E.2.c.3.a. Child Health

 

The domain of Child Health includes the State Priority Needs of #3 Improving Nutrition and Physical Activity and the selected National Performance Measures of #6 Developmental Screening and #8 Physical Activity and State Performance Measure #2 (Children with Elevated Blood Lead Levels). NPMs #6, NPM #8 and SPM #2 were selected during the Five-Year Needs Assessment process for their impact on overall child health and for the evidence-based strategies implemented by NJDOH and its partnerships.

 

Child Health – Annual Report

 

Annual Report - NPM #6: (Percent of children, ages 10 through 71 months, receiving a developmental screening using a parent-completed screening tool)

 

Increasing NPM #6 is an important focus in the domain of Child Health to improve overall child health and well-being. Early identification of developmental disorders is critical to the well-being of children and their families. It is an integral function of the primary care medical home. The percent of children with a developmental disorder has been increasing, yet overall screening rates have remained low. The American Academy of Pediatrics recommends screening tests begin at the nine-month visit.

 

	2007	2011-2012	2016	2017
6: Percent of children, ages 10 through 71 months, receiving a developmental screening using a parent-completed screening tool	12.67	25.02	32.9

Source – National Survey of Children's Health (NSCH)

 

Developmental screening is a required benchmark performance measure for the NJ MIEC Home Visiting Program and improving developmental screening practices and policies is a current focus on HV evaluation and continuous quality improvement. The NJ MIEC Home Visiting Program promotes and monitors parent completed child development screening tools (ASQ and ASQ: SE). In SFY 2018 6,997 families with young children participated across all 21 NJ counties.

 

The NJDOH is an interdepartmental partner active with the NJ Council for Young Children (NJCYC), the Race to the Top-Early Learning Challenge (RTTT-ELC) grant and CDC’s ‘Learn the Signs’ NJ Team. The NJCYC, Infant Child Health Committee has established a priority of improving system connections for children and families with health care providers, community services, early intervention, child care, home visiting to expand screening (prenatal & child development) in health care and early care & education settings. Grow NJ Kids (GNJK) a Quality Improvement Rating System (QRIS) developed for early learning programs requires the use of a “state approved” developmental screening at Level 2 of a 5 level rating with the expectation that 90% of high needs infants and children participating in GNJK will receive developmental screening with an emphasis on using the parent completed child monitoring system Ages and Stages Questionnaires (ASQ and ASQ: SE) screening tools.

 

The Boggs Center on Developmental Disabilities, NJ’s federally-designated University Center of Excellence on Developmental Disabilities, and the Statewide Parent Advocacy Network (SPAN), the state’s federally-designated Parent Training and Information Center (PTI) and Family to Family Health Information Center (F2F) collaborated on the Act Early State Systems Grant with the shared goal of improving access to developmental screening and referral among underserved children in NJ. One of three overarching objectives of this project included strengthening the collaborative efforts between The Boggs Center and SPAN within the scope of promoting developmental screening using validated instruments at appropriate intervals as well as referral for diagnosis, Early Intervention, and community services and supports at NJ’s network of FQHCs and community clinics.

 

Over the project period, SPAN and The Boggs Center partnered to provide 15 parent-led trainings about developmental screenings to healthcare providers at FQHCs throughout the state, attended by a total of 195 participants. Overall, 7 trained SPAN Family Resource Specialists, each with a child on the autism spectrum, participated in the project and a total of 27 SPAN parents were represented at the 15 trainings. Early Intervention representatives presented at 9 of the 15 trainings; all but one were parents and one was a sibling.

