are committed to improving the diet and nutrition of the nation, as set out in the recent Government White Paper, "Choosing Health".
Specific actions to improve children's diet include introducing healthy start vouchers, providing training and support for head teachers, governors, caterers and health professionals, aiming for all schools to be healthy schools, adopting a whole-school approach to food through the food in schools programme, improving school meals and considering the introduction of nutrient-based standards, and introducing Ofsted inspections of healthy eating in schools.
Current action on nutrition includes our investment in the five-a-day programme, the school fruit and vegetable scheme, promotion of breastfeeding and action to improve diet and nutrition across the whole school, as well as working with industry to reduce fat, sugar and salt. In addition to these specific actions, there is a considerable amount of local action including healthy living centres, Sure Start and action to deliver national service frameworksall actions that my hon. Friend mentioned.
The Government recognise the importance of primary prevention and have several actions under way. The importance of good nutrition prior to pregnancy and during pregnancy is well recognised. The welfare food scheme was established in 1940 to protect the health of women and young children at the time of rationing and price rises. The scheme was originally universal, but is now primarily targeted at low income families in receipt of income support, income-based jobseeker's allowance or child tax credit under a certain level. The scheme currently provides tokens for free milkboth liquid milk and infant formulaand vitamins to around 800,000 pregnant women, mothers
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and young children under five in England, Scotland and Wales. A separate but parallel scheme operates in Northern Ireland.
In line with the recommendations made by the committee on medical aspects of food and nutrition policy, the welfare food scheme is being revised to meet the present-day nutritional needs of mothers and children. Following the public health White Paper, from mid-2005 a reformed scheme, Healthy Start, will be introduced. The key features of the new scheme will be to provide access to a broader range of foodsfor example, fresh fruit and fresh vegetables are being added to cow's milk and cow's milk-based infant formula at the outsetand this range will be kept under review. The scheme will use fixed-value vouchers, rather than volume-based tokens, which can be exchanged in the widest possible range of participating retail outlets, including food co-operatives and community shops as well as supermarkets, milk roundsmen, greengrocers, farmers markets and others. Closer links with the NHS will also enable the scheme to become the vehicle for delivering advice and information on diet, exercise, and other health issues to qualifying pregnant women and families. Finally, the new scheme will provide equal value benefits for breastfeeding and non-breastfeeding mothers.
Vulnerable children in qualifying families are also provided with supplements, including vitamins A, C and D. Vitamin C in particular aids the absorption of iron from the diet. Iron supplements may also be prescribed to children with iron deficiency anaemia that does not improve with appropriate dietary advice. The provision of iron supplements for premature and low birth-weight infants is now standard practice, as they are at risk of iron deficiency.
Breast milk provides the best form of nutrition for an infant. Following World Health Organisation revised guidance, the Department of Health recommended in May 2003 exclusive breastfeeding for the first six months of an infant's life. The early introduction of cow's milk, as my hon. Friend said, is associated with an increased risk of anaemia in children. The Department recommends that unmodified cow's milk be given as a main drink only after the age of one year. Appropriate weaning is important. After one year, the child's diet should include a variety of foods to ensure that it is adequate in iron and vitamin C.
My hon. Friend pointed out that this is an agenda spread across two Departments, the Department of Health and the Department for Education and Skills. I believe that is right, as schools are pivotal to achieving our goals. Schools are a key setting through which we can improve children's health. Our vision is that all schools will be healthy schools that provide supportive environments, including policies on healthy and nutritious food, with the time and facilities for physical activity and sport, both within and beyond the curriculum. That needs the support of colleagues in the Department for Education and Skills.
We are committed to improving school food and drink, not just at lunch time but across the school day, and we are revising and extending school meal standards, including food sold through vending machines and tuck shops. School meals should be
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nutritionally balanced and should cater for children's dietary requirements and specific religious or philosophical requirements and medical needs. The Department for Education and Skills is also ensuring that there are special diets for customers from religious and ethnic groups. These include halal meat and a variety of vegetarian options.
We will be supporting school heads, governors and caterers to provide the best meal service possible, for example through training for caterers and guidance on food procurement. We will soon be launching a food in schools toolkit that will guide, inspire and help schools take the whole-school approach to healthy eating. I am delighted to say that, today, almost 2 million four to six-year-old children are now receiving free fruit and vegetables every school day in more than 15,600 schools in England.
Recognising the vulnerability of teenage girls, the Government have also developed targeted healthy eating advice aimed particularly at young women. Following research that it conducted in 2004, the Food Standards Agency has issued special advice to teenage girls and young women. That includes practical tips on how to increase iron intakes and information on iron-rich foods. For example, a glass of orange or grapefruit juice with meals rather than the often consumed cup of tea can increase iron absorption.
My hon. Friend mentioned the Scientific Advisory Committee on Nutrition, and we have indeed asked it to look at issues around dietary iron for us. As too much iron can be harmful, both beneficial and adverse effects are being considered, including the effect of dietary components on iron absorption and utilisation in the body; the interaction of infections and inflammation with iron metabolism and the possibility that that may affect the apparent incidence of iron deficiency; the effect of iron deficiency on health and well-being, for example mental and physical development; and the potentially adverse effects of excess iron, including free radical damage and the risk of cardiovascular disease and cancer. The team is now in the final stages of reviewing evidence for the iron report, which, as my hon. Friend said, is expected to be ready to be released for stakeholder comment in summer 2005.
Finally, as well as the White Paper "Choosing Health", the national service framework for children and young people and maternity services, together with the chief nursing officer's review of school nursing, will also play important roles in our campaign. The NSF puts an emphasis on early identification and intervention in child and family-focused services. The first strand is about promoting health and well-being, identifying needs and intervening early. I assure my hon. Friend that, although the framework began solely as a Department of Health document, with the appointment of the Minister for Children, Young People and Families, it became a joint Department for Education and Skills and Department of Health document, and we are collaborating very closely on ensuring that it is implemented.
One of the key themes of the chief nursing officer's review is the need to follow the child, providing services where vulnerable children and young people are, rather than services being dictated by professional roles and organisational boundaries. In order to fulfil the chief
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nursing officer's vision of having at least one full-time year-round qualified school nurse working in each cluster or group of primary schools, new funding will be provided to make that a reality by 2010. I think that those school nurses will be pivotal in spotting childhood anaemia at an early stage.
Having set out the Government's position, I hope that I have given my hon. Friend some reassurance that the issue is very important to the Government and a
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high priority for us. Obviously, we will keep the situation and emerging evidence under review, and change the position as necessary. I congratulate him once again on raising this important issue, and I assure him that I personally take it very seriously, as do the whole Government.
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