Evidence Summary (from RBR Resources Pages 1-3 )

Summary of current evidence as found on the 3 Resources Pages


Literature Reviewed or indicates published research on this topic that has been critically appraised for level of evidence in order to determine the strength of recommendation for this item on the Rourke Baby Record.

For new literature reviewed for the 2014 RBR, the level of evidence has been evaluated where possible using both the former Canadian Task Force on Preventive Health Care and the GRADE classification systems.

Strength of recommendation retains the previous scheme using “Good, Fair, and Inconclusive evidence/Consensus."

Parent Resources or indicates links to Parent Resources on this topic.

Growth

  • Important: Corrected age should be used at least until 24 to 36 months of age for premature infants born at <37 weeks gestation.
  • Measuring growth – The growth of all term infants, both breastfed and non-breastfed, and preschoolers should be evaluated using Canadian growth charts from the 2006 World Health Organization Child Growth Standards (birth to 5 years) with measurement of recumbent length (birth to 2–3 years) or standing height (≥ 2 years), weight, and head circumference (birth to 2 years). CPS Position Statement WHO Growth Charts Adapted for Canada

Nutrition

Nutrition for healthy term infants: 0–6 months 6–24 months CPS Practice Point 0–6 months
- Ontario Society of Nutrition Professionals in Public Health NutriSTEP® Dietitians of Canada

Breastfeeding

Breastfeeding: Exclusive breastfeeding is recommended for the first six months of life for healthy term infants. Breast milk is the optimal food for infants, and breastfeeding (with complementary foods) may continue for up to two years and beyond unless contraindicated. Breastfeeding reduces gastrointestinal and respiratory infections and helps to protect against SIDS. Maternal support (both antepartum and postpartum) increases breastfeeding and prolongs its duration. Early and frequent mother-infant contact, rooming in, and banning handouts of free infant formula increase breastfeeding rates.


Vitamin D Supplementation

Routine Vitamin D supplementation of 400 IU/day (800 IU/day in high-risk infants) is recommended for all breastfed infants until the diet provides a sufficient source of Vitamin D (~ 1–2 years). Breastfeeding mothers should continue to take Vitamin D supplements for the duration of breastfeeding. CPS Position Statement

Formula Feeding

Infant formula – formula composition and use Alberta Health Services

Milk consumption range is consensus only & is provided as an approximate guide.


Soy-based formula is not recommended for routine use in term infants as an equivalent alternative to cow’s milk formula, or for cow milk protein allergy, and is contraindicated for preterm infants. CPS Position Statement


Colic

Colic – CPS Position Statement

Introduction Of Solid Foods

Introduction of solids should be led by the infant’s signs of readiness – a few weeks before to just after 6 months.
Iron containing foods: At ~6 months, start iron containing foods to avoid iron deficiency.

Allergenic foods: Delaying the introduction of priority food allergens is not currently recommended to prevent food allergies, including for infants at risk of atopy. CPS Position Statement


Avoid honey until 1 year of age to prevent botulism.


Nutrition Concerns

Dietary fat content: Restriction of dietary fat during the first 2 years is not recommended since it may compromise the intake of energy and essential fatty acids, required for growth and development. A gradual transition from the high-fat infant diet to a lower-fat diet begins after age 2 years as per Canada’s Food Guide.
Encourage a healthy diet as per Canada’s Food Guide
Vegetarian diets – CPS Position Statement
Fish consumption: 2 servings/week of low mercury fish – Health Canada

Injury Prevention

In Canada, unintentional injuries are the leading cause of death in children and youth. Most

Transportation in motor vehicles

Transportation in motor vehicles: AAP article
  • Children < 13 years should sit in the rear seat. Keep children away from all airbags.
  • Install and follow size recommendations as per specific car seat model and keep child in each stage as long as possible.
  • Use rear-facing infant/child seat that is manufacturer approved for use until age 2 years.
  • Use forward-facing child seat after 2 years for as long as manufacturer specifications will allow.
  • After this, use booster seat up to 145 cm (4’9”).
  • Use lap and shoulder belt in the rear middle seat for children over 8 years who are at least 36 kg (80 lb) and 145 cm (4’ 9”) and fit vehicle restraint system.

Bicycle Safety

Bicycle: wear bike helmets and advocate for helmet legislation for all ages. Replace if heavy impact or damage.CPS Position Statement

Drowning / Bath safety / Water Safety

Drowning: CPS Position Statement
  • Bath safety: Never leave a young child alone in the bath. Do not use infant bath rings or bath seats.
  • Water safety: Recommend adult supervision, training for adults, 4-sided pool fencing, lifejackets, swimming lessons, and boating safety to decrease the risk of drowning.