 

NJ is part of a national Project LAUNCH initiative funded by HRSA that is designed to promote the wellness of young children ages birth to 8 and to reduce racial and ethnic disparities including an emphasis on routine developmental screening. NJ Project LAUNCH is targeting urban Essex County and is using a Help Me Grow systems approach to strengthen the connections between physicians, parents/families, and community providers to addresses the physical, social, emotional, cognitive, and behavioral aspects of child development. Project LAUNCH ensures that parents/families have access to a continuum of community-based evidence-based programs (EBP) that support parent-child interaction and young child development across a range of settings—health care, home visiting, child care, Early Head Start/Head Start, preschool/school to promote early identification of health and developmental issues that impact child wellness. In FY18, the NJ Project Launch grant ended, however many of the activities to the NJ Project Launch Essex County team aligned with Central Intake, the Help Me Grow System and ECCS Impact continued, which include the reach and linkage of families with young children to services and programs that support family and child well-being; inclusive of developmental health promotion and screening.

 

The selected ESM 6.1 will monitor progress on increasing the use of parent-completed early childhood developmental screening using an online ASQ screening tool and how well early childhood developmental screening is promoted across the Departments of Health, Children and Families, Human Services, and Education which will drive improvement in NPM #6 (Developmental Screening). NJ DCF implements the ECCS Impact grant in 5 communities to promote parent-completed early childhood developmental screenings in children less than 3 years old. ASQ Enterprise software (Brookes Publishing) is being utilized to add a parent/family portal for easy access to developmental screening and links screening to Central Intake hubs. NJ’s expanded data system will link developmental screenings with current Central Intake assessments to support pediatric primary care and/or other systems partners that include at a minimum Home Visiting; and may extend to quality Child Care, Early Head Start/Head Start, and Preschool programs. In FY18, the Project Launch/ECCS Team for Essex County (EPPC) begin a pilot in testing the implementation of the ASQ Family Access online portal within their Central Intake system. They developed, implemented and tested policies and procedures on the use and experience of the Family Access Portal by parents, as well as outreach and engagement strategies.  EPPC was able to provide no cost development screening to 32 children/families, they provide appropriate follow-up and linkage, as well as education to parents on monitoring their child’s developmental milestones and activities parents can do to support their child’s developmental progress. EPPC led the way to the infusion of the ASQ Family Access Portal with the statewide Central Intake System, which led to the 4 additional ECCS Placed Based Communities (PBC’s) to join in the implementation in FY19. In FY2018, the 1,029 children (ages 10 – 71 months) receiving an ASQ developmental screening through the ECCS Impact grant through the NJ Home Visiting Program and Central Intake (ASQ Family Access Portal).

 

Plans for additional expansion of screening to the additional 16 counties is slated to occur in FY20 with the expansion of Early Childhood Specialist staffed within all 21 Central Intake hubs.

 

 

Annual Report - NPM # 8: Percent of children ages 6 through 11 and adolescents ages 12 through 17 who are physically active at least 60 minutes per day

 

Increasing NPM #8 is an important focus in the domains of Child Health and Adolescent and Young Adult Health to prevent obesity and improve overall child health and well-being. FHS has been collaborating on and developing partnerships to address this NPM thru ShapingNJ and the CDC 1305 Cooperative Agreement in Community Health and Wellness and the CDC WSCC School Health NJ Project in MCHS. Regular physical activity can improve the health and quality of life of Americans of all ages. Physical activity in children and adolescents reduces the risk of early life risk factors for cardiovascular disease, hypertension, Type II diabetes, and osteoporosis. In addition to aerobic and muscle-strengthening activities, bone-strengthening activities are especially important for children and young adolescents because the majority of peak bone mass is obtained by the end of adolescence.

 

	2003	2007	2011	2013	2016	2017	2018
8a: Percent of children ages 6 through 11 who are physically active at least 60 minutes per day	23.6	35.5	27.6	n/a	24.7	24.7
8b: Percent of adolescents ages 12 through 17 who are physically active at least 60 minutes per day	19.0	23.0	23.2	27.6*	14.4	14.4

Source – National Survey of Children's Health (NSCH)

*Source – CDC, National Center for Health Statistics

 

 

FHS recognizes that positive physical activity and healthy nutrition behaviors start at a young age and should be addressed as early as possible. Children at greatest risk for overweight and obesity as well as physical inactivity are concentrated in disadvantaged communities. With dedicated supports including training and technical assistance, as well as strengthened child care regulations, the prevalence of obesity among two to four-year-old children from low income families participating in NJ WIC decreased from 18.9% in 2010 to 15.3% in 2014.

