Tags: COVID-19

Casting Long Shadows Report

The ongoing impact of the COVID-19 pandemic on babies, their families and the services that support them.

A brand-new report by the First 1001 Days Movement and the Institute of Health Visiting has been published today – ‘Casting Long Shadows: The ongoing impact of the COVID-19 pandemic on babies, their families and the services that support them.’

The report reveals worrying new statistics about babies and young children born or growing up through the COVID-19 pandemic, highlighting how more young children are at risk of harm, have delayed social skills, and have been affected by poor parental mental health.

The report findings were synthesised from evidence in recently published reports, research and national data, as well as analysis from a national survey of 555 professionals and volunteers who work with babies and their families in health visiting, mental health, maternity, early education, and other services.

The findings are compelling and are consistent with a whole raft of studies from multiple sources across the children’s sector, which all indicate that the wide-reaching impacts of the pandemic are far from over for our youngest members of society:

  • An alarming 94.8% of professionals say the pandemic has an ongoing negative or very negative impact on the personal and social skills of children who were living in the pandemic. 92.4% of professionals say the same for communication, speech, and language skills and for emotional wellbeing and development.
  • Almost half (42.7%) of respondents surveyed stated that “many” babies they work with are affected by parental anxiety, stress, or depression due to the pandemic, which is affecting bonding and responsive care.
  • More than 4 in 10 (44.1%) of respondents said that “many” of the babies they work with are currently affected by increased exposure to domestic conflict, child abuse and neglect.
  • 4 in 10 (40.4%) survey respondents reported “many” babies they worked with had been affected by the loss of family income or increased risk of food poverty.

The report also highlights how:

  • Services have not returned to normal, and this could impact future generations – Whilst there has been innovation in service provision, nearly 6 in 10 respondents (59.5%) who reported that their service was operating differently, told us that the changes were not beneficial for families.
  • Services are in ‘crisis’ – The pandemic exacerbated existing strains on services. A significant number of survey respondents raised issues relating to low staffing numbers and poor staff wellbeing, with some professionals talking about services being in “crisis”.
  • The majority of respondents (90.5% in England) did not feel that national or local governments had taken sufficient action to ensure that babies under two and their families receive the support they need to recover from the impact of the pandemic.

With so much compelling evidence, The First 1001 Days Movement and Institute of Health Visiting are calling for:

  1. National Government to take concerted action to address the impacts of the pandemic on our youngest children.
  2. Integrated local strategies are needed to ensure that all children have the best start in life.
  3. National Governments must have long-term child health and development strategies, supported by workforce plans.
  4. Clear leadership within the UK Government is needed to ensure policy decisions include a cross-government focus on the needs of babies and young children. To ensure that this does not fall in the gaps between departments, a cabinet member should be appointed to drive this forward and act now to mitigate the impacts of the pandemic on our youngest citizens.

Alison Morton, iHV Executive Director, said:

“This report helpfully pulls together the unequivocal evidence that the pandemic’s impacts on our babies and young children have been significant and demand much greater attention from policy makers. What happens during these critical earliest years of life really does matter as they lay the foundations for future health and wellbeing. Yet, the report paints a bleak picture for babies in the UK. Too many are missing out on vital early support that can make such a difference. Ignoring this growing problem of unmet need and avoidable harms is short-sighted and will prove more costly in the long run.”

Georgina Mayes, Policy and Quality Lead at the Institute of Health Visiting, said:

“This new report clearly shows that the pandemic is having a lasting impact on many children’s health, wellbeing and development, and on the ability of services to meet their needs. More children are falling behind, inequalities are widening, and some services are reaching a crisis point. Whilst many professionals are working hard to support the families that they work with, this report clearly shows that demand is outstripping the workforce’s capacity to meet the scale of need.

“We call on national and local governments across the UK to take the findings of this research seriously and act now to mitigate the impact of the pandemic on our youngest children’s lives and life chances.”

Read the full report here

 

 

 

Health visiting study seeks to learn lessons from pandemic

A new £265,000 study led by the University of Stirling is seeking to understand how the COVID-19 pandemic has affected health visiting services across the UK, with a view to improving them in the future.

The 18-month project – funded by the National Institute for Health and Care Research (NIHR) – will explore the changes that health visiting has experienced over the past two years and provide recommendations to enhance organisation and delivery as part of a strong post-pandemic recovery.

