Literature Review

This annotated bibliography lists the literature which has been used to determine the strength of recommendation for selected items on the 2014 Rourke Baby Record. The references included in this review table are not exhaustive, and were selected by the authors for their relevance in supporting the evidence for the items included in the 2014 RBR.

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."

Thanks to Dr. Patricia Li (MD, MSc, FRCPC, FAAP), Assistant Professor of Paediatrics McGill University, and to Bruno Riverin, for their exemplary work on this huge task.





GROWTH

Growth Monitoring Recommendations Strength of Recommendation
  1. 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 (WHO) 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).
Good
  1. Corrected age should be used at least until 24 to 36 months of age for premature infants born at < 37 wks gestation.
Good
Growth Monitoring Resources
  1. Web links to the 2014 WHO Growth Charts for Canada: WHO Growth Charts for Canada
  2. CPS Position Statements:
    Promoting optimal monitoring of child growth in Canada
    Getting it right at 18 months: In support of an enhanced well-baby visit
    Measuring in support of early childhood development
Growth Monitoring References
ReferenceMethods and OutcomesFormer CTFPHC GRADE

R Williams, J Clinton; Canadian Paediatric Society, Early Years Task Force. Getting it right at 18 months: In support of an enhanced well-baby visit. Paediatr Child Health 2011;16(10):647-50. Available from CPS

Methods

Subjects: 18-month olds

Design: Position Statement

Methods: This statement demonstrates the need for measuring/monitoring key indicators of early childhood health and well-being. It offers specific recommendations to physicians, governments and organizations for a universally established and supported assessment of every Canadian child’s developmental health at 18 months.

Outcomes

See Position Statement for specific recommendations. 

C Hertzman, J Clinton, A Lynk; Canadian Paediatric Society, Early Years Task Force.

Measuring in support of early childhood development. Paediatr Child Health 2011;16(10):655-7. Available from CPS

Methods

Subjects: Young children

Design: Position Statement

Methods: The statement explores the objectives for collecting quality information about early child development, its determinants and long-term outcomes. It also examines four approaches to collecting population-based, person-specific and longitudinal data, both in young children and later in life. A key outcome of monitoring development is timely intervention. Linking individual data to the home and community levels is a critical step, so that communities and governments can monitor and take actions that support early child development.

Outcomes

See Position Statement for specific recommendations. 

Lawrence S,  Cummings E, Chanoine JP, Metzger DL, Palmert M, Sharma A, Rodd C; On behalf of the Canadian Paediatric Endocrine Group. Canadian Paediatric Endocrine Group extension to WHO growth charts: Why bother? Paediatr Child Health. 2013;18(6):295-297. Available from: Paediatr Child Health

Methods

Subjects: Children

Design: Commentary

Methods: In response to concerns regarding the presentation of the 2010 WHO data, the CPEG generated complementary growth curves to enhance clarity, reduce potential errors in classification and enable users to better track short term changes, particularly for weight in older children. 

Outcomes

The CPEG curves are based on the 2010 WHO Growth Charts for Canada. The CPEG growth curves “extend weight-for-age beyond 10 years of age, restore additional percentiles within the normal range, remove extreme percentiles and harmonize the choice of body mass index percentiles with adult definitions of overweight and obesity. All modifications followed strict WHO methodology and used core data from the United States National Center for Health Statistics. The curves retain the clean appearance of the 2010 Canadian curves and are available from the CPEG website (http://cpeg-gcep.net).”

Health Canada, Canadian Paediatric Society, Dietitians of Canada and Breastfeeding Committee for Canada. Nutrition for healthy term infants - recommendations from birth to six months. 2012. Available from: http://hc-sc.gc.ca/fn-an/nutrition/infant-nourisson/recom/index-eng.php

Methods

Subjects: 0 to 6 months

Design: Nutrition guidelines during infancy

Methods: A joint statement from Health Canada, Canadian Paediatric Society, Dieticians of Canada, and Breastfeeding Committee for Canada.

Outcomes

Based on a previous CPS statement (Promoting optimal monitoring of child growth in Canada: Using the new World Health Organization growth charts) and on the 2006 WHO growth charts, this statement recommends the use of the Growth Charts for Canada for optimal monitoring of infant growth. The working group also suggests that the assessment of infant growth requires several measurements, taken over time, such as: gestational age at birth (use of corrected age), growth trajectory (growth pattern), birth weight, any problems with lactation, any acute or chronic illness. Recommendation: Use the 2006 WHO growth charts to monitor infant growth.

Valérie Marchand; Canadian Paediatric Society, Nutrition and Gastroenterology Committee. The toddler who is falling off the growth chart.

Paediatr Child Health. 2012;17(8): 447. Available from: http://www.cps.ca/en/documents/position/toddler-falling-off-the-growth-chart

Methods

Subjects: Toddlers

Design: Practice point

Methods: This practice point was produced by the CPS Nutrition and Gastroenterology Committee and has been reviewed by the Community Paediatrics and the Drug Therapy and Hazardous Substances Committees of the CPS.

Outcomes

The expert committee issues several recommendations for health professionals regarding the monitoring of growth and evaluation of a child whose growth falters. The authors also discuss possible interventions when there is inadequate growth and no underlying disease. Conclusion: Following a child’s growth is essential to detecting nutritional deficiencies or underlying disease. Recommendation: When a child’s growth falters, a baseline workup and nutritional assessment should be performed.

D Secker, C Armistead, L Corby, M de Groh, V Marchand, LL Rourke, E Misskey, Canadian Paediatric Society/Société canadienne de pédiatrie, Adolescent Health Committee/Comité de la santé de l'adolescent. Promoting optimal monitoring of child growth in Canada: Using the new World Health Organization growth charts - Executive Summary. Paediatrics and Child Health. 2010;15(2): 77- 83. Abstract available from: http://www.pulsus.com/journals/abstract.jsp?HCtype=Physician&sCurrPg=abstract&jnlKy=5&atlKy=9322&isuKy=897&isArt=t&

Methods

Subjects: 0 to 5 years old

Subjects: Children

Design: Position statement

Methods: The WHO Growth Study was initiated in 1997 to follow a cohort of children’s who had been raised in six different countries (Brazil, Ghana, India, Norway, Oman and USA) under recommended nutritional and health practices.  This position statement gives recommendations for physicians on how to properly use the growth charts.

Outcomes

The WHO growth charts are now considered the gold standard for children’s growth and are recommended to physicians to use during well-baby and well-child visits.  The WHO also recommends using calibrated and well-maintained quality equipment to ensure the accuracy of measurements.  According to this report, physicians should be trained to use the new growth charts and should understand the differences between the WHO and CDC growth charts to be prepared to explain them to parents and caregivers. A table of cut-off points for possible growth problems is included and can be seen on the CPS website.

WHO Multicentre Growth Reference Study Group. WHO Child Growth Standards: Growth velocity based on weight, length and head circumference: Methods and development. Geneva: World Health Organization. 2009;242 pages. Available from: WHO and  http://www.who.int/childgrowth/mgrs/en/

Methods

Subjects: 0 to 5 years old

Design: Population-based study (N=8,440)

Methods: Growth charts based on internationally sampled children with optimal feeding and living conditions (including exclusive breastfeeding for the first 4 to 6 months). Study conducted from 1997-2003. Longitudinal follow-up from birth to 24 months and cross-sectional data from 18 to 71 months.

Outcomes

WHO velocity standards for weight are presented for 1-month increments from birth to 12 months and 2- to 6-month increments from birth to 24 months.  An internationally-sampled cohort was prospectively followed to monitor growth patterns. Mothers and newborns visited at home 21 times; 882 of 1,743 (in the longitudinal sample) completely followed-up. This study reports that growth velocity must be interpreted by taking into account attained growth.  One limitation to these methods is the community-based sampling strategy.  

De Onis M, Garza C, Onyango AW, Borghi E. Comparison of the WHO child growth standards and the CDC 2000 growth charts. The Journal of Nutrition. 2007; 137: 144-148. Abstract available from: PubMed

Methods

Subjects: 0 to 5 years old

Design: Review

Methods: Compared 2006 WHO growth standards to 2000 CDC growth standards. Prepared descriptive comparisons using a pooled sample of 226 healthy infants from 7 studies in North America and Northern Europe

Outcomes

Main difference in weight-for-age curves occurs during infancy. CDC sample seems to be generally heavier and WHO standards are taller. According to this review, CDC growth charts have been proven to be inadequate for monitoring the growth of breastfed infants.  The review reports that the WHO standards are a better tool than the CDC 2000 growth charts for monitoring the growth of breastfed infants.  The WHO standards were based on a prospective longitudinal study design while the CDC standards are based on data collected prospectively and by retrospective review of medical records.

WHO Multicentre Centre Growth Reference Study Group. Assessment of differences in linear growth among populations in the WHO Multicentre Growth Reference Study. Acta Paediatr. 2006; S450(95): 56-65. Full text available from: http://www.who.int/childgrowth/standards/Difference_linear_growth.pdf

Methods

Subjects: 0 to 5 years old

Design: Population-based study (N=8,440)

Methods: Growth charts based on internationally sampled children (from Brazil, Ghana, India, Norway, Oman and the USA) with optimal feeding and living conditions (including exclusive breastfeeding for the first 4 to 6 months, no maternal smoking and environments supportive of unconstrained growth). 

Outcomes

This study looked at differences in length and height among the populations included in the Multicentre Growth Reference Study (MGRS). There were a total of 8,440 children sampled across all sites; 1,743 in the longitudinal sample and 6,697 enrolled in the cross-sectional sample.  Results showed that variance in growth was 20 times more likely the result of individual variation within a population versus country variation (70% vs. 3%, respectively, of total variance).  Ghana and the USA were representative of the pooled average, while Oman and India tended to have lower values and Brazil and Norway had higher values.  

NUTRITION

Nutrition (General) Recommendations Strength of Recommendation
  1. Formula feed (iron-fortified) 150ml(5oz)/kg/day from 0-1month, 450-750ml(15-25oz)/day from 1-2months, 600-900(20-30oz)/day from 2-4 months, 750-1080ml(25-36oz)/day from 4-9months, 720-960ml(24-32oz)/day from 9-12 months
Consensus
  1. Restriction of dietary fat during the first two years is not recommended because it may compromise the intake of energy and essential fatty acids and adversely affect growth and development. A gradual transition from the high-fat diet of infants/toddlers to a diet as per Canada’s Food Guide, which begins after age 2 years and is lower in fat.
Fair
  1. Encourage a healthy diet as per Canada’s Food Guide starting at age 2 years.
Consensus
  1. Skim milk, 1% and 2% are appropriate for children starting at age 2 years.
Consensus
  1. Avoid honey until 1 year of age to prevent botulism.
Consensus
Nutrition Resources
  1. Nutrition risk screening questionnaires: Nutri-eSTEP screening tool, available for both Toddlers (18-35 mos) and Preschoolers (3-5 years).
  2. Nutrition for Healthy Term Infants
    0-6 months  
    6-24 months  
    CPS Practice Point 0-6 months
Nutrition (General) References
ReferenceMethods and OutcomesFormer CTFPHC GRADE

Health Canada, Canadian Paediatric Society, Dietitians of Canada and Breastfeeding Committee for Canada. Nutrition for healthy term infants - recommendations from 6 to 24 months. 2014. Available from: http://www.hc-sc.gc.ca/fn-an/nutrition/infant-nourisson/index-eng.php

Methods

Subjects: 6 to 24 months

Design: Nutrition guidelines

Methods: A joint statement of Health Canada, Canadian Paediatric Society, Dieticians of Canada, and Breastfeeding Committee for Canada.

Outcomes

Not yet available.

Persaud N, Maguire JL, Lebovic G, Carsley S, Khovratovich M, Randall Simpson JA, McCrindle BW, Parkin PC, Birken C; TARGet Kids! collaboration. Association between serum cholesterol and eating behaviours during early childhood: a cross-sectional study. CMAJ. 2013 Aug 6;185(11):E531-6. Abstract available from: PubMed

Methods

Subjects: Children aged 3-5 years and their parents

Design: Cross-sectional study

Methods: Children recruited from 7 primary care practices were assessed for eating behaviours and dietary intake by the NutriSTEP (Nutritional Screening Tool for Every Preschooler) questionnaire and serum levels of non-HDL were also measured.

Outcomes

Laboratory data and data from responses to the NutriSTEP questionnaire were available for 1,076 children out of a total of 1,856. The characteristics of participants and nonparticipants did not statistically differ. The eating behaviours subscore of the NutriSTEP tool was significantly associated with serum non-HDL cholesterol (p = 0.03); for each unit increase in the eating behaviours subscore suggesting greater nutritional risk, the authors saw an increase of 0.02 mmol/L (95% CI 0.002 to 0.05) in serum non-HDL cholesterol. The eating behaviour subscore was also associated with LDL cholesterol and apolipoprotein B, but not with HDL cholesterol or apolipoproteins A1. Conclusion: 1) The results suggest that preschool-aged children and eating behaviours may be potential targets for early interventions to promote cardiovascular health. 

Scharf RJDemmer RTDeBoer MD. Longitudinal evaluation of milk type consumed and weight status in preschoolers. Arch Dis Child. 2013 May;98(5):335-40. Available from: PubMed

Methods

Subjects: Children aged 2 to 4 years

Design: Longitudinal cohort study (n = 10,700)

Methods: Authors examined body mass index (BMI) z score and overweight/obese status as a function of milk type intake.

Outcomes

The majority of children drank whole or 2% milk (87% at 2 years, 79.3% at 4 years). Across racial/ethnic and socio-economic status sub-groups, 1%/skim milk drinkers had higher BMI z-scores than 2%/whole milk drinkers. In multivariable analyses, increasing fat content in the type of milk consumed was inversely associated with BMI z score (p<0.0001). Compared to those drinking 2%/whole milk, 2- and 4-year-old children drinking 1%/skim milk had an increased adjusted odds of being overweight (age 2 OR 1.64, p<0.0001; age 4 OR 1.63, p<0.0001) or obese (age 2 OR 1.57, p<0.01; age 4 OR 1.64, p<0.0001). In longitudinal analysis, children drinking 1%/skim milk at both 2 and 4 years were more likely to become overweight/obese between these time points (adjusted OR 1.57, p<0.05). Conclusions: Consumption of 1%/skim milk is more common among overweight/obese preschoolers, potentially reflecting the choice of parents to give overweight/obese children low-fat milk to drink. Nevertheless, 1%/skim milk does not appear to restrain body weight gain between 2 and 4 years of age in this age range.

Health Canada, Canadian Paediatric Society, Dietitians of Canada and Breastfeeding Committee for Canada. Nutrition for healthy term infants - recommendations from birth to six months. 2012. Available from: http://hc-sc.gc.ca/fn-an/nutrition/infant-nourisson/recom/index-eng.php

Methods

Subjects: 0 to 6 months

Design: Nutrition guidelines during infancy

Methods: A joint statement of Health Canada, Canadian Paediatric Society, Dieticians of Canada, and Breastfeeding Committee for Canada.

Outcomes

This statement provides health professionals with evidence-informed principles and recommendations on infant nutrition in the first six months. The recommendations cover the following outcomes: growth, breastfeeding, supplemental vitamin D, first complementary foods, feeding changes and breast milk substitutes. 

Health Canada. Eating Well with Canada’s Food Guide. Available from: Health Canada

Methods

Subjects: >2 years old

Design: Online resource

Outcomes

The guide indicates that children aged >2 years old can obtain the nutrients and calories they need for healthy growth and development by following Canada’s Food Guide.

Danyliw AD1, Vatanparast HNikpartow NWhiting SJ. Beverage patterns among Canadian children and relationship to overweight and obesity. Appl Physiol Nutr Metab. 2012 Oct;37(5):900-6. Available from: PubMed

Methods

Subjects: children and adolescents aged 2 to 18 years

Design: Cross-sectional study (n = 10,038)

Methods: Using data from the Canadian Community Health Survey 2.2, the authors used cluster analysis to identify beverage intake patterns, and logistic regression to determine the association between overweight and obesity and beverage intake patterns, adjusting for potential confounders.

Outcomes

Clustering resulted in distinct groups of who drank mostly fruit drinks, soft drinks, 100% juice, milk, high-fat milk, or low-volume and varied beverages (termed "moderate"). Boys aged 6-11 years whose beverage pattern was characterized by soft drink intake (553 ± 29 g) had increased odds of overweight-obesity (odds ratio 2.3, 95% confidence interval 1.2-4.1) compared with a "moderate" beverage pattern (23 ± 4 g soft drink). No significant relationship emerged between beverage pattern and overweight and obesity among other age-sex groups. Adjusted odds ratios and 95% confidence intervals for overweight and obesity of 2-5 year olds compared with normal BMI-classification (measured), by age–sex group and cluster:  milk 1.2 (0.7-2.1), high fat milk 0.9 (0.5-1.7). Conclusions: Using national cross-sectional dietary intake data, Canadian children do not show a beverage-weight association except among young boys who drink mostly soft drinks, and thus may be at increased risk for overweight or obesity.

Watson-Jarvis K, McNeil D, Fenton TR, Campbell K. Implementing the Nutrition Screening Tool for Every Preschooler (NutriSTEP®) in community health centres. Can J Diet Pract Res. 2011 Summer;72(2):96-8. Abstract available from: PubMed

Methods

Subjects: Parents of children aged 3-5 years

Design: Survey research, cross-sectional design

Methods: Parents attending preschool immunization clinics were recruited. Parents, staff, and physicians were asked for their opinions on screening.

Outcomes

The 412 (34%) parent questionnaires completed indicated that parents found NutriSTEP easy to complete and helpful for identifying areas of nutrition concern. Staff estimated screening distribution took one to three minutes. Clerks and nurses expressed concern about additional workload and demands on parents. Managers believed NutriSTEP was easy to implement. Physicians considered nutrition screening of preschoolers important, and felt that health centres were the best location for screening. Conclusions: NutriSTEP was relatively easy to implement in two community health clinics. While staff expressed concern about increased workload, parents found it easy to complete and helpful.

Watson-Jarvis K, McNeil D, Fenton TR, Campbell K. Implementing the Nutrition Screening Tool for Every Preschooler (NutriSTEP®) in community health centres. Can J Diet Pract Res. 2011 Summer;72(2):96-8. Abstract available from: PubMed

Methods

Subjects: Parents of children aged 3-5 years

Design: Survey research, cross-sectional design

Methods: Parents attending preschool immunization clinics were recruited. Parents, staff, and physicians were asked for their opinions on screening.

Outcomes

The 412 (34%) parent questionnaires completed indicated that parents found NutriSTEP easy to complete and helpful for identifying areas of nutrition concern. Staff estimated screening distribution took one to three minutes. Clerks and nurses expressed concern about additional workload and demands on parents. Managers believed NutriSTEP was easy to implement. Physicians considered nutrition screening of preschoolers important, and felt that health centres were the best location for screening. Conclusions: NutriSTEP was relatively easy to implement in two community health clinics. While staff expressed concern about increased workload, parents found it easy to complete and helpful.

Watson-Jarvis K, Fenton TR, McNeil D, Campbell K. Preschool nutrition risk in Calgary. Can J Diet Pract Res. 2011 Spring;72(1):e101-6. Abstract available from: PubMed

Methods

Subjects: Parents of children aged 3-5 years

Design: Survey research, cross-sectional design

Methods: Study objectives were to identify the proportion of children at nutrition risk and to assess acceptance and impact of dietitian referrals. Parents attending preschool immunization clinics were asked to complete the NutriSTEP questionnaire and a parent questionnaire to gather demographics and perceptions of NutriSTEP. Follow-up counselling by a dietitian was offered for parents of high-risk children, and parents who attended completed a follow-up questionnaire.

Outcomes

Out of 1,222 families who attended clinic visits, 412 completed a demographic questionnaire (34%) and 438 completed NutriSTEP (36%). Thirty children screened (7%) were at high risk. Almost 50% of parents reported adverse feeding environment behaviours. When using parental reports of daily frequency of a child's consumption as a proxy for daily servings, the majority of children fell short in most food groups. Ten of the 30 parents of high-risk children (33%) completed dietitian counselling. Most parents who were counselled (6 out of 10) reported making changes as a result of counselling and were satisfied with the service (5 out of 10). Conclusions: NutriSTEP was an effective tool for identifying preschool children at nutritional risk. Few parents accepted referral to a pediatric dietitian, but most made changes to improve nutrition and lifestyle risk factors. 

Ontario Society of Nutrition Professionals in Public Health (OSNPPH). Pediatric Nutrition Guidelines for Primary Health Care Providers. Revised May 2011. Available from: http://www.osnpph.on.ca/resources/YORK-Pediatric_Nutrition_Guidelines_for_Primary_Health_Care_Providers-2011.pdf

Methods

Subjects: 0 to 6 years old

Design: Pediatric nutrition guidelines

Methods: Produced by the Ontario Society of Nutrition Professionals in Public Health (OSNPPH).

Outcomes

These guidelines provide various recommendations for feeding and nutrition for infants at certain age increments: birth to 6 months, 6 to 9 months, 9 to12 months, 12 to 18 months, 18 to 24 months, 2 to 3 years, and 3 to 6 years. They also report approximate amounts of fluid consumption as referenced in the Rourke Baby Record. They primarily used references from Health Canada and the Dieticians of Canada.

Huh SYRifas-Shiman SLRich-Edwards JWTaveras EMGillman MW. Prospective association betweenmilk intake and adiposity in preschool-aged children.

 J Am Diet Assoc. 2010 Apr;110(4):563-70. Available from: PubMed

Methods

Subjects: Children aged 2-3 years.

Design: Longitudinal cohort study (n = 852)

Methods: The authors assessed milk and dairy intake at age 2 years with food frequency questionnaires completed by mothers. Our primary outcomes were body mass index (BMI; calculated as kg/m2), z score and overweight at age 3 years, defined as BMI for age and sex >or=85th percentile. They used linear and logistic regression models, adjusting for maternal BMI and education, paternal BMI, and child age, sex, race/ethnicity, intake of energy, nondairy beverages, television viewing, and BMI z score at age 2 years.

Outcomes

At age 2 years, mean milk intake was 2.6 (standard deviation 1.2) servings per day. Higher intake of whole milk at age 2, but not reduced-fat milk, was associated with a slightly lower BMI z score (-0.09 unit per daily serving [95% confidence interval: -0.16 to -0.01]) at age 3 years; when restricted to children with a normal BMI (5th to <85th percentile) at age 2 years, the association was null (-0.05 unit per daily serving [95% confidence interval: -0.13 to 0.02]). Intake of milk at age 2 years, whether full- or reduced-fat, was not associated with risk of incident overweight at age 3 years. Neither total milk nor total dairy intake at age 2 years was associated with BMI z score or incident overweight at age 3 years.

Conclusion: Neither consuming more dairy products, nor switching from whole milk to reduced-fat milk at age 2 years, appears likely to prevent overweight in early childhood.

Randall Simpson JA, Keller HH, Rysdale LA, Beyers JE. Nutrition Screening Tool for Every Preschooler (NutriSTEP): validation and test-retest reliability of a parent-administered questionnaire assessing nutrition risk of preschoolers. Eur J Clin Nutr. 2008 Jun;62(6):770-80. Abstract available from: PubMed

Methods

Subjects: Children aged 3-5 years and their parents

Design: Validation study, test-retest reliability

Methods: Participants were recruited from community programs (e.g., child-care centers) in both rural and urban settings. Parents of 269 preschoolers completed the NutriSTEP questionnaire. Authors selected a nutritional assessment (based on medical and nutritional history, 3 days of dietary recall and anthropometric measurements) completed by a trained dietitian as the criterion validation (gold standard). Receiver operating characteristic (ROC) curve were used to establish validity. The test-retest reliability study occurred 2-4 weeks after initial completion of the NutriSTEP questionnaire. Parents of 140 preschoolers completed NutriSTEP on two occasions. Intraclass correlation (ICC) and kappa were used to assess reliability. 

Outcomes

Validation: Scores on NutriSTEP and the RD rating were correlated (r = 0.48, P = 0.01). Area under the ROC curve for the high risk rating (by dietitian, score 8+) and the moderate risk rating (score 5+) were 81.5 and 73.8%, respectively. A moderate risk cut point of >20 and high risk cut point of >25 were identified for the NutriSTEP scores. Reliability: The NutriSTEP score was reliable between administrations (ICC = 0.89, F = 16.7, P < 0.001). Most items on the questionnaire had adequate (kappa>0.5) or excellent (kappa>0.75) agreement. Conclusions: The NutriSTEP questionnaire is both valid and reliable for determining nutritional risk in preschoolers.

O'Connor TM1, Yang SJNicklas TA. Beverage intake among preschool children and its effect on weight status. Pediatrics. 2006 Oct;118(4):e1010-8. Available from: Pediatrics

Methods

Subjects: Children aged 2 to 5 years

Design: National Health and Nutrition Examination Survey 1999-2002 (n = 1,552)

Methods: Descriptive statistics and group comparisons of beverage intake and overweight classification. 

Outcomes

After removal of subjects with missing data, a total of 1160 children were analyzed, 579 (49.9%) were male. White children represented 35%, black children represented 28.3%, and Hispanic children represented 36.7% of the sample. Twenty-four percent of the children were overweight or at risk for overweight (BMI ≥85%), and 10.7% were overweight (BMI ≥95%). Eighty-three percent of children drank milk, 48% drank 100% fruit juice, 44% drank fruit drink, and 39% drank soda. Whole milk was consumed by 46.5% of the children, and 3.1% and 5.5% of the children consumed skim milk and 1% milk, respectively. Preschool children consumed a mean total beverage volume of 26.93 oz/day, which included 12.32 oz of milk, 4.70 oz of 100% fruit juice, 4.98 oz of fruit drinks, and 3.25 oz of soda. Weight status of the child had no association with the amount of total beverages, milk, 100% fruit juice, fruit drink, or soda consumed. Conclusions: Weight status had no association with total milk consumed after adjustment for age, gender, ethnicity, income, energy intake, and physical activity. There was no clinically significant association between the type of milk (percentage of fat) consumed and weight status.

NUTRITION

Breastfeeding

Breastfeeding Recommendations Strength of Recommendation
  1. Exclusive breastfeeding is recommended for the first six months of life for healthy term infants.
Good
  1. Breastfeeding is the optimal food for infants, and breastfeeding with (with complimentary foods) may continue for up to two years and beyond unless contraindicated.
Consensus
  1. Maternal support, both antepartum and postpartum, increases breastfeeding and prolongs its duration.
Consensus
  1. Implement policies and practices of the Baby-Friendly Initiative (BFI).
Good
Breastfeeding Resources
  1. The Baby Friendly Initiative (BFI) in Canada by Breastfeeding Committee for Canada
Breastfeeding References
ReferenceMethods and OutcomesFormer CTFPHC GRADE

Health Canada, Canadian Paediatric Society, Dietitians of Canada and Breastfeeding Committee for Canada. Nutrition for healthy term infants - recommendations from 6 to 24 months. 2014. Available from: http://www.hc-sc.gc.ca/fn-an/nutrition/infant-nourisson/index-eng.php

Methods

Subjects: 6 to 24 months

Design: Nutrition guidelines

Methods: A joint statement of Health Canada, Canadian Paediatric Society, Dieticians of Canada, and Breastfeeding Committee for Canada.

Outcomes

Not yet available.

Health Canada, Canadian Paediatric Society, Dietitians of Canada and Breastfeeding

 Committee for Canada. Nutrition for healthy term infants - recommendations from birth to six months. 2012. Available from: http://hc-sc.gc.ca/fn-an/nutrition/infant-nourisson/recom/index-eng.php

Methods

Subjects: 0 to 6 months

Design: Nutrition guidelines during infancy

Methods: A joint statement of Health Canada, Canadian Paediatric Society, Dieticians of Canada, and Breastfeeding Committee for Canada.

Outcomes

Based on the systematic review by Kramer and Kakuma (2002) and works by the WHO on infant feeding, this group recommends exclusive breastfeeding to six months of age. They report that exclusive breastfeeding is associated with continued protection for the infant against gastrointestinal infections and illness as well as respiratory tract infections. The authors also cite conclusions by Kramer & Kakuma (2002), namely that the breastfeeding mother also benefits from exclusively breastfeeding her infant to six months, that her weight loss is more rapid after birth and that there may be a delayed return of menses. Recommendation: 1) Breastfeeding is the normal and unequalled method of feeding infants. 2) Implement the policies and practices of the Baby-Friendly Initiative (BFI) for hospitals and community health services.

American Academy of Pediatrics. Breastfeeding and the use of human milk. Pediatrics. 2005; 115: 496-506. Revised March 2012. Abstract available from: PubMed

Methods

Subjects: Infants

Design: Policy statement (review article)

Methods: Review of the evidence from the literature to make evidence-based recommendations for infant feeding practices.

Outcomes

This policy statement reported that breastfeeding is the optimal method of infant feeding. Out of 15 recommendations by the AAP, the use of human breast milk and breastfeeding are the most important means of infant feeding and achieving good nutrition. This report also recommends that supplements of any kind should not be given to the baby until after 6 months of age. Evidence is based on other policy statements from the American Academy of Pediatrics, American Dietetic Association and a study by Gartner (1994).  The revised policy statement (2012) is based on an update of the 2007 report prepared by the Evidence-based Practice Centers of the Agency for Healthcare Research and Quality (AHRQ) titled Breastfeeding and Maternal and Infant Health Outcomes in Developed Countries. The authors also make several recommendations on breastfeeding management for the healthy term infant. Recommendation: Exclusive breastfeeding for about 6 months followed by continued breastfeeding as complementary foods are introduced, with continuation of breastfeeding for 1 year or longer as mutually desired by mother and infant.

Kramer MS, Kakuma R. Optimal duration of exclusive breastfeeding. Cochrane Database of Systematic Reviews 2012, Issue 8. Art. No.: CD003517.  Abstract available from: PubMed

Methods

Subjects: Infants

Design: Systematic review

Methods: Performed searches in many databases (MEDLINE, CINAHL, HealthSTAR, BIOSIS, CAB Abstracts, EMBASE-Medicine, etc.). Total citations retrieved 2,668. The updated literature review in June 2011 yielded 3,425 additional unique citations.

Outcomes

Twenty-three studies met the inclusion criteria, including one additional study and a follow-up from the June 2011 search: 11 from developing countries (2 internally-controlled trials from Honduras) and 12 from developed countries (all observational studies). The review showed that infants breastfed exclusively for six months have a reduced risk of gastrointestinal infection and respiratory infection and no observable deficits in growth; exclusive breastfeeding for six months does not seem to confer any long-term (at least to early school age) protection against obesity or allergic disease, nor any benefits in cognitive ability or behaviour, compared with exclusive breastfeeding for three to four months with continued partial breastfeeding to six months. Conclusion: Breastfeeding reduces gastrointestinal and respiratory infection. Recommendation: Exclusive breastfeeding is recommended for the first six months of life in both developed and developing countries.

Breastfeeding and SIDS Recommendations Strength of Recommendation
  1. Breastfeeding helps protect against SIDS
Good
Breastfeeding and SIDS References
ReferenceMethods and OutcomesFormer CTFPHC GRADE

Moon, R. Y., K. O. Tanabe, et al. Pacifier use and SIDS: Evidence for a consistently reduced risk. Maternal and Child Health Journal. 2012; 16(3): 609-614. Available from: Springer

Methods

Subjects: infants

Design: Case-control study (SIDS n = 260, control n = 260)

Methods: The objective of this study was to examine the association between pacifier use during sleep and SIDS in relation to other risk factors and to determine if pacifier use modifies the impact of these risk factors.

Outcomes

Data source was a population-based case–control study of 260 SIDS deaths and 260 matched living controls. Pacifier use during last sleep decreased SIDS risk (aOR 0.30, 95% CI 0.17–0.52). Furthermore, pacifier use decreased SIDS risk more when mothers were 20 years of age, married, nonsmokers, had adequate prenatal care, and if the infant was ever breastfed. Pacifier use also decreased the risk of SIDS more when the infant was sleeping in the prone/side position, bedsharing, and when soft bedding was present. The association between adverse environmental factors and SIDS risk was modified favourably by pacifier use, but the interactions between pacifier use and these factors were not significant. Conclusion: Pacifier use may provide an additional strategy to reduce the risk of SIDS for infants at high risk or in adverse sleep environments.

Task Force On Sudden Infant Death Syndrome. SIDS and Other Sleep-Related Infant Deaths: Expansion of Recommendations for a Safe Infant Sleeping Environment. Pediatrics. 2011;128:1030–1039. Abstract available from: Pediatrics

Methods

Subjects: Infants

Design: Technical report and policy statement

Methods: Literature searches since 2005 using PubMed on topics related to SIDS. Based on the technical report, Task Force members determined the strength of evidence for each recommendation using the U.S. Preventive Services Task Force (USPSTF) grade system. The graded recommendations are listed in the policy statement. The rationale supporting the recommendations can be found in the Technical Report.

Outcomes

Since the last AAP statement published in 2005, the recommendations are expanded from being only SIDS-focused to focusing on a safe sleep environment that can reduce the risk of all sleep-related infant deaths including SIDS. This 2011 AAP policy statement includes 18 recommendations (12 Level A recommendations, 3 Level B recommendations and 3 Level C recommendations) for parents and healthcare providers but also for public health policy makers and researchers. The recommendations described in this policy statement include supine positioning, use of a firm sleep surface, breastfeeding, room-sharing without bed-sharing, routine immunizations, consideration of using a pacifier, and avoidance of soft bedding, overheating, and exposure to tobacco smoke, alcohol, and illicit drugs. Recommendation (regarding breastfeeding and SIDS):  Breastfeeding is recommended.

Hauck FR, Thompson JMD, Tanabe KO, Moon RY, Vennemann MM. Breastfeeding and reduced risk of sudden infant death syndrome: A Meta-Analysis. Pediatrics. 2011;128:103-110.

Methods

Subjects: Infants

Design: Meta-analysis

Methods: Searched MEDLINE 1966-2009 for observational studies reporting on the relationship of breastfeeding and sudden infant death syndrome (SIDS).

Outcomes

Eighteen case-control studies were included.  The univariable and multivariable summary odds ratios (SOR) for infants who received breastmilk for any duration was 0.40 (95% CI 0.35-0.44) and 0.55 (95% CI 0.44-0.69), respectively.  The univariable SOR for any breastfeeding at ≥2 months of age and exclusive breastfeeding of any duration was 0.38 (95% CI 0.27-0.54) and 0.27 (95% CI 0.24-0.31), respectively. The authors concluded that breastfeeding is protective against SIDS, with a stronger association when  breastfeeding is exclusive.   