Choking

Choking: Avoid hard, small and round, smooth and sticky solid foods until age 3 years. Use safe toys, follow minimum age recommendations, and remove loose parts and broken toys.


Burns

Burns: Install smoke detectors in the home on every level. Keep hot water at a temperature < 49°C.


Poisons

Poisons: Keep medicines and cleaners locked up and out of child’s reach. Have Poison Control Centre number handy. Use of ipecac is contraindicated in children.

Falls

Falls: Assess home for hazards – never leave baby alone on change table or other high surface; use window
guards and stair gates. Baby walkers are banned in Canada and should never be used. Ensure stability of furniture
and TV. Advise against trampoline use at home. CPS Position Statement


Safe Sleeping

Safe sleeping environment: CPS Position Statement
  • Sleep position and SIDS/Positional plagiocephaly: Healthy infants should be positioned on their backs for sleep. Their heads should be placed in different positions on alternate days. Sleep positioners should not be used. While awake, infants should have supervised tummy time. Counsel parents on the dangers of other contributory causes of SIDS such as overheating, maternal smoking or second-hand smoke.
  • Bed sharing: Advise against bed sharing which is associated with an increased risk for SIDS.
  • Crib safety/Room sharing: Encourage putting infant in a crib, cradle or bassinette, that meets current Health Canada regulations in parents’ room for the first 6 months of life. Room sharing is protective against SIDS.

Pacifier

Pacifier use may decrease risk of SIDS and should not be discouraged in the 1st year of life after breastfeeding is well established, but should be restricted in children with chronic/recurrent otitis media. CPS Position Statement


Firearm safety

Firearm safety: Advise on removal of firearms from home or safe storage to decrease risk of unintentional firearm injury, suicide, or homicide. CPS Position Statement

Behaviour and Family Issues


Behaviour


Crying

Crying: Excessive crying may be caused by behavioral or physical factors or be the upper limit of the normal spectrum. Evaluation of these etiological factors and of the burden for parents is essential and raises awareness of the potential for the shaken baby syndrome.

Abusive head trauma: CPS Position Statement
National Center on Shaken Baby Syndrome

Abusive head trauma

Abusive head trauma: CPS Position Statement
National Center on Shaken Baby Syndrome


Assess healthy sleep habits

Assess healthy sleep habits: Normal sleep (quality and quantity for age) is associated with normal development and leads to better health outcomes. National Sleep Foundation, Children and Sleep


Night waking

Night waking: occurs in 20% of infants and toddlers who do not require night feeding. Counselling around positive bedtime routines (including training the child to fall asleep alone), removing nighttime positive reinforcers, keeping morning awakening time consistent, and rewarding good sleep behaviour has been shown to reduce the prevalence of night waking, especially when this counselling begins in the first 3 weeks of life. MJA article PubMed article

Swaddling

Swaddling: Proper swaddling of the infant for the first 2 months of life may promote longer sleep periods but could be associated with adverse events (hyperthermia, SIDS, or development of hip dysplasia) if misapplied. A swaddled infant must always be placed supine with free movement of hips and legs, and the head uncovered. AAP article

Parenting/Discipline

Inform parents that warm, responsive, flexible & consistent discipline techniques are associated with positive child outcomes. Over reactive, inconsistent, cold & coercive techniques are associated with negative child outcomes. CPS Position Statement

Family Healthy Active Living/Sedentary Behaviour

Encourage increased physical activity, with parents as role models, through interactive floor-based play for infants and a variety of activities for young children, and decreased sedentary pastimes.


Maternal depression

  • Maternal depression – Physicians should have a high awareness of maternal depression, which is a risk factor for the socio-emotional and cognitive development of children. Although less studied, paternal factors may compound the maternal-infant issues. CPS Position Statement

FASD


Adoption/Foster care

  • Adoption/Foster care – Children newly adopted or entering foster care are a high risk population with special needs for health supervision. CPS Position Statement

Prevention of child maltreatment

  • Prevention of child maltreatment – USPSTF current recommendations
    • Assess home visit need: There is good evidence for home visiting by nurses during the perinatal period through infancy for first-time mothers of low socioeconomic status, single parents or teenaged parents to prevent physical abuse and/or neglect. CMAJ article
    • Risk factors for physical abuse: low SES; young maternal age (<19 years); single parent family;  parental experiences of own physical abuse in childhood; spousal violence; lack of social support;  unplanned pregnancy or negative parental attitude towards pregnancy.
    • Risk factors for sexual abuse: living in a family without a natural parent; growing up in a family with poor marital relations between parents; presence of a stepfather; poor child-parent relationships; unhappy family life.