The project is led by Dr Erica Gadsby, a Senior Lecturer in Public Health from Stirling’s Faculty of Health Sciences and Sport, and also involves researchers at the Universities of Oxford and Kent.

Alison Morton, Executive Director of the Institute of Health Visiting, said:

“Congratulations to the team, led by the University of Stirling, which has been awarded this prestigious NIHR funding.

“The last two years have been a period of tumultuous change, with health visiting services facing significant challenges in their efforts to support babies, young children and families. Health visitors responded rapidly with service innovations, but many of these adaptations have not been tested in the health visiting context and their impacts are largely unknown.

“This much-needed realist review will help us to gain a greater understanding of the pandemic response in order to learn lessons that can be applied to future emergencies, as well as strengthening the evidence base to support the embedding of new innovations and ways of working.”

The pandemic caused enormous pressure and disruption to child health services, as well as to families and young children, but it also prompted some important innovations in service delivery. The new study will explore how the pandemic affected health visiting services in Scotland, England, Northern Ireland, and Wales, with a view to understanding how the organisation and delivery of services can be improved for a stronger post-pandemic recovery.

The researchers will undertake a ‘realist review’, which is a type of theory-driven review of evidence. They will pull together different forms of information related to what has happened in health visiting services since March 2020 and use that to explore how the pandemic has affected services, service providers and families.

The team includes realist review, health visiting and public health experts, as well as a patient and public involvement lead. A stakeholder group – comprising practitioners, commissioners, policymakers, policy advocates, and members of the public – will advise and provide feedback throughout the project.

The team will work closely with the Institute of Health Visiting and the stakeholder group to ensure the findings of the study are developed into a range of outputs suitable for the various stakeholders and disseminated to the appropriate audience.

Dr Gadsby is supported on the project, Realist Review: Health Visiting in Light of the COVID-19 Pandemic Experience (RReHOPE), by Professor Kendall; Dr Geoff Wong and Ms Claire Duddy (both of the University of Oxford, Nuffield Department of Primary Care Health Sciences); and Mrs Madeline Bell (expert by experience).

Government responds to Petitions Committee’s report on impact of COVID-19 on new parents

Yesterday, the House of Commons Petitions Committee published the Government’s response to the Committee’s first report on the impact of the COVID-19 pandemic on new parents. The response is available here.

The Committee’s report focused on the additional pressures that COVID-19 and the pandemic response have brought for new and expectant parents, and called for: strengthened perinatal mental health services; increased in-person visits by health visitors to new parents; a review of monitoring and enforcement activity relating to employers’ health and safety obligations to new parents; legislation on extended redundancy protections for new and expectant mothers; and a review into the funding and affordability of childcare

The Government’s response states:

“We understand that the pandemic and the pandemic response have involved a significant amount of upheaval for new parents, including through changes or delays to services, and national lockdowns presenting barriers to support and care from friends and relatives. The first 1,001 days from conception to the age of two are critical: they set the foundations for an individual’s cognitive, emotional and physical development through the early years and growing up well. We continue to support giving every child the best start in life, including through building back better from the COVID-19 pandemic. In October 2021, an additional £500 million was announced through the Budget for Start for Life and family help services [this includes £200m for the Supporting Families Programme for children of all ages]. This represents an important step in implementing the vision set out in The Best Start for Life: a Vision for the 1,001 critical days, published by the Early Years Healthy Development Review led by Dame Andrea Leadsom.”

At the iHV, we support the Petitions Committee’s conclusion that, whilst this investment is an important first step and a welcome commitment to the ‘First 1,001 Days’, this does not go far enough. The Committee’s response states:

“We welcome the long-term vision of the Government’s Best Start for Life review, but to date COVID-19 recovery funding aimed at children aged under 2 appears to have been unjustifiably neglected compared to the funding made available for older children. As we emerge from the pandemic, the Government must ensure it invests proportionately in the infrastructure which supports these families.”

The iHV is working closely with the Parent-Infant Foundation and many other leading organisations who are calling on the Government for a fully funded COVID-19 recovery plan for babies, young children and families.

Alison Morton, iHV Executive Director commented:

“There is no denying that the impact of the pandemic on babies, young children and families has been wide ranging, and disproportionately affects those who were already disadvantaged. Whilst the Government’s recent commitment of £300m for the Start for Life Offer is a welcomed step in the right direction, it doesn’t go anywhere near far enough to address the scale of unmet need and intensity of support required.