Breastfeeding and Pacifiers Recommendations Strength of Recommendation
  1. 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 ottitis media.
Fair
  1. Counsel on safe and appropriate use of pacifiers during routine anticipatory guidance.
Consensus
Breastfeeding and Pacifiers References
ReferenceMethods and OutcomesFormer CTFPHC GRADE

Kair LR, Kenron D, Etheredge K, Jaffe AC, Phillipi CA. Pacifier restriction and exclusive breastfeeding. Pediatrics. 2013 Apr;131(4):e1101-7. Abstract available from: PubMed

Methods

Subjects: infants

Design: retrospective cohort

Authors retrospectively compared exclusive breastfeeding, breastfeeding plus supplemental formula feeding, and exclusive formula feeding rates for 2,249 infants admitted to the mother-baby unit (MBU) at a university teaching hospital during the 5 months before and 8 months after restriction of routine pacifier distribution. Formula supplementation, if not medically indicated, was discouraged per standard practice, but access to formula was not restricted.

Outcomes

Of the 2,249 infants, 79% were exclusively breastfed from July through November 2010, when pacifiers were routinely distributed. During the 8-month period after pacifier restriction, this proportion decreased significantly to 68% (P < .001). A corresponding increase from 18% to 28% was observed in the number of breastfed infants receiving supplemental formula feeds in the same period (P < .001). During the study period, the proportion of exclusively formula-fed infants increased from 1.8% to 3.4% (P < .05). Conclusion: Restricting pacifier distribution during the newborn hospitalization without also restricting access to formula is associated with decreased exclusive breastfeeding, increased supplemental formula feeding, and increased exclusive formula feeding.

Jaafar SH, Jahanfar S, Angolkar M,Ho JJ. Effect of restricted pacifier use in breastfeeding term infants for increasing duration of breastfeeding. Cochrane Database of Systematic Reviews 2012, Issue 7. Abstract available from: The Cochrane Library

Methods

Subjects: Infants

Design: Systematic review

Methods: Performed a literature review using the Cochrane Pregnancy and Childbirth Group’s Trials Register for randomised and quasi-randomised controlled trials comparing unrestricted versus restricted pacifier use in healthy full-term newborns who have initiated breastfeeding regardless of whether they were born at home or in the hospital.

Outcomes

Three studies met the inclusion criteria but only two trials (involving 1,302 healthy full term breastfeeding infants) were included in the analysis. Meta-analysis of the two combined studies showed that pacifier use in healthy breastfeeding infants had no significant effect on the proportion of infants exclusively breastfed at three months (risk ratio (RR) 0.99; 95%confidence interval (CI) 0.93 to 1.05), and at four months of age (RR 0.99; 95% CI 0.92 to 1.06) and also had no effect on the proportion of infants partially breastfed at three months (RR 1.00; 95% CI 0.98 to 1.13), and at 4 months of age (RR 1.01; 95% CI 0.98 to 1.03). Conclusion: For mothers motivated to breastfeed, the decision to use a pacifier is based on personal preference. Note: Several methodological issues and issues regarding conflict of interest in one trial included were raised by a WHO expert committee as a comment to the article. According to these experts, the validity of the conclusions is questionable. 

M Ponti; Canadian Paediatric Society, Community Paediatrics Committee. Recommendations for the use of pacifiers. Paediatr Child Health. 2003;8(8):515-9. Reaffirmed January 2012. Available from: http://www.cps.ca/documents/position/pacifiers

Methods

Subjects: Infants

Design: Position statement and literature review

Methods: Authors searched Medline and Cochrane Library databases to assess the evidence on the use of pacifiers in healthy term infants and children. A special section is included for the preterm infant. 

Outcomes

The authors concluded that the decision to use pacifiers in infants and children remains controversial and an individual choice for parents, yet paediatricians and other child health care providers must be vigilant in advising parents on the appropriateness of pacifier use. Negative impacts of pacifiers have been reported in relation to otitis media, early weaning and dental problems, but the associations and scope of impact is unclear. The review states that due to the lack of strong evidence, either for or against the use of pacifiers, selective use and safe use cannot be over-emphasized to those who choose them. Conclusion: Selective and safe use of pacifiers.

Alejandro G. Jenik, MD, Nestor E. Vain, MD, Adriana N. Gorestein, MD, and Noemı´ E. Jacobi, MD, for the Pacifier and Breastfeeding Trial Group. Does the Recommendation to Use a Pacifier Influence the Prevalence of  Breastfeeding? J Pediatrics 2009; 155: 350-354. 

Methods

Subjects: Newborn infants

Design: Multi-centre randomized non-inferiority controlled trial

Methods: Mothers highly motivated to breastfeed and newborns at 15 days old randomized to offer vs. not to offer pacifiers.

Outcomes

Primary outcome, exclusive breastfeeding at 3 months, was 85.8% and 86.2% in the “offer” and “not to offer” pacifier groups, respectively, which satisfied the pre-specified non-inferiority requirement of -7%.  No significant differences between the two groups were observed for secondary outcomes (frequency of exclusive breastfeeding, any breastfeeding at different ages or duration of breastfeeding).The authors concluded that offering a pacifier is appropriate in populations similar to this study.

O’Connor NR, Tanabe KO, Siadaty MS, Hauck FR. Pacifiers and Breastfeeding. A Systematic Review. Arch Pediatr Adolesc. 2009; 163: 378-382. Abstract available from: PubMed

Methods

Subjects: Mother-infant pairs

Design: Systematic review

Methods: Performed a literature review using the databases MEDLINE, CINAHL, the Cochrane Library, EMBASE, POPLINE and bibliographies of identified articles.

Outcomes

Twenty-nine studies met the inclusion criteria: 4 RCTs, 20 cohort and 5 cross-sectional studies.  Due to significant heterogeneity in the studies no meta-analysis could be performed. The RCTs showed no difference in weaning between using pacifiers and controls. However, observational studies have shown a strong association. Potential limitations in both these study designs might contribute to the mixed results.  For example in one RCT, there might have been a problem with compliance. 

Collins CT, Ryan P, Crowther CA, McPhee AJ, Paterson S, Hiller JE. Effect of bottles, cups and dummies on breast feeding in preterm infants: a randomized controlled trial. BMJ. 2004 Jul 24;329(7459):193-8. Abstract available from: PubMed

Methods

Subjects: Preterm infants (<34 weeks)

Design: RCT

Methods: Participants were randomized to 1 of 4 groups (cup/no dummy, cup/dummy, bottle/no dummy or bottle/dummy) and used block randomization to stratify infants based on gestational weeks.

Outcomes

Main outcome was the proportion of infants fully breastfeeding by time of discharge. Secondary outcomes included length of hospital stay and prevalence of breastfeeding at 3 and 6 months after discharge. In this study, there was no effect between dummy use and breast feeding at discharge or after 3 and 6 months based on intention to treat analysis. However, there was a significant effect of cup feeding on full breastfeeding at discharge (OR=1.73, 95% CI:1.04-2.88). Also, cup feeds were significantly associated with longer hospital stay.

Kramer MS, Barr RG, Dagenais S, Yang H, Jones P, Ciofani L, Jané F. Pacifier use, early weaning and cry/fuss counselling: A randomized controlled trial. JAMA. 2001; 286: 322-326. Abstract available from: PubMed

Methods

Subjects: Healthy term breastfed infants and mothers

Design: Double blinded Randomized Controlled Trial

Methods: Participants (N=281) were randomized to 1 of 2 counselling interventions. Each group was counselled by a trained research nurse. The experimental group was different than control as they were counselled to avoid pacifier use and given alternative methods to calm a crying baby. 

Outcomes

Early weaning (i.e., within the first 3 months) was compared between groups. Detailed behaviour logs for each infant were maintained describing the frequency and duration of crying and pacifier use at 4, 6, and 9 weeks. Analysis based on random allocation showed no effect between experimental or control groups for either early weaning or cry/fuss behaviour (OR=1.0, 95% CI: 0.6-1.7). When random allocation was ignored a strong observational association was found (RR=1.9).  Follow-up was completed by 91.8% of participants. Data strongly suggest that pacifier use is a marker of breastfeeding difficulties or reduced motivation to breastfeed rather than a cause of early weaning.

Breastfeeding and Maternal Medications Resources
  1. Sick Kids’ – Motherisk Program
  2. United States National Library of Medicine’s Drugs and Lactation Database (LactMed)
Weaning of Breastfeeding Recommendations Strength of Recommendation
  1. Advise slow, progressive, natural weaning whenever possible.
Consensus
Weaning of Breastfeeding References
ReferenceMethods and OutcomesFormer CTFPHC GRADE

Barbara Grueger; Canadian Paediatric Society, Community Paediatrics Committee. Weaning from the breast. Paediatrics & Child Health. 2013;18(4):210. Available from:  http://www.cps.ca/documents/position/weaning-from-the-breast#ref15

Methods

Subjects: Healthy term infants

Design: Policy statement

Methods: A review of the literature was performed using MEDLINE (1966 to 2012), the Cochrane database and relevant websites, including those of the WHO, the Canadian Paediatric Society, Health Canada and the American Academy of Pediatrics. 

Outcomes

This document replaces a previous Canadian Paediatric Society position statement on weaning published in 2004. This statement addresses issues affecting the weaning process and the different ways weaning can occur. It includes suggestions that physicians can offer to breastfeeding women about weaning and nutritional alternatives and for problems associated with weaning. This statement focuses on healthy term infants and its recommendations may not be appropriate for infants with special circumstances (eg, prematurity, chronic illness, failure to thrive).  Recommendation: 1) Advise slow, progressive, natural weaning whenever possible. 2) Ensuring adequate nutrition for the infant regardless of the timing of weaning.

Ankyloglossia (tongue-tie) and Breastfeeding Recommendations Strength of Recommendation
  1. Inspection of the tongue and its function should be part of the routine neonatal examination.
Consensus
  1. Frenotomy is not universally recommended for ankyloglossia.
Consensus
Ankyloglossia (tongue-tie) and Breastfeeding References
ReferenceMethods and OutcomesFormer CTFPHC GRADE

Buryk M, Bloom D, Shope T. Efficacy of neonatal release of ankyloglossia: a randomized trial. Pediatrics. 2011 Aug;128(2):280-8. Abstract available from: PubMed

Methods

Subjects: Neonates who had difficulty breastfeeding and significant ankyloglossia (using Hazelbaker Assessment Tool for Lingual Frenulum Function). Other inclusion criterion was maternal nipple pain.

Design: RCT

Methods: Neonates assigned to either frenotomy (n=30) or sham (n=28) and followed over 12 months. Breastfeeding was assessed by a preintervention and postintervention nipple-pain scale and the Infant Breastfeeding Assessment Tool.

Outcomes

Fifty-eight of 3,025 normal newborns (1.9%) met enrolment criteria and were enrolled over a 12-month period from December 2007 to December 2008. The mean age of patients at enrolment was 6 days (SD: 6.9 [range 1–35 days]). There were no statistically significant differences between groups at baseline. Both the frenotomy and sham groups demonstrated significant decreases on the nipple pain scale scores after the intervention but frenotomy group improved significantly more than sham group (P<0.001), yielding an effect size of 0.38. In addition, frenotomy group compared with the sham group (P = .029) improved breastfeeding competence as measured by reliable questionnaire, yielding an effect size of 0.31. Conclusion: When frenotomy is performed for clinically significant ankyloglossia, there is a clear and immediate improvement in reported maternal nipple pain and infant breastfeeding scores. Recommendation: There is compelling evidence to seek frenotomy when indicated. 

Community Paediatrics Committee, Canadian Pediatric Society. Ankyloglossia and breastfeeding. Paediatrics & Child Health. 2011; 16(4), 222. Available from: http://www.cps.ca/documents/position/ankyloglossia-breastfeeding

Methods

Subjects: Breastfeeding infants

Design: Position statement (review)

Methods: Reviewed the literature for evidence of the association between ankyloglossia and breastfeeding difficulties.

Outcomes

According to this review, the incidence of ankyloglossia ranges from 4 - 10% in the newborn population.  Evidence suggests that despite newborn or infant ankyloglossia, most babies are able to breastfeed without too much difficulty.  In most cases, surgical intervention is usually not warranted.  If surgical intervention is deemed necessary, frenotomy should be performed by a clinician experienced with the procedure. Conclusion: Surgical intervention (frenotomy) is not universally recommended.  Recommendation: Ankyloglossia is relatively uncommon in the newborn population, but inspection of the tongue and its function should be part of the routine neonatal examination.

NUTRITION

Vitamin D Supplementation

Vitamin D Supplementation Recommendations Strength of Recommendation
  1. 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 year of age).
Consensus
  1. Breastfeeding mothers should continue to take Vitamin D supplements for the duration of breastfeeding.
Consensus
Vitamin D Supplementation References
ReferenceMethods and OutcomesFormer CTFPHC GRADE

Canadian Paediatric Society. Vitamin D supplementation: Recommendations for Canadian mothers and infants. Paediatrics & Child Health. 2007; 12(7): 683-89. Reaffirmed 2013 Jan 30. Available from: http://www.cps.ca/documents/position/vitamin-d

Methods

Subjects: Infants

Design: Position statement (review)

Methods: Reviewed the literature for studies looking at vitamin D deficiency and rickets. Also reviewed intervention studies.

Outcomes

The focus of research has shifted from rickets exclusively to the prevention of associated childhood and adult diseases. Vitamin D deficiency is very common, therefore according to this review, supplementation for mothers and infants, especially those in high risk groups such as Inuit and First Nations is recommended. Studies reviewed were mainly case-control and cohort study designs (no randomized controlled trials due to ethical implausibility.)

Health Canada, Canadian Paediatric Society, Dietitians of Canada and Breastfeeding Committee for Canada. Nutrition for healthy term infants - recommendations from 6 to 24 months. 2014. Available from: http://www.hc-sc.gc.ca/fn-an/nutrition/infant-nourisson/index-eng.php

Methods

Subjects: 6 to 24 months

Design: Nutrition guidelines

Methods: A joint statement of Health Canada, Canadian Paediatric Society, Dieticians of Canada, and Breastfeeding Committee for Canada.

Outcomes

Not yet available.

Health Canada, Canadian Paediatric Society, Dietitians of Canada and Breastfeeding Committee for Canada. Nutrition for healthy term infants - recommendations from birth to six months. 2012. Available from: http://hc-sc.gc.ca/fn-an/nutrition/infant-nourisson/recom/index-eng.php

Methods

Subjects: 0 to 6 months

Design: Nutrition guidelines during infancy

Methods: A joint statement of Health Canada, Canadian Paediatric Society, Dieticians of Canada, and Breastfeeding Committee for Canada.

Outcomes

The Infant Feeding Working Group recommends a daily vitamin D supplement for breastfed infants. This recommendation is largely based on the new report by the Institute of Medicine (IOM, 2011) on vitamin D and calcium. According to the Infant feeding Working Group and the IOM report:  1) the level of adequate intake for vitamin D for infants is 10 µg (400 IU) per day, 2) for infants under six months of age, vitamin D intake should not exceed 25 µg (1000 IU) per day, 3) 1000 IU/day is the highest average daily intake level likely to pose no risk of adverse health effects, and 4) there are no known health benefits associated with intakes above 10 µg (400 IU) per day. Recommendation: Daily vitamin D supplement of 10 µg (400 IU) for breastfed infants.

Ward LM1, Gaboury ILadhani MZlotkin S. Vitamin D-deficiency rickets among children in Canada. CMAJ. 2007 Jul 17;177(2):161-6. Available from: CMAJ

Methods

Subjects: Pediatricians

Design: Longitudinal study

Methods: A total of 2325 Canadian pediatricians were surveyed monthly from July 1, 2002, to June 30, 2004, through the Canadian Paediatric Surveillance Program to determine the incidence, geographic distribution and clinical profiles of confirmed cases of vitamin D-deficiency rickets. Authors calculated incidence rates based on the number of confirmed cases over the product of the length of the study period (2 years) and the estimates of the population by age group.

Outcomes

There were 104 confirmed cases of vitamin D- deficiency rickets during the study period. The overall annual incidence rate was 2.9 cases per 100,000. The incidence rates were highest among children residing in the north (Yukon Territory, Northwest Territories and Nunavut). The mean age at diagnosis was 1.4 years (standard deviation [SD] 0.9, min-max 2 weeks-6.3 years). Sixty-eight children (65%) had lived in urban areas most of their lives, and 57 (55%) of the cases were identified in Ontario. Ninety-two (89%) of the children had intermediate or darker skin. Ninety-eight (94%) had been breast-fed, and 3 children (2.9%) had been fed standard infant formula. None of the breast-fed infants had received vitamin D supplementation according to current guidelines (400 IU/d). Maternal risk factors included limited sun exposure and a lack of vitamin D from diet or supplements during pregnancy and lactation. The majority of children showed clinically important morbidity at diagnosis, including hypocalcemic seizures (20 cases, 19%). Author’s conclusions: Vitamin D-deficiency rickets is persistent in Canada, particularly among children who reside in the north and among infants with darker skin who are breast-fed without appropriate vitamin D supplementation. Since there were no reported cases of breast-fed children having received regular vitamin D (400 IU/d) from birth who developed rickets, the current guidelines for rickets prevention can be effective but are not being consistently implemented. The exception appears to be infants, including those fed standard infant formula, born to mothers with a profound vitamin D deficiency, in which case the current guidelines may not be adequate to rescue infants from the vitamin D-deficient state.

Taylor SN, Wagner CL, Hollis BW. Vitamin D supplementation during lactation to support infant and mother. Journal of the American College of Nutrition. 2008; 27(6): 690-701. Abstract available from: PubMed

Methods

Subjects: Mothers and infants

Design: Review

Methods: Reviewed the literature for studies and position statements looking at vitamin D deficiency and rickets in infants and mothers. Key words: human milk, lactation, infant, rickets, vitamin D.

Outcomes

Many populations all over the world suffer from vitamin D deficiency. There was contrasting evidence about the benefits and harms of vitamin D supplementation; however it is now known to be very beneficial. This review reports that vitamin D supplementation for mothers and infants is recommended, especially for high risk groups (i.e., dark pigmented skin, Northern latitudes, whole-body covering). The authors report that there is some evidence that supports giving breastfeeding mothers higher doses to eliminate direct supplementation to infants.

NUTRITION

Infant Formula

Infant Formula Recommendations Strength of Recommendation
  1. If at risk of iron deficiency, iron-fortified infant formulas are recommended
Fair
Infant Formula Resources
  1. For formula composition and algorithm regarding use: Alberta Health Services
  2. Recommendations for the preparation and handling of powdered infant formula (PIF), see Health Canada
  3. Nutrition for Healthy Term Infants
    0-6 months
    6-24 months
    CPS Practice Point 0-6 mos
Infant Formula References
ReferenceMethods and OutcomesFormer CTFPHC GRADE

Health Canada, Canadian Paediatric Society, Dietitians of Canada and Breastfeeding Committee for Canada. Nutrition for healthy term infants - recommendations from 6 to 24 months. 2014. Available from: http://www.hc-sc.gc.ca/fn-an/nutrition/infant-nourisson/index-eng.php

Methods

Subjects: 6 to 24 months

Design: Nutrition guidelines

Methods: A joint statement of Health Canada, Canadian Paediatric Society, Dieticians of Canada, and Breastfeeding Committee for Canada.

Outcomes

Not yet available.

Health Canada, Canadian Paediatric Society, Dietitians of Canada and Breastfeeding Committee for Canada. Nutrition for healthy term infants - recommendations from birth to six months. 2012. Available from: http://hc-sc.gc.ca/fn-an/nutrition/infant-nourisson/recom/index-eng.php

Methods

Subjects: 0 to 6 months

Design: Nutrition guidelines during infancy

Methods: A joint statement of Health Canada, Canadian Paediatric Society, Dieticians of Canada, and Breastfeeding Committee for Canada.

Outcomes

Recommendation: 1) Recommend cow milk-based, commercial infant formula for an infant who is not exclusively fed breastmilk. 2) Soy-based infant formula is indicated only for those infants who have galactosemia or who cannot consume dairy-based products for cultural or religious reasons. 3) Recommend infant formulas for special medical purposes only when you detect or suspect that the formula-fed infant has the indicated condition. 4) Discourage the use of home-made, evaporated milk formula; cow milk, goat milk, soy beverage, rice beverage or any other beverages should not be given to young infants. 5) Advise on proper preparation and storage to reduce the risk of bacteria-related illness. 6) Warn of the risk of choking if infants are left alone while feeding. 7) Explain the dangers of 'propping' a bottle.

Martinez JA, Ballew MP. Infant Formulas. Pediatrics in Review. 2011;32(5):179-189. Available from: Peds in Review

Methods

Subjects: Infants

Design: Narrative review

Methods: This review describes the macronutrient content of infant (preterm and term) formulas, identifies appropriate clinical applications of infant formulas that have altered nutrient content, discusses components added to infant formulas (e.g., probiotics), and delineates standards for composition, performance and safety criteria for commercial infant formulas. 

Outcomes

Summary points of authors: 1) Based on strong research evidence, formulas supplemented with DHA (between 0.3% and 0.5% of total fatty acids) and at least equal amounts of ARA are beneficial for visual and neurological development. 2) Based on strong research evidence, formulas supplemented with probiotics reduce the incidence of clinical eczema in high-risk infants (parent or sibling who has atopy). 3) Based on strong research evidence, formulas supplemented with probiotics reduce the incidence of NEC and all-cause mortality in VLBW infants. 4) Based on some research evidence, formulas supplemented with prebiotics or probiotics decrease the risk of infections during infancy. 5) Based on strong research evidence, partially or extensively hydrolyzed formulas are effective in preventing or delaying development of atopic dermatitis in high-risk infants. 6) Based on strong research evidence, thickened formulas reduce the number of episodes of vomiting, regurgitation, and signs of GERD such as irritability and crying.

American Academy of Pediatrics Committee on Nutrition. Iron-fortification of infant formulas. Pediatrics. 1999; 104(1):119-123. Abstract available from: PubMed

Methods

Subjects: 0 to12 months old

Design: Policy statement

Methods: Review of the 1976 and 1989 statements on infant formulas as well as a scientific update and compilation of recommendations.

Outcomes

The AAP recommends the use of iron-fortified infant formula to prevent iron-deficiency anemia. They also recommend that breastfeeding is optimal for all infants however, for parents who choose to formula feed, formula should contain 4-12 mg/L of iron for the first year of life. This statement reports that parents should be educated on the importance and role of iron for infant growth and development.

Long-chain polyunsaturated fatty acids (LCPUFA) Supplementation of Infant Formula References
ReferenceMethods and OutcomesFormer CTFPHC GRADE

Qawasmi A, Landeros-Weisenberger A, Bloch MH. Meta-analysis of LCPUFA Supplementation of Infant Formula and Visual Acuity. Pediatrics. Published online December 17, 2012. Abstract available from: Pediatrics

Methods

Subjects: 0 to 1 year old

Design: Systematic review and meta-analysis

Methods: Systematic review and meta-analysis of randomized studies of the effect of LCPUFA supplemented (versus unsupplemented) infant formula on visual acuity.  Authors searched PubMed, PsychInfo and Scopus databases for RCTs and meta-analyses available since 1965 until 2011. Study quality was evaluated by using Jadad scale.

Outcomes

Seven studies on pre-term infants and nine on term infants were included in the meta-analysis (N=1,949). Of the these studies, 10 studies (N=852) showed a small significantly favourable effect of LCPUFAs on infant visual resolution acuity at 2, 4 and 12 months and on visual acuity (using behavioural methods) at 2 months. The other studies reported non-significant effects. The authors noted significant heterogeneity between studies at time points where a significant positive effect was observed (I2 ranged from 69% to 92%). Authors also discuss the potential sources of heterogeneity in details and conclude that there is significant benefit of LCPUFA supplementation to infant formula on infant visual acuity during the first year of life. Conclusion: LCPUFA supplementation of infant formulas confers a significant benefit on infants’ visual acuity up to 12 months of age.

Qawasmi A, Landeros-Weisenberger A, Leckman JF, and Bloch MH. Meta-analysis of Long-Chain Polyunsaturated Fatty Acid Supplementation of Formula and Infant Cognition.Pediatrics 2012;129;1141.

Methods

Subjects: 0 to 1 year old

Design: systematic review and meta-analysis

Methods: Systematic review and meta-analysis of randomized studies of the effect of LCPUFA supplemented (versus unsupplemented) infant formula  on cognitive outcomes (using the Bayley Scales of Infant Development (BSID)). Authors searched PubMed, PsychInfo and Scopus databases for RCTs and meta-analyses available since 1965 until 2011. Study quality was evaluated by using the Jadad scale.

Outcomes

Authors identified 12 trials (N=1,802) of which two reported a significant benefit of supplementation with LCPUFAs on cognition, one showed a positive benefit of supplementation on some but not all subscales of the BSID, and nine showed no effect of supplementation on cognition. The meta-analysis demonstrated no significant effect of LCPUFA supplementation of formula on infant cognition. There was a modest non-significant heterogeneity between the trials (I2=38%). Conclusion: No significant association exists between LCPUFA supplementation of infant formula and cognitive development at ∼1 year of age.

Soy-based Formula Recommendations Strength of Recommendation
  1. 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.
Fair
Soy-based formula Recommendations
ReferenceMethods and OutcomesFormer CTFPHC GRADE

Health Canada, Canadian Paediatric Society, Dietitians of Canada and Breastfeeding Committee for Canada. Nutrition for healthy term infants - recommendations from birth to six months. 2012. Available from: http://hc-sc.gc.ca/fn-an/nutrition/infant-nourisson/recom/index-eng.php

Methods

Subjects: 0 to 6 months

Design: Nutrition guidelines during infancy

Methods: A joint statement of Health Canada, Canadian Paediatric Society, Dieticians of Canada, and Breastfeeding Committee for Canada.

Outcomes

Recommendations: 1) Cow milk-based infant formula is recommended for an infant who is not exclusively fed breastmilk. 2) Soy-based infant formula is indicated only for infants who have galactosemia or who cannot consume dairy-based products for cultural or religious reasons. 3) The Canadian Paediatric Society recommends the use of an infant formula based on extensively hydrolyzed protein for the formula-fed infant with a cow milk protein allergy (CPS, 2009). 4) When a diagnosis of non-IgE-mediated cow milk protein allergy can be ruled out, the use of soy-based infant formula may be considered (CPS, 2009).

Andres A et al. Developmental Status of 1-Year-Old Infants Fed Breast Milk, Cow’s Milk Formula, or Soy Formula. Pediatrics. 2012;129(6):1134 -1140. Abstract available from:  PubMed                                                                                                                                                                                                                 

Methods

Subjects: Infants 1 to 12 months old

Design: Prospective cohort

(N= 391)

Methods: Infants were recruited at 1-2 months and were either breast fed (BF) or formula fed (soy (SF) or milk (MF)). Follow-up visits were scheduled at 3, 6, 9 and 12 months. All examiners were blinded to feeding group unless BF infants were fed during the testing period.

Outcomes

Healthy infants enrolled in BF, SF or MF were assessed for development at each study visit. No differences were found between formula-fed infants (MF versus SF). BF infants scored slightly higher on some development measures than formula-fed infants. Conclusion: Infants fed soy protein–based formula scored within normal limits on standardized developmental testing and did not differ from infants fed cow’s milk–based formula.

Canadian Paediatric Society. Concerns for the use of soy-based formulas in infant nutrition. Paediatrics & Child Health. 2009; 14(2): 109-113. Abstract available from: PubMed

Methods

Subjects: Infants and mothers

Design: Practice point

Methods: Review of clinical and observational studies.

Outcomes

Other studies have been done showing potential harmful effects of soy-based formulas because of the presence of phytoestrogens. According to this statement, mothers’ personal preference could be the main reason for use of soy-based formulas. This practice point reports that soy-based formula is not recommended for infants and that the recommendation for soy-based formula for infants with cow’s milk protein allergy (CMPA) or living a vegan lifestyle is no longer valid. One main limitation of studies on CMPA and soy-based formulas is failing to distinguish between IgE- and non-IgE- mediated CMPAs.

Badger TM Gilchrist JM, Pivik RT, Andres A, Shankar K, Chen JR, Ronis MJ. The health implications of soy infant formula. American Journal of Clinical Nutrition. 2009; 89(Suppl): 1668S-72S. Available from: PubMed

Methods

Subjects: 0 to 6 months old

Design: Prospective longitudinal study

Methods: Arkansas Children’s Nutrition Center currently conducting a study comparing growth, development and health of breastfed children with formula-fed children.

Outcomes

After 5 years of the study, all children are growing within the normal limits and no adverse effects have been seen. Many countries have recommended reduced use of soy formulas. According to this study, concerns about soy formulas are not supported by convincing data. Most of the evidence against soy formulas is based on RCTs using animal models and cannot be generalized to humans. The follow-up time of this study is adequate to determine any early developmental problems but not longer-term effects.

Bhatia J, Greer F. American Academy of Pediatrics Committee on Nutrition. Use of soy protein-based formulas in infant feeding. Pediatrics. 2008; 121: 1062-1068. Abstract available from: PubMed

Methods

Subjects: Infants and mothers

Design: Review

Methods: Reviewed literature on soy-based formulas for infants. Recommendations are based on a few randomized controlled trials, controlled clinical trials, observational studies and review articles.

Outcomes

According to this review, soy-based formulas do not have adverse effects for normal term infants. However, the review reports that there is no added benefit over cow’s milk (unless the infant has CMPA) and that soy-based formulas should not be used for preterm babies. There is no evidence to support that soy-based formulas prevent atopic diseases or colic. This review reports that soy-based formula should only be used in infants with galactosemia or when a vegetarian diet is preferred. 

Osborn DA, Sinn JKH. Soy formula for prevention of allergy and food intolerance in infants (Review). Cochrane Database of Systematic Reviews. 2006, Issue 4 Art No.:CD003741. Abstract available at: http://onlinelibrary.wiley.com/doi/10.1002/14651858.CD003741.pub4/abstract

Methods

Subjects: 0 to 6 months old

Design: Meta-analysis

Methods: Used the standard search strategy of the Cochrane Neonatal review group. Selected studies that compared the use of adapted soy formula to human milk, an adapted cow’s milk or a hydrolyzed protein formula. 

Outcomes

Only 3 randomized and quasi-randomized studies met the inclusion criteria. According to this meta-analysis, the use of soy formula cannot be recommended for the prevention of allergy or food intolerance in infants at high risk of these conditions. Ten to 14% of infants with CMPA allergy are also allergic to soy protein. 

NUTRITION

Introduction of Solid Foods

Introduction of Solid Foods Recommendations Strength of Recommendation
  1. Discuss future introduction of solids at the 4-month visit.
Consensus
  1. Introduction of solids should be led by the infant’s signs of readiness – a few weeks before to just after 6 months.
Good
  1. Advise to introduce iron-fortified foods in the form of iron-fortified cereals, meat, tofu, poultry, fish, or whole eggs as first foods, to avoid iron deficiency.
Good
  1. Introduce 1 food at a time (3-5 day intervals) to identify the cause of an allergic reaction should one occur; combination foods may be offered once each component tolerated.
Consensus
  1. Delaying the introduction of priority food allergens is not currently recommended as a way to prevent food allergies, including for infants at
Fair
  1. Avoid hard, small and round, smooth and sticky solid foods until age 3 years.
Consensus
Introduction of Solid Foods References
ReferenceMethods and OutcomesFormer CTFPHC GRADE

Health Canada, Canadian Paediatric Society, Dietitians of Canada and Breastfeeding Committee for Canada. Nutrition for healthy term infants - recommendations from 6 to 24 months. 2014. Available from: http://www.hc-sc.gc.ca/fn-an/nutrition/infant-nourisson/index-eng.php

Methods

Subjects: 6 to 24 months

Design: Nutrition guidelines

Methods: A joint statement of Health Canada, Canadian Paediatric Society, Dieticians of Canada, and Breastfeeding Committee for Canada.

Outcomes

Not yet available.

Edmond S Chan, Carl Cummings; Canadian Paediatric Society, Community Paediatrics CommitteeAllergy Section. Dietary exposures and allergy prevention in high-risk infants. Paediatr Child Health 2013;18(10):545-9. Available from CPS

Methods

Subjects: Infants

Design: Position Statement

Methods: This position statement reviews current evidence on dietary exposures and allergy prevention in infants at high risk for developing allergic conditions. It revisits previous dietary recommendations for pregnancy, breastfeeding and formula feeding, and provides an approach for introducing solid foods to high-risk infants. 

Outcomes

Author’s conclusions: While there is no evidence that delaying the introduction of any specific food beyond six months of age helps to prevent allergy, the protective effect of early introduction of potentially allergenic foods (at four to six months of age) remains under investigation. Recent research appears to suggest that regularly ingesting a new, potentially allergenic food may be as important as when that food is first introduced. See Position Statement for specific recommendations.

Fleischer, DM, J M Spergel, et al. Primary Prevention of Allergic Disease Through Nutritional Interventions. Journal of Allergy and Clinical Immunology: In Practice. 2013;1(1): 29-36. Available from: http://www.jaci-inpractice.org/article/S2213-2198(12)00014-1/abstract

Methods

Subjects: Infants, children (with no known allergic diseases), mothers

Design: Review

Methods: The Adverse Reactions

to Foods Committee of the American Academy of Allergy,

Asthma & Immunology reviewed the current available literature and expert opinion on the primary prevention of allergic disease through nutritional interventions. This group made several recommendations based on peer-reviewed and non-peer-reviewed findings. 

Outcomes

The authors report on several nutritional interventions: 1) maternal avoidance of highly allergenic foods during pregnancy, 2) breastfeeding, 3) infant formula, and 4) introduction of complementary foods. The available data for each intervention is critically appraised and a recommendation is developed based on their evaluation.  Recommendation: 1) Maternal avoidance of allergenic foods during pregnancy and lactation is not recommended. 2) Exclusive breastfeeding for at least 4 months and up to 6 months may help in reducing incidence of some but not all allergic disease later in life. 3) Complementary foods, including highly allergenic foods, may be introduced between 4 and 6 months of age into the diet of healthy infants. The highly allergenic foods may be given once a few complementary foods have been tolerated. 4) For infants at increased risk of allergic disease who cannot be exclusively breast-fed for the first 4 to 6 months of life, hydrolyzed formula may be advantageous for the prevention of allergic disease and cow’s milk allergy.

Health Canada. Nutrition for Healthy Term Infants: Recommendations from Birth to Six Months - Should parents be concerned about offering infants foods that are considered common allergens? Revised September 2012. Available from: Health Canada

Methods

Subjects: 0 to 6 months

Design: Nutrition guidelines during infancy

Methods: A joint statement of Health Canada, Canadian Paediatric Society, Dieticians of Canada, and Breastfeeding Committee for Canada.

Outcomes

Recommendation: Delaying the introduction of priority food allergens is not currently recommended as a way to prevent food allergies, including for infants at risk for atopy.       

Przyrembel H. Timing of introduction of complementary food: short- and long-term health consequences. Ann Nutr Metab. 2012; 60(suppl):8-20. Available from: PubMed

Methods

Subjects: infants and children

Design: review

Methods: Reviewed the literature for studies on the health effects of age at which complementary food has been introduced regardless of breastfeeding or formula feeding. Authors define complementary as any food, solid or (semi-) liquid, besides breast milk or its substitutes, i.e. infant (or follow-on) formula.