 

ShapingNJ, the state public-private partnership for nutrition, physical activity and obesity prevention consists of some 230 organizations working to reduce and prevent obesity in NJ. The work is focused in 6 settings, including early care and education, schools, communities, work sites, health care and faith-based. In the communities, the NJDOH is part of a funding collaborative that together supports 66 NJ at-risk communities charged with implementing one healthy food access strategy and one physical activity strategy through policy and environmental change. The NJDOH also funds Faith in Prevention, an initiative charged with engaging faith-based organizations in the battle against chronic disease in Trenton, Camden and Newark.

 

School health objectives aim to: Provide training and technical assistance from 75 of the State’s 600+ school districts (K -12) in 2016 to 100 by 2017 to create school environments that provide healthy nutrition and opportunities for physical activity throughout the day including quality physical education.

 

• NJ Association for Health, Physical Education, Recreation and Dance (NJAHPERD), with CDC funding, conducts professional development sessions at statewide and regional meetings on: Physical Education/Physical Activity for K-12 teachers; School Food Service guidelines and nutrition standards for K-12 teachers; Preparing fresh fruits and vegetables for School Food Service staff.

 

• The NJ State Alliance of the YMCA, with CDC funding, continues to provide intensive training and technical assistance in five low-income school districts (including five - K-8 schools per district for a total of 25 schools; 1 high school per district in three districts = 3 high schools) to implement Comprehensive School Physical Activity and improve school nutrition environments.

 

• Health Corps, with State funding, supports efforts targeting three high schools. This funding supports three, full time, school-based youth coordinators to serve as peer mentors at the three high school sites to implement nutrition, physical activity and healthy lifestyles activities with students, teachers and the greater surrounding community.

 

Other nutrition, physical fitness and obesity prevention initiatives within the Office of Tobacco Control, Nutrition and Fitness (OTCNF) that are funded by the CDC - “State Public Health Actions to Prevent and Control Diabetes, Heart Disease, Obesity and Associated Risk Factors and Promote School Health” (CDC funding ends 6/30/18) support breastfeeding initiation, duration and exclusivity for the first six months of life and healthy communities.

 

• NJ Hospital Association (NJHA) - The OTCNF provides funding to the NJHA to continue training and technical assistance to eighteen of the 52 NJ maternity hospitals to help move them towards implementation of the WHO/UNICEF’s “Ten Steps to Successful Breastfeeding”, a program designed to promote exclusive and sustained breastfeeding. In September 2016, NJHA convened a statewide training summit for all NJ maternity hospitals. Birthing facilities utilize the 2015 document published by NJHA titled:  Healthy Beginnings NJ: Supporting Breastfeeding Moms and Babies Technical Assistance Guide for Hospital Providers. Periodic webinars are provided to interested hospitals. All efforts are overseen by an Advisory Group that convenes quarterly.

 

• NJ Prevention Network (NJPN) - The OTCNF provides funding to NJPN’s Get Active NJ program which provides technical assistance, training and incentives to assist municipalities to find ways to educate stakeholders on different policies that can promote walking and the many benefits that walking may have on their communities. The Get Active NJ - Walkability Toolkit created by NJPN, is intended to provide information and examples on how local policies are created at the municipal level to support walkability.

 

• The Food Trust - The OTCNF contracts with The Food Trust to implement activities and projects to promote policy and environmental change for obesity prevention in local communities. Trainings and technical assistance are provided to corner store owners in order to increase community residents access to healthy foods and beverages, particularly those at high-risk for obesity and other chronic disease. The Food Trust provides on-site technical assistance to a minimum of 14 small retailers to promote healthy retail sales in their stores. Corner stores are targeted through a collaboration with the NJ Department of Health WIC Program, the Office of Community Health and Wellness - OTCNF and The Food Trust. Beyond requiring WIC authorization, participating stores must meet either of two definitions including 1) ‘underserved areas’ - defined by CDC as ‘no healthier food retailers or 2) USDA criteria – defined as ‘low income – low access at half mile urban and 10 miles rural’.