“Left unaddressed, the burden of vulnerability and early adversity is cumulative and may last a lifetime for some children. But, in a world of seemingly intractable challenges, there is hope – meaningful prevention, early intervention and care promises better health and wellbeing across generations. Inequalities are not inevitable; they are within our gift to change if we have the will and the means to tackle them.

“We therefore join with others in calling for a clear COVID-19 recovery plan for babies, young children and families at the scale of intensity required, and with the investment needed, to put this right. This includes tackling the workforce ‘elephant in the room’. The current workforce shortages in health visiting have been ignored for far too long, and their impact is being felt across the health and social care system and by parents who face the brunt of short-sighted policy making. We need more health visitors, and we need to start rebuilding this vital infrastructure of support for families now.”

We are grateful to the support of more than 700 leading children’s organisations who have supported our call for investment in health visiting. The Parent-Infant Foundation has highlighted three areas where they feel that the Government’s response is insufficient:

  • The Government is diminishing the impact of the pandemic on our babies
  • Disparities in recovery funding are inconsistent with Government’s own acknowledgement of the importance of the first 1001 days
  • More must be done to strengthen our health visiting services.
Read the Parent-Infant Foundation's analysis of the Government's response here

Read the Petitions Committee's news story on the publication of the Government's response

 

 

 

Health visiting in England: The impact of the COVID-19 pandemic

 

Last week, we were delighted that the international ‘Public Health Nursing’ journal published a paper written by Alison Morton, the iHV’s Executive Director, and Dr Cheryll Adams CBE, Former Executive Director, on the impact of the COVID-19 pandemic in 2020 on families with children under 5 years in England, and the health visiting (HV) service that supports them.

The paper (Health visiting in England: The impact of the COVID-19 pandemic) presents a targeted review of the evidence, with data drawn from national surveys of health visitors and parents, a freedom of information request of employers, published research, and national data. Framework analysis and triangulation, using the Key Elements of an effective health visiting service, were used to categorise the key findings.

The findings from the review indicate that the impacts of the pandemic were wide-ranging and disproportionately affected the most disadvantaged families, increasing demand for health visiting support. The pandemic exacerbated factors that can lead to poorer outcomes for families. Health visitors’ ability to respond was compromised due to national policy decisions to partially stop the service and variations in local implementation including the redeployment of health visitors, pre-existing workforce capacity issues, and the effectiveness of innovations to identify and support vulnerable families.

Key learning from the pandemic response, including the need to prioritise the health visiting service, must be acted upon to reduce ongoing impacts now and ensure that the service is equipped for future emergencies.

Alison Morton commented:

“History has a habit of ‘airbrushing’ the past and it is therefore important that the events of the earliest months of the pandemic are recorded, and the learning is captured to support future responses to similar emergency situations. It was an honour to be able to complete this review in partnership with my predecessor, Dr Cheryll Adams. We are both delighted to see it published in the prestigious international journal, ‘Public Health Nursing’ which is the official journal of the Council of Public Health Nursing Organizations worldwide.

“Babies, young children and families have largely been forgotten in the pandemic response and we hope that this paper, alongside numerous others presenting similar messages, will provide the impetus for much-needed change and investment in the health visiting service in England”

The paper has been published online by Wiley – Public Health Nursing journal as an open access paper – you can read the paper in full here:

https://onlinelibrary.wiley.com/doi/abs/10.1111/phn.13053

PIMS-TS: the COVID-19 linked syndrome affecting children – information for Health Visitors

Most children and teenagers do not become seriously ill with COVID-19, but doctors have seen a very small number of patients with an unusual condition which seems to be linked to the virus. Paediatric Multisystem Inflammatory Syndrome temporally associated with SARS-CoV-2 (PIMS-TS) is very rare; it occurs in less than 0.05% of children with COVID-19. Most children with the condition will not be seriously affected but, in some cases, it can be serious.

This news story has been written in collaboration with Dr Sanjay Patel (paediatric infectious disease and immunology consultant – Southampton Children’s Hospital) to raise awareness of this condition and provide some helpful links to trusted sources of information to support you in your work with families.