Outcomes

The author reviewed the evidence on timing of infant feeding and health outcomes such as weight gain, obesity, nutritional inadequacy, development, infection, type 1 and 2 diabetes, coronary heart disease and allergy. The author of this review concludes that there is little evidence on the strength of the relationship between the timing of the introduction of complementary food and the risk of disorders in later life. The author found some evidence of an association between early (12-15 weeks) introduction of complementary foods and increased weight gain/obesity and the risk for atopic eczema later in life. Studies included also suggested that the late introduction of complementary foods (>26 weeks) increased the risk of wheat allergy and was associated with an increase in the presence of diabetes-associated antibodies. Recommendation: Advise against the introduction of complementary food before the age of 12 weeks. Conclusion: Delaying the introduction of complementary food beyond the age of 26 weeks is associated with the risk of nutritional insufficiency, particularly in low-income populations.                                            

Jonsdottir OH et al. Timing of the introduction of complementary foods in infancy: a randomized controlled trial. Pediatrics. 2012; 130(6):1038-45. Abstract available from: PubMed

Methods

Subjects: Infant-mother pairs

Design: Randomized controlled trial (N=119)

Methods: Infants were randomly assigned to receive complementary foods from age 4 months in addition to breast milk or continue being exclusively breastfed.

Outcomes

One hundred infants completed the trial (84% participation rate). The results regarding growth showed no significant differences between the two groups. Infants in complementary feeding group had higher mean serum ferritin levels at 6 months (P = .02), which remained significant when adjusted for baseline characteristics. No difference was seen between groups in iron deficiency anemia, iron deficiency, or iron depletion. Conclusion: In a high-income country, feeding complementary foods in addition to breast milk to infants from 4 months of age has a small and positive effect on iron status at 6 months.

Nwaru BI et al. Timing of infant feeding in relation to childhood asthma and allergic diseases. J Allergy Clin Immunol. 2012; article in press.Abstract available from: PubMed

Methods

Subjects: 0 to 5 years old

Design: multicentre prospective population-based birth cohort

(N=3,791)

Methods: From 1994, consecutive infants born with susceptibility to type 1 diabetes were recruited from 3 university hospitals. At the age of 5 years, 3,781 (93% of those invited) took part in the study. The diet of the child was assessed by means of age-specific dietary questionnaires at the ages of 3, 6, and 12 months and a follow-up ‘‘age at introduction of new foods-form’’ for recording the age at introduction of complementary foods. The exposures of interest were duration of exclusive and total breast-feeding and age at introduction of cow’s milk; roots (potatoes, carrot, and turnip); fruits and berries; wheat, rye, oats, and barley; meat; fish; egg; and other cereals (maize, rice, millet, and buckwheat).

Outcomes

End points included asthma, allergic rhinitis, atopic eczema, and atopy (sensitization to allergens). Authors found that longer duration of total breast-feeding, rather than its exclusivity, was protective against the development of nonatopic but not atopic asthma. Further, the results of this study suggest that early introduction of cereals, fish, and egg in infancy (respective to the timing of introduction of each food) might confer protection against the development of asthma, allergic rhinitis, and atopic sensitization by the age of 5 years. Conclusions: 1) Total duration of breastfeeding, rather than its exclusivity, might be the more important determinant of the occurrence of asthma in childhood. 2) Introduction of wheat, rye, oats, and barley cereals at 5.5 months or less; fish at 9 months or less; and egg at 11 months or less might decrease the risk of asthma, allergic rhinitis, and atopic sensitization in childhood. 3) Emerging evidence does not support current recommendations on breastfeeding and introduction of complementary foods for the prevention of childhood asthma and allergies.

Chuang CH et al. Infant feeding practices and physician diagnosed atopic dermatitis: a prospective cohort study in Taiwan. Pediatric Allergy and Immunology . 2011; 22: 43–49. 2012. Abstract available from: PubMed

Methods

Subjects: 0 to 18 months

Design: national (multicentre) prospective population-based birth cohort

(n=18,773)

Methods: Based on a systematic representative sample of newborns. Variables related to infant nutrition were collected, including breastfeeding and solid food through interview questionnaires at 6 and 18 months of age. Solids feeding was defined as the infant receiving any solid food (e.g. fruit mash, porridge, or dairy products), and data on the start and kinds of feeding were collected. The main outcome measure was parent reported physician’s diagnosis of AD within 6 and 18 months. All potential confounders including reverse causality were accounted for.          

Outcomes

After adjustment for potential confounders, results suggested that the increased duration of breastfeeding seemed to increase the risk of children with AD at 18 months.  No significant effect was found for the different timings of solid food introduction on the risk of AD. Conclusion: Longer duration of breastfeeding (not necessarily exclusive) and a delayed introduction of solids beyond 6 months did not prevent the AD by age 18 months when reverse causality was considered.                                                                                                                                                                                                                                                                                                                                                                  

Palmer DJ and Prescott SL. Does early feeding promote development of oral tolerance. Curr Allergy Asthma Rep. 2012; 12:321-331. Abstract available from: PubMed

Methods

Subjects: Infants

Design: Review

Methods: This review discusses the history of the recommendations regarding the commencement of complementary foods and/or the avoidance or exposure to specific allergenic foods. Authors conducted a literature review of prospective birth cohort studies since 2008 and other large scale unselected population studies (cross-sectional). The ongoing randomized controlled trials are also presented in a table.

Outcomes

Recommendation: Delaying the introduction of any or specific complementary foods has either no benefit or even increases the risk of allergy outcomes. 

Roduit C. Frei R. Loss G. Buchele G. Weber J. Depner M. Loeliger S. Dalphin ML. Roponen M. Hyvarinen A. Riedler J. Dalphin JC. Pekkanen J. von Mutius E. Braun-Fahrlander C. Lauener R. Protection Against Allergy-Study in Rural Environments study group. Development of atopic dermatitis according to age of onset and association with early-life exposures. Journal of Allergy & Clinical Immunology. 2012;130(1):130-6.e5. Abstract available from: PubMed

Methods

Subjects: 0 to 4 years of age

Design: Prospective cohort study

(N=1,041)

Methods: This analysis is based on data from the birth cohort study Protection Against Allergy–Study in Rural Environments (PASTURE) which offered the opportunity to evaluate the effect of early postnatal exposures, especially food introduction and its diversity, on the development of atopic dermatitis. Children with data available on atopic dermatitis (parent reported doctor’s diagnosis) up to 4 years of age, farming status, parental allergic history, and feeding practices in the first year of life were included.

Outcomes

After correcting for reverse causality, the results of this large birth cohort study suggest that feeding practices in the first year of life are associated with the onset of atopic dermatitis. The introduction of yogurt and shop milk (adjusted odds ratios, 0.41; 95% CI, 0.23-0.73 and 0.52; 95% CI, 0.30-0.92, respectively) and the introduction of a diversity of food items (adjusted odds ratio for atopic dermatitis with each additional major food item introduced, 0.76; 95% CI, 0.65-0.88) were both associated with a risk reduction of atopic dermatitis later in life. Except for shop milk, these associations were independent of parental history of allergies. Conclusion: Introducing yogurt and a diversity of food in the first year of life might have a protective effect against atopic dermatitis.

Joseph CL. Ownby DR. Havstad SL. Woodcroft KJ. Wegienka G. MacKechnie H. Zoratti E. Peterson EL. Johnson CC. Early complementary feeding and risk of food sensitization in a birth cohort. J Allergy Clin Immunol. 2011 May;127(5):1203-10.e5. doi: 10.1016/j.jaci.2011.02.018. Epub 2011 Apr 1. Abstract available from: PubMed

Methods

Design: prospective birth cohorts (N=594)

Methods: This analysis is based on the Wayne County Health, Environment, Allergy and Asthma Longitudinal Study birth

cohort of Detroit, Mich. Authors sought to explore the relationship between introduction of complementary food <4 months and IgE to egg, milk, and peanut allergen at 2 years. Mothers were interviewed about feeding practices at infant ages 1, 6, and 12 months and blood samples were collected at age 2 to 3 years to assess sensitization.

Outcomes

Authors reported that complementary food introduced <4 months was associated with a reduced risk of peanut sensitization by age 2 to 3 years only among children with a parental history (adjusted odds ratio, 0.2 [95% CI, 0.1-0.7]; P <.007). The relationship also became significant for egg when a cutoff for IgE of >0.70 IU/mL was used (adjusted odds ratio, 0.5 [95% CI, 0.3-0.9]; P < .022). Reverse causality due to previous allergic manifestations (eg, atopic dermatitis [AD]) in the infant or parental history of asthma or allergy was accounted for by examining associations at 2 years. The authors also presented a stratified multivariate analysis because they found that parental history of asthma or allergy modified the association between early feeding and sensitization.  Conclusion: Complementary food introduced <4 months may reduce the risk of peanut (and perhaps egg) sensitization by age 2 to 3 years in children with a parental history of asthma or allergy.

Huh SY, Rifas-Shiman SL, Taveras EM, Oken E, Gillman MW. Timing of Solid Food Introduction and Risk of Obesity in Preschool-Aged Children. Pediatrics. 2011;127;e544. Available from: Pediatrics

Methods

Subjects: Infants

Design: Prospective birth cohort

(N=847)

Methods: The authors examined the association between the timing of solid food introduction (<4, 4-5, ≥6 mo) and obesity at 3 years of age. 

Outcomes

The outcome of interest was obesity at 3 years of age defined as ≥95th percentile. The authors found that among infants who were never breastfed or who stopped breastfeeding before 4 months, there was a six-fold increase in the odds of obesity at 3 years if complementary foods were introduced before the age of 4 months compared to between 4 and 5 months of age. According to the authors, this finding is independent of rapid early growth. Conclusion: For infants breastfed for at least four months, the timing of solid food introduction had no significant effects on obesity.  

Foisy M et al. Overview of Reviews The prevention of eczema in infants and children: an overview of Cochrane and non-Cochrane reviews. Evid Based Child Health. 2011 September; 6(5): 1322–1339. Abstract available from: PubMed

Methods

Subjects: Infants (0-2yrs old) and children (2-18 yrs old) at different risk levels of developing the disease

Design: Overview of reviews

Methods: Cochrane reviews and most up-to-date non-Cochrane reviews of randomized trials (except for breastfeeding and pet allergen) published since 2006 on any intervention for the prevention of eczema. The latest search was conducted in August 2010. Although search strategy was only designed to identify reviews on eczema prevention, authors also pre-specified incidence of asthma/wheezing and incidence of all allergic disease as secondary outcomes.

Outcomes

Seven systematic reviews containing 39 relevant trials with 11,897 participants were included in this overview, including six Cochrane reviews which covered five topic areas: breastfeeding, formulas (two reviews), maternal dietary exclusions, prebiotics and probiotics; and one non-Cochrane review on diet. On the effect of interventions, for eczema, the authors found that exclusive breastfeeding for at least 6 months compared to introduction of solids at 3 to 6 months did not decrease the overall incidence of eczema (2 RCTs, n=3,731), decreased the risk of developing eczema in high-risk infants by 60% (NS beyond 2 years). Only prolonged feeding of hydrolysed formula compared to cow's milk formula decreased the incidence of all allergic diseases (RR: 0.75; 95% CI: 0.59, 0.95) based on 7 trials (n=1,434 and n= 2,514 high-risk infants). Conclusion: Based on current evidence, no definitive recommendation can be made for preventing development of eczema

Tromp IIM et al. The Introduction of Allergenic Foods and the Development of Reported Wheezing and Eczema in Childhood. Arch Pediatr Adolesc Med. 2011;165(10):933-938. Abstract available from: PubMed

Methods

Subjects: 0 to 4 years old

Design: Population-based prospective birth cohort

Methods: 6905 children were included from birth between 2002 and 2006. Exposure: timing (or delaying) of introduction of cow's milk, hen's egg, peanuts, tree nuts, soy, gluten. Comparison groups: for each allergenic food, (control) introduction at or less than 6 months of age, or (intervention) more than 6 months of age. Potential confounders and mediators were considered.

Outcomes

Outcomes: from ISAAC, reported wheezing and eczema at ages 2, 3 and 4. The introduction of cow’s milk, hen’s egg, peanuts, tree nuts, soy, and gluten before the age of 6 months was not significantly associated with eczema or wheezing at any age after adjustment for potential confounders (P<0.10 for all comparisons). The results did not alter after stratification according to the child’s history of cow’s milk allergy and parental history of atopy. Conclusion: Delaying the introduction of allergenic foods at an age older than 6 months does not prevent atopic diseases, eczema and wheezing.

Sausenthaler S et al. Early diet and the risk of allergy: what can we learn from the prospective birth cohort studies GINIplus and LISAplus? Am J Clin Nutr. 2011; 94(suppl):2012S-7S.Abstract available from: PubMed

Methods

Subjects: infants and children

Design: a review of two prospective birth cohort studies

Methods: 9,088 infants recruited between 1995 and 1999, a subgroup of 2,252 infants with a hereditary risk of atopy enrolled in a RCT to investigate the effect of feeding regimen in infancy on the development of allergy with the strict recommendation that allergenic solid foods be introduced late in the study. Maternal food intake assessed by FFQs, complementary feeding assessed at 12 mo old, including breastfeeding practices and timing of solid-food introduction (48 single food items).

Outcomes

Outcomes: parent reported doctor-diagnosed eczema, parent report of symptomatic eczema, allergic sensitization against food and inhalant allergens. Results: up to the age of 6 years, there was no evidence of a protective effect of delaying the introduction of solid foods beyond the fourth to the sixth month, or beyond the sixth month on parent-reported doctor-diagnosed eczema, allergic rhinitis, or asthma. A high diversity of different solids introduced before the end of the fourth month may increase the risk of later allergy, particularly eczema. Avoidance of allergenic foods during the first year does not seem to be beneficial in allergy prevention. Conclusion: Delaying the introduction of solid foods or the avoidance of highly allergenic foods during the first year is not beneficial for allergy prevention.

Chafen JJ, Newberry SJ, Riedl MA, et al. Diagnosing and Managing Common Food Allergies: A Systematic Review. JAMA. 2010; 303(18): 1848-1856.Abstract available from: http://www.ncbi.nlm.nih.gov/pubmed/20460624

Methods

Subjects: 0 to 5 years old

Design: Systematic Review

Methods: Electronic database searches of PubMed, Cochrane Databases from January 1988 to September 2009. Included studies were assessed using the AMSTAR criteria, QUADAS criteria and Jadad criteria depending on study design. Systematic reviews and RCTs looking at management and prevention of food allergies were selected as well as diagnostic tests that used food challenge as a criterion standard.

Outcomes

Seventy-two studies were included in the systematic review. Studies looked at specific foods such as cow’s milk, hen’s egg, peanut, tree-nut, shellfish and fish.  In the diagnostic studies, there was no statistical difference between skin prick tests and serum food-specific tests.  There are not many studies that look at elimination diets and insufficient evidence to recommend the use of immunotherapy.  There is some evidence for use of hydrolyzed formulas to prevent cow’s milk allergy. However, standardized definitions of “hydrolyzed formula” and “high-risk” do not exist.  Overall, “the evidence for the prevalence and management of food allergy is greatly limited by a lack of uniformity for criteria for making a diagnosis.”

Greer FR, Sicherer S, Burks AW and the Committee on Nutrition and Section on Allergy and Immunology. Effects of Early Nutritional Interventions on the Development of Atopic Disease in Infants and Children: The role of maternal dietary restriction, breastfeeding, timing of introduction of complementary foods and hydrolyzed formulas. Pediatrics. 2008; 121:183-191. Abstract available from: PubMed

Methods

Subjects: Mothers and infants

Design: Clinical report/Review

Methods: This statement replaces the AAP statement on hypoallergenic formulas (2000).  This clinical report reviews nutritional and dietary options for mothers during pregnancy, lactation and the first year of life for infants Specifically, it reviews the Cochrane Review (above) and other trials to assess nutritional options during pregnancy, lactation and the first year of infancy and any potential relation to the development of atopic disease. Many of the reviewed studies focus on high-risk children.

Outcomes

According to this report, there is insufficient evidence to support a protective effect of delaying certain solid foods (e.g. eggs, milk, nuts) after the infant has reached the age of 6 months. The reviewers at AAP conclude that the only documented benefits of nutritional intervention that might prevent or delay atopic disease are for high-risk children (described as infants with at least 1 first-degree relative (parent or sibling) with allergic disease.)  Extensively hydrolyzed formulas may be more effective than partially hydrolyzed formulas in the prevention of atopic disease (modest evidence). The statement also notes that there is lack of evidence that antigen avoidance during pregnancy and lactation have a preventative effect on atopic disease. However, there is evidence that exclusive breastfeeding for at least 4 months may help prevent or delay the occurrence of atopic dermatitis, cow milk allergy and wheezing in early childhood. They report that soy formula is not recommended for the purpose of allergy prevention. Many studies had limitations that compromised their conclusions (e.g. no concealment of allocation for RCTs). The power to detect differences was small in many studies.

Thygarajan A and Burks AW. American Academy of Pediatrics recommendations on the effects of early nutritional interventions on the development of atopic disease. Current Opinion in Pediatrics. 2008; 20: 698-702. Abstract available from: http://www.ncbi.nlm.nih.gov/pubmed/19005338

Methods

Subjects: Infants and children

Design: Review

Methods: Reviews the 2008 AAP clinical report on the effects of nutritional interventions on the development and prevention of atopic disease in infants and children.

Outcomes

The reviewers of this study report that there is evidence for exclusive breastfeeding for at least 4 months and delaying complementary foods until 4-6 months may prevent the development of allergy in high-risk infants. There is no benefit to maternal dietary restriction and insufficient evidence to support a protective effect of any dietary intervention beyond 4 to 6 months of age.

Nutritional Interventions for Colic References
ReferenceMethods and OutcomesFormer CTFPHC GRADE

Iacovou M, Ralston RA, Muir J, Walter KZ, Truby Z. Dietary management of infantile colic: a systematic review. Matern Child Health J. 2012;16:1319–1331. Abstract available  from: http://www.ncbi.nlm.nih.gov/pubmed/21710185

Methods

Subjects: mothers and infants

Design: systematic review

Methods: Performed searches in MEDLINE, CINAHL, AMED, Scopus, NUTRITIONnetBASE, Cochrane Library) to retrieve studies examining whether dietary change provides an effective therapy for infantile colic. Randomized and non-randomized studies were included in the analysis. 

Outcomes

The authors included 24 studies in the final review: two systematic reviews, 17 RCTs with 15–158 subjects, four studies with 6–115 subjects (three non-randomized interventions, and one case–control study), and one cross-sectional study. These studies examined the following dietary interventions: hypoallergenic maternal diet, partially hydrolyzed infant formula, extensively hydrolyzed infant formula, completely hydrolyzed infant formula, soy-based infant formula, fiber-enriched infant formula and carbohydrate alteration. Results suggest that in breastfed infants, a hypoallergenic maternal diet may improve symptoms of colic, while changing to a hydrolyzed protein formula may reduce colic in formula-fed infants. Other modifications either had poor, too little or conflicting evidence to support a recommendation. Recommendation: 1) Seek expert nutritional guidance as very restricted maternal diets have the potential to be nutritionally inadequate. 2) The use of hydrolyzed milk formula and the use of a hypoallergenic diet for the mother have cost implications that could be problematic for low-income families. 3) Support and reassurance is emphasized as this is a self-limiting condition that infants tend to grow out of by 3–4 months of age.

JN Critch; Canadian Paediatric Society, Nutrition and Gastroenterology Committee. Infantile colic: Is there a role for dietary interventions? Paediatr Child Health 2011;16(1):47-49. Available from: http://www.cps.ca/documents/position/infantile-colic-dietary-interventions

Methods

Subjects: infants

Design: practice point

Methods: Updated the previous Canadian Paediatric Society practice point concerning the role of dietary modifications for infantile colic.

Outcomes

Regarding dietary interventions for the management of infantile colic, the authors conclude that the evidence is often conflicting and many of the studies were unblinded, suffered from small sample sizes and had inadequate outcome measures. Further, they emphasize that it is important to avoid making nutritional interventions in the vast majority of infants with colic. Certain modifications may (or may not) offer benefits:  1) maternal consumption of a hypoallergenic diet may reduce colic in the minority of infants who display symptoms of infantile colic secondary to cow’s milk protein allergy, 2) extensively (not partially) hydrolyzed protein formulas may reduce colic in a small number of bottle-fed infants, 3) the therapeutic use of soy formulas in colic is not recommended because soy protein is a frequent allergen in infancy, and 4) there is insufficient evidence to recommend the use of lactase or pro- prebiotics. Conclusion: Overall, certain dietary modifications may (or may not) offer benefits for the management of infantile colic.

Probiotics References
ReferenceMethods and OutcomesFormer CTFPHC GRADE

Hempel S, Newberry SJ, Maher AR, et al. Probiotics for the prevention and treatment of antibiotic-associated diarrhea. A systematic review and meta-analysis. JAMA. 2012;307(18):1959-1969. Abstract available from: PubMed

Methods

Subjects: All ages

Design: Systematic review and meta-analysis

Methods: The objective of this review was to evaluate the evidence for probiotic use in the prevention and treatment of antibiotic-associated diarrhea (AAD). The authors performed a systematic search in 12 relevant electronic databases up to February 2012. RCTs for the prevention or treatment of AAD were included.

Outcomes

The majority of 82 included trials used Lactobacillus-based interventions alone or in combination with other. Strains were poorly documented. Overall, using probiotics as adjunct therapy reduces the risk of AAD, with an RR of 0.58 (95% CI, 0.50 to 0.68; P < .001; I2, 54%). The result was consistent across a number of subgroup and sensitivity analyses. The treatment effect equates to a Number Needed to Treat (NNT) of 13. The main limitations to this result are residual unexplained heterogeneity, poor documentation of the probiotic strains, and lack of assessment of probiotic-specific adverse events. Conclusion: Adjunct probiotic administration is associated with a reduced risk of AAD.

Canadian Paediatric Society. Using probiotics in the paediatric population. Paediatrics & Child Health. 2012;17(10):575.

Canadian Paediatric Society

Methods

Subjects: Infants, children, and adolescents 

Design: Position statement

Statement compiled by the CPS Nutrition and Gastroenterology Committee. The statement examines the evidence supporting the use of different probiotics to treat common paediatric conditions, such as diarrhoea, atopy, functional intestinal disorders and necrotizing enterocolitis. Authors conducted a literature review in English and French using Medline, the Cochrane database and relevant websites.

Outcomes

Based on their review of the literature, the committee concludes that there are benefits to using probiotics for treating some diseases, such as antibiotic-associated diarrhoea and acute infectious viral diarrhoea, and to help prevent necrotizing enterocolitis. There is insufficient evidence to support the use of probiotics to treat or prevent IBD, colic, and atopic diseases. Authors also advise that caution should be exercised in giving probiotics to patients with an immunodeficiency, that the efficacy of probiotics is both strain- and disease-specific, and that any probiotic must be provided in adequate amount.      Recommendation: Probiotics may help prevent antibiotic-associated diarrhea and necrotizing enterocolitis in preterm infants who are at risk of necrotizing enterocolitis.

Johnston BC, Goldenberg JZ, Vandvik PO, Sun X, Guyatt GH. Probiotics for the prevention of pediatric antibiotic-associated

diarrhea. Cochrane Database of Systematic Reviews. 2011;(11).  

 

The Cochrane Library

Methods

Subjects: Children (0 to 18 years) receiving antibiotics

Design: Systematic review

Methods: The authors performed a comprehensive search using MEDLINE, EMBASE, CENTRAL, CINAHL, AMED, the Web of Science and more to identify randomized controlled trials that compare probiotics to placebo, active alternative prophylaxis, or no treatment and measure the incidence of diarrhoea secondary to antibiotic use (AAD).

Outcomes

The authors looked primarily at the incidence of diarrhoea and the number and type of adverse events. Secondary outcomes included mean duration of diarrhoea and mean stool frequency. Sixteen studies (N= 3,432) met the inclusion criteria, eight of which had a low risk of bias (versus high). For the incidence of diarrhoea, the relative risk calculated was of the magnitude of 0.4 (95% CI, 0.29-0.55) based on 7 studies (N=1,474) with an overall low risk of bias. The mean duration of diarrhoea in the intervention group was 0.6 days lower (95% CI, 1.18 to 0.02 lower). There was heterogeneity in probiotic strain, dose, and duration, as well as in study quality. Nevertheless, the overall evidence provided by this systematic review suggests that probiotics, and possibly high-dose probiotics, have a protective effect in preventing AAD. Conclusion: Probiotics have a protective effect in preventing antibiotic-associated diarrhea.

Reducing Bottle Use in Toddlers Recommendations Strength of Recommendation
  1. Counsel on weaning of bottle use at 9 month-visit.
Good
  1. Promote open cup instead of bottle at the 12-13 and 15 month visits.
Consensus
Reducing Bottle Use in Toddlers References
ReferenceMethods and OutcomesFormer CTFPHC GRADE

Health Canada, Canadian Paediatric Society, Dietitians of Canada and Breastfeeding Committee for Canada. Nutrition for healthy term infants - recommendations from 6 to 24 months. 2014. Available from: http://www.hc-sc.gc.ca/fn-an/nutrition/infant-nourisson/index-eng.php

Methods

Subjects: 6 to 24 months

Design: Nutrition guidelines

Methods: A joint statement of Health Canada, Canadian Paediatric Society, Dieticians of Canada, and Breastfeeding Committee for Canada.

Outcomes

Not yet available.

Maguire JL, Birken CS, Jacobson S, Peer M, Taylor C, Khambalia A, Mekky M, Thorpe KE, Parkin P. Office-Based Intervention to Reduce Bottle Use Among Toddlers: TARGet Kids! Pragmatic, Randomized Trial. Pediatrics. 2010; 126: e343-e350. Abstract available from: http://www.ncbi.nlm.nih.gov/pubmed/20624802

Methods

Subjects: 9 month old infants

Design: RCT

Methods: Parents of 9 month old infants were randomized (through a computerized, random number generator) to intervention or control group. The intervention included parents following a 1-week protocol to wean their babies from the bottle. Control group received a placebo counselling session. Allocation concealment was done using sequentially numbered, opaque, sealed envelopes and all  paediatricians and study personnel were blinded. Outcome measures were reduced bottle use and iron depletion at 2 years old.

Outcomes

Out of 251 randomized infants, 201 completed follow-up at 2 years old. All parents were counselled on healthy nutrition and told to limit fruit juice intake. Only parents in the intervention group were told to limit the amount of milk consumption per day as part of the weaning process.  Rates of iron depletion and milk consumption were not statistically significant between the two groups. Intervention group infants started using a cup 3 months earlier and were weaned from the bottle 4 months earlier compared to control group. Overall, there was a 60% reduction in prolonged bottle use. This study recommends weaning counselling at 9 months because it is easier for the child to give up the bottle earlier in life. Also, there is time at the 9 month visit to spend time on anticipatory guidance because there are no vaccines given at this time.

Avoid Sweetened Juices/Liquids Recommendation Strength of Recommendation
  1. Counsel on avoidance of sweetened juices and liquids.
Consensus
Avoid Sweetened Juices/Liquids References
ReferenceMethods and OutcomesFormer CTFPHC GRADE

Health Canada, Canadian Paediatric Society, Dietitians of Canada and Breastfeeding Committee for Canada. Nutrition for healthy term infants - recommendations from 6 to 24 months. 2014. Available from: http://www.hc-sc.gc.ca/fn-an/nutrition/infant-nourisson/index-eng.php

Methods

Subjects: 6 to 24 months

Design: Nutrition guidelines

Methods: A joint statement of Health Canada, Canadian Paediatric Society, Dieticians of Canada, and Breastfeeding Committee for Canada.

Outcomes

Not yet available.

Danyliw AD1, Vatanparast HNikpartow NWhiting SJ. Beverage patterns among Canadian children and relationship to overweight and obesity. Appl Physiol Nutr Metab. 2012 Oct;37(5):900-6. Available from: PubMed

Methods

Subjects: children and adolescents aged 2 to 18 years

Design: Cross-sectional study (n = 10,038)

Methods: Using data from the Canadian Community Health Survey 2.2, the authors used cluster analysis to identify beverage intake patterns, and logistic regression to determine the association between overweight and obesity and beverage intake patterns, adjusting for potential confounders.

Outcomes

Clustering resulted in distinct groups of who drank mostly fruit drinks, soft drinks, 100% juice, milk, high-fat milk, or low-volume and varied beverages (termed "moderate"). Boys aged 6-11 years whose beverage pattern was characterized by soft drink intake (553 ± 29 g) had increased odds of overweight-obesity (odds ratio 2.3, 95% confidence interval 1.2-4.1) compared with a "moderate" beverage pattern (23 ± 4 g soft drink). No significant relationship emerged between beverage pattern and overweight and obesity among other age-sex groups. Conclusions: Using national cross-sectional dietary intake data, Canadian children do not show a beverage-weight association except among young boys who drink mostly soft drinks, and thus may be at increased risk for overweight or obesity.

O'Connor TM1, Yang SJNicklas TA. Beverage intake among preschool children and its effect on weight status. Pediatrics. 2006 Oct;118(4):e1010-8. Available from: Pediatrics

Methods

Subjects: Children aged 2 to 5 years

Design: National Health and Nutrition Examination Survey 1999-2002 (n = 1,552)

Methods: Descriptive statistics and group comparisons of beverage intake and overweight classification. 

Outcomes

After removal of subjects with missing data, a total of 1160 children were analyzed, 579 (49.9%) were male. White children represented 35%, black children represented 28.3%, and Hispanic children represented 36.7% of the sample. Twenty-four percent of the children were overweight or at risk for overweight (BMI ≥85%), and 10.7% were overweight (BMI ≥95%). Eighty-three percent of children drank milk, 48% drank 100% fruit juice, 44% drank fruit drink, and 39% drank soda. Whole milk was consumed by 46.5% of the children, and 3.1% and 5.5% of the children consumed skim milk and 1% milk, respectively. Preschool children consumed a mean total beverage volume of 26.93 oz/day, which included 12.32 oz of milk, 4.70 oz of 100% fruit juice, 4.98 oz of fruit drinks, and 3.25 oz of soda. Weight status of the child had no association with the amount of total beverages, milk, 100% fruit juice, fruit drink, or soda consumed. There was no clinically significant association between the types of milk (percentage of fat) consumed and weight status. Conclusions: Increased beverage consumption was associated with an increase in the total energy intake of the children but not with their BMI.

NUTRITION

Nutrition Concerns

Vegetarian Diets Recommendations Strength of Recommendation
  1. Inquire about vegetarian diets.
Consensus
Vegetarian Diets References
ReferenceMethods and OutcomesFormer CTFPHC GRADE

Community Paediatrics Committee, Canadian Pediatric Society. Vegetarian diets in children and adolescents. Paediatrics & Child Health. 2010; 15(3), 303-14. Available from: http://www.cps.ca/english/statements/CP/cp10-02.htm

Methods

Subjects: Children and adolescents

Design: Review

Methods: Statement compiled by the CPS Community Paediatrics Committee. Searched PubMed (1980 to 2008).

Outcomes

The committee concludes that a well-balanced vegetarian diet ensuring adequate amounts of specific nutrients can support growth and development at all stages (fetus to adolescent). The recommendations highlight the particular nutrients to monitor in children following various vegetarian diets (eg. vegans, lacto-ovo-vegetarians). Guides and tools are referenced for healthcare professionals and families/children.

Vegetarian Diets Recommendations Strength of Recommendation
  1. Encourage parents and caregivers to offer fish, working up to 2 servings of fish per week by 24 months.
Consensus
  1. Young children, children and breastfeeding mothers should limit their consumption of fish that contain higher levels of mercury.
Consensus
Fish Consumption References
ReferenceMethods and OutcomesFormer CTFPHC GRADE

Wine O, Osornio-Vargas AR, Buka IS. Fish consumption by children in Canada: Review of evidence, challenges and future goals. Paediatr Child Health. 2012;17(5):241-245. Available from: Pulsus

Methods

Subjects: focus on children

Design: narrative review

Methods: The authors performed comprehensive searches in The Cochrane Library and PubMed to identify recent publications (2003-2011) from the US and Canada on the health benefits and health risks associated with fish consumption. This review also presents Health Canada’s fish consumption advice for children and discusses public health challenges of communicating certain recommendations.    

Outcomes

The authors weighed the risk and benefits of fish consumption in children to inform the best practices for children’s health. Recommendations:

-Health Canada recommends children consume 2 portions weekly (75g each)

-Salmon, farmed trout, sardines, mackerel (Atlantic), anchovies oysters and herrings are excellent sources of omega-3 PUFAs

-For canned tuna, there are no limitations on light tuna, eat Albacore (white tuna) moderately, and limit weekly servings for children <4 years to one (75g = ½ small can) and children between 5 and 11 years to two (125g = 1 small can)

-Limit consumption of swordfish, fresh/frozen tuna, orange roughy, shark, marlin and escolar once a month

-Consult local advisories before consuming catch

Health Canada Advisories:

Human Health Risk Assessment of Mercury in Fish and Health Benefits of Fish Consumption available from:  http://www.hc-sc.gc.ca/fn-an/pubs/mercur/merc_fish_poisson-eng.php

Mercury available from: http://www.hc-sc.gc.ca/fn-an/securit/chem-chim/environ/mercur/index-eng.php

Health Canada's revised assessment of mercury in fish enhances protection while reflecting advice in Canada's Food Guide available from: http://www.healthycanadians.gc.ca/recall-alert-rappel-avis/hc-sc/2007/13194a-eng.php

Methods

Target audience: All Canadians

Design: Government Advisory/Statement

Outcomes

Health Canada's standards for mercury in fish, the most stringent and protective in the world, have been revised and strengthened. The standards now include fish previously excluded from Health Canada’s standard (fresh and frozen tuna, shark, swordfish, escolar, marlin and orange roughy) and are subject to Canada’s 1.0 parts per million mercury limit.  The recommendations are as follows: general population - 150 g/week of these fish species combined; women who are or may become pregnant and breastfeeding mothers - up to 150 g/month; children between 5 and 11 years of age - up to 125 g/month; children between 1 and 4 years of age - no more than 75 g/month. Health Canada still advises on the importance and nutritional benefits of fish consumption.  

Kris-Etherton PM, Innis S, American Dietetic Association, Dietitians of Canada. Position of the American Dietetic Association and Dietitians of Canada -dietary fatty acids. J Am Diet Assoc. 2007 Sep;107(9):1599-611. Abstract available from: http://www.ncbi.nlm.nih.gov/pubmed/17936958

Methods

Subjects: Healthy adults and children

Design: Position statement

Methods: This paper evaluates the evidence of benefits and adverse effects (or lack thereof) of dietary fatty acids to issue dietary recommendations for total fat, SFA, TFA, monounsaturated fatty acids (MUFA), and n-6 and n-3 PUFA for healthy individuals

Outcomes

The American Dietetic Association (ADA)/Dietitians of Canada (DC)’s position paper on dietary fatty acids is consistent with other expert recommendations that omega-3 fats from fish are an important part of a healthy diet.  Fish and seafood, particularly fatty fish such as mackerel, herring, salmon, tuna, and trout, as well as oysters, are the richest dietary sources of the n-3 longer carbon chain PUFA, EPA, and DHA. Recommendation: ADA and DC recommend a food-based approach for achieving these fatty acid recommendations; that is, a dietary pattern high in fruits and vegetables, whole grains, legumes, nuts and seeds, lean protein (i.e., lean meats, poultry, and low-fat dairy products), fish (especially fatty fish high in n-3 fatty acids), and use of nonhydrogenated margarines and oils.