Nonparental Child Care

Inquire about current child care arrangements. High quality child care is associated with improved paediatric outcomes in all children.

Factors enhancing quality child care include: practitioner general education and specific training; group size and child/staff ratio; licensing and registration/accreditation; infection control and injury prevention; and emergency procedures.

  • CPS Position Statement: Health implications of children in child care centres Part A and Part B
  • CPS guide to child-care in Canada Well Beings

Toilet Learning

The process of toilet learning has changed significantly over the years and within different cultures. In Western culture, a child-centred approach is recommended, where the timing and methodology of toilet learning is individualized as much as possible. CPS Position Statement


Literacy

Encourage parents to read to their children within the first few months of life and to limit TV, video and computer games to provide more opportunities for reading. CPS Position Statement

 


Environmental Health


Second-hand smoke exposure

Second-hand smoke exposure: contributes to childhood illnesses such as URTI, middle ear effusion, persistent cough, pneumonia, asthma, and SIDS.

Sun exposure/sunscreens/insect repellents

Sun exposure/sunscreens/insect repellents: Minimize sun exposure. Wear protective clothing, hats, properly applied sunscreen with SPF ≥ 30 for those > 6 months of age. No DEET in < 6 months; 6–24 months 10% DEET apply max once daily; 2–12 years 10% DEET apply max TID.

Pesticides

Pesticides: Avoid pesticide exposure. Encourage pesticide-free foods. OCFP review

Lead Screening

Lead Screening is recommended for children who: CFP article: Lead and Children
  • in the last 6 months lived in a house or apartment built before 1978;
  • live in a home with recent or ongoing renovations or peeling or chipped paint;
  • have a sibling, housemate, or playmate with a prior history of lead poisoning;
  • live near point sources of lead contamination;
  • have household members with lead-related occupations or hobbies;
  • are refugees aged 6 months–6 years, within 3 months of arrival and again in 3–6 months.

Lead Levels

Even for blood levels less than 10ug/dL, evidence suggests an association, and perhaps partial causal relationship with lower cognitive function in children. CPS article: Lead levels in Canadian children: Do we have to review the standard?

Websites about environmental issues

Websites about environmental issues:

Other Issues


OTC cough/cold medications

Advise parents against using OTC cough/cold medications. Restricting Cough and Cold Medicines in Children

Complementary and alternative medicine (CAM)

Complementary and alternative medicine (CAM): Questions should be routinely asked on the use of homeopathy and other complementary and alternative medicine therapy or products, especially for children with chronic conditions. CPS Position Statement

Fever advice/thermometers

Fever advice/thermometers: Fever ≥ 38oC in an infant < 3 months needs urgent evaluation. Ibuprofen and acetaminophen are both effective antipyretics. Acetaminophen remains the first choice for antipyresis under 6 months of age; thereafter ibuprofen or acetaminophen may be used. Alternating acetaminophen with ibuprofen for fever control is not recommended in primary care settings as this may encourage fever phobia, and the potential risks of medication error outweigh measurable clinical benefit. CPS Position Statement


Footwear

Footwear: Shoes are for protection, not correction. Walking barefoot develops good toe gripping and muscular strength. CPS Position Statement

Dental Care

Dental Care:

  • Dental Cleaning: As excessive swallowing of toothpaste by young children may result in dental fluorosis, children 3–6 years of age should be supervised during brushing and only use a small amount (e.g., pea-sized portion) of fluoridated toothpaste twice daily. Children under 3 years of age should have their teeth and gums brushed twice daily by an adult using either water (if low risk for tooth decay) or a rice grain sized portion of fluoridated toothpaste (if at caries risk).
  • Systemic fluoride and/or fluoride varnish should be considered based on caries risk assessment. American Academy Of Pediatric Dentistry Assessment tool, CDA Position Statement
  • To prevent early childhood caries: avoid sweetened juices/liquids and constant sipping of milk or natural juices in both bottle and cup.

Developmental Milestones

Maneuvers are based on the Nipissing District Development Screen™ and other developmental literature. They are not a developmental screen, but rather an aid to developmental surveillance. They are set after the time of normal milestone acquisition. Thus, absence of any one or more items is considered a high-risk marker and indicates consideration for further developmental assessment, as does parental or caregiver concern about development at any stage.

Autism Spectrum Disorder (ASD)

AUTISM SPECTRUM DISORDER
Specific screening for ASD at 18–24 months should be performed on all children with any of the following: 
failed items on the social/emotional/communication skills inquiry, sibling with autism, or developmental 
concern by parent, caregiver, or physician.