Signs and Symptoms of PIMS-TS:

  • fever, which persists over several days
  • there’s a very wide range of other symptoms that children might have, including abdominal pain, diarrhoea, vomiting, rash, cold hands/feet and red eyes. These symptoms can be found in other illnesses too.

Children and young people who are seriously affected will have symptoms which are very similar to other life-threatening conditions such as sepsis or meningitis. Some of the symptoms of PIMS-TS can overlap with other rare conditions, such as Kawasaki disease and Toxic Shock Syndrome. Kawasaki disease tends to affect children under five, whereas PIMS seems to affect older children and teenagers.

While most children won’t be seriously unwell, some children may be severely affected by the syndrome. Experts advise, the most important thing is to remember that any child who is seriously unwell needs to be treated quickly – whatever the illness.

Laura is mother to Oliver, and she is raising awareness of PIMS and the symptoms to look out for:

“Oliver tested positive for Covid with no symptoms in March. Four weeks later, he lost his appetite, became lethargic and developed tummy pains. I took him to A&E, where he was diagnosed with tonsillitis and sent home. Over the next few days, Oliver developed a persistently high temperature, a blotchy rash, swelling, deep red lips, palms and eyelids and bloodshot eyes and was admitted to hospital. Oliver’s blood pressure kept dropping and his heart function was deteriorating so he was transferred to the paediatric intensive care unit. Oliver was then diagnosed with PIMS-TS. Thankfully, Oliver has made a good recovery after 5 days in ICU and 2 weeks in hospital, we were able to return home. There appears to be no long-term heart damage, although he still needs regular heart check-ups”.

(Shared with permission from Laura)

Children from all ethnic minority backgrounds have been affected by PIMS. A greater proportion of children from Black and Asian backgrounds appear to be affected by PIMS-TS, although it is still not clear what the reason for this is. Nonetheless, it is important for families from all ethnic backgrounds to be aware of the signs and symptoms of the condition, however rare.

Dr Sanjay Patel said:

 “The good news is that effective treatments are readily available for treating PIMS-TS and the vast majority of children make an excellent recovery.”

The Royal College of Paediatrics and Child Health has developed a series of posters and information for parents and young people to help explain when and how to seek medical help for their child:

Further information and answers to commonly asked questions can be found on the Healthier Together website for parents and professionals:

iHV welcomes Petitions Committee Report – Impact of COVID-19 on new parents: one year on

The iHV welcomes today’s Petitions Committee Report which calls on the Government to publish a dedicated COVID-19 recovery strategy for new parents. 12 months on from the Petitions Committee Report last year, it is clear that the pandemic continues to impact on new and expectant parents.

The Petitions Committee Report – Impact of COVID-19 on new parents: one year on calls for:

  • extra funding and resources to allow catch-up mental health support for new parents and to boost perinatal mental health services
  • funding for local authorities to arrange in-person visits to new parents by councils, voluntary organisations or health visiting staff by the end of the year
  • a review of monitoring and enforcement activity relating to employers’ health and safety obligations to pregnant women
  • legislation on the planned extension of redundancy protections for new and expectant mothers
  • a review into the funding, affordability and provision of childcare, and the sustainability of the childcare sector

Alison Morton, iHV Executive Director, said:

“We thank the Petitions Committee for their ongoing work championing the needs of new and expectant parents which have been largely overlooked during the pandemic. This hard-hitting report adds to the growing weight of evidence that has helped raise this important issue. It recognises the vital role that parents play in raising the next generation and the devastating and far-reaching impact that the pandemic has had on babies, young children and their families.

“We share the Committee’s disappointment that despite the government’s pledges to ‘build back better’, this has not translated into any tangible action or investment to make the changes that are needed to strengthen the support that families receive during these important earliest years of life.

“We support the calls for investment into the health visiting workforce which adds weight to the groundswell of support that the profession has received from a multitude of partners in the current #TurnOffTheTaps campaign. We join with them in calling on the Government to invest in giving children the best start in life.

“It is difficult to understand what more evidence policy makers need to take this matter seriously. We are currently wasting billions of pounds of taxpayers’ money every year on ‘getting it wrong’ with spiralling costs of late intervention. Babies, young children and families need action now – this cannot wait any longer.”