EDUCATION AND ADVICE

Injury Prevention Resources

Websites Description

Parachute 2012. Available from

Parachute
Parachute is a national, charitable organization dedicated to preventing injury and saving lives. It was created from the amalgamation of four leading Canadian injury prevention groups: Safe Communities Canada, Safe Kids Canada, SMARTRISK and ThinkFirst Canada. This organization aims to become a strategic injury prevention partner for families, communities, the health sector, researchers, governments and business.
Safe Kids Canada 2008. Available from: Safe Kids Canada This website is a good reference to check up-to-date guidelines for basic injury prevention for infants and young children. The website provides information about public policy and advocacy from the municipal to the national level.
Transportation Matrix This website is part of the American Academy of Pediatrics’ (AAP). Transportation Initiative for Children’s Health. This tool provides paediatricians and other child health care providers with links to key resources within the AAP with regards to issues related to transportation and beyond. The website is divided into four topical areas: 1) Injury Prevention addresses several issues to keep children safe on the road, 2) Air Quality addresses important threats to children’s health, such as asthma, which can be lessened by reducing vehicle emissions and increasing use of non-motorized transportation, mass transit, and carpooling, 3) Physical Activity provides resources for policy, planning, and programs that can encourage use of non-motorized forms of transportation and have significant health benefits, and 4) Built Environment addresses the he shape and character of the built environment which have a large and significant effect on children’s health.
Injury Prevention (General) References
ReferenceMethods and OutcomesFormer CTFPHC GRADE

Keim SA, Fletcher EN, TePoel MRW, McKenzie LB. Injuries Associated With Bottles, Pacifiers, and Sippy Cups in the United States, 1991–2010. Pediatrics. 2012;129;1104; originally published online May 14, 2012. Abstract available from: Pediatrics

Methods

Subjects: Children < 3 years treated in emergency departments for an injury associated with a bottle, pacifier, or sippy cup

Design: Retrospective cohort (1991-2010)

Methods: The authors of this study aimed to investigate the range of injuries requiring emergency department visits associated with bottles, pacifiers, and sippy cups among children.

Outcomes

This study based on a nationally representative sample (US) revealed that on average 2,270 cases of injuries related to the use of bottles, pacifiers, and sippy cups occurred every year between 1991-2010. The majority of injuries involved 1-year-old children (66.4%) and boys (61.2%). Most injuries (95.9%) occurred at home, and most children (98.8%) were not hospitalized. The most common mechanism was a fall while using the product (86.1% of injuries). Conclusion: Children who are just learning to walk and run are at the highest risk of these injuries and that close adherence to current AAP recommendations regarding age-appropriate use of these products may help prevent injuries.

Natalie L Yanchar, Lynne J Warda, Pamela Fuselli; Canadian Paediatric Society, Injury Prevention. Child and youth injury prevention: A public health approach. Paediatr Child Health. 2012. 17(9): 511. Available from: Canadian Paediatric Society

Methods

Subjects: children and youth

Design: position statement

Methods: This position statement describes the burden and pattern of unintentional injuries of children in Canada, as well as the principles of effective intervention for prevention.

Outcomes

This statement is a background document for health professionals, health policy-makers and researchers designed to educate about unintentional injuries in children and orient efforts in injury prevention. This position statement also recommends actions and resources for health professionals and practitioners. Recommendations: 1) Health practitioners should include injury prevention in their practices (eg, supporting car seat and home safety knowledge). 2) Health practitioners should advocate for local and regional injury prevention policies and actions.

Bond GR, Woodward RW, Ho M. The growing impact of pediatric pharmaceutical poisoning. J Pediatr. 2012 Feb;160(2):265-270.e1. Abstract available from: PubMed

Methods

Subjects: Children aged ≤ 5 years

Design: Retrospective cohort

Methods: Patient records from 2001-2008 obtained from the National Poison Data System of the American Association of Poison Control Centers for children evaluated in a health care facility following exposure to a potentially toxic dose of a pharmaceutical agent. . Pharmaceutical agents were classified as OTC or prescription. Exposures were classified as child self-ingested the medication or as therapeutic error.

Outcomes

A total of 453 559 children were evaluated for ingestion of a single pharmaceutical product. Child self-exposure was responsible for 95% of visits. Child self-exposure to prescription products dominated the health care impact with 248,023 of the visits (55%), 41,847 admissions (76%), and 18,191 significant injuries (71%). The greatest resource use and morbidity followed self-ingestion of prescription products, particularly opioids, sedative-hypnotics, and cardiovascular agents. These results confirm that numbers of children aged 5 years or less visiting EDs after medication exposure is increasing. The largest part of that burden (admissions, morbidity, and mortality) results from children finding and ingesting medication by themselves. Conclusion: The problem of paediatric medication poisoning is getting worse. Recommendations: 1) Education interventions should readdress home storage of all medications, repackaging of medications, particularly grandparents’ medications in ‘pill minders,’ and the fact that older siblings may not be as careful as parents when opening containers or taking medications. 2) Storage devices and child-resistant closures may need to improve.

P Fuselli; NL Yanchar; Canadian Paediatric Society, Injury Prevention. Preventing playground injuries. Paediatr Child Health. 2012;17(6):328. Available from: Canadian Paediatric Society

Methods

Subjects: Children

Design: Position statement

Methods: This position statement reviews the risks associated with playgrounds and the strategies for safer play. This position statement replaces the one published in 2002.

Outcomes

This position statement reports that playground injuries are common, and especially in children aged 5 to 9 years. Because a significant proportion of injuries involve backyard equipment, the prevention strategies suggested in this statement mainly consist of improving playground design, especially to equipment height and surfacing. Recommendation: Health care providers should offer anticipatory guidance about playground injuries and what parents can do to reduce children’s risk.

Anna Banerji; Canadian Paediatric Society, First Nations, Inuit and Métis Health Committee. Preventing unintentional injuries in Indigenous children and youth in Canada. Paediatr Child Health. 2012;17(7):393. Available from: Canadian Paediatric Society

Methods

Subjects: Indigenous children and youth

Design: Position statement

Methods: This statement presents the current available evidence on unintentional injuries in Canadian Indigenous children. 

Outcomes

For Indigenous children and youth, injuries occur at rates three to four times the national average. Reasons for this discrepancy include lower incomes, less education, higher unemployment, unsafe and substandard housing, and local shortages of health care personnel and resources. This contrasts with the lack of statistics, ongoing surveillance or injury prevention programs in this population. This statement presents common causes of unintentional injuries or deaths due to injuries (fires, motor vehicles collision, drowning, falls, etc.) as well as injury prevention strategies. The CPS makes recommendations regarding surveillance, education and advocacy. These are intended primarily for policy-makers but can be useful to health providers caring for Indigenous children. Summary Recommendation: Provide a culturally and multidisciplinary framework for injury prevention strategies.

Kendrick D, Young B,Mason-Jones AJ, Ilyas N, Achana FA, Cooper NJ, Hubbard SJ, Sutton AJ, Smith S, Wynn P, Mulvaney C, Watson MC, Coupland C. Home safety education and provision of safety equipment for injury prevention. Cochrane Database of Systematic Reviews. 2012; 9. Abstract available from:  The Cochrane Library

Methods

Subjects: 19 years and under

Design: Systematic review

Methods: The authors searched all relevant electronic databases (MEDLINE, EMBASE, PsychInfo, CINHAL) for randomized controlled trials and controlled before and after studies evaluating the effects home safety education with or without the provision of safety equipment.

Outcomes

Authors included studies where home safety interventions where provided to children or families to reduce home injuries or increase home safety practices or use of home safety equipment. Most of the studies included in the meta-analysis were based on one-to-one, face-to-face education delivered either at home or in a clinical setting. The outcomes of interest were injury rates, safety practices and possession and use of home safety equipment. Authors found that some evidence of a favourable effect of such interventions mainly on safety practices (safe hot tap water temperatures, functional smoke alarms, a fire escape plan, storing medicines and cleaning products out of reach, having syrup of ipecac or poison control centre numbers accessible, having fitted stair gates, and having socket covers on unused sockets. Conclusion: Child health and social care providers should offer home safety interventions, which may include education and access to free, low cost or discounted safety equipment, as part of their child health and wellbeing programmes.

Morrongiello BA, Zdzieborski D, Sandomierski M, Munroe K. Results of a randomized controlled trial assessing the efficacy of the Supervising for Home Safety program: Impact on mothers' supervision practices. Accid Anal Prev. 2013 Jan;50:587-95. Abstract available from: PubMed

Methods

Subjects: Parents and children

Design: Randomized controlled trial

Methods: Parent volunteers were recruited from the community and randomly assigned to either an Intervention or Control group. The intervention group consisted of the 4 week Supervising for Home Safety intervention program. Parents and children aged 2-5 years were unobtrusively observed in a naturalistic laboratory setting and used a participant-event monitoring procedure to complete supervision recording sheets weekly both before and after exposure to the intervention program. Control parents completed the same measures but received a program focusing on child nutrition and active lifestyles. Unobtrusive video recordings of parent supervision of their child in a room containing contrived hazards also were taken pre- and post-intervention.

Outcomes

Intervention (n = 96) and Control (n = 90) groups were approximately equal with respect to child sex and age. Comparisons of post- with pre-intervention diary reported home supervision practices revealed a significant decrease in time that children were unsupervised, an increase in in-view supervision, and an increase in level of supervision when children were out of view, with all changes found only for the Intervention group. Similarly, only parents in the Intervention group showed a significant increase in attention to the child in the contrived hazards context, with these differences evident immediately after and 3 months after exposure to the intervention. These results provide the first evidence that an intervention program can positively impact caregiver supervision. Recommendation: Programs to educate home safety supervision appear to have significant benefits and should be encouraged/advocated by health practitioners if they are available.

Gardner HG and the Committee on Injury, Violence, and Poison Prevention. Office-based counselling for unintentional injury prevention. Pediatrics. 2007; 119: 202-206. Abstract available from: PubMed

Methods

Subjects: 0 to 18 years old

Design: Clinical report

Methods: Reviews topics for office-based counselling. Topics covered are: traffic safety, burn prevention, fall prevention, choking prevention, drowning prevention, safe sleep environments, CPR, poison control and firearm safety.

Outcomes

This clinical report gives recommendations for physicians to advise parents and children about unintentional injury risk and prevention, which are consistent with AAP and CPS policy statements on these topics. Separate recommendations are given for different ages (i.e., infants, preschool-aged children, school-aged children, and adolescents). This is a consensus document put together by experts in the field of injury prevention.

Transportation in Motor Vehicles: Car Seats Recommendations Strength of Recommendation
  1. Children <13 years should sit in the rear seat.
  2. Keep children away from all airbags.
  3. Install and follow size recommendations as per specific car seat model and keep child in each stage as long as possible.
  4. Recommend rear-facing infant/child seats that is manufacturer approved for use until age 2 years.
  5. Use forward-facing child seat after 2 years for as long as manufacturer specifications will allow. After this, use booster seat up to 145cm (4’9”).
  6. Use lap and shoulder belt in the rear seat for children over 8 years who are at least 36kg (80lb) and 145cm (4’9”) and fit vehicle restraint system.
Good
Transportation in Motor Vehicles References
ReferenceMethods and OutcomesFormer CTFPHC GRADE

American Academy of Pediatrics. Car Safety Seats: A Guide for Families. 2013.  Available from:American Academy of Pediatrics

Methods

Subjects: Children

Design: Guidelines for parents

Methods: Recommendations for parents on proper use, installation and type of child restraint for transportation of children in a vehicle.

Outcomes

The report gives detailed descriptions of available restraint types for use at various ages, heights and weights. The AAP have similar recommendations as the CPS: rear-facing, forward-facing, booster and then seat belts should be sequentially used.

Durbin DR. Committee on Injury, Violence, and Poison Prevention. Child passenger safety. Pediatrics. 2011;127(4):e1050-66. Available from: Pediatrics

Methods

Subjects: Children and adolescent

Design: Policy statement

Methods: The AAP presents 5 recommendations for best practice to optimize safety in passenger vehicles for children from birth through adolescence. A summary of the evidence supporting the recommendations can be found in the Technical Report.

Outcomes

Authors provide four evidence-based recommendations along with complementary information for best practices in the choice of a child restraint system to optimize safety in passenger vehicles for children from birth through adolescence. A fifth evidence-based recommendation is intended for children younger than 13 years to ride in the rear seats of vehicles. They also provide an algorithm to facilitate the implementation of the recommendations by paediatricians to their patients and families. These recommendations are for the most part similar to the CPS recommendations. Recommendations: 1) All infants and toddlers should ride in a rear-facing child safety seat until they are 2 years of age or until they reach the highest weight or height allowed by the manufacturer of their child safety seat. 2) All children 2 years or older, or those younger than 2 years who have outgrown the rear-facing weight or height limit for their child safety seat, should use a forward-facing child safety seat with a harness for as long as possible, up to the highest weight or height allowed by the manufacturer of their child safety seat. 3) All children whose weight or height is above the forward- facing limit for their child safety seat should use a belt-positioning booster seat until the vehicle lap-and- shoulder seat belt fits properly, typically when they have reached 4 feet 9 inches in height and are between 8 and 12 years of age. 4) When children are old enough and large enough to use the vehicle seat belt alone, they should always use lap-and-shoulder seat belts for optimal protection. 5) All children younger than 13 years should be restrained in the rear seats of vehicles for optimal protection.

Durbin DR, Elliot MR, Winston FK. Belt-positioning booster seats and reduction in risk of injury among children in vehicle crashes. JAMA 2003;289:2835-2840. Abstract available from: PubMed. Updated assessment in 2009 available from PubMed

Methods

Subjects: 4 to 7 years old

Design: Cross-sectional study

Methods: Sample taken from vehicle crash insurance claims. Eligible vehicles/drivers were then screened to partake in a full telephone interview. The type of restraint used for the child was determined during the phone interview.

Outcomes

Among children in this study, 81% had been using some type of restraint. In this age group, odds of injury were 61% lower for children using belt-positioning booster (BPB) seats than those wearing seat belts. This study reports that physicians should advocate the use of booster seats and educate parents. Conclusion: This study reconfirms previous reports that BPB seats reduce the risk for injury in children aged 4 through 8 years. Recommendation: Parents, paediatricians, and health educators should continue to recommend as best practice the use of BPB seats once a child outgrows a harness-based child restraint until he or she is at least 8 years of age.

Bull MJ, Engle WA, and the Committee on Injury, Violence and Poison Prevention and the Committee on Fetus and Newborn. American Academy of Pediatrics. Safe transportation of preterm and low birth weight infants at hospital discharge. Pediatrics. 2009; 123: 1424-1429. Abstract available from: PubMed

Methods

Subjects: Newborns

Design: Clinical report

Methods: Gives guidelines for physicians and other caregivers who counsel parents of preterm and low birth weight infants.

Outcomes

The size of the infant being transported by vehicle is an important consideration. According to this report, any necessary medical equipment should be restrained during travel. Risks while traveling include oxygen desaturation, apnea or bradycardia. They report that families should be taught by trained hospital staff to correctly position the car safety seat. As well, proper positioning of the infant in the seat is important. It is suggested in this report that infants be placed in the car seat while still in the hospital and watched for 90 to 120 minutes to help ensure safe travel.

Rice TM, Anderson CL. The effectiveness of child restraint systems for children aged 3 years or younger during motor vehicle collisions: 1996 to 2005. American Journal of Public Health. 2009; 99: 252-257. Available from: PubMed

Methods

Subjects: ≤3 years old

Design: Matched cohort study (N=6,303)

Methods: Data obtained from the Fatality Analysis Reporting System from 1996 to 2005. Identified crashes involving vehicles carrying a child ≤3 years and in which at least 1 person died from the matched pair.

Outcomes

This cohort study reports that child safety seats are extremely effective in reducing the risk of death during severe traffic accidents and collisions. Restrained children were 67% less likely to suffer a fatal injury than children who were unrestrained. The authors suggest that parents of young children should be encouraged to use child safety seats instead of seat belts.

Canadian Pediatric Society. Transportation of infants and children in motor vehicles. Paediatr Child Health. 2008; 13: 313-318. Abstract available from: PubMed

Methods

Subjects: Infants and young children

Design: Position statement (reviewed by Transport Canada and the CPS Fetus and Newborn Committee)

Methods: Review of guidelines for child restraints for transportation in vehicles. Also looked at seating position, seat installation and placement of the child in the seat.

Outcomes

This statement reports that there are 4 stages to child restraints: rear-facing (up to 10kg), forward-facing (up to 22kg), booster (up to 36kg) and finally seat belt (>36kg). Guidelines are based on age but height and weight limitations are more important. The CPS recommends that physicians should counsel parents on the appropriate use of child restraints, as parental misuse of equipment is a common source of harm. Children riding in rear seats in vehicles are 1.7 times less likely to incur a fatal or severe injury than front seat travelers. Recommendations are based on the most current knowledge from the literature and legislation. Evidence is good as the review is based on good methodological case-control studies and RCTs are not ethically feasible.

Henary B, Sherwood CP, Crandall JR, Kent RW, Vaca FE, Arbogast KB, Bull MJ. Car safety seats for children: rear facing for best protection. Injury Prevention. 2007; 13: 398-402. Abstract available from: PubMed

Methods

Subjects: 0 to 23 months old

Design: Case-control study

(N=870)

Methods: U.S. National Highway Traffic Administration vehicle crash database for the years 1988-2003 was used to obtain data on children 0 to 23 months who were sitting in a rear-facing car seat (RFCS) or forward-facing car seat (FFCS) and involved in a car crash.

Outcomes

This case-control study showed that RFCS are more effective than FFCS in restraining children 0 to 23 months old. Infants (<1 year old) were at an even greater risk of injury (5.32 [3.43-8.24]) when analyzed separately. Overall, children who suffered serious injuries were 1.76 (95% CI: 1.40-2.20) times more likely to be riding in a FFCS as compared to children riding in a RFCS.  
In this study, young children wearing seat belts are more likely to sustain an injury (particularly head injuries) in the event of a car crash than children in child restraint systems (CRS). Very few children 4 to 8 years old were in booster seats (i.e., the appropriate CRS) and were thus not properly restrained. According to this study, the authors report that the use of belt-positioning booster seats is recommended until the child is the appropriate height and weight for seat belt use.

Winston FK, Durbin DR, Kallan MJ, Moll EK. The danger of premature graduation to seat belts for young children. Pediatrics. 2000;105:1179-1183. Abstract available from: PubMed

Methods

Subjects: 2 to 5 years old

Design: Case-control study (N=2,077)

Methods: Data obtained through the Partners for Child Passenger Safety child-focused crash surveillance system and from reported crashes to State Farm Insurance. Driver and parental reports were obtained through phone interviews using a validated survey.

Outcomes

In this study, young children wearing seat belts are more likely to sustain an injury (particularly head injuries) in the event of a car crash than children in child restraint systems (CRS). Very few children 4 to 8 years old were in booster seats (i.e., the appropriate CRS) and were thus not properly restrained. According to this study, the authors report that the use of belt-positioning booster seats is recommended until the child is the appropriate height and weight for seat belt use.

Berg MD, Cook L, Corneli HM, Vernon DD, Dean JM. Effect of seating position and restraint use on injuries to children in motor vehicle crashes. Pediatrics. 2000; 105: 831-835. Abstract available from: PubMed

Methods

Subjects: 0 to 14 years old

Design: Case-control study

(N=5,751)

Methods: Analyzed motor vehicle crash records from 1992 to 1996 from the Utah Department of Transportation. Study included crashes that resulted in injuries and crashes with damage costing over $750.

Outcomes

Out of the 5,751 children involved in the accidents, 37% of children 0 to 4 years old were riding in the front seat and only 38% were optimally restrained. The odds ratio (OR) for being involved in a serious car accident is 1.7 (95% CI: 1.6-2.0) times higher for children sitting in the front as compared to the back of a vehicle. The OR for no restraint use was 2.7 (95% CI: 2.4-3.1) compared to restraint use. The investigators report that young children should be properly restrained and seated in the back seat of a vehicle.

Bicycle Helmets Recommendation Strength of Recommendation
  1. Recommend wearing a bicycle helmets.
Good
  1. Advocate for helmet legislation for all ages.
Consensus
Bicycle Helmets References
ReferenceMethods and OutcomesFormer CTFPHC GRADE

Brent E Hagel, Natalie L Yanchar; Canadian Paediatric Society, Injury Prevention Committee. Bicycle helmet use in Canada: The need for legislation to reduce the risk of head injury. Paediatr Child Health 2013;18(9):475-80. Available from: CPS

Methods

Subjects: Children

Design: Position Statement

Methods: Reviewed the evidence on bicycle helmet use in Canada, the risk of head injury, and helmet legislation.

Outcomes

Recommendations: Based on current evidence and the importance of preventing head injuries in children and youth, the CPS makes the following recommendations: 1) All jurisdictions in Canada should legislate and enforce bicycle helmet use for all ages. 2) Legislation should be rolled out using social marketing and education to raise awareness of bicycle helmet efficacy, accessibility and importance. 3) Other strategies to prevent bicycling injuries, such as separating riders from motor traffic with bicycle lanes, pathways for commuting and recreational cycling, and community safety programs should be implemented concurrently. 4) Physicians should counsel families about the importance of wearing bicycle helmets. Where all-ages legislation does not exist, parents should wear a bicycle helmet to model good behaviour and protect themselves. 5) Sales tax exemptions or rebates and federal tax credits to make the purchase of bicycle helmets less expensive should be adopted.

Russell, K., Foisy, M., Parkin, P. and Macpherson, A. The promotion of bicycle helmet use in children and youth: an overview of reviews. Evid.-Based Child Health. 2011;6: 1780–1789. Abstract available from: The Cochrane Library

Methods

Subjects: children

Design: overview of reviews

Methods: The authors searched the Cochrane Database of Sytematic Reviews for systematic reviews of the effectiveness of helmet use in children on head injuries. The search included ways to promote helmet use in this population.

Outcomes

The authors found three systematic reviews including 21 observational studies and 14 experimental studies. One review examined the role of nonlegislative strategies to promote bicycle helmet use, a second the role of legislation on helmet use and effectiveness, and a third on the effectiveness of helmet use for the prevention of head and facial injuries. The authors of this overview report that helmet use among children significantly reduced the odds of medically reported head injuries by 63% and the odds of brain injuries by 86%. Mandatory helmet legislation were also effective for some health outcomes and nonlegislative helmet promotion activities significantly increased helmet use. Conclusion: Child health professionals should recommend helmet use and work towards the enactment of helmet legislation in jurisdictions where such legislation does not exist.

American Academy of Pediatrics, Committee on Injury and Poison Prevention. Bicycle helmets. Pediatrics. 2001; 108: 1030-1032. Reaffirmed February 2012. Abstract available from: PubMed

Methods

Subjects: Children

Design: Policy statement

Methods: This policy statement describes the role of the paediatrician in helping to attain universal helmet usage among children and teens.

Outcomes

This policy statement reports that all bicyclists should wear a properly fitting helmet every time they are riding. Parents and children should also learn the essential aspects of bike safety. The AAP recommends that physicians should counsel parents and encourage bicycle helmet use during well-child visits as well as in the community.

Wesson DE, Stephens D,  Lam K, Parsons D, Spence L, Parkin PC.  Trends in Pediatric and Adult Bicycling Deaths Before and After Passage of a Bicycle Helmet Law. Pediatrics. 2008;222(3):605-610. Available from: http://www.ncbi.nlm.nih.gov/pubmed/18762532

Methods

Subjects: All ages

Design: Before and after study

Methods: This is a pre-post study to determine the effect of bike helmet legislation on bicycle-related mortality.  Average numbers of deaths per year and mortality rates per 100 000 person-years were analyzed over a 12 year period from 1991 to 2002. Bicycle helmet legislation was passed in 1995 in Ontario.  Analysis was done on deaths occurring in the age group 1-15 and 16 and over. Data was collected from database of the Office of the Chief Coroner of Ontario.

Outcomes

Overall, there were 362 bicycle-related deaths in the 12 year period of this study (107 in the age group 1-15 years and 255 in the 16 year old and above group).  After legislation, for bicyclists 1 to 15 years old, the average number of deaths per year decreased 52%. This reduction was not seen in the older age group.  Due to the fact that legislation was enforced in the younger age group by fining the parents of the children and not enforced for the older age group, this study reported that legislation may have a positive effect on reducing the number of bicycle-related deaths.

Thompson DC, Rivara FP, Thompson RS. Helmets for preventing head and facial injuries in bicyclists. Cochrane Database Syst Rev. 2000;(2):CD001855. Abstract available from: PubMed

Methods

Subjects: All ages

Design: Systematic review

Methods: Searched databases such as CENTRAL, MEDLINE AND EMBASE. Checked reference lists of past reviews and review articles and contacted colleagues around the world. Searches were last updated November 2006.

Outcomes

Five case-control studies met the inclusion criteria. This review reports that helmets provide a 63 to 88% reduction in the risk of head, brain and severe brain injury for all ages of bikers. Helmets also reduce head and facial injuries for all ages of bikers involved in all types of crashes (including crashes involving motor vehicles). All studies found a large protective effect of wearing helmets.

Thompson DC, Rivara, FP, Thompson RS. Effectiveness of bicycle safety helmets in preventing head injuries. A case-control study. JAMA. 1996;276:1968-73. Abstract available from: PubMed

Methods

Subjects: All ages

Design: Case-control study

Methods: Data was collected from 7 hospitals. Subjects were eligible for the study if they were injured while on a bicycle. Cases sustained head injuries and controls sustained any other injury. Questionnaires were sent out to subjects 7 to14 days after the initial ER visit.

Outcomes

This study showed that controls were more likely to have been wearing helmets during the crash than cases (56.8% vs. 29.3%). The OR for the association between wearing helmets and sustaining a head injury was 0.31 (95% CI: 0.26-0.37), showing a protective effect of helmets. According to this study, bicycle helmets provide protection to bicyclists of all ages. They reduce the chance of severe head and brain injury. The study suggests that strategies to prevent bicycle injury should focus on the promotion of helmet use through legislation and education.

Bath Safety and Water Safety Recommendations Strength of Recommendation
  1. Keep hot water at a temperature < 49°C to prevent burns.

Fair

  1. Never leave a young child alone in the bath. Do not use infant bath rings or bath seats.

Fair

  1. Recommend adult supervision, CPR training for adults, 4-sided pool fencing, lifejackets, swimming lessons, and boating safety to decrease the risk of drowning.

Fair

Bath Safety and Water Safety References
ReferenceMethods and OutcomesFormer CTFPHC GRADE

American Academy of Pediatrics. Committee on Injury and Poison Prevention. Pediatrics. 1993;92;292-294. This policy has been revised May 2010. Abstract available from: Pediatrics

Methods

Subjects: 0 to 19 years old

Design: Policy statement

Methods: Overview of causes and strategies to prevent drowning in children and adolescents. Provides recommendations for patient/parent and physicians. The AAP decided to revise the previous policy statement because of new information and research on the classification of drowning, on drain entrapment and hair entanglement, on swimming lessons for young children, and on inflatable and portable pools. 

Outcomes

Effectiveness of swimming lessons at all ages for drowning prevention has not been determined. Four-sided fencing for home pools has been shown to reduce the number of pool immersion injuries by more than 50%. It is recommended by that AAP that children be taught how to swim and that they never swim without adult supervision. Drowning outcomes are now classified as ‘death’, ‘no morbidity’, or ‘morbidity’. Injuries and deaths due to body entrapment or hair entanglement in pools or spas have been reported. These can be prevented by the use of special drain covers, safety vacuum-release systems (SVRSs), filter pumps with multiple drains, and a variety of other pressure-venting filter-construction techniques. Deaths related to inflatable pools have also been reported. The AAP also relaxes its previous policy on the age of first swimming lessons for young children in light of new evidence that shows that swimming lessons from age 1 to 4 years may reduce the risk of drowning. However, this new evidence is insufficient to support a change in the recommendation and swimming lessons must be considered only with proper protection with effective pool barriers and constant, capable supervision. The policy statement also includes 14 ‘messages’ to paediatricians, particularly with regards to constant supervision and proper water safety equipment.

Mao SJ, McKenzie LB, Xiang H, Smith GA. Injuries associated with bathtubs and showers among children in the United States. Pediatrics. 2009 Aug;124(2):541-7. Abstract available from: PubMed

Methods

Subjects: children ≤18 years of age

Design: retrospective cohort

Methods: The goal of this study was to describe the epidemiological features of injuries associated with bathtubs and showers, especially those related to slips, trips, and falls, among US children. Data was from the US Consumer Product Safety Commission National Electronic Injury Surveillance System from 1990 through 2007.

Outcomes

There were an estimated 791,200 bathtub- and shower-related injuries among children ≤18 years of age who were treated in US emergency departments in 1990–2007, with an average of 43,600 cases per year or ∼5.9 injuries per 10,000 US children per year. The largest number of injuries involved children 2 years of age; children ≤4 years accounted for 54.3% of injuries. The most common diagnosis was laceration (59.5%). The most common mechanism of injury was a slip, trip, or fall, accounting for 81.0% of cases or 4.6 injuries per 10,000 US children per year. The most frequently injured body part was the face (48.0%), followed by the head/neck (15.0%). The majority (71.3%) of injuries occurred in a bathtub. Of the cases with a known place of injury, 97.1% occurred at home. An estimated 2.8% of patients were admitted, transferred to another hospital, or held for observation. Conclusion: 1) Slips, trips, and falls in bathtubs and showers are a common cause of injury among children, especially children ≤4 years of age. 2) The incidence of these injuries may be decreased by increasing the coefficient of friction of bathtub and shower surfaces.

Brenner RA, Gitanjali ST, Haynie DL, Trumble AC, Qian C, Klinger RM, Klebanoff MA. Association between swimming lessons and drowning in childhood. A case-control study. Arch Pediatr Adolesc Med 2009;163(3):203-210. Abstract available from: PubMed

Methods

Subjects: 1 to 19 years old

Design: Case-control study

Methods: Interviews were conducted with 61of the 88 families who had a child aged 1 to 4 years unintentionally drown. These were identified across specific jurisdictions in the U.S. through medical examiners or coroners. Cases were matched with 213 controls based on age, sex and area of residence by random-digit-dialling.

Outcomes

Of the 61 cases interviewed, only 3% had taken formal swimming lessons as compared to 26% of the controls. There was an 88% reduction in the risk of drowning when 1 to 4 year olds participated in formal swimming lessons (95% CI: 0-.01-0.97). Informal swimming lessons did not significantly reduce the risk of drowning. The authors concluded that swimming lessons do provide some protective effect, however, due to the imprecise estimate (shown in the wide confidence intervals) the true magnitude of the effect remains unclear. 

Byard RW, Donald T. Infant bath seats, drowning and near-drowning. J  Paediatr. Child Health. 2004; 40: 305-307. Abstract available from: PubMed

Methods

Subjects: 0 to 2 years old

Design: Review

Methods: Reviewed files of the Forensic Science Centre and Child Protection Unit, Women’s and Children’s Hospital, Adelaide, South Australia, for immersion incidents in bathtub seats.

Outcomes

Six cases of drowning and near-drowning were found over a 6-year period, three cases were reviewed in this article. One case of drowning occurred in a 7-month old boy who slipped from his bath seat. Two cases of near drowning happened in boys of the same age. The review reports that bathtub seats are associated with problems of trapping infants underwater if they slip down under the ring or seat. They have also been known to give parents false confidence to leave their children unattended.

Canadian Pediatric Society. Swimming lessons for infants and toddlers. Paediatric & Child Health. 2003; 8(2): 113-114. Abstract available from: PubMed

Methods

Subjects: Infants

Design: Position statement

Methods: Recommendations and guidelines for swimming lessons for infants and toddlers.

Outcomes

The CPS statement reports evidence that swimming lessons improve swimming ability and deck behaviour but there is no evidence that it prevents drowning or near drowning. The CPS states that parental supervision and four-sided fencing are the best strategies for prevention against drowning. The CPS also states that swimming lessons should not be promoted as effective prevention against drowning and that there should be constant supervision for all children <4 years old who are swimming.

Thompson DC, Rivara FP. Pool fencing for preventing drowning in children. Cochrane Database Systematic Review. 2000;2:CD0001047. Abstract available from: PubMed

Methods

Subjects: 0 to 14 years old

Design: Systematic review

Methods: Searched databases such as CENTRAL, MEDLINE AND EMBASE. Checked reference lists of past reviews and review articles and contacted relevant organizations and experts. Searches were last updated in October 2006.

Outcomes

Three case-control studies met the inclusion criteria. All 3 studies concluded that fenced pools are associated with a decreased risk of drowning compared to unfenced pools (OR 0.27 [95% CI: 0.16 to 0.47]). The study reports that isolation fencing (4-sided) is better than perimeter fencing (3-sided). Legislation and maintenance of pool fencing requires improvement in most communities.

Counsel on Pacifier Use Recommendation Strength of Recommendation
  1. Pacifier use may decrease the risk of SIDS and should not be discouraged in the first year of life after breastfeeding is well established, but should be restricted in children with chronic/recurrent otitis media.

Fair

  1. Counsel on safe and appropriate use of pacifiers during routine anticipatory guidance.

Consensus

Counsel on Pacifier Use References
ReferenceMethods and OutcomesFormer CTFPHC GRADE

Moon, R. Y., K. O. Tanabe, et al. Pacifier use and SIDS: Evidence for a consistently reduced risk. Maternal and Child Health Journal. 2012; 16(3): 609-614. Available from: Springer

Methods

Subjects: Infants

Design: Case-control study (SIDS n = 260, control n = 260)

Methods: The objective of this study was to examine the association between pacifier use during sleep and SIDS in relation to other risk factors and to determine if pacifier use modifies the impact of these risk factors.

Outcomes

Data source was a population based case–control study of 260 SIDS deaths and 260 matched living controls. Pacifier use during last sleep decreased SIDS risk (aOR 0.30, 95% CI 0.17–0.52). Furthermore, pacifier use decreased SIDS risk more when mothers were C20 y./

ears of age, married, nonsmokers, had adequate prenatal care, and if the infant was ever breastfed. Pacifier use also decreased the risk of SIDS more when the infant was sleeping in the prone/side position, bedsharing, and when soft bedding was present. The association between adverse environmental factors and SIDS risk was modified favorably by pacifier use, but the interactions between pacifier use and these factors were not significant. Recommendation: Pacifier use may provide an additional strategy to reduce the risk of SIDS for infants at high risk or in adverse sleep environments, but its use should be particularly encouraged for those infants who are in adverse sleep environments.

Canadian Pediatric Society. Recommendations for the use of pacifiers. Paediatric & Child Health 2003; 8: 515-519.