Use the revised M-CHAT-R, and if abnormal, use the follow-up M-CHAT-R/F to reduce the false positive rate and 
avoid unnecessary referrals and parental concern. Electronic M-CHAT-R is available


Physical Examination

Fontanelles

Fontanelles –The posterior fontanelle is usually closed by 2 months and the anterior by 18 months.

Vision Screening

Vision inquiry/screening: CPS Position Statement
  • Check Red Reflex for serious ocular diseases such as retinoblastoma and cataracts.
  • Corneal light reflex/cover–uncover test & inquiry for strabismus: With the child focusing on a light source, the light reflex on the cornea should be symmetrical. Each eye is then covered in turn, for 2–3 seconds, and then quickly uncovered. The test is abnormal if the uncovered eye “wanders” OR if the covered eye moves when uncovered.
  • Check visual acuity at age 3–5 years.

Hearing inquiry/screening

Hearing inquiry/screening – Any parental concerns about hearing acuity or language delay should prompt a rapid referral for hearing assessment. Formal audiology testing should be performed in all high-risk infants, including those with normal UNHS. Older children should be screened if clinically indicated.

Ankyloglossia

Inspect tongue mobility for ankyloglossia. CPS Position Statement

Tonsil size/sleep-disordered breathing

Tonsil size/sleep-disordered breathing – Screen for sleep problems (behavioural sleep problems and snoring in the presence of sleep-disordered breathing which warrants assessment re obstructive sleep apnea). AAP article

Muscle tone

Muscle tone – Physical assessment for spasticity, rigidity, and hypotonia should be performed.

Hips

Hips – There is insufficient evidence to recommend routine screening for developmental dysplasia of the hips, but examination of the hips should be included until at least one year, or until the child can walk. AAP article

Investigations / Screening

Anemia screening

Anemia screening: All infants from high-risk groups for iron deficiency anemia require screening between 6 and 
12 months of age, e.g., Lower SES; Asian; First Nations children; low-birth-weight and premature infants, and 
infants fed whole cow’s milk during their first year of life

Hemoglobinopathy screening

Hemoglobinopathy screening: Screen all neonates from high-risk groups: Asian, African & Mediteranean.

Universal newborn hearing screening

Universal newborn hearing screening (UNHS) effectively identifies infants with congenital hearing loss and 
allows for early intervention & improved outcomes. CPS Position Statement

Immunizations

Routine Immunization

Vaccine Notes (Adapted from NACI website: December 16, 2013)

Diphtheria

Diphtheria, Tetanus, acellular Pertussis and inactivated Polio virus vaccine (DTaP-IPV): DTaP-IPV vaccine is the preferred vaccine for all doses in the vaccination series, including completion of the series in children < 7 years who have received ≥ 1 dose of DPT (whole cell) vaccine (e.g., recent immigrants).


Haemophilus

Haemophilus influenzae type b conjugate vaccine (Hib): Hib schedule shown is for the Haemophilus b capsular polysaccharide – PRP conjugated to tetanus toxoid (Act-HIBTM) or the Haemophilus b oligosaccharide conjugate – HbOC (HibTITERTM) vaccines. This vaccine may be combined with DTaP in a single injection.


Measles, Mumps and Rubella

Measles, Mumps and Rubella vaccine (MMR): A second dose of MMR is recommended, at least 1 month after the first dose, for the purpose of better measles protection. For convenience and high uptake rates, this second dose of MMR should be given with the 18 month or preschool dose of DTaP/IPV(±Hib) (depending on the provincial/territorial policy), or at any intervening age that is practical. The need for a second dose of mumps and rubella vaccine is not established but may benefit (given for convenience as MMR). MMR and varicella vaccines should be administered concurrently, at different sites if the MMRV [combined MMR/varicella] is not available, or separated by at least 4 weeks.


Varicella vaccine

Varicella vaccine: Children aged 12 months to 12 years who have not had varicella should receive 2 doses of varicella vaccine (univalent varicella or MMRV). Unvaccinated individuals ≥ 13 years who have not had varicella should receive two doses at least 28 days apart (univalent varicella only). Consult NACI guidelines for recommended options for catch-up varicella vaccination. Varicella and MMR vaccines should be administered concurrently, at different sites if the MMRV [combined MMR/varicella] vaccine is not available, or separated by at least 4 weeks. CPS Position Statement

Hepatitis B vaccine (Hep B):

Hepatitis B vaccine (Hep B): Hepatitis B vaccine can be routinely given to infants or preadolescents, depending on the provincial/territorial policy. The first dose can be given at 2 months of age to fit more conveniently with other routine infant immunization visits. The second dose should be administered at least 1 month after the first dose, and the third at least 2 months after the second dose, but again may fit more conveniently into the 4- and 6-month immunization visits. A two-dose schedule for adolescents is an option. For infants born to chronic carrier mothers, the first dose should be given at birth (with Hepatitis B immune globulin).