Read Petitions Committtee news story

iHV welcomes new F1001D report – Working for Babies: Lockdown lessons from local systems

iHV welcomes a new report published today by the First 1001 Days Movement (F10001D) which provides insight into the impacts of COVID-19 and the Spring 2020 lockdown on babies.

The report, Working for Babies: Lockdown lessons from local systems, presents hard-hitting findings about the direct and indirect harm to babies, young children and their families caused by the pandemic. These “hidden harms” were broad and significant, and experienced unevenly depending on family circumstances and background.  Historically inadequate or insecure funding, and a rising tide of need, has inhibited the ability of some services and local systems to respond to the needs of babies and their families during the pandemic. There were often ‘baby blind-spots’ where babies’ needs were overlooked in policy, planning and funding.

However, the report also provides some “good news stories” of organisations and systems which reacted and adapted positively to the pandemic. The report introduces the concept of “baby-positive” local responses and provides the beginnings of a formula for what good local systems should look like. In particular, it sets out the positive difference that was made by professionals who were connected to each other, and to their communities, and were empowered to meet families’ needs.

Most importantly, the report seeks to ensure that lessons are learned for the future of service provision for this age group. It provides further evidence of the importance of many things that the iHV campaigns for, such as clear leadership, a focus on babies’ needs, and a joined-up response.

Alison Morton, Acting Executive Director of the iHV said:

“This report adds further weight to the growing body of evidence on the direct and indirect impact of the COVID-19 pandemic on families with babies and young children. The message is clear, despite the indisputable evidence that the first 1001 days are the most crucial period of human development, babies and young children have largely been forgotten in the national pandemic response. Now we know better, we must do better.

“We hope the report brings a much-needed tipping point for change. It provides a powerful impetus to the Government to focus their efforts on the things that matter most by investing in our youngest citizens, to put things right and achieve their ambition to ‘build back better’.”

Working for Babies: Lockdown lessons from local systems

Download F1001D report - Working for Babies: Lockdown lessons from local systems

The report will be officially launched today at the APPG on Conception to Age Two meeting. For those not able to secure a space on at the APPG meeting itself, F1001D will be live streaming it at 3pm this afternoon via the Parent Infant Foundation YouTube channel. It will also be available to watch back later.

Please get involved by talking about the report on your social media channels! Get involved with the conversation and the report by using the hashtags #WorkingForBabies  #BabyBlindSpots on social media.

 

 

Call for volunteers

As the country continues to face the most serious public health challenge in living memory, the Government faces a huge task to vaccinate millions of people as quickly as possible. To help ensure that the NHS is able to deliver a large-scale vaccination programme without significantly impacting on other vital services (including health visiting), they are recruiting now to thousands of roles, including vaccinators, while also working with partners to build a bank of volunteers from all walks of life who can support vaccine services.

It is encouraging to hear the positive response to this call in the recent NHS update:

“The response of current NHS staff and those who have come forward to help out – whether the tens of thousands of former staff and students, or the hundreds of thousands of volunteers – has been nothing short of inspirational”

NHS England and NHS Improvement.

If you are interested in becoming a volunteer vaccinator, please see https://www.england.nhs.uk/coronavirus/join-the-nhs-covid-19-vaccine-team/ for further information.

Details of the Health Education England e-learning modules that you will need to complete are available below.

Following the significant learning from the response to the first wave of COVID-19 on the importance of supporting babies, young children and their families, particularly the most vulnerable families, the Government’s position on the redeployment of health visitors from their substantive posts remains unchanged from that set out in the joint statement in October:

“Therefore, we advise that professionals supporting children and families, such as health visitors, school nurses, designated safeguarding officers and nurses supporting children with special educational needs should not be redeployed to other services and should be supported to provide services through in pregnancy, early years (0-19) and to the most vulnerable families.”

Public Health England, NHS England and Improvement, Local Government Association

HEE e-LfH COVID-19 Vaccination e-learning

Health Education England e-Learning for Healthcare has worked in partnership with Public Health England and NHS England and NHS Improvement to develop the COVID-19 Vaccination e-learning programme.  The e-learning programme is designed to provide the health and care workforce involved in the national COVID-19 vaccination programme with the knowledge they need to confidently promote high uptake of the vaccine and deliver the vaccine programme effectively.

Go to HEE e-LfH COVID-19 Vaccination e-learning

 

iHV launches 8th Annual Report

The Institute of Health Visiting (iHV) is delighted to announce the launch of its eighth Annual Report.