Reaffirmed: Jan 30 2013. Available from: http://www.cps.ca/en/documents/position/pacifiers

Methods

Subjects: Infants

Design: Policy statement

Methods: Reviewed literature on pacifier use in infants and its association with breastfeeding, otitis media, dentition, SIDS, infection and analgesic effects. Also reviewed product safety guidelines and pacifiers use in preterm infants.

Outcomes

According to the CPS statement, 1) the decision to use pacifiers is the choice of the parents; 2) physicians should counsel parents on the potential benefits (reduced risk of SIDS) and potential harms (increased risk of recurrent otitis media).  The CPS recommends that “Health care professionals should recognize pacifier use as a parental choice determined by the needs of their newborn, infant or child.” They also report that early pacifier use might be associated with breastfeeding difficulties and infants with recurrent otitis media should not use pacifiers. 

Rovers MM, Numans ME, Langenbach E, Grobbee DE, Verheij TJM and Schilder AGM. Is pacifier use a risk factor for acute otitis media? A dynamic cohort study. Family Practice. 2008; 25: 233–236. Abstract available from: PubMed

Methods

Subjects: 0 to 4 years old

Design: Prospective cohort study (N=476)

Methods: Followed a cohort of infants from 2000 to 2005 from Leidsche Rijn, a residential area in Utrecht, The Netherlands. Parents completed a questionnaire on pacifier use at baseline and GPs diagnosed acute otitis media (AOM) events.

Outcomes

The odds ratio for pacifier use and a single AOM event was 1.3 (95% CI: 0.9-1.9) and was therefore not significant. However, for recurrent AOM, the odds ratio was 1.9 (95% CI: 1.1-1.3). According to this study,  pacifier use appears to be a risk factor for recurrent AOM. The authors report that physicians should counsel parents on the risks of pacifier use once their child has received their first diagnosis of AOM.

Hauck FR, Omojokun OO, Siadaty MS. Do pacifiers reduce the risk of sudden infant death syndrome? A meta-analysis. Pediatrics. 2005; 116: e716. Abstract available from: PubMed

Methods

Subjects: Infants

Design: Meta-analysis

Methods: Performed a systematic review of the literature by searching the MEDLINE database. All studies that met the inclusion criteria (published articles with data on the relationship between pacifier use and SIDS risk) as well as a test for homogeneity were included in the meta-analysis.

Outcomes

Nine studies were found during the systematic review however only 7 of the 9 case-control studies were included in the meta-analysis due to two of the studies being heterogeneous. The meta-analysis showed a reduced risk of SIDS with pacifier use when used for sleep (OR=0.71, 95% CI: 0.59-0.85).  Based on this evidence, the authors recommend that pacifiers be used for infants less than 1 year of age. This is a US Preventive Services Task Force level B strength of recommendation, meaning the beneficial effects will outweigh any potential negative effects.

Smoke Detectors Recommendation Strength of Recommendation
  1. Install smoke detectors in the home on every level.

Fair

Smoke Detectors References
ReferenceMethods and OutcomesFormer CTFPHC GRADE

DiGuiseppi C, Higgins JP. Interventions for promoting smoke alarm ownership and function. Cochrane Database Syst Rev. 2001;(2):CD002246. Abstract available from: http://www.ncbi.nlm.nih.gov/pubmed/11406039

Methods

Subjects: All

Design: Cochrane review

Methods: Searched appropriate databases for randomized, quasi-randomized or nonrandomized controlled trials completed or published after 1969 evaluating an intervention to promote residential smoke alarms.

Outcomes

Authors identified 26 trials, of which 13 were randomised. Overall, counselling and educational interventions had only a modest effect on the likelihood of owning an alarm (OR=1.26; 95% CI: 0.87 to 1.82) or having a functional alarm (OR=1.19; 0.85 to 1.66). Counselling as part of primary care child health surveillance had greater effects on ownership (OR=1.96; 1.03 to 3.72) and function (OR=1.72; 0.78 to 3.80). Results were sensitive to trial quality, however, and effects on fire-related injuries were not reported. In two non-randomized trials, direct provision of free alarms significantly increased functioning alarms and reduced fire-related injuries. Media and community education showed little benefit in non-randomized trials. Conclusion: 1) Counselling as part of child health surveillance may increase smoke alarm ownership and function. 2) Community smoke alarm give-away programmes apparently reduce fire-related injuries

LeBlanc JC, Pless IB, King WJ, Bawden H, Bernard-Bonnin AC, Klassen T, Tenenbein M. Home safety measures and the risk of unintentional injury among young children: a multicentre case-control study. CMAJ. 2006; 175(8): 883-887. Available from:

PubMed

Methods

Subjects: 0 to 7 years old

Design: Case-control study

Methods: Investigators used records from 5 pediatric hospital emergency departments to look for cases of falls, burns or scalds, ingestions or choking. Matched control subjects were children who presented during the same period with acute non-injury related conditions.

Outcomes

An investigator blinded to case/control status assessed 19 injury hazards at each child’s home. Overall, 17% percent of homes had no functioning smoke alarm and 51% had no functioning fire extinguisher. After controlling for siblings, maternal education and employment it was found that cases differed from controls for 5 hazards: presence of a baby walker, presence of choking hazards, no child-restraint lids in bathroom, no smoke alarm and no functioning smoke alarm. Compared to controls, cases were 3.2 (95% CI: 1.4-7.7). times more likely to have been injured in a house without a smoke alarm 

DiGuiseppi C, Roberts I, Li L. Smoke alarm ownership and house fire death rates in children. J Epidemiol Community Health. 1998; 52: 760-761. Abstract available from: PubMed

Methods

Subjects: 0 to 14 years old

Design: Ecological study

Methods: Used data from the Office for National Statistics in England and Wales. Recorded all injury deaths of children 0 to14 years old from 1980-1995.

Outcomes

Case-control studies have shown that smoke alarms are associated with a reduced risk of death.  In this study, a 10% increase in smoke alarm ownership was associated with a 13% risk reduction of fire death in infants 0 to 4 years old (95% CI 0.81-0.94). The main limitation of this study is in its ecological design.  There are other factors that might be contributing to the decrease in deaths that are not related to fire alarms such as reduced risk of fire occurrence or severity in this time period.

American Academy of Pediatrics. Committee on Injury and Poison Prevention. Reducing the number of deaths and injuries from residential fires. Pediatrics. 2000; 105: 1355-1357. Abstract available from: PubMed

Methods

Subjects: Children

Design: Review

Methods: Reports an overview of intervention strategies and prevention messages for reducing injury due to residential fires.

Outcomes

The review reports that smoke alarms need to be installed and maintained in the home; they should be tested once a month and the batteries should be changed once a year; young children and older adults are at the highest risk for incurring serious injury and death due to residential fires. 

Poisons: PCC# (Poison Control Centre number) Strength of Recommendation
  1. Keep medicines and cleaners locked up and out of child’s reach.

Good

  1. Have Poison Control Centre number handy.

Good

  1. Use of ipecac is contraindicated in children.

Fair

Poison: PCC# (Poison Control Centre number) References
ReferenceMethods and OutcomesFormer CTFPHC GRADE

Ferguson RW, Mickalide AD. An In-Depth Look at Keeping Young Children Safe Around Medicine. Washington, DC: Safe Kids Worldwide, March 2013.Available from: Safe Kids Worldwide

Methods

Subjects: Young children

Design: Report

Methods: Analyzes data from the U.S. Consumer Product Safety Commission to explore trends in unsupervised accidental medication exposure and dosing errors, and provide greater insight into the risk factors related to these incidents.

Outcomes

Accidental medication exposures are a large and growing problem. Based on descriptive data, the authors developed several tips with regards to storage, dosing, and disposal of medicines, as well as safety tips when visiting seniors. Recommendation: See report for specific safety tips. 

McGregor T, Parkar M, Rao S. Evaluation and management of common childhood poisonings. American Family Physician. 2009; 79: 397-403. Abstract available from: PubMed

Methods

Subjects: Children

Design: Review

Methods: Reviews the literature on children evaluated for suspected toxin ingestion, commonly ingested substances and various treatments.

Outcomes

Patients who have ingested toxins and who are presenting with respiratory, circulatory or neurological symptoms should be taken to the nearest ED. According to this study, use of ipecac is no longer recommended for treatment and the use of activated charcoal is discouraged, except if within one hour of ingestion.

Falls (Stairs, Walkers, Furniture, Change Table and Trampoline Use) Recommendations Strength of Recommendation
  1. Assess home for hazards- never leave baby alone on change table or other high surface; use window guards and stair gates.

Fair

  1. Baby walkers are banned in Canada and should never be used.

Fair

  1. Advise against trampoline use at home.

Fair

  1. Ensure stability of furniture and TV and counsel parents about the dangers of flat screen televisions, dressers and other furniture and appliances that can fall and crush children. 

Fair

Falls (stairs, walkers, furniture, change table and trampoline use) References
ReferenceMethods and OutcomesFormer CTFPHC GRADE

United States Consumer Product Safety Commission. Instability and Tipover of Appliances, Furniture, and Televisions: Estimated Injuries and Reported Fatalities: 2011 Report.  Published 13 August 2012. Available from: http://www.cpsc.gov/PageFiles/118043/tipover2011.pdf

Methods

Subjects: All

Design: Report

Methods: This report contains information on instability of televisions, furniture, and appliances. An estimate of emergency department-treated instability injuries is presented. This is followed by the counts of reported fatalities. The death incidents are from 2000 through 2010, and the injury estimates are for 2006 through 2010.

Outcomes

Of the estimated annual average of 43,400 emergency department-treated injuries (2008–2010), 25,300 (58%) involved children, under age 18 years, with a large majority of the victims being under 5 years of age. Of the 293 reported fatalities occurring between 2000 and 2010, 245 (84%) involved children, victim ages 1 month to 8 years. ED-treated injuries: 44% involved televisions (or TV + furniture) falling; 52% involved only furniture falling; and 4% involved appliances falling. Reported fatalities: 60% involved televisions falling (36% only TV, 24% TV + furniture); 31% involved only furniture falling; 9% involved appliances falling.

Council On Sports Medicine And Fitness. Trampoline Safety in Childhood and Adolescence. Pediatrics. 2012. Available from:  Pediatrics

Methods

Subjects: Children

Design: Policy statement

Methods: This policy statement is an update to previous statements, reflecting the current literature on prevalence, patterns, and mechanisms of trampoline-related injuries.

Outcomes

The authors report that although trampoline-related injuries such as sprains, strains, contusions, or other soft tissue injury are common, more serious injuries such as bone injury can also occur, especially in children younger than 5 years. Recommendations: 1) Advise patients and families against recreational trampoline use and explain that current data indicate safety measures have not significantly reduced injury rates and that catastrophic injuries do occur. 2) For parents and families who choose to use a trampoline despite the recommendation, advise on the specific guidelines provided in the Policy Statement.

Zielinski AE. Rochette LM. Smith GA. Stair-related injuries to young children treated in US emergency departments, 1999-2008. Pediatrics. 2012;129(4):721-7. Abstract available from: PubMed

Methods

Subjects: Children aged <5 years treated in a US emergency department

Design: Retrospective cohort

N= 931,886 children treated from 1999 through 2008

Methods: This analysis was performed to characterize the epidemiology, secular trends, and mechanisms of stair-related injuries of children.

Outcomes

The authors observed a significant decrease in the number of stair-related injuries over the study period (1999-2008) as well as an 11.6% decrease in cases/year.  However, the authors note that stairs still represent an important source of injury to young children. A significant portion of children with stair-related injuries were reported to have been carried by a caretaker. Other stair-related injuries were reported to be caused by baby-walkers or from playing around the stairs. The authors also found that cases of falls occur when stair gates were either left open or improperly installed and therefore parents should not solely rely upon them. Supervision is advised. Recommendation:  Advise caretakers to minimize stair use while carrying children and to keep the stairs well-maintained and free of objects that could result in tripping.

Thompson AK, Bertocci G, Rice W, Pierce MC. Pediatric short-distance household falls: Biomechanics and associated injury severity. Accid Anal Prev. 2011 Jan;43(1):143-50. Abstract available from: PubMed

Methods

Subjects: Children 0-4 years

Design: Observational descriptive

Methods: Children aged 0-4 years who presented to the Emergency Department with a history of a short furniture fall were included in the study. Detailed case-based biomechanical assessments were performed using data collected through medical records, interviews, and fall scene investigations. Injuries were rated using the Abbreviated Injury Scale (AIS). Each case was reviewed by a child abuse expert; cases with a vague or inconsistent history and cases being actively investigated for child abuse were excluded.

Outcomes

Seventy-nine subjects were enrolled in the study; 15 had no injuries, 45 had minor (AIS 1) injuries, 17 had moderate (AIS 2) injuries, and 2 had serious (AIS 3) injuries. No subjects had injuries classified as AIS 4 or higher, and there were no fatalities. Children with moderate or serious injuries resulting from a short-distance household fall tended to have fallen from greater heights, have greater impact velocities, and have a lower body mass index than those with minor or no injuries. Conclusion: Children aged 0-4 years involved in a short-distance household fall did not sustain severe or life-threatening injuries, and no children in this study had moderate or serious injuries to multiple body regions.

Pomerantz WJ, Gittelman MA, Hornung R, Husseinzadeh H. Falls in children birth to 5 years: Different mechanisms lead to different injuries. J Trauma Acute Care Surg. 2012 Oct;73(4 Suppl 3):S254-7. Abstract available from: PubMed

Methods

Subjects: Children < 5 years

Design: Observational descriptive

Methods: This study aimed to compare the number of children injured, ages of injured children, and injuries sustained in falls from furniture and falls from stairs in hospitalized children. All records of individuals from 0 year through 4 years, hospitalized at our institution for a fall from furniture or stairs between January 1, 1996, and December 31, 2006, were retrospectively reviewed. 

Outcomes

A total of 171 patients were hospitalized for falls from stairs and 318 for falls from furniture. There were no differences between the groups with regard to age, sex, race, type of insurance, and length of stay, Injury Severity Score, or total cost. The most common pieces of furniture from which children fell were beds (33.0%), couches (18.9%), and chairs (17.9%). Children who fell from stairs were significantly more likely to have injuries to their head (64.3% vs. 38.1%); those that fell from furniture were more likely to sustain arm injuries (33.3% vs. 9.9%). There were significantly more skull fractures in those that fell from stairs (39.8% vs. 20.1%) and humerus fractures in those that fell from furniture (30.8% vs. 9.4%) (p < 0.001). Falls from furniture increased during the study period, while falls from stairs fell; the difference was not statistically significant, however. Conclusion: Falls from furniture and stairs are important causes of morbidity in children and that more anticipatory guidance should be developed and given to families regarding falls from furniture to help prevent these injuries.

McFaull SR, Frechette M, Skinner R. Emergency department surveillance of injuries associated with bunk beds: the Canadian Hospitals Injury Reporting and

Prevention Program (CHIRPP), 1990–2009. Chronic Diseases and Injuries in Canada. 2012;33(1). Available from:  Public Health Agency of Canada

Methods

Subjects: All

Design: National surveillance system

Methods: CHIRPP is an injury and poisoning surveillance system operating in 11 paediatric and 4 general emergency departments across Canada. Records were extracted using CHIRPP product codes and narratives.

Outcomes

Over the 20-year surveillance period, 6,002 individuals presented to Canadian emergency departments for an injury associated with a bunk bed. Overall, the frequency of bunk bed-related injuries in CHIRPP has remained relatively stable with an average annual percent change of 21.2% (21.8% to 20.5%). Over 90% of upper bunk-related injuries were due to falls and children 3–5 years of age were most frequently injured (471.2/100,000 CHIRPP cases). Children with bunk bed-related injuries continue to present to Canadian emergency departments, many with significant injuries. Injury prevention efforts should focus on children under 6 years of age. Recommendation: Children aged less than 6 years should not be allowed on the upper bunk.

Harris VA, Rochette LM, Smith GA. Pediatric Injuries Attributable to Falls From Windows in the United States in 1990–2008. Pediatrics. 2011 Sep;128(3):455-62. Abstract available from: PubMed

Methods

Subjects: Children

Design: Retrospective cohort

Methods: By using the National Electronic Injury Surveillance System, emergency department (ED) data for paediatric injury cases associated with window falls in 1990-2008 were reviewed. 

Outcomes

An estimated 98,415 children (95% confidence interval [CI]: 82,416-114,419) were treated in US hospital EDs for window fall-related injuries during the 19-year study period (average: 5,180 patients per year [95% CI: 4,828-5,531]). The mean age of children was 5.1 years, and boys accounted for 58.1% of cases. One-fourth (25.4%) of the patients required admission to the hospital. The annual injury rate decreased significantly during the study period because of a decrease in the annual injury rate among 0- to 4-year-old children. Children 0 to 4 years of age were more likely to sustain head injuries (injury proportion ratio [IPR]: 3.22 [95% CI: 2.65-3.91]) and to be hospitalized or to die (IPR: 1.65 [95% CI: 1.38-1.97]) compared with children 5 to 17 years of age. Children who landed on hard surfaces were more likely to sustain head injuries (IPR: 2.05 [95% CI: 1.53-2.74]) and to be hospitalized or to die (IPR: 2.23 [95% CI: 1.57-3.17]) compared with children who landed on cushioning surfaces. Conclusion: 1) Prevention measures for young children should aim to prevent falls by reducing the child’s opportunity to exit the window, through the use of devices such as window guards or window locks and through placement of furniture away from windows, to decrease access to windows by young children. 2) Prevention measures for all children should address softening the landing surfaces below windows, to help reduce the severity of injury when a fall does occur.

Kendrick D, Watson MC, Mulvaney CA, Smith SJ, Sutton AJ, Coupland CA, Mason-Jones AJ. Preventing childhood falls at home: meta-analysis and meta-regression. Am J Prev Med. 2008 Oct;35(4):370-379.

PubMed

Methods

Subjects: Children

Design: Meta-analysis

Methods: A systematic review of literature was conducted up to June 2004 and meta-analysis using individual patient data to evaluate the effect of home-safety interventions on fall-prevention practices and fall-injury rates. Meta-regression examined the effect of interventions by child age, gender, and social variables. 

Outcomes

Included were 21 studies, 13 of which contributed to meta-analyses. Home-safety interventions increased stair-gate use (OR=1.26; 95% CI=1.05, 1.51), and there was some evidence of reduced baby-walker use (OR=0.66; 95% CI=0.43, 1.00), but little evidence of increased possession of window locks, screens, or windows with limited opening (OR=1.16, 95% CI=0.84, 1.59) or of nonslip bath mats or decals (OR=1.15; 95% CI=0.51, 2.62). Two studies reported nonsignificant effects on falls (baby-walker–related falls on flat ground [OR=1.35; 95% CI=0.64, 2.83] or down steps or stairs [OR=0.70; 95% CI=0.14, 3.49]) and medically attended falls (OR=0.78; 95% CI=0.61, 1.00). Authors conclude that home-safety education and the provision of safety equipment improved some fall-prevention practices, but the impact on fall-injury rates is unclear. There was some evidence that the effect of home-safety interventions varied by social group. Recommendation: Child health and social care providers should continue to provide fall-safety interventions as part of their strategies to improve child health.

Leduc S, Maurice P. Testimony of the Institut National de Santé Publique du Québec to the Board of Review Inquiring into the Nature and Characteristics of Baby Walkers. October 2006; pp. 1-9. Available from: INSPQ

Methods

Subjects: Children

Design: Review

Methods: Based on a recommendation from Health Canada, “the Governor in Council issued an Order under section 6 of the Hazardous Products Act that prohibited the advertising, sale and importation of baby walkers”. This is a review of that ban in light of the current literature.

Outcomes

This review states that baby walkers are dangerous products and should not be sold or used.  The authors report that they increase the risk of serious injury or death and also potentially delay psychomotor development. Not only are baby walkers dangerous but they can give parents a false sense of security when their infants are in them. The conclusion of the review is that the ban of April 7, 2004 must be maintained. 

American Academy of Pediatrics. Committee on Injury and Poison Prevention. Falls from heights: windows, roofs, and balconies. Pediatrics. 2001; 107: 1188-1191. Abstract available from: PubMed

Methods

Subjects: 0 to 15 years old

Design: Policy statement

Methods: Review of the literature to compile a policy statement on the epidemiology of falls from heights. Lists recommendations for preventive strategies for parent counselling. 

Outcomes

Preventive strategies for physicians include: parent counselling, community programs, building code changes and legislation. The AAP recommends a variety of tools (e.g. window guards and stops) to prevent accidental falls from windows. Also, parents are recommended not to place furniture on which children could climb near windows or balconies.

American Academy of Pediatrics. Committee on Injury and Poison Prevention. Injuries associated with infant walkers. Pediatrics 2001; 108: 790-792. Available from: http://pediatrics.aappublications.org/cgi/reprint/108/3/790

Methods

Subjects: Children

Design: Review

Methods: Review of the literature on infant walkers and recommendations given by the AAP.

Outcomes

From 1973 to 1998, there were 34 infant walker-related deaths, mainly from falls down the stairs. This review reports that walkers do not help infants learn to walk and can in fact delay normal development. Due to the high risk of injury, the AAP recommends a ban on the manufacture and sale of mobile infant walkers. If parents are determined to use them, they must meet the American Society for Testing and Materials standards.

Canadian Pediatric Society and the Canadian Academy of Sport Medicine. Trampoline use in homes and playgrounds. Paediatric & Child Health. 2007;12(6):501-505.Reaffirmed Jan. 30 2012. Available from:  http://www.cps.ca/english/statements/IP/IP07-01.htm

 

PubMed

Methods

Subjects: Children

Design: Position statement

Methods: A literature review was performed using the MEDLINE database from 1966 to 2006. Canadian injury data were provided by the Public Health Agency of Canada.

Outcomes

This statement reviews the incidence, type and circumstance of injuries sustained as a result of using a home trampoline as well as the disposition of children after the injury. Trampoline injuries occur most frequently in children 5 to 14 years old. Fractures of the upper extremities are the most common injuries. Recommendation: Advise against trampoline use for recreational purposes at home by children or adolescents

Safe Sleep Environment (Sleep Position/Bed Sharing/Room Sharing) Recommendations Strength of Recommendation
  1. Healthy infants should be positioned on their backs for sleep.
  2. Sleep positioners should not be used.
  3. Counsel parents on the dangers of other contributory causes of SIDS such as overheating, maternal smoking or second-hand smoke.
  4. Advise against bed sharing which is associated with an increased risk for SIDS.
  5. Encourage putting infant in a crib, cradle or bassinette, which meets current Canada Health regulations in parents’ room for the first 6 months of life.
  6. Room sharing is protective against SIDS.

Good

Safe Sleep Environment References
ReferenceMethods and OutcomesFormer CTFPHC GRADE

Joint statement on safe sleep: preventing sudden infant deaths in Canada. December 2012.  Available from: http://www.phac-aspc.gc.ca/hp-ps/dca-dea/stages-etapes/childhood-enfance_0-2/sids/pdf/jsss-ecss2011-eng.pdf

Methods

Subjects: Infants

Design: joint statement

Methods: The Public Health Agency of Canada produced this document for health practitioners so they may provide parents and caregivers with information and support to prevent deaths due to SIDS and unsafe sleeping practices. Parents and all caregivers are encouraged to practice the principles of safe sleep at home, in child care settings, and when travelling.

Outcomes

A joint statement developed by North American experts in the field of SIDS, the CPS, the Canadian Foundation for the Study of Infant Deaths, the Canadian Institute of Child Health, Health Canada, and the Public Health Agency of Canada with input from provincial/territorial, national, and regional public health stakeholders. Conclusion: 1) Infants placed on their backs to sleep, for every sleep, have a reduced risk of SIDS. 2) Preventing exposure to tobacco smoke, before and after birth, reduces the risk of SIDS. 3) The safest place for an infant to sleep is in a crib, cradle, or bassinet that meets current Canadian regulations. 4) Infants who share a room with a parent or caregiver have a lower risk of SIDS. 5) Breastfeeding provides a protective effect against SIDS.

Vennemann MM. Hense HW. Bajanowski T. Blair PS. Complojer C. Moon RY. Kiechl-Kohlendorfer U. Bed sharing and the risk of sudden infant death syndrome: can we resolve the debate? Journal of Pediatrics. 2012;160(1):44-8.e2. Abstract available from: PubMed

Methods

Subjects: Infants

Design: Meta-analysis

Methods: PubMed and Medline searches were conducted up to December 2009 for case-control studies about SIDS and bed sharing.

Outcomes

The authors included eleven case-control in their meta-analysis, consisting of 2,464 cases and 6,495 controls, where 710 cases (28.8%) and 863 controls (13.3%) bed shared. Analyses were stratified according to parental smoking status , age of infant at the time of last sleep regardless of smoking status (12 week cut-off), and bed sharing as a usual habit versus bed sharing not usual but in the last night. ORs for bed sharing and SIDS were 2.89 (95% CI, 1.99-4.18) overall, 6.27 (95% CI, 3.94-9.99) for maternal smoking compared to 1.66 (95% CI, 0.91-3.01) for non-smoking mothers, and 10.37 (95% CI, 4.44-24.21) as compared to 1.02 (95% CI, 0.49-2.12 for bed sharing with infants aged <12 weeks versus ≥ 12 weeks. Conclusion: Bed sharing is a risk factor for SIDS and is especially enhanced in smoking parents and in very young infants.

Task Force On Sudden Infant Death Syndrome. SIDS and Other Sleep-Related Infant Deaths: Expansion of Recommendations for a Safe Infant Sleeping Environment. Pediatrics. 2011;128:1030–1039. Abstract available from: Pediatrics

Methods

Subjects: Infants

Design: Technical report and policy statement

Methods: Literature searches since 2005 using PubMed on topics related to SIDS. Based on the technical report, Task Force members determined the strength of evidence for each recommendation using the U.S. Preventive Services Task Force (USPSTF) grade system. The graded recommendations are listed in the policy statement. The rationale supporting the recommendations can be found in the Technical Report.

Outcomes

Since the last AAP statement published in 2005, the recommendations are expanded from being only SIDS-focused to focusing on a safe sleep environment that can reduce the risk of all sleep-related infant deaths including SIDS. This 2011 AAP policy statement includes 18 recommendations (12 Level A recommendations, 3 Level B recommendations and 3 Level C recommendations) for parents and healthcare providers but also for public health policy makers and researchers. The recommendations described in this policy statement include supine positioning, use of a firm sleep surface, breastfeeding, room-sharing without bed-sharing, routine immunizations, consideration of using a pacifier, and avoidance of soft bedding, overheating, and exposure to tobacco smoke, alcohol, and illicit drugs. Recommendations (Level A): 1) Back to sleep for every sleep; 2) Use a firm sleep surface; 3) Room-sharing without bed-sharing is recommended; 4) Keep soft objects and loose bedding out of the crib; 5) Pregnant women should receive regular prenatal care; 6) Avoid smoke exposure during pregnancy and after birth; 7) Avoid alcohol and illicit drug use during pregnancy and after birth; 8) Breastfeeding is recommended; 9) Consider offering a pacifier at nap time and bedtime; 10) Avoid overheating; 11) Do not use home cardiorespiratory monitors as a strategy for reducing the risk of SIDS; 12) Expand the national campaign to reduce the risks of SIDS to include a major focus on the safe sleep environment and ways to reduce the risks of all sleep related infant deaths, including SIDS, suffocation, and other accidental deaths; paediatricians, family physicians, and other primary care providers should actively participate in this campaign. Recommendations (Level B): 1) Infants should be immunized in accordance with recommendations of the AAP and Centers for Disease Control and Prevention; 2) Avoid commercial devices marketed to reduce the risk of SIDS; 3) Supervised, awake tummy time is recommended to facilitate development and to minimize development of positional plagiocephaly. Recommendations (Level C): 1) Health care professionals, staff in newborn nurseries and NICUs, and child care providers should endorse the SIDS risk-reduction recommendations from birth; 2) Media and manufacturers should follow safe-sleep guidelines in their messaging and advertising; 3) Continue research and surveillance on the risk factors, causes, and pathophysiological mechanisms of SIDS and other sleep-related infant deaths, with the ultimate goal of eliminating these deaths entirely.

Canadian Pediatric Society. Recommendations for safe sleeping environments for infants and children. Paediatric & Child Health. 2004; 9(9): 659-663. Reaffirmed: Jan 30 2013. Abstract available from: PubMed

Methods

Subjects: Infants and young children

Design: Position statement

Methods: Reviewed the available scientific literature on the safety of various sleeping environments for infants and children. Gives recommendations for physicians  to counsel parents and caregivers.

Outcomes

A few well-designed case-control studies and some case series were found. The case-control studies were large and population-based and conducted in several different countries. The studies reviewed in this CPS statement concluded that 1) prone sleeping and exposure to tobacco products are potential risk factors for SIDS; 2)“When infants sleep in their own crib, they are significantly safer than when they bed share.”; and 3) a sudden change in sleeping pattern is associated with the highest risk of sudden death.

Vennemann MM, Bajanowski T, Brinkmann B, Jorch G, Sauerland C, Mitchell EA and the GeSID Study Group. Sleep environment risk factors for sudden infant death syndrome: The German sudden infant death syndrome study. Pediatrics. 2009; 123: 1162-1170

PubMed

Methods

Subjects: Infants

Design: Population-based case-control study

Methods: Cases of SIDS (n=333) were collected from 1998 to 2001 from all over Germany. Controls (n=998) were matched for age, region, gender and sleep time and recruited from the same vital registry as the cases.

Outcomes

This case-control study found that the risk of SIDS is significantly higher when the infant’s last sleep was not in the parental home as well as when he/she is sleeping in the living room compared to the parents’ bedroom. They also found that sleeping prone, bed sharing, sleeping prone on sheepskin and duvets are associated with increased risk of SIDS. This study supports the statement from the AAP and their recommendations for safe sleeping environments. Novel risk factors include sleeping outside the parents’ home, sleeping in the living room, and sleeping prone on sheepskin (high risk).

Horsley T, Clifford T, Barrowman N, Bennett S, Yazdi F, Sampson M, Moher D, Dingwall O, Schachter H, Côté A. Benefits and harms associated with the practice of bed sharing: a systematic review. Arch Pediatr Adolesc Med. 2007 Mar;161(3):237-45. Abstract available from: PubMed

Methods

Subjects: Children 0 to 2 years

Design: systematic review

Methods: Searched MEDLINE, CINAHL, Healthstar, PsycINFO, the Cochrane Library, Turning Research Into Practice, and Allied and Alternative Medicine databases between January 1993 and January 2005 to identify investigating the practice of bed sharing (defined as a child sharing a sleep surface with another individual) and associated benefits and harms.

Outcomes

Evidence from 40 observational studies included consistently suggests that there may be an association between bed sharing and sudden infant death syndrome (SIDS) among smokers (however defined), but the evidence is not as consistent among non-smokers. This does not mean that no association between bed sharing and SIDS exists among non-smokers, but that existing data do not convincingly establish such an association. Data also suggest that bed sharing may be more strongly associated with SIDS in younger infants. A positive association between bed sharing and breastfeeding was identified. Current data could not establish causality. It is possible that women who are most likely to practice prolonged breastfeeding also prefer to bed share. Conclusions: 1) Bed sharing may be associated with SIDS, particularly among smokers and in younger infants.

Positional Plagiocephaly Recommendations Strength of Recommendation
  1. Infant heads should be placed in different positions on alternate days for sleep.

Consensus

  1. While awake, infants should have supervised tummy time.

Good

Positional Plagiocephaly References
ReferenceMethods and OutcomesFormer CTFPHC GRADE

Task Force On Sudden Infant Death Syndrome. SIDS and Other Sleep-Related Infant Deaths: Expansion of Recommendations for a Safe Infant Sleeping Environment. Pediatrics. 2011;128:1030–1039. Abstract available from: Pediatrics

Methods

Subjects: infants

Design: Technical report and policy statement

Methods: Literature searches since 2005 using PubMed on topics related to SIDS. Based on the technical report, Task Force members determined the strength of evidence for each recommendation using the U.S. Preventive Services Task Force (USPSTF) grade system. The graded recommendations are listed in the policy statement. The rationale supporting the recommendations can be found in the Technical Report.

Outcomes

Since the last AAP statement published in 2005, the recommendations are expanded from being only SIDS-focused to focusing on a safe sleep environment that can reduce the risk of all sleep-related infant deaths including SIDS. This 2011 AAP policy statement includes 18 recommendations (12 Level A recommendations, 3 Level B recommendations and 3 Level C recommendations) for parents and healthcare providers but also for public health policy makers and researchers. The recommendations described in this policy statement include supine positioning, use of a firm sleep surface, breastfeeding, room-sharing without bed-sharing, routine immunizations, consideration of using a pacifier, and avoidance of soft bedding, overheating, and exposure to tobacco smoke, alcohol, and illicit drugs. Recommendation: Supervised, awake tummy time is recommended to facilitate development and to minimize development of positional plagiocephaly

Joint statement on safe sleep: preventing sudden infant deaths in Canada. December 2012. Available from: http://www.phac-aspc.gc.ca/hp-ps/dca-dea/stages-etapes/childhood-enfance_0-2/sids/pdf/jsss-ecss2011-eng.pdf

Methods

Subjects: Infants

Design: Joint statement

Methods: The Public Health Agency of Canada produced this document for health practitioners so they may provide parents and caregivers with information and support to prevent deaths due to SIDS and unsafe sleeping practices. Parents and all caregivers are encouraged to practice the principles of safe sleep at home, in child care settings, and when travelling.

Outcomes

On plagiocephaly or flat heat. Recommendation: Infants will benefit from supervised tummy time, when they are awake, several times every day, to counteract any effects of regular back sleeping on muscle development or the chance of developing plagiocephaly, commonly referred to as flat head.

Laughlin J, Luerssen TG, Dias MS; Committee on Practice and Ambulatory Medicine, Section on Neurological Surgery. Prevention and management of positional skull deformities in infants. Pediatrics. 2011 Dec;128(6):1236-41.

PubMed

Methods

Subjects: Infants

Design: Clinical report

Methods: This report provides guidance for the prevention, diagnosis, and management of positional skull deformity in an otherwise normal infant without evidence of associated anomalies, syndromes, or spinal disease.

Outcomes

In most cases, the diagnosis and successful management of positional skull deformity can be assumed by the pediatrician or other primary health care clinician. This management includes examination for and counseling regarding positional skull deformity in the newborn period and at health supervision visits during infancy, as well as monitoring for improvement or progression. For the mild-to-moderate deformity, positioning and observation is the recommended treatment. Both positional changes and molding helmets are options for the infant with severe deformity. Cranial orthoses should be reserved for severe cases of deformity or for the infant whose deformity does not improve after 6 months of age. Referral to a pediatric neurosurgeon with expertise in craniofacial malformations, a craniofacial surgeon, or a craniofacial team should be considered if there is progression or lack of improvement after a trial of mechanical adjustments or suspicion of craniosynostosis. Recommendations: 1) To prevent the deformity, parents should be counselled during the newborn period (by 2–4 weeks of age) when the skull is maximally deformable. 2) Parents should be instructed to lay the infant down to sleep in the supine position, alternating positions (ie, left and right occiputs).  3) When awake and being observed, the infant should spend time in the prone position for at least 30 to 60 minutes/day.  4) The infant should spend minimal time in car seats (when not a passenger in a vehicle) or other seating that maintains supine positioning. Conclusion: Aside from potentially preventing positional skull deformity, routine awake tummy time has been shown to enhance infant motor developmental scores during the first 15 months of life. 