 

• Child care healthy eating and physical activity (HEPA) subject matter experts provide training and technical assistance to licensed child care centers who need intensive assistance to improve and sustain HEPA best practices. Additionally, NJDOH collaborates with NJ Department of Human Services to provide training to Quality Improvement Specialists (QIS) and Regional Technical Assistance Specialists (TAS) who then are able to provide HEPA TA and other supports across the state as part of the NJ Quality Rating and Improvement System for Child Care (QRIS) called Grow NJ Kids.

 

The ShapingNJ child care workgroup has collaborated on a number of systems efforts. Child care partners continue to offer training and technical assistance at county and statewide trainings to increase center staff capacity for best practices that will prevent obesity in our most vulnerable population. Beginning in April 2013, NJ received funding from Nemours Foundation as part of a six-state early care and education learning collaborative to ensure that licensed child care providers offer children healthy food, breastfeeding support and opportunities for active play. One hundred licensed centers serving 100 or more children were enrolled. Participation in this project will assist centers meet and exceed new licensing requirements. New licensing requirements were adopted by the Office of Licensing (Department of Children and Families) and became effective September 30, 2013 (http://www.state.nj.us/dcf/providers/licensing/laws/CCCmanual.pdf). Sustainability efforts can be achieved through participation in a six-state early care and education learning collaborative coordinated by the Nemours Foundation and funded by CDC. A state coordinator was hired to work within the NJDOH and five regional learning collaboratives were established in NJ in year one of a five-year funding that focused on improving skills of child care center staff.

 

The Child Care Workgroup of ShapingNJ developed and distributed a best practices toolkit to partners at the annual ShapingNJ meeting in June 2013 and was shared with county-level partners through the Office of Local Public Health for more rapid dissemination. It is also posted on the ShapingNJ.gov website.

 

For three years beginning Fall 2015, DOH regional school health grantees annually renewed a MOA with Sustainable Jersey for Schools.  The MOA was terminated June 2018.

 

Actions to Increase Physical Activity or Improve the Built Environment	# Schools Approved 2015	# Schools Approved 2016	# Schools/ Districts Approved 2017	# Schools/ Districts Approved 2018
Pedestrian and Bicycle Safety and Promotion Initiatives (School)	3	12	22	35
Policies to Promote Physical Activity (District)	0	6	17	30
Programs to Promote Physical Activity (School)	3	14	72	141
Safe Routes to School District Policy	0	1	13	27
School Travel Plan for Walking and Biking	3	8	15	23

 

In Fall 2018, 26 schools focused their work on capacity building during year 1 of a 3-year pilot project.  The framework for this 3-year pilot is premised on the National Association of Chronic Disease Directors (NACCD) document “The Whole School, Whole Community, Whole Child Model: A Guide to Implementation.” In year 1, the schools: 1) Collected school data; 2) Completed a baseline log to determine steps for improvement; 3) Identified a Team Leader and a Health and Wellness Team representing school administration and staff, youth, parents and the community; 4) Completed CDC’s School Health Index (SHI) assessment tool; and, 5) Developed a School Health Improvement Plan (SHIP) for implementation in year 2, beginning September 2019.

 

The selected ESM 8.1 (Number of schools participating in an activity (training, professional development, policy development, technical assistance) to improve physical activity among children (6-17)) will be monitored to assess progress on promoting physical activity of children 6 through 17 by improving policies and practices in schools regarding physical activity.

 

 

Annual Report - SPM # 2: The percentage of children with elevated blood lead levels (≥10 ug/dL).