Launched at the iHV annual Leadership conference on 1 December 2020, the report details the Institute’s developments, partnerships and projects over the past 12 months, plus the preliminary findings from our latest annual survey.

After the initial disappointment of having to postpone so many of our plans for 2020, #TeamiHV quickly embraced the challenges of working online to not only deliver our conferences and PIMH Forums on a virtual platform but our training as well, and this has been very enthusiastically received.

2020 has been a year like none before for health visiting, as it faced the challenges of adapting to a world forced into “lockdown”. The challenges of COVID-19 have been felt both by the Institute and in practice, bringing with them much learning. Our first concern is always the families we support, whom we know this year did not receive either adequate or, in some cases, any support during a crucial time.

Whilst much of the world’s attention was focused on reducing the transmission of the virus and treating acutely ill patients (mostly adults), it was clear that the needs of children and families were increasing, yet they were largely overlooked by policy makers. At the iHV, we have been concerned from the outset about the wider impacts of the pandemic and have raised concerns about the vulnerability of babies and young children who are at home, hidden from society and some living with significant adversity and abuse.

Download eighth iHV Annual Report

 

 

 

 

 

iHV supports F1001D statement on rise in neglect and abuse of babies during COVID-19

Following today’s statement from Ofsted which says that abuse and neglect of babies is up by a fifth compared to the same period last year (as covered in the Guardian here and on by the BBC here), The First 1001 Days movement has issued a statement – read part of it below:

We are deeply saddened to see reports today about the awful harms suffered by babies during the pandemic. Ofsted reports that the numbers of babies who have suffered serious injury through abuse or neglect during the Covid pandemic is up by a fifth on the same period last year, and eight have died from their injuries.

These are not the only babies who will have suffered harm as a result of the pandemic, sadly they are only the tip of the iceberg. Many other babies will have experienced adversity and emotional trauma during these difficult times.

The harms are undoubtedly a result of the “pressure cooker” of the pandemic, and the enormous additional stresses faced by families. This additional stress was all too predictable, as we have warned since the spring about the impact that the pandemic and lockdown have had on families during this crucial period of their children’s early development.

Some of these harms were preventable. The suffering experienced by babies might have been identified early, prevented or mitigated with professional support. But the pandemic caused a “perfect storm” where vital services and support were withdrawn from many families at a time when they needed it most. The redeployment of health visitors, reduction in contacts with families by many services, and pivot to digital and telephone service delivery – where babies are often invisible – all hampered services’ ability to protect our youngest and most vulnerable citizens.

Many charities, including those in the Movement, have been warning of these harms for more than six months, but little action has been taken. There must be no more delay, Government must act quickly to strengthen vital services that can prevent future harm to babies and support the recovery of all of the families who have already suffered as a result of this pandemic.

Dr Cheryll Adams CBE, Executive Director iHV, commented:

“As a member of the F1001D Movement we fully support their statement. It is very sad that the number of babies losing their lives in infancy has increased, especially since the onset of the COVID-19 pandemic. Sadly this was predicted early in lockdown. All the research suggests that, with the right resources, these figures should be reducing not increasing. We really hope that the publication of these figures will encourage government to take investment in the early years of life as seriously as they do other critical times in a person’s life course. Indeed, with sufficient investment in early life, large sums of money could be saved across the later life course.”

The F1001D Movement calls on Government to:

  • take urgent action now to increase the resources available to services, including, but not limited to, health visiting and children’s services, which can play an important role in protecting our babies and young children.
  • give local commissioners the resources they need to fund targeted and specialist services – including statutory services and charities, such as parent-infant teams – which can help families to recover from the harms caused by the pandemic.
  • commit to learning lessons from the lockdown to inform the restructure of Public Health England and revision of the Healthy Child Programme, recognising the value of high quality health visiting services and the important role they can play in protecting and promoting babies’ health and wellbeing.
  • ensure there is joined up action across Government, with clear leadership at the Cabinet table, to ensure that babies are kept safe and receive the nurturing care they need to thrive. Babies’ needs must be kept in mind in future decision making.

Babies must not pay the price for measures introduced to protect the health of the wider population. Government must protect all our children – from pregnancy onwards – during this difficult time.

Read Full statement from First 1001 Days