Canadian Pediatric Society Statement Update. Positional plagiocephaly and sleep positioning: An update to the joint statement on sudden infant death syndrome. Paediatric & Child Health. 2001;6(10): 788-789. Abstract available from: PubMed

Methods

Subjects: Infants

Design: Policy statement

Methods: Since the Back to Sleep campaign, there have been a few reports of an increased incidence of positional plagiocephaly. Positional plagiocephaly can occur if the infant consistently sleeps with their head in the same position. 

Outcomes

This policy statement reports that plagiocephaly can be prevented by ensuring that infants have supervised tummy time during the day (while awake), and by placing infants’ heads in different positions for sleep.

Crib Safety Recommendation Strength of Recommendation
  1. The safest place for an infant to sleep is in a crib, cradle, or bassinet that meets current Canadian regulations

Good

Crib Safety References
ReferenceMethods and OutcomesFormer CTFPHC GRADE

Health Canada. Crib Safety Tips for Parents and Caregivers.  June 2012. Available from: Health Canada

Methods

Subjects: Infants

Design: Consumer product safety document

Methods: Crib safety tips for parents and caregivers published online by Health Canada.

Outcomes

This consumer product safety sheet states that cribs are the safest place for babies to sleep in if they meet Canada’s current safety regulations. Toddler bed or standard bed should be used for babies that could possibly climb out of the crib on their own or if they are taller than 90 cm (35 inches). The safety tips include using a recent crib with its original parts (<10 years), a firm mattress tight against all sides of the crib and in good condition and more. Refer to website for specific safety tips.  

Moon RY, Kotch L, Aird L. State child care regulations regarding infant sleep environment since the healthy child care America-Back to Sleep campaign. Pediatrics. 2006; 118: 73-83.  Abstract available from: PubMed

Methods

Subjects: Infants

Design: Review

Methods: Reviewed the regulations in 50 states pertaining to SIDS, infant sleep position, crib safety, bedding safety, smoking and provision of information about sleep positioning policies and arrangements to parents before the infant is enrolled in child care.

Outcomes

Eighty-one out of 101 state regulations have ≥ 1 crib safety standard. The review reports that the most common regulations pertain to the distance between slates and the firmness and fit of the mattress. The AAP recommends the use of cribs, bassinets or cradles that conform to the safety standards of the Consumer Product Safety Commission. 

Firearm Safety/Removal/Storage Recommendation Strength of Recommendation
  1. Advise on removal of firearms from home or safe storage to decrease the risk of unintentional firearm injury, suicide, or homicide.

Good

Firearm Safety/Removal/Storage References
ReferenceMethods and OutcomesFormer CTFPHC GRADE

Dowd MD. Sege RD. Council on Injury, Violence, and Poison Prevention Executive Committee. American Academy of Pediatrics. Firearm-Related Injuries Affecting the Pediatric

Population. Pediatrics. 2012;130(5):e1416-23. Abstract available from: Pediatrics

Methods

Subjects: Children and adolescents

Design: Policy statement

Methods: Review of the literature on firearms related injuries in children. 

Outcomes

The AAP makes several recommendations, which reaffirm and expand on the 1992 and the 2000 policy statements. The primary prevention of firearm-related injuries or deaths is essential. Strategies include trigger locks, lock boxes, personalized safety mechanisms, and trigger pressures that are too high for young children. Authors cite two randomized trials where brief physician counselling directed at parents, combined with distribution of gunlocks, and safe storage campaign with gun safe distribution, are two effective interventions to limit access to guns in household with children. Recommendations: 1) The most effective measure is the absence of guns from homes and communities. 2) Child health care providers counsel on the danger of allowing children to have access to guns and educate parents on how to limit access by unauthorized users.

Laraque D, and the Committee on Injury, Violence and Poison Prevention. American Academy of Pediatrics. Injury risk of nonpowder guns. Pediatrics. 2004; 114: 1357-1361. Reaffirmed February 2012. Abstract available from: PubMed

Methods

Subjects: Children and adolescents

Design: Technical report review

Methods: Review of the literature on non-powder guns which include BB guns, pellet guns, air rifles and paintball guns. Launched projectiles can be made of lead, copper, brass, steel or paint.

Outcomes

From 1990 to 2000, 32 deaths occurred in children <15 years old. Overall, non-powder guns are associated with serious injury, permanent disability and death. They are weapons and should never be characterized as toys. This review reports that injuries resulting from these guns should receive medical attention similar to firearm-related injuries.

Canadian Paediatric Society. Youth and firearms in Canada. Paediatric & Child health. 2005; 10(8): 473-477. Reaffirmed: Jan 30, 2012. Available from: Canadian Paediatric Society

Methods

Subjects: Children

Design: Policy statement

Methods: Reviewed the literature on youth and firearm safety from Canada and the United States. Mainly focuses on older children and adolescents, however there have been incidents involving children as young as 3 years old.

Outcomes

The CPS statement reports that the presence of a firearm in the home increases the risk of domestic homicide, suicide and unintentional injury as compared to homes without a firearm and that non-powder firearms are also dangerous, especially for younger children. The Canadian Firearms Act states that firearms in the home have to be stored unloaded, in a locked container, separate from ammunition. Education programs for children have shown no benefit in preventing injury and death. Recommendation: Advise families to remove firearms from the homes of depressed, potentially suicidal adolescents.

EDUCATION AND ADVICE

BEHAVIOUR AND FAMILY ISSUES

Sleeping/Crying Resources
  1. Tips/recommendations for healthy sleep habits are available from Caring for Kids
  1. For information on shaken baby syndrome and abusive head trauma, see: www.dontshake.org
Crying References
ReferenceMethods and OutcomesFormer CTFPHC GRADE

Douglas P, Hill P. Managing infants who cry excessively in the first few months of life. BMJ. 2011 Dec 15;343:d7772. Abstract available from: PubMed

Methods

Subjects: Infants

Design: Clinical review

Methods: The authors searched in PubMed, Medline, CINHAL and the Cochrane Database for Systematic Reviews for systematic reviews, trials and cohort studies on the management of term infants who cry excessively in the first few months of life. They employed meta-narrative mapping to synthesize the evidence and did not assess the quality of the evidence. One of the authors   also interviewed 24 experts in infant cry-fuss behaviour from the disciplines of paediatrics, general practice, perinatal psychiatry, midwifery, community child health, speech pathology, lactation, social work, psychology, occupational therapy, and physiotherapy.

Outcomes

Based on their review of the literature, the authors map the possible causes of excessive infant crying and provide a practical guide intended for paediatricians, family physicians and other child health providers to assess and manage the crying baby. The assessment suggested includes specific questions to obtain history of feeding and elimination and simple instructions for the physical examination. Several management strategies that may be effective in otherwise healthy babies are listed and briefly explained. These include advice on breastfeeding, dealing with maternal mental health, cow’s milk allergy, advice about sleep, and sensory integration. The recommendation made deals with the development of a clinical approach to excessive crying.

Blunden SL, Thompson KR, Dawson D. Behavioural sleep treatments and night time crying in infants: challenging status quo. Sleep Med Rev. 2011;15(5):335-337.

PubMed

Methods

Background: This paper focuses on the behavioural techniques by which parents are trained and instructed to teach their child to sleep alone, sometimes known as extinction methods. Some behavioural extinction treatments necessitate a parent leaving an infant to cry for extended periods unattended, a practice reportedly difficult for parents. Despite parent’s anxieties and the potential stress to the infant, the pursuit of those behavioural sleep treatments are advocated by many psychologists and clinicians as acceptable and necessary interventions.

Subjects: Infants

Design: Theoretical review

Methods: The central debate in this paper is if and why an infant’s nocturnal cries should be ignored. 

Outcomes

Behavioural techniques could prevent parents from responding consistently and sensitively to their child, thereby leading to long-term adverse impacts on child-parent bonding, child stress regulation, mental health, and emotional development. These concerns originated with pure extinction (“crying-it-out”), which is not usually recommended nowadays because of the distress it causes parents and infants. However, the concerns have extended to extinction derivatives like controlled comforting and “camping out”.

Hemmi MH, Wolke D, Schneider S. Associations between problems with crying, sleeping and/or/feeding in infancy and long-term behavioural outcomes in childhood: a meta-analysis. Arch Dis Child. 2011;96:622-629.

Methods

Subjects: Children with regulatory problems

Design: Systematic review and meta-analysis

Methods: Authors performed a systematic review of the literature and a quantitative meta-analysis of 22 longitudinal studies from 1987 to 2006 that statistically tested the association between infant regulatory problems and childhood internalising, externalising and attention-deficit/hyperactivity disorder (ADHD) problem.  

Outcomes

The weighted mean effect size for the main regulatory problems-behavioural problems association was 0.41 (95% CI 0.28 to 0.54), indicating that children with previous regulatory problems have more behavioural problems than controls. Externalising and ADHD problems were the strongest outcome of any regulatory problem, indicated by the highest fail-safe N and lowest correlation of sample size to effect size. Meta-analyses of variance revealed no significant moderating influences of regulatory problem comorbidity (I(2)=44.0, p>0.05), type (I(2)=41.8, p>0.05) or duration (I(2)=44.0, p>0.05). However, cumulative problems and clinical referral increased the risk of behavioural problems. Conclusion: Children with previous regulatory problems have more behavioural problems than controls, particularly in multi-problem families.

McRury JM, Zolotor AJ. A randomized, controlled trial of a behavioral intervention to reduce crying among infants. J Am Board Fam Med. 2010 May-Jun;23(3):315-22. Abstract available from: PubMed

Methods

Subjects: Mothers and their newborns

Design: RCT

Methods: This study aimed to evaluate the efficacy of videotaped instruction of a behavioral intervention to reduce crying among newborns. Mothers of healthy, full-term newborns were recruited from the postpartum unit of a large community hospital for a prospective, randomized, controlled trial of an intervention to reduce infant crying. Mothers participating in the intervention viewed a videotape with instructions involving swaddling, side positioning, white noise, jiggling, and sucking. Mothers in the control group viewed a videotape with instructions for normal newborn care. 

Outcomes

Intervention was assessed by mean hours per day of infant total crying (fussing, crying, and unsoothable crying) and sleeping as recorded in a diary 3 days a week during the 1st, 4th, 6th, 8th, and 12th weeks of age; the Parenting Stress Index was also used during the 6th and 12th weeks. Fifty-one mother-infant pairs were recruited; 35 completed the study (18 intervention and 17 controls). Sixteen were lost to follow-up. There were no statistically significant differences between the groups in the hours of mean daily total crying or sleeping during the 1st, 4th, 6th, 8th, or 12th weeks of age. For example, during the 6th week of age mean daily total crying was 1.9 hours for infants in the control group versus 2.2 hours for infants in the intervention group (P = .4); sleep was 14.5 hours for infants in the control group versus 14.4 hours for infants in the intervention group (P = .8). During the 12th week mean daily total crying was 1.2 hours for infants in the control group versus 1.8 hours for infants in the intervention group (P = .8) and sleep was 14.1 hours for infants in the control group versus 14.0 hours for infants in the intervention group (P = 1.0). There was no difference between the groups in the Parenting Stress Index during the 6th week of age. Conclusion: The behavioural intervention was not efficacious in decreasing total crying among infants.

Canadian Pediatric Society. Joint statement on shaken baby syndrome. Paediatr Child Health. 2001;6(9):663-7. Abstract available from: PubMed

Methods

Subjects: Infants

Design: Position statement

Review of the evidence on shaken baby syndrome to inform the community and develop effective preventive strategies.

Outcomes

Shaken baby syndrome is a condition that occurs in young infants when they are shaken violently by a parent or caregiver. The main injury is usually impact trauma to the head. The CPS states that the main preventive strategy is to disseminate information to the community to “Never shake a baby!”as well as to provide resources to parents who are angry or frustrated because of an infant’s crying or behaviour. Recommendations: 1) Strategies should provide the general public and targeted audiences not just with the caution regarding shaking a baby but with guidance for coping with the demands of a baby. 2) National, provincial/territorial, regional and local preventive strategies should include an increased implementation of accessible parent support programs. 3) Approaches targeted to those at higher risk for violence include child development, parenting programs and anger management.

Colic
ReferenceMethods and OutcomesFormer CTFPHC GRADE

Dobson D, Lucassen PL, Miller JJ, Vlieger AM, Prescott P, Lewith G. Manipulative therapies for infantile colic. Cochrane Database Syst Rev. 2012 Dec 12;12:CD004796. Abstract available from: PubMed

Methods

Subjects: Infants

Design: Cochrane review

Methods: Searched electronic databases to identify and evaluate  the results of randomized trials designed to address efficacy or effectiveness of manipulative therapies (specifically, chiropractic, osteopathy and cranial manipulation) for infantile colic in infants less than six months of age. 

Outcomes

Authors identified six studies for inclusion with a total of 325 infants. Of the six included studies, five were suggestive of a beneficial effect and one found no evidence that manipulative therapies had any beneficial effect on the natural course of infantile colic. Tests for heterogeneity imply that there may be some underlying difference between this study and the other five. Five studies measured daily hours of crying and these data were combined, suggesting that manipulative therapies had a significant effect on infant colic - reducing average crying time by one hour and 12 minutes per day (mean difference (MD) -1.20; 95% confidence interval (CI) -1.89 to -0.51). This conclusion is sustained even when considering only studies with a low risk of selection bias (sequence generation and allocation concealment) (MD -1.24; 95% CI -2.16 to -0.33); those with a low risk of attrition bias (MD -1.95; 95% CI -2.96 to -0.94), or only those studies that have been published in the peer-reviewed literature (MD -1.01; 95% CI -1.78 to -0.24). However, when combining only those studies with a low risk of performance bias (parental 'blinding'), the improvement in daily crying hours was not statistically significant (MD -0.57; 95% CI -2.24 to 1.09).One study considered whether the reduction in crying time was clinically significant. This found that a greater proportion of parents of infants receiving a manipulative therapy reported clinically significant improvements than did parents of those receiving no treatment (reduction in crying to less than two hours: odds ratio (OR) 6.33; 95% CI 1.54 to 26.00; more than 30% reduction in crying: OR 3.70; 95% CI 1.15 to 11.86).Analysis of data from three studies that measured 'full recovery' from colic as reported by parents found that manipulative therapies did not result in significantly higher proportions of parents reporting recovery (OR 11.12; 95% CI 0.46 to 267.52).One study measured infant sleeping time and found manipulative therapy resulted in statistically significant improvement (MD 1.17; 95% CI 0.22 to 2.12).The quality of the studies was variable. There was a generally low risk of selection bias but only two of the six studies were evaluated as being at low risk of performance bias, three at low risk of detection bias and one at low risk of attrition bias. One of the studies recorded adverse events and none were encountered. The authors conclude that the studies included in this meta-analysis were generally small and methodologically prone to bias, which makes it impossible to arrive at a definitive conclusion about the effectiveness of manipulative therapies for infantile colic. The majority of the included trials appeared to indicate that the parents of infants receiving manipulative therapies reported fewer hours crying per day than parents whose infants did not, based on contemporaneous crying diaries, and this difference was statistically significant. The trials also indicate that a greater proportion of those parents reported improvements that were clinically significant. However, most studies had a high risk of performance bias due to the fact that the assessors (parents) were not blind to who had received the intervention. When combining only those trials with a low risk of such performance bias, the results did not reach statistical significance. No definitive conclusion. 

Healthy Sleep Habits
ReferenceMethods and OutcomesFormer CTFPHC GRADE

Galland BC, Taylor BJ, Elder DE, Herbison P. Normal sleep patterns in infants and children: a systematic review of observational studies. Sleep Med Rev. 2012 Jun;16(3):213-22. Abstract available from: PubMed

Methods

Subjects: Infants and children 0-12 years

Design: Systematic review of observational studies

Methods: Reviewed the scientific literature for longitudinal and cross-sectional data on normal sleep patterns in infants and children. 

Outcomes

Mean and variability data for sleep duration, number of night wakings, sleep latency, longest sleep period overnight, and number of daytime naps were extracted from questionnaire or diary data from 34 eligible studies. The best-fit (R(2)=0.89) equation for hours over the 0-12 year age range was 10.49-5.56×[(age/10)^0.5-0.71]. Night waking data provided 4 age-bands up to 2 years ranging from 0 to 3.4 wakes per night for infants (0-2 months), to 0-2.5 per night (1-2 year-olds). Sleep latency data were sparse but estimated to be stable across 0-6 years. Conclusions:  Reference values (means) and ranges (±1.96 SD) for sleep duration (hours) were: infant, 12.8 (9.7-15.9) and toddler/preschool, 11.9 (9.9-13.8).

Gagnon AJ, Bryanton J. Postnatal parental education for optimizing infant general health and parent-infant relationships. Cochrane Database of Systematic Reviews. 2009;1. Art. No.: CD004068. Abstract available from: PubMed

Methods

Subjects: one or both parents of infant

Design: Cochrane review

Methods: Performed systematic literature search to identify studies examining interventions being used to educate new parents about caring for themselves and their newborns during this time. 

Outcomes

Of the 25 trials (3,689 mothers and 793 fathers) that met the inclusion criteria, only 15 (2,868 mothers and 613 fathers) reported useable data. Educational interventions included: four on infant sleep enhancement, 13 on infant behaviour, two on general post-birth health, two on infant care, three on infant safety, and one on father involvement/skills with infants. Details of the randomization procedures, allocation concealment, blinding, and participant loss were often not reported. Of the outcomes analyzed, only six were measured similarly enough by more than one study to be combined in meta-analyses. Of these six meta-analyses, only two were found to have a low enough level of heterogeneity to provide an overall estimate of effect. Education on sleep enhancement resulted in a mean difference of 29 more minutes of infant sleep in 24 hours (95% confidence interval (CI) 18.53 to 39.73) than usual care. Education on infant behaviour increased maternal knowledge of infant behaviour by a mean difference of 2.85 points (95% CI 1.78 to 3.91). Four studies included (St James-Roberts 2001; Stremler 2006; Symon 2005; Wolfson 1992) were on infant sleep enhancement. Conclusion: Education on sleep enhancement appears to increase infant sleep. 

Ednick M, Cohen AP, McPhail GL, Beebe D, Simakajornboon N, Amin RS. A review of the effects of sleep during the first year of life on cognitive, psychomotor, and temperament development. Sleep. 2009;32(11):1449-1458.

PubMed

Methods

Subjects: Infants

Design: Review of the literature

Methods: Assessed relevant published literature to determine what is currently known of the effects of sleep during infancy on cognitive, psychomotor, and temperament development. The authors offer as preface an overview of brain maturation, sleep development, and various assessment tools of both sleep and development. 

Outcomes

It is impossible to conclude that a causal relationship exists between infant sleep and cognitive, psychomotor, and temperament development due to important heterogeneity between studies. For mental development, the 13 studies included reported low to moderate significant correlations between various sleep characteristics and mental development scores. For psychomotor development, the 3 of the 5 studies included reported no significant association between sleep and motor development; one study showed that on day 1 on life, increased mean sleep period and decreased sleep-wake transition were predictive of lower motor scores and increased amount of quiet sleep was predictive of lower motor scores; another study found that infants who had more wakefulness at birth and those who showed declining rates in their out of crib time, performed better on psychomotor scales. For temperament development, significant correlations were found between various measures of sleep and temperament at different time points. Conclusion: Early screening of sleep-related issues may be a useful tool to guide targeted prevention and early intervention.

Hiscock H, Bayer JK, Hampton A, Ukoumunne OC, Wake M. Long-term mother and child mental health effects of a population-based infant sleep intervention: cluster-randomized, controlled trial. Pediatrics. 2008 Sep;122(3):e621-7. Abstract available from: Pediatrics

Methods

Subjects: Mothers and infants

Design: Cluster-randomized trial

Methods: Set in well-child centers across 6 government areas of Melbourne, Australia. Participants included 328 mothers reporting an infant sleep problem at 7 months, drawn from a population sample (N = 739) recruited at 4 months. Authors compared the usual well-child care (n = 154) versus a brief behaviour-modification program designed to improve infant sleep (n = 174) delivered by well-child nurses at ages 8 to 10 months and measured maternal depression symptoms (Edinburgh Postnatal Depression Scale); parenting practices (Parent Behavior Checklist); child mental health (Child Behavior Checklist); and maternal report of a sleep problem (yes or no). 

Outcomes

At 2 years, mothers in the intervention group were less likely than control mothers to report clinical depression symptoms: 15.4% vs 26.4% (Edinburgh Postnatal Depression Scale community cut point) and 4.2% vs 13.2% (Edinburgh Postnatal Depression Scale clinical cut point). Neither parenting style nor child mental health differed markedly between the intervention and control groups. A total of 27.3% of children in the intervention group versus 32.6% of control children had a sleep problem.

Pin, T., Eldridge, B., & Galea, M.P. A review of the effects of sleep position, play position, and equipment use on motor development in infants. Developmental Medicine & Child Neurology. 2007;49(11):858-867.

PubMed

Methods

Subjects: Infants

Design: Systematic review

Methods: Electronic databases (Medline, CINAHL, PsycINFO, Embase, full Cochrane Library, and the Physiotherapy Evidence Database [PEDro]) were searched from the earliest date until June 2007 to identify studies investigating the relation between different play / sleep positions and/or use of infant equipment and the motor development of the participants. 

Outcomes

Nineteen studies with evidence at level II were selected against the selection criteria and scored against the Physiotherapy Evidence Database scale. Despite the generally poor methodological quality, the studies have consistently shown that there was transient delay in motor development for healthy term and low-risk preterm infants who were not exposed to the prone position or who did not use infant equipment. However, most of these infants walked unaided within a normal time frame. Limited evidence was found for the effect on more vulnerable infants. 

Swaddling Recommendations Strength of Recommendation
  1. Proper swaddling of the infant for the first 6 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.

Consensus

Swaddling References
ReferenceMethods and OutcomesFormer CTFPHC GRADE

Manaseki-Holland S, Spier E, Bavuusuren B, Bayandorj T, Sprachman S, Marshall T. Effects of traditional swaddling on development: a randomized controlled trial. Pediatrics. 2010 Dec;126(6):e1485-92. Abstract available from: PubMed  

Methods

Subjects: Healthy newborns

Design: Randomized controlled trial

Methods: This trial aimed to test whether infants not swaddled or swaddled tightly in a traditional setting have significantly different scores on a development scale. 1,279 newborns in Mongolia were allocated at birth to traditional swaddling or nonswaddling. The families received 7 months of home visits to collect data and monitor compliance. At 11 to 17 months of age, the Bayley Scales of Infant Development (II) was administered to 1,100 children.

Outcomes

No significant between-group differences were found in mean scaled mental and psychomotor developmental scores. The unadjusted mean difference between the groups was -0.69 (95% confidence interval [CI]: -2.59 to 1.19) for psychomotor and -0.42 (95% CI: -1.68 to 0.84) for mental scores in favour of the swaddling group. A subgroup analysis of the compliant sample produced similar results. BSID-II-scaled psychomotor and mental scores were 99.98 (95% CI: 99.03-100.92) and 105.52 (95% CI: 104.89-106.14), respectively. Background characteristics were balanced across the groups. The Mongolian infants in this trial had scaled BSID-II mental and psychomotor scores comparable to United States norms. Conclusion: In the Mongolian context, prolonged swaddling in the first year of life did not have any significant impact on children's early mental or psychomotor development.

van Sleuwen BE, Engelberts AC, Boere-Boonekamp MM, Kuis W, Schulpen TWJ, L’hoir MP. Swaddling: A Systematic Review. Pediatrics. 2007; 120: e1097-e1106. Abstract available from: PubMed

Methods

Subjects: Infants

Design: Systematic review

Methods: Performed an electronic search of PubMed, PsycINFO, Embase, Cochrane Library and Blackwell Synergy. The articles looked at 10 topics associated with swaddling: sleep and arousal, temperature control, motor development, SIDS, rickets and developmental dysplasia of the hip (DDH), respiratory infections, pain control, crying behaviour, breastfeeding as well as swaddling start and duration. 

Outcomes

Seventy-eight articles, including 9 RCTs, met the inclusion criteria. The review reports that there are potential benefits and harms of swaddling. Healthy infants have less startles, less arousals and longer sleep when swaddled. Swaddling can also benefit preterm infants, decrease crying and does not negatively impact breastfeeding. Potential harms include an increased risk for DDH, SIDS (when infant placed prone), and overheating.  Because of the potential benefits and harms, the authors did not reach conclusions regarding recommendations for swaddling.   

Gerard CM, Harris KA, Thach BT. Spontaneous arousals in supine infants while swaddled and unswaddled during rapid eye movement and quiet sleep. Pediatrics. 2002; 110(6):e70. Abstract available from: PubMed

Methods

Subjects: Infants

Design: Non-randomized cross-over controlled trial

Methods: Infants were observed during nap times in alternate swaddled and unswaddled (left in a free state) conditions. Behavioural cues determined whether the infant was in REM or quiet sleep (QS).

Outcomes

Outcomes were sighs, startles and full arousals. This study found that swaddling had a significant effect in preventing the progression of arousals in QS. It also decreased spontaneous arousals in QS and increased duration of REM sleep. The study reports that this could potentially help the baby return to sleep without parent intervention and that a safe form of swaddling (allowing for hip flexion and chest wall excursion) may be beneficial.

Night Waking Recommendations Strength of Recommendation
  1. Counseling around positive bedtime routines (including training the child to fall asleep alone), keeping morning awakening time consistent, and rewarding good sleep behaviour has been shown to reduce the prevalence of night waking, especially when this counseling begins in the first 3 weeks of life.

Good

Night Waking Recommendations
ReferenceMethods and OutcomesFormer CTFPHC GRADE

Garrison MM, Christakis DA. The impact of a healthy media use intervention on sleep in preschool children. Pediatrics. 2012;130(3):1-8.

Pediatrics

Methods

Subjects: families of children aged 3 to 5 years

Design: randomized controlled trial

Methods: this RCT evaluated the influence of an intervention based on social cognitive theory that encouraged families to replace violent or age-inappropriate media content with quality educational and prosocial content, through an initial home visit and follow-up telephone calls over 6 months. In the intervention group, parents were also encouraged to engage in co-viewing and to discuss media content with their children, because co-viewing can increase parent awareness of the media content consumed. Representative recommended shows included Curious George, Sesame Street, and Dora the Explorer. Sleep measures were derived from the Child Sleep Habits Questionnaire and collected at 6, 12, and 18 months after baseline. 

Outcomes

This article focuses on sleep outcomes; however, the primary outcomes of the trial were decreased aggressive behaviour and increased prosocial behaviours. Among the 565 children analyzed, the most common sleep problem was delayed sleep-onset latency (38%). Children in the intervention group had significantly lower odds of “any sleep problem” at follow-up in the repeated-measures analysis (odds ratio = 0.36; 95% confidence interval: 0.16 to 0.83), with a trend toward a decrease in intervention effect over time (P = .07). Although there was no significant effect modification detected by baseline sleep or behaviour problems, gender, or low-income status, there was a trend (P = .096) toward an increased effect among those with high levels of violence exposure at baseline. Conclusion: The significant effects of a healthy media use intervention on child sleep problems in the context of a randomized controlled trial suggest that the previously reported relationship between media use and child sleep problems is indeed causal in nature. Recommendation: Clinicians and parents should be mindful that healthy media use choices could be a valuable strategy in treating and preventing child sleep problems.

Mindell JA, Kuhn B, Lewin DS, Meltzer LJ, Sadeh A; American Academy of Sleep Medicine. Behavioral treatment of bedtime problems and night wakings in infants and young children. Sleep. 2006;29(10):1263-1276. Abstract available from: PubMed

Methods

Subjects: Young children

Design: Review

Methods: A task force appointed by the American Academy of Sleep Medicine reviewed the evidence regarding the efficacy of behavioral treatments for bedtime problems and night wakings in young children. Treatment studies selected for review were identified through PsycLIT and MEDLINE searches (1970-2005).  

Outcomes

52 intervention studies were reviewed in which nearly half of the subject pool (n=1,135) participated in the methodologically strongest studies employing a randomized controlled trial design. Interventions for bedtime problems and night wakings consist primarily of time-limited parent training strategies that incorporate behaviorally-based interventions, founded on principles of learning and behavior (e.g., reinforcement, extinction, shaping). Parent training typically involves a therapist “coaching” the parents to become the active agents of change to address their child’s problematic sleep patterns, habits, or sleep-related behaviors. Among the many forms of behavioral health services for young children, no other treatment has been more thoroughly investigated or widely applied as parent management training. The findings indicate that behavioral therapies produce reliable and durable changes. Across all studies, 94% report that behavioral interventions were efficacious, with over 80% of children treated demonstrating clinically significant improvement that was maintained for 3 to 6 months. In particular, empirical evidence from controlled group studies utilizing Sackett criteria for evidence-based treatment provides strong support for unmodified extinction and preventive parent education. Conclusion: Evidence supports the use of unmodified extinction, graduated extinction, bedtime fading/positive routines, scheduled awakenings, and preventive parent education

Symon BG, Marley JE, Martin AJ, Norman ER. Effect of a consultation teaching behaviour modification on sleep performance in infants: A randomized controlled trial. MJA. 2005; 182(5): 215-218. Abstract available from: PubMed

Methods

Subjects: Infants

Design: RCT

Methods: Families with newborn infants were randomized to a control group or an intervention group consisting of a consultation with a nurse 2 to 3 weeks after birth.  The consultation included a tutorial discussion on normal sleep patterns as well as related written material.

Outcomes

Out of 1,001 families contacted, 346 were randomized to the control or intervention groups and 268 were included in the statistical analysis (i.e., reached 6- or 12-week follow-up). The intervention group had greater mean total hours of sleep, hours of night sleep and hours of daytime sleep per 24hour period, both at 6 and 12 weeks. The study found that  a single consultation 2 to 3 weeks after a child’s birth can significantly improve a child’s sleep performance, and this effect is maintained at 3 months of age.

Kerr SM, Jowett SA, Smith LN. Preventing sleep problems in infants: a randomized controlled trial. J Adv Nurs. 1996 Nov;24(5):938-42. Abstract available from: PubMed

Methods

Subjects: Parents and their infant

Design: Randomized controlled trial

Methods: 202 families were randomly selected to either intervention group which consisted of sleep health education (home visit, education booklet) or to a control group. The information and advice provided in the intervention group was research based and focused on two main areas, namely settling methods and the importance of routine. Parental knowledge of sleep and settling behaviour was manipulated when the children in the intervention group were 3 months old. The sleeping behaviour of the infants in both groups was compared 6 months later, when the children were 9 months old. 

Outcomes

Data was collected from 86 families in the intervention group and 83 families in the control group. For settling and night waking difficulties, a significantly smaller percentage of babies in the intervention group presented with difficulties (21% and 23% respectively) as compared to the control group (39% and 46% respectively) (all P values < 0.05). Conclusion: Sleep health education appears to have benefits on settling and night waking in infants.

Discipline/Parenting Education Programs/Parenting Skills Recommendations Strength of Recommendation
  1. 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.

Good

  1. Refer parents of children at risk of, or showing signs of, behavioral or conduct problems to structured parenting programs which have been shown to increase positive parenting, improve child compliance, and reduce general behavior problems. Access community resources to determine the most appropriate and available research-structured programs. (eg. The Incredible Years, Right from the Start, COPE program).

Good

Discipline/Parenting Education Programs/Parenting Skills Resources
  1. Evidence-based programs for parents, children and teachers: The Incredible Years
  2. Parenting courses: Right from the Start
  3. Encyclopedia on Early Childhood Development: CEED Parenting Skills
Discipline/Parenting Education Programs/Parenting Skills References
ReferenceMethods and OutcomesFormer CTFPHC GRADE

Campbell KJ, Lioret S, McNaughton SA, Crawford DA, Salmon J, Ball K, McCallum Z, Gerner BE, Spence AC, Cameron AJ, Hnatiuk JA, Ukoumunne OC, Gold L, Abbott G, Hesketh KD. A parent-focused intervention to reduce infant obesity risk behaviors: a randomized trial. Pediatrics. 2013 Apr;131(4):652-60. Abstract available from: PubMed

Methods

Subjects: Infants

Design: Cluster RCT

Methods: To assess the effectiveness of a parent-focused intervention on infants' obesity-risk behaviors and BMI, 542 parents and their infants (mean age 3.8 months at baseline) were recruited from 62 first-time parent groups. Parents were offered six 2-hour dietitian-delivered sessions over 15 months focusing on parental knowledge, skills, and social support around infant feeding, diet, physical activity, and television viewing. Control group parents received 6 newsletters on nonobesity-focused themes; all parents received usual care from child health nurses.

Outcomes

The primary outcomes of interest were child diet (3 × 24-hour diet recalls), child physical activity (accelerometry), and child TV viewing (parent report). Secondary outcomes included BMI z-scores (measured). Data were collected when children were 4, 9, and 20 months of age. Unadjusted analyses showed that, compared with controls, intervention group children consumed fewer grams of noncore drinks (mean difference = -4.45; 95% confidence interval [CI]: -7.92 to -0.99; P = .01) and were less likely to consume any noncore drinks (odds ratio = 0.48; 95% CI: 0.24 to 0.95; P = .034) midintervention (mean age 9 months). At intervention conclusion (mean age 19.8 months), intervention group children consumed fewer grams of sweet snacks (mean difference = -3.69; 95% CI: -6.41 to -0.96; P = .008) and viewed fewer daily minutes of television (mean difference = -15.97: 95% CI: -25.97 to -5.96; P = .002). There was little statistical evidence of differences in fruit, vegetable, savory snack, or water consumption or in BMI z-scores or physical activity. Conclusion: A group-level low-dose intervention focused on parent knowledge and skills may reduce sweet snack consumption and television viewing in young children.

Comer JS, Chow C, Chan PT, Cooper-Vince C, Wilson LA. Psychosocial treatment efficacy for disruptive behavior problems in very young children: a meta-analytic examination. J Am Acad Child Adolesc Psychiatry. 2013 Jan;52(1):26-36.

Methods

Subjects: Children

Design: Meta-analysis

Methods: We used random-effects meta-analytic procedures to empirically evaluate the overall effect of psychosocial treatments on early disruptive behavior problems, as well as potential moderators of treatment response. Thirty-six controlled trials, evaluating 3,042 children, met selection criteria (mean sample age, 4.7 years; 72.0% male; 33.1% minority youth). 