 

SPM #2 was selected to address the issue of elevated blood lead levels in children which is not specifically addressed by the NPMs or NOMs. Long-term exposure to lead can cause serious health problems, particularly in young children. Lead is toxic to everyone, but unborn babies and young children are at greatest risk for health problems from elevated blood lead levels— their smaller, growing bodies make them more susceptible to absorbing and retaining lead. Lead exposure can cause permanent damage to the brain and nervous system, resulting in hearing problems, slowed growth and anemia. Children with elevated blood lead levels are at increased risk for behavioral problems, developmental delays, and learning disorders. Increased childhood morbidity will result from undetected and untreated elevated blood lead levels. In New Jersey, per N.J.A.C. §8:51A, all children are required to be tested at both 12 and 24 months of age. Children three (3) years of age or older must be tested at least once before their sixth birthday (if they had not been screened at age one (1) and two (2) years). 

 

Meaningful progress was made toward SPM # 2 in CY 2017. Provisional data from the 2017 Annual Childhood Lead Report indicates that more than 219,000 blood lead tests were reported on 205,291 children <17 years of age. Of the children tested during CY 2017, 83.8% were under the age of 6 years. Among these children, 2.62% had results >5 ug/dL. Of all the children tested, 93,109 were between six months and 26 months of age, the ages at which State regulations require children to be screened for elevated bold lead levels. This represents 43.4% of all children in that age group. Looking at all blood lead tests reported since 1999, it is estimated that 78% of children have had at least one blood lead test before the age of three years, and 59% of children have had at least one blood lead test before the age of 2 years.

 

Table SPM #2

	CY 2011	CY 2012	CY 2013	CY 2014	CY 2015	CY 2016	CY 2017	CY 2018
The percentage of *children with elevated blood lead levels (≥10 ug/dL).	0.6	0.5	0.5	0.5	0.5	0.5
Numerator*	1,103	898	793	816	862	867
Denominator*	182,040	183,215	176,847	171,521	174,887	174,162
Is the Data Provisional or Final?	Final	Final	Final	Final	Final	Final

*Children ≤6 years of age

**State regulations adopted a reference level of 5 ug/dL or greater September 2017.

Notes - Source: Childhood Lead Information Database, MCHS, FHS.

 

Ongoing efforts to increase the percentage of laboratories reporting electronically resulted in an increase from 99.8% in CY 2016 to 99.9% in CY 2017. NJDOH continued to assist the remaining laboratories to transition from reporting on hard copies to electronic reporting. NJ has legislation that requires children to be screened for elevated blood lead levels. Every primary care provider and health care facility that provides care to children less than six years of age is required to comply with the law.

 

The City of Newark has the greatest number of children with elevated blood lead levels (EBLLs) compared to any other municipality in the State.  This large municipality comprised 13% of the State’s children less than 72 months of age with an EBLL during SFY 2017, while only 3.8% of the entire State’s population of children in that age group reside in Newark.

 

Newark addresses the issue of elevated blood lead levels in children through several means and has been allotted and continues to seek grants from governmental and non-governmental sources.  In the past decade, Newark established and locally administers the State’s only Lead-Safe Houses, which are municipally-owned properties.  The Lead-Safe Houses are used to relocate residents who have a child with an EBLL when the family has no other temporary lead-safe housing alternatives.  This is a great accomplishment that other municipalities have expressed an interest in also achieving. Further, Newark provides a primary prevention focused, community-based presence through the Newark Partnership for Lead-Safe Children.  This partnership provides outreach, education and professional development opportunities to parents, property owners, child care providers and health, social services and housing professionals.      

 

Training on healthy homes principles for staff of local health departments and home visitation-based programs in the Department of Children and Families (DCF) continue. Home Visiting programs, funded in part by NJ’s MIEC Home Visiting Grant, provide services to pregnant women, infants, and young children. In addition, staff that assess the suitability of homes for placement of children who have entered foster care or are registered as family child care homes were targeted for training. Emphasis is placed on developing strategic partnerships with additional home visitation and government-funded home inspection agencies that serve highest-risk, hard to reach populations. A CDC Cooperative Agreement, awarded in October 2014, focuses on childhood lead surveillance to determine key indicators progress and deficiencies.