Hepatitis B immune globulin and immunization:
Infants with HBsAg-positive parents or siblings require Hepatitis B vaccine at birth, at 1 month, and 6 months of age.
Infants of HBsAg-positive mothers also require Hepatitis B immune globulin at birth and follow-up immune status at 9–12 months for HBV antibodies and HBsAg.

Hepatitis B vaccine should also be given to all infants from high-risk groups, such as:

  • infants where at least one parent has emigrated from a country where Hepatitis B is endemic;
  • infants of mothers positive for Hepatitis C virus;
  • infants of substance-abusing mothers.

Pneumococcal conjugate vaccine

Pneumococcal conjugate vaccine 13-valent (Pneu-Conj): Recommended schedule, number of doses and subsequent use of 23 valent polysaccharide pneumococcal vaccine depend on the age of the child, previous administration of -7 or-10 valent vaccine, if at high risk for pneumococcal disease, and when vaccination is begun. Consult NACI guidelines for maximizing coverage up to 59 months of age.


Meningococcal

Meningococcal conjugate vaccine (MCV): CPS Position Statement – Monovalent vaccine to Type C (MCV-C) is indicated for all ages, and quadravalent to Types A/C/W/Y (MCV-4) for age 2 years and over. Recommended vaccine, schedule and number of doses of meningococcal vaccine depend on the age of the child and vary between provinces/territories. Possible schedules include:

     MCV-C: 1 dose at 12 months
     OR
     MCV-C: 2 doses at 2 and 4 months if at increased risk AND booster dose at 12 months

MCV-C or MCV-4 booster dose should also be given at 12 years of age or during adolescence.

Diphtheria, Tetanus, acellular Pertussis vaccine

Diphtheria, Tetanus, acellular Pertussis vaccine – adult/adolescent formulation (dTap): a combined adsorbed “adult type” preparation for use in people ≥ 7 years of age, contains less diphtheria toxoid and pertussis antigens than preparations given to younger children and is less likely to cause reactions in older people. This vaccine should be used in individuals > 7 years receiving their primary series of vaccines.


Influenza vaccine

Influenza vaccine: Recommended for all children between 6 and 23 months of age, and for older high-risk children. Previously unvaccinated children up to 9 years of age require 2 doses with an interval of at least 4 weeks. The second dose is not required if the child has received one or more doses of influenza vaccine during the previous immunization season. Live attenuated influenza vaccine can be used at age 2 years and above, if no contraindication.


Rotavirus vaccine

Rotavirus vaccine: Universal rotavirus vaccine is recommended by NACI and CPS. Two oral vaccines are currently authorized for use in Canada: Rotarix (2 doses) and RotaTeq (3 doses). Dose #1 is given between 6 weeks and 14 weeks/6 days with a minimum interval of 4 weeks between doses. Maximum age for the last dose is 8 months/0 days. CPS Position Statement

Infectious Diseases

Selected Infectious Diseases Recommendations

CPS position statements of the Infectious Diseases and Immunization Committee


Hepatitis B immunization

  • Hepatitis B immune globulin and immunization:
    Infants with HBsAg-positive parents or siblings require Hepatitis B vaccine at birth, at 1 month, and 6 months of age.
    Infants of HBsAg-positive mothers also require Hepatitis B immune globulin at birth and follow-up immune status at 9–12 months for HBV antibodies and HBsAg.
    Hepatitis B vaccine should also be given to all infants from high-risk groups, such as:
    • infants where at least one parent has emigrated from a country where Hepatitis B is endemic;
    • infants of mothers positive for Hepatitis C virus;
    • infants of substance-abusing mothers.

Human Immunodeficiency Virus type 1 (HIV-1)

  • Human Immunodeficiency Virus type 1 (HIV-1) maternal infections:
    Breastfeeding is contraindicated for an HIV-1 infected mother even if she is receiving antiretroviral therapy.

Hepatitis A or A/B combined

  • Hepatitis A or A/B combined (when Hepatitis B vaccine has not been previously given):
    These vaccines should be considered when traveling to countries where Hepatitis A or B are endemic.

Tuberculosis