Outcomes

Psychosocial treatments collectively demonstrated a large and sustained effect on early disruptive behavior problems (Hedges' g = 0.82), with the largest effects associated with behavioral treatments (Hedges' g = 0.88), samples with higher proportions of older and male youth, and comparisons against treatment as usual (Hedges' g = 1.17). Across trials, effects were largest for general externalizing problems (Hedges' g = 0.90) and problems of oppositionality and noncompliance (Hedges' g = 0.76), and were weakest, relatively speaking, for problems of impulsivity and hyperactivity (Hedges' g = 0.61). Conclusion: Psychosocial treatment options for early disruptive behaviour problems, especially behavioural methods which target child problems indirectly by reshaping parenting practices, may have large positive effects.

Shelleby EC, Shaw DS, Cheong J, Chang H, Gardner F, Dishion TJ, Wilson MN. Behavioral control in at-risk toddlers: the influence of the family check-up. J Clin Child Adolesc Psychol. 2012 May;41(3):288-301. Abstract available from: PubMed

Methods

Subjects: Primary caregiver-child dyads. Children were at risk for externalizing problems on the basis of child, family, and sociodemographic factors.

Design: RCT

Methods: This study examined the role of behavioural control on children's early behaviour problems by examining whether increases in parental positive behaviour support brought about by a family-centered intervention were associated with greater child behavioural control. The sample included 713 at-risk children and their primary caregivers who were randomly assigned to the intervention or control group.

Outcomes

Results indicated that the intervention improved parental positive behaviour support and reduced growth of child behaviour problems. One dimension of positive behaviour support, proactive parenting, was modestly associated with behavioural control at age 3, which in turn was significantly associated with growth in behaviour problems from ages 2 to 4, with greater behavioural control related to lower levels of growth in behaviour problems. Results provide support for the notion that proactive parenting is an important factor in the development of children's behavioural control and that behavioural control plays an important role in the growth of behaviour problems. Conclusion: A parenting intervention to increase proactive parenting may have benefits on child behaviour problems.

Landry SH, Smith KE, Swank PR, Zucker T, Crawford AD, Solari EF. The effects of a responsive parenting intervention on parent-child interactions during shared book reading. Dev Psychol. 2012 Jul;48(4):969-86.  Abstract available from: PubMed

Methods

Subjects: Mothers from low-income backgrounds and their infant

Design: RCT

Methods: This study examined whether the Play and Learning Strategies (PALS) intervention that targets global parenting techniques by facilitating a range of responsive behaviours in everyday activities can also support mothers’ use of more effective shared book reading behaviours and children’s engagement and use of language. Four groups of randomized mothers and their children (PALS I-II, PALS I-DAS II, DAS I-PALS II, DAS I-II) were observed in shared reading interactions during the toddler-preschool period and coded for (a) mother's affective and cognitive-linguistic supports and (b) child's responses to maternal requests and initiations.

Outcomes

The efficacy of PALS was previously demonstrated for improving mother and child behaviours within play contexts, everyday activities, and standardized measures of child language. Authors hypothesized that PALS effects would generalize to influence maternal and child behaviours during a shared reading task even though this situation was not a specific focus of the intervention and that this would be similar for children who varied in biological risk. Participation in at least PALS II was expected to have a positive effect due to children's increased capacity to engage in book reading at this age. Support was found for significant changes in observed maternal and child behaviours and evidence of mediation was found for the intervention to affect children's behaviours through change in maternal responsiveness behaviours. These results add to other studies supporting the importance of targeting a broad range of responsive behaviours across theoretical frameworks in interventions to facilitate children's development. Conclusion: An intervention that targets global parenting techniques may be effective in supporting mothers’ use of more effective shared book reading behaviours.

Lioret S, Campbell KJ, Crawford D, Spence AC, Hesketh K, McNaughton SA. A parent focused child obesity prevention intervention improves some mother obesity risk behaviors: the Melbourne inFANT program. Int J Behav Nutr Phys Act. 2012 Aug 28;9:100.

PubMed

Methods

Subjects: Mothers and newborns

Design: Cluster-RCT

Methods: The Melbourne InFANT Program aimed to assess the effect of a parent-focused early childhood obesity prevention intervention on first-time mothers' diets, physical activity and TV viewing time. The intervention focused on parenting skills and strategies, including parental modeling, and aimed to promote development of healthy child and parent behaviors from birth, including healthy diet, increased physical activity and reduced TV viewing time.

Outcomes

The scores of both the "High-energy snack and processed foods" and the "High-fat foods" dietary patterns decreased more in the intervention group: -0.22 (-0.42;-0.02) and -0.25 (-0.50;-0.01), respectively. No other significant intervention vs. control effects were observed regarding total physical activity, TV viewing time, and the two other dietary patterns, i.e. "Fruits and vegetables" and "Cereals and sweet foods". Conclusion: A low intensity childhood obesity prevention intervention which focuses on parenting skills to promote positive lifestyle behaviours may improve mother’s dietary patterns.

Taveras EM, Gortmaker SL, Hohman KH, Horan CM, Kleinman KP, Mitchell K, Price S, Prosser LA, Rifas-Shiman SL, Gillman MW. Randomized controlled trial to improve primary care to prevent and manage childhood obesity: the High Five for Kids study. Arch Pediatr Adolesc Med. 2011 Aug;165(8):714-22. Abstract available from: PubMed

Methods

Subjects: overweight/obese children aged 2 to 7 years and parents

Design: Cluster RCT

Methods: This study aimed to examine the effectiveness of a primary care-based obesity intervention over the first year (6 intervention contacts) of a planned 2-year study. It took place in 10 paediatric practices, 5 intervention and 5 usual care. Intervention practices received primary care restructuring, and families received motivational interviewing by clinicians and educational modules targeting television viewing and fast food and sugar-sweetened beverage intake.

Outcomes

Outcome measures were change in BMI and obesity-related behaviours from baseline to 1 year. Compared with usual care, intervention participants had a smaller, nonsignificant change in BMI (-0.21; 95% confidence interval [CI], -0.50 to 0.07; P = .15), greater decreases in television viewing (-0.36 h/d; 95% CI, -0.64 to -0.09; P = .01), and slightly greater decreases in fast food (-0.16 serving/wk; 95% CI, -0.33 to 0.01; P = .07) and sugar-sweetened beverage (-0.22 serving/d; 95% CI, -0.52 to 0.08; P = .15) intake. In post hoc analyses, we observed significant effects on BMI among girls (-0.38; 95% CI, -0.73 to -0.03; P = .03) but not boys (0.04; 95% CI, -0.55 to 0.63; P = .89) and among participants in households with annual incomes of $50 000 or less (-0.93; 95% CI, -1.60 to -0.25; P = .01) but not in higher-income households (0.02; 95% CI, -0.30 to 0.33; P = .92). Conclusion: The High Five for Kids intervention in primary care setting may reduce television viewing in children.

Gagnon AJ, Bryanton J. Postnatal parental education for optimizing infant general health and parent-infant relationships. Cochrane Database of Systematic Reviews. 2009;1. Art. No.: CD004068.

PubMed

Methods

Subjects: One or both parents of infant

Design: Cochrane review

Methods: Performed systematic literature search to identify studies examining interventions being used to educate new parents about caring for themselves and their newborns during this time. 

Outcomes

Of the 25 trials (3,689 mothers and 793 fathers) that met the inclusion criteria, only 15 (2,868 mothers and 613 fathers) reported useable data. Educational interventions included: four on infant sleep enhancement, 13 on infant behaviour, two on general post-birth health, two on infant care, three on infant safety, and one on father involvement/skills with infants. Details of the randomization procedures, allocation concealment, blinding, and participant loss were often not reported. Of the outcomes analyzed, only six were measured similarly enough by more than one study to be combined in meta-analyses. Of these six meta-analyses, only two were found to have a low enough level of heterogeneity to provide an overall estimate of effect. Education on sleep enhancement resulted in a mean difference of 29 more minutes of infant sleep in 24 hours (95% confidence interval (CI) 18.53 to 39.73) than usual care. Education on infant behaviour increased maternal knowledge of infant behaviour by a mean difference of 2.85 points (95% CI 1.78 to 3.91). Conclusion: Education on sleep enhancement appears to increase infant sleep and education about infant behaviour potentially enhances mothers' knowledge.

Fergusson D, Stanley L, Horwood J. Preliminary data on the efficacy of the Incredible Years Basic Parent Programme (IYBPP) in New Zealand. Australian and New Zealand Journal of Psychiatry. 2009; 43:76-79. Abstract available from: PubMed

Methods

Subjects: 2½ to 8 years old

Design: Non-randomized controlled trial

Methods: Participants attended IYBPP session. Data was gathered from parents using self-completed questionnaires. Outcomes included pre-test-post-test comparisons and parental satisfaction.

Outcomes

Based on preliminary data (from agency records rather than based on a systematic research design) the results of the pre-test-post-test comparisons are positive. There was significant improvement in test scores at post-test assessment. Effect sizes were in the range of moderate to large. Parents’ responses to the program were positive overall. This study found that there seem to be improvements in scores after a minimum of 9 sessions of the IYBPP. A more rigorous evaluation of the IYBPP is needed.

Jones K, Daley D, Hutchings J, Bywater T, Eames C. Efficacy of the Incredible Years programme as an early intervention for children with conduct problems and ADHD: long-term follow-up. Child: care, health and development. 2008;34(3):380-390. Abstract available from: PubMed

Methods

Subjects: 3 to 5 years old

Design: RCT

Methods: Participants for this study were drawn from an existing sample of 133 families from an on-going RCT, 79 were eligible for inclusion. Fifty were randomized into intervention and 29 into control group. The intervention received the Incredible Years parenting programme (a 2-hour session once a week for 12 weeks)

Outcomes

In the short-term, mean scores on the Conners rating scale decreased from 20.56 to 14.6. 52% of children in the intervention group showed improvements compared to 21% in the control group. These results remained stable over time. There was a significant reduction in ADHD symptoms at post-intervention assessment. Intervention gains were maintained for at least a year after the programme’s completion. According to the authors, these results show good potential for the Incredible Years Parenting Program.

Melhuish E, Belsky J, Leyland AH, Barnes J, and the National Evaluation of Sure Start Research Team. Effects of fully-established Sure Start Local Programmes on 3-year-old children and their families living in England: a quasi-experimental observational study. Lancet. 2008;372 :1641-1647. Abstract available from: PubMed

Methods

Subjects: 3 years old

Design: Quasi-randomized controlled trial

Methods: Children were randomly selected from the Millennium Cohort study and compared to controls. All participants were from low socioeconomic status (SES) families. The authors looked at 14 outcomes.

Outcomes

In this trial, five of the 14 outcomes showed beneficial effects of the SSLP intervention: better social development, more positive social behaviour, greater independence, less negative parenting and a better home-learning environment. Overall, children in the intervention group had more benefits than those in the control group. This study showed the effects of SSLP to be positive with no adverse effects. According to this study, early interventions may improve the life course of many children living in low SES families. 

Canadian Paediatric Society. Effective discipline for children. Paediatric & Child Health. 2004; 9(1): 37-41. Reaffirmed January 2013. Available from: PMC

Methods

Subjects: Children

Design: Position statement

Methods: Review of evidence for effective discipline of children, role of the physician, developmental considerations, forms of discipline, setting rules and applying consequences.

Outcomes

The CPS recommends that physicians should ask non-judgmentally about discipline techniques used in the home and should counsel parents on forms appropriate to the child’s developmental level. Discipline is about changing behaviour and not punishing the child. Spanking and other forms of physical punishment are associated with negative child outcomes therefore the CPS strongly discourages spanking.

Minkovitz CS, Hughart N, Strobino D, Scharfstein D, Grason H, Hou W, et al. A practice-based intervention to enhance quality of care in the first 3 years of life: the Healthy Steps for Young Children Program. JAMA 2003;290(23):3081-91. Abstract available from: http://www.ncbi.nlm.nih.gov/pubmed/14679271

Methods

Subjects: 0 to 3 years old

Design: Prospective controlled clinical trial

Methods: Children enrolled at birth and followed up until 3 years old. There were 6 randomization sites and 9 quasi-randomized sites (pediatric practices) across the US. The intervention (Healthy Steps Program) included incorporating developmental specialists and enhanced developmental services into pediatric care. The control group was given standard pediatric care.

Outcomes

In total 5565 families were enrolled, 88% completed interviews at 2 to 4 months and 67.2% completed interviews at 30 and 33 months.  There were 4 main domains to determine quality care: effectiveness, patient-centeredness, timeliness and efficiency. Measures included: discussing more than 6 anticipatory guidance topics, being highly satisfied with care provided, receiving timely well-child visits and vaccinations and remaining at the practice for 20 months or longer.  Overall, families that participated in the Healthy Steps Program had greater odds of receiving 4 or more Healthy Steps related services compared to controls. Parenting skills also improved with reduced odds of severe discipline (slapping or spanking with object).  Possible limitations are that parents that completed the 30 to 33 month interview were more socially advantaged than the average enrolled population. This would lead to an overestimation if families lost to follow up would require more intensive interventions.

Barlow J, Stewart-Brown D. Behaviour problems and group-based parent education programs. J Dev Behav Pediatr 2000;(21)5:356-70. Abstract available from: http://www.ncbi.nlm.nih.gov/pubmed/11064964

Methods

Subjects: 3 to 10 years old

Design: Review article

Methods: An electronic review of the literature was performed from 1970 to 1997. Inclusion criteria for studies included: randomized trials, study participants from age 3 to 10, the intervention had to include at least one group-based parent education program and at least one standardized child behaviour outcome measures (parent report or independent observation).

Outcomes

A total of 255 primary studies were retrieved but only 16 studies met the inclusion criteria. Six of the 16 studies used rigorous methods for randomization, whereas several other studies were methodologically flawed. Examples of the types of programs studied were verbal instruction with manual or pamphlet supplementation and Webster-Stratton’s video-tape modelling.  Of the five studies that used parent report to determine effect sizes, all programs showed a positive change in parent perception of child behaviour.  Group-based programs produced better results than individual or self-administered programs.  All studies but one showed long term beneficial effects of programs on children’s behaviour.  

Family Healthy Active Living/Sedentary Behaviour Recommendations Strength of Recommendation
  1. 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.

Good

  1. Counsel on appropriate media use; for children <2 years, screen time (eg, TV, computer, electronic games) is not recommended; for children 2-4 years, screen time should be limited to <1 h/day; less is better; educational and prosocial programming is better.

Fair

Family Healthy Active Living/Sedentary Behaviour Resources
  1. The Canadian Physical Activity Guidelines and Canadian Sedentary Behaviour Guidelines
Family Healthy Active Living/Sedentary Behaviour References
ReferenceMethods and OutcomesFormer CTFPHC GRADE

Christakis DA, Garrison MM, Herrenkohl T, Haggerty K, Rivara FP, Zhou C, Liekweg K. Modifying Media Content for Preschool Children: A Randomized Controlled Trial. Pediatrics. 2013 Feb 18. Available from: Pediatrics

Methods

Subjects: Preschool children

Design: Randomized control trial

Methods: Authors devised a media diet intervention wherein parents were assisted in substituting high quality prosocial and educational programming for aggression-laden programming without trying to reduce total screen time. The control group received a nutritional intervention designed to promote healthier eating habits. 565 parents of preschool-aged children ages 3 to 5 years were recruited from community pediatric practices.

Outcomes

Outcomes were derived from the Social Competence and Behavior Evaluation at 6 and 12 months. At 6 months, the overall mean Social Competence and Behavior Evaluation score was 2.11 points better (95% confidence interval [CI]: 0.78–3.44) in the intervention group as compared with the controls, and similar effects were observed for the externalizing subscale (0.68 [95% CI: 0.06–1.30]) and the social competence subscale (1.04 [95% CI: 0.34–1.74]). The effect for the internalizing subscale was in a positive direction but was not statistically significant (0.42 [95% CI: 20.14 to 0.99]). Although the effect sizes did not noticeably decay at 12 months, the effect on the externalizing subscale was no longer statistically significant (P = .05). In a stratified analysis of the effect on the overall scores, low-income boys appeared to derive the greatest benefit (6.48 [95% CI: 1.60–11.37]). Conclusion: An intervention to modify the viewing habits / content of preschool-aged children can significantly enhance their overall social and emotional competence and that low-income boys may derive the greatest benefits.

S Lipnowski, CMA LeBlanc; Canadian Paediatric Society, Healthy Active Living and Sports Medicine Committee. Healthy active living: Physical activity guidelines for children and adolescents. Paediatr Child Health. 2012;17(4):209-10. Abstract available from: PubMed

Methods

Subjects: Children and adolescents

Design: Position statement

Methods: This position statement aims to provide child health care providers with counselling and advocacy strategies to promote physical activity and reduce sedentary time.

Outcomes

A systematic review by Timmons et al. showed that physical activity (PA) improves motor skills, body composition and aspects of metabolic health and social development in children younger than five years of age. Based on evidence from two systematic reviews (Timmons et al. and LeBlanc et al.), the authors developed sedentary and physical activity guidelines for infants, toddlers and preschoolers. Recommendations: 1) Caregivers should minimize the time infants (<1 yr of age), toddlers (1-2 yrs) and preschoolers (3-4 yrs) spend being sedentary during waking hours, including prolonged sitting or being restrained (eg, in a stroller, high chair) for >1 h at a time. 2) For children <2 years, screen time (eg, TV, computer, electronic games) is not recommended. 3) For children 2-4 years, screen time should be limited to <1 h/day; less is better. 4) Infants (<1 yr of age) should be physically active several times daily – particularly through interactive floor-based play. 5) Toddlers (1-2 yrs) and preschoolers (3-4 yrs) should accumulate at least 180 min of physical activity at any intensity spread throughout the day, including: a variety of activities in different environments, activities that develop movement skills, and progression toward at least 60 min of energetic play by 5 yrs of age. 6) More daily physical activity provides greater benefits.

Timmons BW, LeBlanc AG, Carson V, Connor Gorber S, Dillman C, Janssen I, Kho ME, Spence JC, Stearns J, Tremblay MS. Systematic review of the relationship between physical activity and health indicators in the early years (ages 0-4 years). Appl Physiol Nutr Metab. 2012;37: 773–792. Available from: NRC Research Press

Methods

Subjects: Children aged 0-4 years

Design: Systematic review

Methods: Searched all major electronic bibliographic databases (Medline, EMBASE, PsychInfo, EBSCO SportDiscus, Cochrane Central Database), personal libraries and government documents for studies examining the relationship between physical activity and specified health indicators during the early years (ages 0–4 years). The quality of the evidence was assessed using GRADE.

Outcomes

This review included 18 studies, including trials (randomized and non randomized) and prospective cohort studies, comprising of 12,742 participants. Health indicators chosen by an expert committee included the following: adiposity (n=11), bone and skeletal health (n=2), motor skill development (n=4), psychosocial health (n=3), cognitive development (n=1), and cardiometabolic health indicators (n=3). For different indicators or combination of, this review found low, moderate and high quality evidence suggesting benefits of increased or higher physical activity in infants, toddlers and preschool children. Although the quality of the evidence was heterogeneous among studies, the authors found no serious inconsistencies. The available evidence is insufficient to prescribe the amount of physical activity needed to achieve these benefits. The authors also considered potential harmful effects of physical activity.

LeBlanc AG, Spence JC, Carson V, Connor Gorber S, Dillman C, Janssen I, Kho ME, Stearns J, Timmons BW, Tremblay MS. Systematic review of the relationship between sedentary behaviours and health indicators in the early years (ages 0-4 years). Appl Physiol Nutr Metab. 2012;37: 773–792. Available from: Full article

Methods

Subjects: Children aged 0-4 years

Design: Systematic review

Methods: Searched all major electronic bibliographic databases (Medline, EMBASE, PsychInfo, EBSCO SportDiscus, Cochrane Central Database), personal libraries and government documents for studies examining the relationship between sedentary behaviours and specified health indicators during the early years (ages 0–4 years). The quality of the evidence was evaluated using GRADE.

Outcomes

This review included 21 unique studies, mostly of prospective cohort design, comprising of 22,417 participants. Health indicators chosen by an expert committee included the following: adiposity (n=11), bone and skeletal health, motor skill development, psychosocial health (n=6), cognitive development (n=8), and cardiometabolic health indicators. Results suggested that increased television viewing is associated with unfavourable measures of adiposity and decreased scores on measures of psychosocial health and cognitive development. The overall quality of the evidence was graded as low to moderate. The authors also note that a dose–response relationship was observed between increased time spent watching television and decreased psychosocial health or cognitive development.

Tremblay MS, LeBlanc AG, Carson V, Choquette L, Connor Gorber S, Dillman C, et al. Canadian physical activity guidelines for the early years (aged 0-4 years). Appl Physiol Nutr Metab. 2012;37:345-56. Available from: NRC Research Press

Methods

Subjects: 0-4 years old

Design: National guidelines

Methods: The Canadian Society developed these national guidelines for Exercise Physiology in partnership with various experts and stakeholders. The guideline development process was informed by the Appraisal of Guidelines for Research Evaluation (AGREE) II instrument and the evidence assessed using the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) system.

Outcomes

The recommendations of this group are largely based on evidence obtained from a systematic review by Timmons et al. The guidelines are the same as those reported in the CPS position statement.

Tremblay MS, LeBlanc AG, Carson V, Choquette L, Connor Gorber S, Dillman C, et al. Canadian sedentary behaviour guidelines for the early years (aged 0-4 years). Appl Physiol. Nutr Metab. 2012;37:370-80. Available from: NRC Research Press

Methods

Subjects: 0-4 years old

Design: National guidelines

Methods: The Canadian Society developed these national guidelines for Exercise Physiology in partnership with various experts and stakeholders. The guideline development process was informed by the Appraisal of Guidelines for Research Evaluation (AGREE) II instrument and the evidence assessed using the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) system.

Outcomes

The recommendations of this group are largely based on evidence obtained from a systematic review by LeBlanc et al.. The guidelines are the same as those reported in the CPS position statement.

Council on Communications and Media. Brown A. Media use by children younger than 2 years. Pediatrics. 2011;128(5):1040-5. Abstract available from: Pediatrics

Methods

Subjects: Children younger than 2 years

Design: Policy statement

Methods: This policy statement reaffirms the 1999 AAP policy statement and provides updated research findings on media use in infants and children younger than 2 years. The new 2011 policy statement addresses the following: (1) the lack of evidence supporting educational or developmental benefits for media use by children younger than 2 years, (2) the potential adverse health and developmental effects of media use by children younger than 2 years, and (3) adverse effects of parental media use (background media) on children younger than 2 years.

Outcomes

The previous AAP policy statement addressing media use in children younger than two years recommended that media use should be discouraged in this age group. This statement is reaffirmed based on updated evidence that both foreground (intended for children) and background (intended for adults when a child is in the room) media exposure has potentially negative effects and no known positive effects for children younger than 2 years. Other recommendations to paediatricians include parent-provider discussions on setting “media limits”, on promoting unstructured and unplugged play and on encouraging reading to their chid. Other related recommendations for parents and further recommendations for the industry and for research are also presented in this policy statement. Recommendations: 1) Discourage media use in children younger than 2 years and promote unstructured and unplugged play as well as reading to the child. 2) Media use in children older than 2 years should be limited to <2 h of quality educational screen time per day.

American Academy of Pediatrics Council on Sports Medicine and Fitness and Council on School Health. Active Healthy Living: Prevention of childhood obesity through increased physical activity. Pediatrics. 2006;117(5):1834-1842. Reaffirmed February 2010. Abstract available from: PubMed

Methods

Subjects: All ages

Design: Policy statement

Methods: Reviews evidence and strategies for physicians to encourage, monitor and advocate increased physical activity for children and adolescents.

Outcomes

According to the AAP, for infants and toddlers, there is insufficient evidence to recommend exercise programs to promote increased physical activity. AAP recommends no TV watching for children <2 years old.  The AAP also recommends that physicians should encourage appropriate outdoor play and activity with proper supervision for children <5 years old. As well, parents should reduce sedentary transportation (by car or stroller) and limit screen time (TV and computer) to <2 hours a day.

Parental/Family Issues – High Risk Infants/Children Recommendations Strength of Recommendation
  1. 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.

Good

  1. 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.

Good

  1. Risk factors for physical abuse: low socioeconomic status, 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.
  1. 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.
Parental/Family issues – High Risk Infants/Children References
ReferenceMethods and OutcomesFormer CTFPHC GRADE

Selph SS, Bougatsos C, Blazina I, Nelson HD. Behavioral interventions and counseling to prevent child abuse and neglect: a systematic review to update the US Preventive services task force recommendation. Ann Intern Med. 2013 Feb 5;158(3):179-90.

PubMed

Methods

Subjects: Children

Design: Systematic review update

Methods: In 2004, the U.S. Preventive Services Task Force determined that evidence was insufficient to recommend behavioural interventions and counselling to prevent child abuse and neglect. Authors used systematic methods to review new evidence on the effectiveness of behavioural interventions and counselling in health care settings for reducing child abuse and neglect and related health outcomes, as well as adverse effects of interventions.

Outcomes

Eleven fair-quality randomized trials of interventions and no studies of adverse effects met inclusion criteria. A trial of risk assessment and interventions for abuse and neglect in paediatric clinics for families with children aged 5 years or younger indicated reduced physical assault, Child Protective Services (CPS) reports, nonadherence to medical care, and immunization delay among screened children. Ten trials of early childhood home visitation reported reduced CPS reports, emergency department visits, hospitalizations, and self-reports of abuse and improved adherence to immunizations and well-child care, although results were inconsistent. Conclusions: 1) Risk assessment and behavioural interventions in paediatric clinics reduce abuse and neglect outcomes for young children. 2) Early childhood home visitation reduces abuse and neglect.

Perrin EC, Siegel BS, the COMMITTEE ON PSYCHOSOCIAL ASPECTS OF CHILD AND FAMILY HEALTH. Promoting the Well-Being of Children Whose Parents Are Gay or Lesbian Pediatrics; originally published online March 20, 2013. Available from: Pediatrics

Methods

Subjects: Children

Design: Policy statement and technical report

Outcomes

To promote optimal health and well-being of all children, the American Academy of Pediatrics (AAP) supports access for all children to (1) civil marriage rights for their parents and (2) willing and capable foster and adoptive parents, regardless of the parents’ sexual orientation. The AAP has always been an advocate for, and has developed policies to support, the optimal physical, mental, and social health and well-being of all infants, children, adolescents, and young adults. In so doing, the AAP has supported families in all their diversity, because the family has always been the basic social unit in which children develop the supporting and nurturing relationships with adults that they need to thrive. Children may be born to, adopted by, or cared for temporarily by married couples, nonmarried couples, single parents, grandparents, or legal guardians, and any of these may be heterosexual, gay or lesbian, or of another orientation. Children need secure and enduring relationships with committed and nurturing adults to enhance their life experiences for optimal social-emotional and cognitive development. Scientific evidence affirms that children have similar developmental and emotional needs and receive similar parenting whether they are raised by parents of the same or different genders. If a child has 2 living and capable parents who choose to create a permanent bond by way of civil marriage, it is in the best interests of their child(ren) that legal and social institutions allow and support them to do so, irrespective of their sexual orientation. If 2 parents are not available to the child, adoption or foster parenting remain acceptable options to provide a loving home for a child and should be available without regard to the sexual orientation of the parent(s). Conclusion: Children need secure and enduring relationships with committed and nurturing adults, regardless of sexual orientation or legal status, to enhance their life experiences for optimal social-emotional and cognitive development.

Fergusson DM. Boden JM. Horwood LJ. Nine-Year Follow-up of a Home-Visitation Program: A Randomized Trial. Pediatrics. 2013;131(2):297-303. Available from: Pediatrics

Methods

Subjects: Families

Design: Randomized controlled trial (N=443)

Methods: Families were randomized into a control group and an intervention group that received a home-visitation program (Early Start) for up to 5 years. Assessments were made at baseline, 6 months, annually from 1 year to 6 years, and then at 9 years after trial enrolment.

Outcomes

Comparisons between the Early Start and control series showed that families in the Early Start program showed significant (P < .05) benefits in reduced risk of hospital attendance for unintentional injury, lower risk of parent-reported harsh punishment, lower levels of physical punishment, higher parenting competence scores, and more positive child behavioural adjustment scores. Effect sizes (Cohen’s “d”) ranged from 0.13 to 0.29 (median = 0.25). There were no significant differences (all P values >.05) between the Early Start and control series on a range of measures of parental behaviour and family outcomes, including maternal depression, parental substance use, intimate partner violence, adverse economic outcomes, and life stress. Conclusion: Home visitation has benefits in terms of reducing child abuse, increasing parental competence, and improving childhood behavioural adjustment.

Milteer RM. Ginsburg KR. Council On Communications And Media. Committee On Psychosocial Aspects Of Child And Family Health. The importance of play in promoting healthy child development and maintaining strong parent-child bond: focus on children in poverty. Pediatrics. 2012;129(1):e204-13. Available from: Pediatrics

Methods

Subjects: Children, focus on children who live in poverty

Design: Clinical report

Methods: The AAP’s Council on Communication and Media and the Committee on Psychosocial Aspects on Child and Family Health Issues discuss in this reports issues that may deprive children who live in poverty from gaining the maximum benefit from play.

Outcomes

The authors first present a narrative review on the benefits of play, which include child development and creativity, increasing physical activity levels, and developing resilience, social and emotional ties, and school engagement. Based on an assessment of the factors associated with reduced play, the authors suggest solutions and offer advice to paediatricians on how they can advocate for children by helping families, school systems, and communities consider how best to ensure play is protected and promoted. Recommendation: Paediatricians should promote the inclusion of play in homes, schools, and communities.

Shelleby EC, Shaw DS, Cheong J, Chang H, Gardner F, Dishion TJ, Wilson MN. Behavioral control in at-risk toddlers: the influence of the family check-up. J Clin Child Adolesc Psychol. 2012 May;41(3):288-301. Abstract available from: PubMed

Methods

Subjects: At-risk infancts (n=713) and their primary caregivers

Design: RCT

Methods: This study examined whether increases in parental positive behaviour support (PBS), including proactive parenting, parent involvement, positive reinforcement, and engaged parent–child interaction, was associated with greater child behaviour control.

Outcomes

Results indicated that the intervention improved parental positive behaviour support and reduced growth of child behaviour problems. One dimension of positive behaviour support, proactive parenting, was modestly associated with behavioural control at age 3, which in turn was significantly associated with growth in behaviour problems from ages 2 to 4, with greater behavioural control related to lower levels of growth in behaviour problems. Conclusion: Proactive parenting is an important factor in the development of children's behavioural control and that behavioural control plays an important role in the growth of behaviour problems.

Zielinki DS, Eckenrode J, Olds DL. Nurse home visitation and the prevention of child maltreatment: Impact on the timing of official reports. Development and Psychopathology. 2009; 21: 441-453. Abstract available from: 

PubMed

Methods

Subjects: Mothers with at least one risk factor

Design: RCT

Methods: Families were randomized into a control group and an intervention group that had nurse home-visits from the onset of the mother’s pregnancy until the child was 2 years of age. Participants were followed for 15 years. Outcome ascertainment was measured using Child Protective Services official reports.

Outcomes

In the intervention group, 76% of children “survived” until the age of 15 without a CPS report compared to 68% of children in the comparison group. Intervention and control groups were similar until ages 5 to 6. After age 6 the two curves separated and a significant difference was seen in the intervention and comparison group. The control group continued to generate new reports of maltreatment until children were age 15, while there were practically none in the intervention group. This study found that home-visits have an effect on the onset of child maltreatment. This study also supports the current evidence that the Nurse Family Partnership, a program to reduce child maltreatment in high-risk families can be successful.

MacMillan HL, Thomas BH, Walsh CA, Boyle MH, Shannon HS, Gafni A. Effectiveness of home visitation by public-health nurses in prevention of the recurrence of child physical abuse and neglect: a randomized controlled trial. Lancet. 2005; 365 : 1786-1793. Abstract available from: PubMed

Methods

Subjects: Families

Design: RCT

Methods: Enrolled 163 families with a history of at least one child being exposed to physical abuse or neglect. The control group received the standard of care, which included routine follow-up by CPA (child protection agency) caseworkers. The intervention group was treated with the standard of care and a program of home visitation by nurses. 

Outcomes

Incidents of physical abuse and neglect were measured by CPA records and hospital records. There was no difference in the recurrence of physical abuse and neglect between the control and intervention groups using CPA records. However, hospital records showed a significantly higher recurrence of physical abuse or neglect among the intervention group. One possible explanation for this is potential ascertainment bias when nurses visited the homes of the intervention group. This study failed to show positive results for an intervention to reduce recurrence of physical abuse or neglect. This study  underlines the importance of initiating prevention strategies against child maltreatment before a pattern of abuse can be established in the family. 

Canadian Pediatric Society. Psychosocial Paediatrics Committee. Maternal depression and child development. Paediatr Child Health. 2004;9(8):575-583. Abstract available from: PubMed

Methods

Subjects: Mothers and children

Design: Position statement

Methods: Review of the current knowledge and literature on the consequences of maternal depression on children. Performed a literature search on MEDLINE over the past 15 years. Included mainly longitudinal prospective cohort studies.

Outcomes

There is a negative impact of maternal depression on a child’s cognitive development. The CPS suggests screening for postpartum depression at 2-, 6- and 12-month well-baby care visits. There is fair evidence against routine testing for maternal depression, however, it is strongly suggested that physicians maintain a high degree of clinical suspicion for depression among their patients. The CPS also recommends that patients with symptoms should be referred to psychiatric services.

MacMillan HL and the Canadian Task Force on Preventive Health Care. Preventive health care, 2000 update: prevention of child maltreatment. CMAJ. 2000;163(11):1451-1458. Abstract available from: PubMed

Methods

Subjects: Children

Design: Review

Methods: Review of the evidence for the effectiveness of interventions to prevent child maltreatment. Searched MEDLINE, PSYCINFO, ERIC etc. and consulted experts.

Outcomes

The review reports that the harms of screening for child maltreatment outweigh its potential benefits because of the high rate of false positives. Two RCTs showed reduced child maltreatment with nurse home-visiting interventions from pregnancy to age 2 in high-risk mothers. There is good evidence to recommend nurse home-visits to target high-risk mothers (i.e., less than 19 years old, unmarried and of low socioeconomic status). There is insufficient evidence to recommend education programs for the prevention of sexual abuse.

American Academy of Pediatrics. The role of home-visitation programs in improving health outcomes for children and families. Pediatrics. 1998;101(3):486-489. Abstract available from: PubMed

Methods

Subjects: Children

Design: Review

Methods: Reviews the current research on home-visitation programs and gives recommendations for the role of physicians in supporting home-visitation programs and identifying children at high-risk.

Outcomes

The review reports that some long-term effects of home visitation programs include: decrease in use of welfare, decrease in verified incidents of child abuse and neglect, fewer subsequent pregnancies, reduced maternal criminal behaviour. The beneficial effects of home-visitation programs are seen in high-risk children/families (i.e. mothers who are teenagers, unmarried, poor or having a history of abuse and preterm and low birth weight babies). 

Ethanol in Pregnancy Recommendation Strength of Recommendation
  1. Abstinence from alcohol during pregnancy is recommended.

Good

Ethanol in Pregnancy References
ReferenceMethods and OutcomesFormer CTFPHC GRADE

O’Leary CM, Jacoby PJ, Bartu A, D’Antoine H, Bower C. Maternal Alcohol Use and Sudden Infant Death Syndrome and Infant Mortality Excluding SIDS. Pediatrics. 2013;131;e770. Available from: Pediatrics

Methods

Subjects: Mothers and newborns

Design: Cohort study

Methods: To assess the risk of SIDS associated with maternal alcohol-use disorder, mothers exposed (n = 21.841) were frequency matched with mothers without an alcohol diagnosis (n = 56.054).

Outcomes

The highest risk of SIDS occurred when a maternal alcohol diagnosis was recorded during pregnancy (adjusted Hazards Ratio (aHR) 6.92, 95% CI 4.02–11.90) or within 1 year postpregnancy (aHR 8.61, 95% CI 5.04–14.69). An alcohol diagnosis recorded during pregnancy more than doubled the risk of infant deaths (excluding SIDS) (aHR 2.35, 95% CI 1.45–3.83). Maternal alcohol-use disorder is attributable for at least 16.41% (95% CI 9.73%–23.69%) of SIDS and 3.40% (95% CI 2.28%–4.67%) of infant deaths not classified as SIDS. Conclusion: At least 16.4% of SIDS and 3.4% of infant deaths not classified as SIDS are attributable to maternal alcohol use. Maternal alcohol-use disorder increases the risk of infant mortality through direct effects on the foetus and indirectly through environmental risk factors.

Foltran F, Gregori D, Franchin L, Verduci E, Giovannini M. Effect of alcohol consumption in prenatal life, childhood, and adolescence on child development. Nutrition Reviews. 2011;69(11):642-59. Abstract available from: PubMed

Methods

Subjects: Mothers and infants

Design: Review

Methods: This report reviews existing evidence on the short- and long-term adverse effects of alcohol consumption in children and adolescents, and consider the following periods of exposure: prenatal life, childhood, and adolescence. 

Outcomes

The authors present summaries of studies from systematic reviews and meta-analyses on the effects of prenatal drinking and different alcohol consumption patterns (low, low to moderate, moderate) in infants, children and adolescent. The findings of the few human studies point to a negative effect of prenatal drinking on several outcomes in the child, including FASD and neurodevelopmental outcomes. Some studies fail to generate evident adverse effects of low prenatal ethanol exposure in the offspring, but these should be interpreted with caution as some negative effects might not be noticed for many years. Recommendation: Abstinence during pregnancy is recommended.

Benz J, Rasmussen C, Andrew G. Diagnosing fetal alcohol spectrum disorder: History, challenges and future directions.
Paediatr Child Health. 2009;14(4). Abstract available from: Paediatrics & Child Health

Methods

Subjects: Mothers and Infants

Design: Review

Methods: Reviews the history of fetal alcohol spectrum disorders and discusses future directions and implications of diagnostic strategies.

Outcomes

The clinical use of the term fetal alcohol effects (FAE) has been abandoned for the umbrella term fetal alcohol spectrum disorder (FASD). There were 5 separated classes of prenatal alcohol effects determined by the US Institute of Medicine (IOM). In 1999, a 4-digit code was developed to enhance accuracy and clarity of diagnosis which was updated in 2004. Canadian guidelines recommend assessment pre- or post-natal growth against appropriate norms and controlling for confounding variables. This review reports that evaluation of cognitive performance along with prenatal and postnatal factors is required to make an FASD diagnosis.  

Chudley AE, Conry J, Cook JL, Loock C, Rosales T, LeBlanc N. Fetal alcohol spectrum disorder: Canadian guidelines for diagnosis. CMAJ. 2005; 172(5 suppl):S1-S21. Available from: PubMed

Methods

Subjects: Children

Design: Review

Methods: Reviews the epidemiology, risk factors, diagnosis, screening and referral practices for FASD.

Outcomes

This review provides recommendations for screening and referral, the physical examination and differential diagnosis, growth and facial features, neurobehavioral assessment, treatment and follow-up, maternal alcohol history in pregnancy and diagnostic criteria for FAS, partial FAS and ARND for physicians to counsel mothers and their partners on the risks and treatment of FASD. 

Schröter, H. Canadian Paediatric Society, First Nations, Inuit and Métis Health Committee. Fetal alcohol spectrum disorder. Paediatrics & Child Health. 2002; 7(3): 161-74. Reaffirmed: Jan 30 2013. Available from: http://www.cps.ca/documents/position/fetal-alcohol-syndrome

Diagnostic update. Paediatrics & Child Health. 2010; 15: 455-6.

Methods

Subjects: Children

Design: Position Statement

Methods: Update from 2002 CPS position statement

Outcomes

This CPS position statement on FASD is a diagnostic update from the 2002 CPS position statement.  It highlights: 1) the new diagnostic guidelines for FASD that were published in 2005 by an expert subcommittee of the Public Health Agency.  These guidelines have become the Canadian standard for the diagnosis of FASD (see reference: Chudley et al, 2005); 2) special consideration for First Nations, Métis, and Inuit children; and 3) the need for research and prevention intervention strategies. 

Adoption/Foster Care Recommendations Strength of Recommendation
  1. Children newly adopted or entering foster care are a high-risk population requiring special needs for health supervision.

Consensus

Adoption/Foster Care References
ReferenceMethods and OutcomesFormer CTFPHC GRADE

Jones VF. Committee On Early Childhood, Adoption, And Dependent Care. Comprehensive health evaluation of the newly adopted child. Pediatrics. 2012;129(1):e214-23. Abstract available from: Pediatrics

Methods

Subject: Adopted children

Design: Clinical report

Methods: This report was produced by the Committee on Early Childhood, Adoption, and Dependent Care.

Outcomes

Adopted children often have multiple health care needs. This report offers practical guidance to paediatricians and other child healthcare providers in performing a comprehensive health evaluation of the newly adopted child. Topics covered include: the pre-adoption visit, the initial history and medical records, the initial physical examination, referral for diagnostic testing, immunizations, chronic health concerns, hearing and vision screening, dental, age determination, developmental screening, mental health review, issues of adjustment, kinship-specific issues, role of adoption medical specialist and financial considerations. Authors also specify that although the initial health evaluation of an adopted child should be comprehensive in nature, it can span over several visits. Recommendation: In the context of adoption, the paediatrician should perform a comprehensive evaluation, which should include child’s medical history, complete physical examination, and results of necessary diagnostic testing.

Jones VF. Schulte EE. Committee on Early Childhood. Council on Foster Care, Adoption, and Kinship Care. The pediatrician's role in supporting adoptive families. Pediatrics. 2012;130(4):e1040-9. Abstract available from: Pediatrics

Methods

Subjects: Adopted children

Design: Clinical report

Methods: This report is a joint effort by the AAP’s Committee on Early Childhood and the Council on Foster Care, Adoption, and Kinship Care Executive Committee. 

Outcomes

In order to provide optimal health care to adopted children, this report is intended for paediatricians to better understand their unique medical, developmental, mental health, and behavioural needs. The authors argue that adoptive families are changing, with an increasing number of domestic adoptions and a decreasing number of international adoptions, as well as a greater diversity seen in adoptive parents (gay or lesbians, older parents, single parent, relatives). Several issues are addressed but this report serves as a guide and no official recommendation was made. For specific recommendations, see AAP’s clinical report Comprehensive health evaluation of the newly adopted child.

Leve LD, Harold GT, Chamberlain P, Landsverk JA, Fisher PA, Vostanis P. Practitioner review: Children in foster care-vulnerabilities and evidence-based interventions that promote resilience processes. J Child Psychol Psychiatry. 2012 Dec;53(12):1197-211. Abstract available from: PubMed

Methods

Subjects: Children

Design: Systematic review

Methods: Based on a systematic search of the PsycINFO database (to March 2012), eight efficacious evidence-based interventions for foster families are summarized. 

Outcomes

Although the development of evidence-based interventions that improve outcomes for foster children has lagged behind the delivery of interventions in other service sectors (e.g., mental health and educational sectors), several interventions across childhood and adolescence offer promise. Service system constraints offer both challenges and opportunities for more routine implementation of evidence-based interventions. Conclusion: Specifically on early childhood, three independent interventions for young foster children demonstrate that, when foster caregivers are given appropriate support and training, children can develop healthy emotion and behaviour regulation and positive, secure social relationships.

Macdonald GM, Turner W. Treatment foster care for improving outcomes in children and young people. Cochrane Database Syst Rev. 2008 Jan 23;(1):CD005649. Abstract available from: PubMed

Methods

Subjects: children who require out-of-home placement

Design: Cochrane review

Methods: Electronic databases were searched to identify randomized studies assessing the impact of treatment foster care (TFC), a foster family-based intervention,  on psychosocial and behavioural outcomes, delinquency, placement stability, and discharge status for children and adolescents who require out-of-home placement. 

Outcomes

Treatment foster care (TFC) is a foster family-based intervention that aims to provide young people (and, where appropriate, their families) with a tailored programme designed to effect positive changes in their lives. TFC was designed specifically to cater for the needs of children whose difficulties or circumstances place them at risk of multiple placements and/or more restrictive placements such as hospital or secure residential or youth justice settings. Five studies including 390 participants were included in this review. Data suggest that treatment foster care may be a useful intervention for children and young people with complex emotional, psychological and behavioural need, who are at risk of placements in non-family settings that restrict their liberty and opportunities for social inclusion. Conclusion: Children and young people at risk of placement in settings that restrict their liberty and who are at risk of a range of adverse outcomes may benefit from a foster family-based intervention designed specifically to cater their needs.

Canadian Pediatric Society. Special considerations for the health supervision of children and youth in foster care. Paediatrics & Child Health .2008; 13(2): 128-132. Available from: PubMed

Methods

Subjects: Children in foster care

Design: Position Statement

Methods: Pubmed searches for relevant articles from 1997-2007 were done. Keywords included: foster, care and health, children 0-18. Hand-searches of references from relevant studies were also conducted. Resource material from the Child Welfare League of Canada and other government statistics were used.

Outcomes

“Children entering foster care are a high risk population requiring special needs for health supervision.”

 

The CPS recommends the physicians should recognize that children and adolescents in foster care usually have a higher incidence of special needs (medical conditions, mental health disorders and developmental delays). An initial medical assessment (physical examination) of children entering foster care should be done. Based on the child’s needs (case-by-case basis), screening tests such as complete blood count, ferritin, lead level, HIV, hep B and C etc. should be done.

Non Parental Child Care Recommendations Strength of Recommendation
  1. Inquire about current child care arrangements.

Fair

  1. High quality child care is associated with improved paediatric outcomes in all children.

Consensus

  1. 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.

Consensus

Non Parental Child Care Recommendations
ReferenceMethods and OutcomesFormer CTFPHC GRADE

Canadian Pediatric Society. Well Beings: A Guide to Health in Child Care. Available from: http://www.caringforkids.cps.ca/wellbeings/about_well_beings

Methods

This book provides information on the daily care, health and safety of children from birth to preschool. It is an excellent resource for child care centers, agencies, home-based providers and public-health professionals.

Outcomes

Canadian Pediatric Society. Health implications of children in child care centres. Part A: Canadian trends in child care, behaviour and developmental outcomes. Paediatr Child Health. 2008 13(10): 863-867. Reaffirmed: Jan 30 2013. Abstract available from: PubMed

Methods

Subjects: <5 years old

Design: Position statement

Methods: Searched MEDLINE (1950 to Aug. 2008), EMBASE (1988 to Aug. 2008), PsycInfo (1985 to 2008) and Cochrane Reviews. Keywords: day care, child day care centres AND child development or cost analysis or health care costs.

Outcomes

Most child care studies are longitudinal or cross-sectional. Randomization and blinding are hard to achieve in child care research, lowering the quality of RCTs. Also, it is difficult to control for confounding variables. Quality of child care is optimized when keeping with AAP-recommended ratios of staff to children (strength of recommendation A). Low child to caregiver ratios have been associated with high cognitive and language scores.

NICHD Early Child Care Research Network. Child-care effect sizes for the NICHD study of early child care and youth development. Am Psychol 2006;61(2):99-116. Abstract available from: http://www.ncbi.nlm.nih.gov/pubmed/16478355

Methods

Subjects: 6 to 36 months old

Design: Cohort study

Methods: Early Child Care Research Network started in 1991 and followed children from birth independent of parents’ decision for child care. The objective of this study was to look at exclusive maternal care versus non parental child care. For children in child-care, type, quality and quantity of child-care were measured.

Outcomes

In this study, higher quality care was related to advanced cognitive, language and pre-academic outcomes at every age (15, 24, 36 and 54 months). Exclusive maternal care was not predictive of any child outcomes. Better socio-emotional and peer outcomes were seen at some ages.  Generally, higher quality care is correlated with better behavioural outcomes and higher income level of the families.  In terms of quantity of child care, the evidence is weak and inconsistent. 

American Academy of Pediatrics. Quality early education and child care from birth to Kindergarten. Pediatrics. 2005; 115: 187-191. Revised 2010. Abstract available from: PubMed

Methods

Subjects: <5 years old

Design: Policy statement

Methods: Review and recommendations written by expert committee. No definitive methods section.

Outcomes

The AAP reports that it is important for early education and child care to be of high quality. Given its limited availability, the AAP recommends that physicians should work with parents and the community to facilitate access to the best child care possible. Evidence shows that high quality (i.e., developmentally sound and emotionally supportive) early education has a positive effect on both the child and their family. The AAP recommends that physicians are encouraged to ask families about their child care situation.

Zoritch B, Roberts I, Oakley A. Day care for pre-school children. Cochrane Database of Systematic Reviews 2000, Issue 3:CD000564. Abstract available from: http://www.ncbi.nlm.nih.gov/pubmed/10796726

Methods

Subjects: 0 to 5 years old

Design: Systematic Review

Methods: An extensive literature review was performed using 7 electronic databases (i.e., Medline, Embase, etc.)Eligibility criteria for inclusion in the review: trials had to be randomized or quasi-randomized. Intervention was non parental day-care for pre-school education. 

Outcomes

This review looks at the relation between non parental child-care and various outcomes.  A total of 8 trials were found with a total of 2,203 children randomized to receive day care or be in the control group. Length of follow-up ranged from 6 months to 27 years. Authors concluded that out of home day-care is beneficial in important areas of children’s well-being such as enhancing cognitive development and preventing later school failure.  Authors also concluded that it is beneficial for children’s behaviour. This review was methodologically rigorous in their inclusion criteria and assessed the possibility for bias. They concluded that there is potential for some interview bias in certain studies included.

NICHD Early Child Care Research Network. Child Outcomes when child care center classes meet recommended standards for quality. Am J Public Health. 1999;89:1072-7. Abstract available from: http://www.ncbi.nlm.nih.gov/pubmed/10394318

Methods

Subjects: 6 to 36 months old

Design: Cohort study

Methods: Early Child Care Research Network started in 1991 and followed children from birth independent of parents’ decision for child care. The objective was to determine the outcomes of children who attended child care centres that meet recommended care standards.

Outcomes

The total sample size of this study was 1526.  1,364 (89%) completed a 1 month visit, out of those 1,216 (89%) continued to 36 months. The measures for quality of non parental child care were: child-staff ratio, observed group size, caregiver training and caregiver education.  The average child-staff ratio and average group size was higher than recommended at ages 6, 15 and 24 months. At 36 months the ratio and group size were approximately equal to the recommended numbers.  Caregiver training and education were at recommended levels at all 4 ages. Fewer behaviour problems, higher school readiness and language comprehension scores were reported in children that attended classes that met more of the recommended standards.

Literacy/Encourage Reading Recommendations Strength of Recommendation
  1. 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.

Good

Literacy/Encourage Reading References
ReferenceMethods and OutcomesFormer CTFPHC GRADE

Landry SH, Smith KE, Swank PR, Zucker T, Crawford AD, Solari EF. The effects of a responsive parenting intervention on parent-child interactions during shared book reading. Dev Psychol. 2012 Jul;48(4):969-86. Abstract available from: PubMed

Methods

Subjects: Mothers from low-income backgrounds and their infant

Design: RCT

This study examined whether the Methods: Play and Learning Strategies (PALS) intervention that targets global parenting techniques by facilitating a range of responsive behaviours in everyday activities can also support mothers’ use of more effective shared book reading behaviours and children’s engagement and use of language. Four groups of randomized mothers and their children (PALS I-II, PALS I-DAS II, DAS I-PALS II, DAS I-II) were observed in shared reading interactions during the toddler-preschool period and coded for (a) mother's affective and cognitive-linguistic supports and (b) child's responses to maternal requests and initiations.

Outcomes

The efficacy of PALS was previously demonstrated for improving mother and child behaviours within play contexts, everyday activities, and standardized measures of child language. Authors hypothesized that PALS effects would generalize to influence maternal and child behaviours during a shared reading task even though this situation was not a specific focus of the intervention and that this would be similar for children who varied in biological risk. Participation in at least PALS II was expected to have a positive effect due to children's increased capacity to engage in book reading at this age. Support was found for significant changes in observed maternal and child behaviours and evidence of mediation was found for the intervention to affect children's behaviours through change in maternal responsiveness behaviours. These results add to other studies supporting the importance of targeting a broad range of responsive behaviours across theoretical frameworks in interventions to facilitate children's development. Conclusion: An intervention that targets global parenting techniques may be effective in supporting mothers’ use of more effective shared book reading behaviours.

Mol SE , Bus AG, de Jong MT,.

Smeets DJH. Added Value of Dialogic Parent–Child Book Readings: A Meta-Analysis. 2008. Early Education & Development, 19:1, 7-26. Abstract available from:

http://www.tandfonline.com/doi/abs/10.1080/10409280701838603#.Uaxw4ys6Wp0

Methods

Subjects: 2 to 6 year old children

Design: Systematic review and meta-analysis

Methods: This study aimed to examine the added value of an interactive shared book reading format that emphasizes active as opposed to noninteractive participation by the child. Studies that included a dialogic reading intervention group and a reading-as-usual control group, and that reported vocabulary as an outcome measure were identified through a systematic search to March 2007.

Outcomes

After extracting relevant data from 16 eligible studies, a meta-analysis was conducted to attain an overall mean effect size reflecting the success of dialogic reading in increasing children’s vocabulary compared to typical shared reading. When focusing on measures of expressive vocabulary in particular (k = 9, n = 322), Cohen’s d was .59 (SE = .08; 95% CI = 0.44, 0.75; p < .001), which is a moderate effect size. However, the effect size reduced substantially when children were older (4 to 5 years old) or when they were at risk for language and literacy impairments. Dialogic reading can change the home literacy activities of families with 2- to 3-year-old children but not those of families with children at greatest risk for school failure. Conclusion: Enhancing the dialogue between parent and child during reading sessions strengthens the effects of book reading, especially in young children (2-3 years old) and those not at risk for language and literacy impairments.

Duursma E, Augustyn M, Zuckerman B. Reading aloud to children: the evidence.

Arch Dis Child. 2008;93:554-557. Abstract available from: PubMed

Methods

Subjects: Children

Design: Review

Methods: The authors compiled evidence to support parents and caregivers reading aloud to children and participating in shared book reading to promote language development.

Outcomes

This review reports that children who are read to aloud from an early age tend to have higher scores on language measures later in life. Socioeconomic status, race/ethnicity and parental education are factors that can affect the development of literacy and oral language skills. The authors report that parents should take into account their child’s personal interests and physicians should encourage reading aloud.

Needleman R, Toker KH, Dreyer BP, Klass P, Mendelsohn AL. Effectiveness of a primary care intervention to support reading aloud: a multicenter evaluation. Ambul Pediatr 2006;(5)4:209-215. Abstract available from: http://www.ncbi.nlm.nih.gov/pubmed/16026185

Methods

Subjects: 6 to 72 months old

Design: Before-after intervention study

Methods: 19 clinical sites were included in 10 states. At each site a convenience sample was interviewed before the implementation of the Reach Out and Read (ROR) program, which served as the control group. A separate convenience sample was interviewed after the program which served as the experimental group.

Outcomes

The total sample size was 1,647 subjects.  Main outcome measures were parental interviews based on questions from validated questionnaires about their attitudes and practices related to reading out loud.  There was a significant association (p < 0.001) between exposure to ROR and reading aloud as a favourite parenting activity, at bedtime, 3 or more days a week and ownership of >= 10 picture books.  Limitations to this study are taking a convenience sample of subjects and sites that were different before and after.  This can limit the ability to generalize the findings to the population and can introduce selection bias. There is also possibility for social desirability bias from parents’ answers to the questions.

Canadian Paediatric Society. Read, speak, sing: Promoting literacy in the physician’s office. Paediatric & Child Health. 2006;11(9):601-606.

Reaffirmed Feb 1, 2011. Available from: Paediatrics & Child Health

Methods

Subjects: 0 to 18 years old

Design: Position statement

Methods: Performed a search of electronic databases MEDLINE and Psych INFO from 1995 to June 2006. Keywords: reading, literacy and illiteracy.

Outcomes

Recommendations and strategies to promote reading and literacy in young children are discussed. Quantity and quality of language exposure are important. The CPS reports that book exposure among infants and toddlers promotes the development of early literacy skills.  The CPS recommends that physicians should include literacy promotion in their routine clinical practice.

Sharif I, Rieber S, Ozuah PO. Exposure to Reach Out and Read and vocabulary outcomes in inner city preschoolers. J Natl Med Assoc. 2002;(94)3:171-7. Abstract available from: http://www.ncbi.nlm.nih.gov/pubmed/11918387

Methods

Subjects: 2 to 5.9 years old

Design: Cross-sectional survey

Methods: Two federally funded health centres were used as the two sites of comparison. Subjects attending clinic A had a 3 year Reach Out and Read (ROR) intervention while attendants of clinic B had no ROR exposure. The ROR program included counselling parents about reading to children and parents received an age-appropriate book at each well-child visit.

Outcomes

The sample size for this study was 200 parent/child pairs with mean age of children of 3.8 years.  The outcome measures were expressive and receptive one word picture vocabulary tests, a home literacy orientation scale created by the authors, and the STIMQ-READ subscale.  Comparing English-speaking children, there was a statistically significant difference (p=0.01) between ROR-exposed children and controls.  A positive association between the Reach Out and Read program and better receptive vocabulary scores were reported. Higher scores were also found on measures of home reading activities. Limitations of this study include the cross-sectional design’s inability to determine a causal relationship and parental reports of home reading activity may have lead to a degree of recall bias.

High PC, LaGasse L, Becker S, Ahlgren I, Gardner A. Literacy promotion in primary care: can we make a difference? Pediatrics. 2000;105:927-934. Abstract available from: PubMed

Methods

Subjects: 5 to 11 months old

Design: RCT

Methods: Low-income families were randomized to intervention or control groups. At baseline. The intervention group received children’s books, educational materials and advice from  paediatricians about sharing books with children.  Follow-up included family interviews and child language testing. A Child-Centered Literacy Orientation was defined as a stated enjoyment of reading and/or report of usual reading together at bedtime.

Outcomes

At follow-up (an average of 3.4 well-child visits later; mean age 18.4 months), there was a 40% increase in Child-Centered Literacy Orientation among the intervention families compared to 16% among controls. In older intervention toddlers, receptive and expressive vocabulary scores were higher, but not for younger intervention toddlers. When reading aloud was added to a multivariate analysis, the effect of the intervention was no longer evident.  The authors concluded that this simple intervention changed parental attitudes, and as they increasingly read to their children older toddlers in particular experienced enhanced language development.

Toilet Learning Recommendation Strength of Recommendation
  1. A child-centered approach, where the timing and methodology of toilet learning is individualized as much as possible, is recommended.

Consensus

Toilet Learning References
ReferenceMethods and OutcomesFormer CTFPHC GRADE

Kaerts N, Van Hal G, Vermandel A, Wyndaele JJ. Readiness signs used to define the proper moment to start toilet training: a review of the literature. Neurourol Urodyn. 2012 Apr;31(4):437-40. Abstract available from: PubMed

Methods

Subjects: Healthy children < 6 years old

Design: Review

Methods: Searched PubMed and CSA-database for literature on toilet training in the Western society. 

Outcomes

Twenty-one signs of readiness were found. In order of age in which they appear: child can imitate behaviour, child is capable of sitting stable and without help, child can walk without help, child is able to pick up small objects, child can say no as a sign of independence, voluntary control over bowel and bladder reflex actions, child understands and can respond to directions, questions or explanations and can follow simple commands, child expresses a need to evacuate by non-verbal communication (such as mimicry, posture or gestures, going to the toilet, or grabbing the potty) or by words, child enjoys putting things in containers, awareness of bladder sensations and the need to void, child understands potty related words and has an adequate vocabulary of his own, child wants to participate in, wants to cooperate with the toilet training and the child shows interest in toilet training, child has bigger bladder capacity, child insists on completing tasks without help and is proud of new skills, child is asking for the pot, child wants to be clean and is distressed by wet or soiled diapers, child wants to wear grown-up clothes, child is able to pull clothes up and down, child stays bowel movement-free overnight, child begins to put things where they belong, child can sit still on the potty for 5-10 min. No evidence-based research assessing which readiness sign should be used is currently available. 

Russell K, Lang ME. Among healthy children, what toilet-training strategy is most effective and prevents fewer adverse events (stool withholding and dysfunctional voiding)? Paediatric & Child Health. 2008; 13(3):201-204. Abstract available from: PubMed

Methods

Subjects: Infants >18 months old

Design: Review (Part A: Evidence-based answer and summary; Part B: Clinical commentary.)

Methods: Reviews the literature on the best method to toilet-train an infant. Searched databases MEDLINE, EMABSE, ERIC, PsycINFO and Cinahl.

Outcomes

The current CPS and AAP guidelines recommend a child-oriented approach starting between 18 and 24 months and not beginning before the child displays interest. The two main methods are the child-oriented approach and the Foxx and Azrin Method of Toilet Training in Less Than One Day. According to this review, neither method has conclusive evidence that makes it better than the other.

Canadian Pediatric Society Community Paediatrics Committee. Toilet learning: Anticipatory guidance with a child-oriented approach. Paediatrics & Child Health. 2000;5(6):333-335. Reaffirmed: Jan 30 2013. Available from: Paediatrics & Child Health

Methods

Subjects: <4 years old

Design: Position statement

Methods: Review of issues surrounding toilet training in children. Includes appropriate timing, using a child-oriented approach, assessing a child’s readiness, toilet refusal and children with special needs.

Outcomes

Reaching developmental milestones can be difficult for the child and their parents. According to the report, there is a wide range of timing for toilet training that is considered normal, usually between 24 and 48 months. After 48 months, referral to a general or developmental paediatrician is recommended. The CPS recommends that physicians should inform parents and encourage the child-oriented approach; differences in cultures need to be taken into consideration (i.e., 24 to 48 months in a Western norm); moreover, motor, language and social milestones should also be considered when assessing a child’s readiness for toilet learning.

ENVIRONMENTAL HEALTH

General Environmental Health Issues References
ReferenceMethods and OutcomesFormer CTFPHC GRADE

Karr C. Addressing environmental contaminants in pediatric practice. Pediatrics in Review. 2011;32(5):190-200. Available from: http://pedsinreview.aappublications.org/content/32/5/190.full.pdf+html

Methods

Subjects: Children

Design: Narrative review

Methods: Not reported

Outcomes

This article provides an overview of issues pertaining to environmental contaminants in pediatric practice. Summary points of the author (specific references for each point are listed in article): 1) Pediatricians are a trusted, desired, and important source of information on environmental health topics. 2) It is well established that children are more vulnerable to environmental contaminants due to their rapid and ongoing growth and development and potential for higher exposures based on behavioral and physiologic differences. 3) Evidence and consensus highlight the importance of the environmental history in identifying and reducing children’s exposure to hazardous contaminants. 4) There is sufficient evidence that lead exposure is common among United States children and that concentrations below the current action level (BLL >10 g/dL [0.48 mol/L]) are associated with adverse effects on neurodevelopment and behavior. A joint federal advisory from the FDA and the EPA recommends reducing exposure to mercury by highlighting the importance of selecting fish that contain lower concentrations of methylmercury. 5) Multiple studies identify risks in the indoor environment that reflect housing quality, choice of building sites, and exposures that include lead from paint or water, asbestos, radon, particulate matter, mold, pesticide use patterns, and carbon monoxide.

Wigle DT, Arbuckle TE, Walker M, Wade MG, Liu S, Krewski D. Environmental hazards: evidence for effects on child health. J Toxicol Environ Health B Crit Rev. 2007;10(1-2):3-39. Abstract available from: PubMed

Methods

Subjects: Children

Design: Review

References: This review summarizes knowledge of associations between child health and development outcomes and environmental exposures, including lead, methylmercury, polychlorinated biphenyls (PCBs), dioxins and related polyhalogenated aromatic hydrocarbons (PHAHs), certain pesticides, environmental tobacco smoke (ETS), aeroallergens, ambient air toxicants (especially particulate matter [PM] and ozone), chlorination disinfection by-products (DBPs), sunlight, power-frequency magnetic fields, radiofrequency (RF) radiation, residential proximity to hazardous waste disposal sites, and solvents.

Outcomes

The adverse health effects linked to such exposures include fetal death, birth defects, being small for gestational age (SGA), preterm birth, clinically overt cognitive, neurologic, and behavioral abnormalities, subtle neuropsychologic deficits, childhood cancer, asthma, other respiratory diseases, and acute poisoning. Some environmental toxicants, notably lead, ionizing radiation, ETS, and certain ambient air toxicants, produce adverse health effects at relatively low exposure levels during fetal or child developmental time windows. 

Wigle DT, Arbuckle TE, Turner MC, Bérubé A, Yang Q, Liu S, Krewski D. Epidemiologic evidence of relationships between reproductive and child health outcomes and environmental chemical contaminants. J Toxicol Environ Health B Crit Rev. 2008 May;11(5-6):373-517. Abstract available from: PubMed

Methods

Subjects: Mother and child

Design: Review

Methods: This review summarizes the level of epidemiologic evidence for relationships between prenatal and/or early life exposure to environmental chemical contaminants and fetal, child, and adult health. Discussion focuses on fetal loss, intrauterine growth restriction, preterm birth, birth defects, respiratory and other childhood diseases, neuropsychological deficits, premature or delayed sexual maturation, and certain adult cancers linked to fetal or childhood exposures. Environmental exposures considered here include chemical toxicants in air, water, soil/house dust and foods (including human breast milk), and consumer products. Reports reviewed here included original epidemiologic studies (with at least basic descriptions of methods and results), literature reviews, expert group reports, meta-analyses, and pooled analyses

Outcomes

There was sufficient epidemiological evidence for causal relationships between several adverse pregnancy or child health outcomes and prenatal or childhood exposure to environmental chemical contaminants. These included prenatal high-level methylmercury (CH(3)Hg) exposure (delayed developmental milestones and cognitive, motor, auditory, and visual deficits), high-level prenatal exposure to polychlorinated biphenyls (PCBs), polychlorinated dibenzofurans (PCDFs), and related toxicants (neonatal tooth abnormalities, cognitive and motor deficits), maternal active smoking (delayed conception, preterm birth, fetal growth deficit [FGD] and sudden infant death syndrome [SIDS]) and prenatal environmental tobacco smoke (ETS) exposure (preterm birth), low-level childhood lead exposure (cognitive deficits and renal tubular damage), high-level childhood CH(3)Hg exposure (visual deficits), high-level childhood exposure to 2,3,7,8-tetrachlorodibenzo-p-dioxin (TCDD) (chloracne), childhood ETS exposure (SIDS, new-onset asthma, increased asthma severity, lung and middle ear infections, and adult breast and lung cancer), childhood exposure to biomass smoke (lung infections), and childhood exposure to outdoor air pollutants (increased asthma severity). Evidence for some proven relationships came from investigation of relatively small numbers of children with high-dose prenatal or early childhood exposures, e.g. CH(3)Hg poisoning episodes in Japan and Iraq. In contrast, consensus on a causal relationship between incident asthma and ETS exposure came only recently after many studies and prolonged debate. There were many relationships supported by limited epidemiologic evidence, ranging from several studies with fairly consistent findings and evidence of dose-response relationships to those where 20 or more studies provided inconsistent or otherwise less than convincing evidence of an association. The latter included childhood cancer and parental or childhood exposures to pesticides. In most cases, relationships supported by inadequate epidemiologic evidence reflect scarcity of evidence as opposed to strong evidence of no effect. 

Second-Hand Smoke Exposure Recommendations Strength of Recommendation
  1. Second-hand smoke exposure contributes to childhood illnesses such as URTI, middle ear effusion, persistent cough, pneumonia, asthma, SIDS and neurobehavioural disorders.

Good

Second-Hand Smoke Exposure References
ReferenceMethods and OutcomesFormer CTFPHC GRADE

Kabir Z, Connolly GN, Alpert HR. Secondhand smoke exposure and neurobehavioral disorders among children in the United States. Pediatrics. 2011 Aug;128(2):263-70. Abstract available from: Pediatrics

Methods

Subjects: Children aged < 12 years

Design: 7 National Survey on Children’s Health

Methods: The association between parent-reported postnatal second-hand tobacco smoke exposure in the home and neurobehavioral disorders (attention-deficit/hyperactivity disorder, learning disabilities, and conduct disorders) among children younger than 12 years in the United States was examined using the 2007 National Survey on Children’s Health. Excess neurobehavioral disorders attributable to secondhand smoke (SHS) exposure in the home in 2007 were further investigated. The methods used in this study were multivariable logistic regression models that accounted for potential confounders and complex survey designs to evaluate associations.

Outcomes

A total of 6% of 55,358 children (aged < 12 years), corresponding to a weighted total of 4.8 million children across the United States, were exposed to SHS in the home. The weighted prevalence and 95% confidence intervals of each of the children’s neurobehavioral outcomes were 8.2% (7.5– 8.8) with learning disabilities, 5.9% (5.5– 6.4) with attention-deficit/hyperactivity disorder, and 3.6% (3.1– 4.0) with behavioural and conduct disorders. Children exposed to SHS at home had a 50% increased odds of having ≥ 2 childhood neurobehavioural disorders compared with children who were not exposed to SHS. Boys had a significantly higher risk. Older children, especially those aged 9 to 11 years, and those living in households with the highest poverty levels were at greater risk. In absolute terms, 274,100 excess cases in total of these 3 disorders could have been prevented if children had not been exposed to SHS in their homes. Recommendation: Smoke-free home policies are vigorously encouraged.

Kwok MK, Schooling CM, Ho LM, Leung SS, Mak KH, McGhee SM, Lam TH, Leung GM. Early life second-hand smoke exposure and serious evidence from Hong Kong’s “Children of 1997” birth cohort. Tobacco Control. 2008;17:263-270. Abstract available from: PubMed

Methods

Subjects: 0 to 8 years old

Design: Prospective,

population-based cohort study

Methods: Using data from the 1997 birth cohort from April and May in Hong Kong, investigators followed up with infants and parents at 3, 9 and 18 months.  Based on self-reported smoking data, families were classified as no exposure, smoking more than 3 meters and less than 3 meters away from the child.

Outcomes

In this study, second-hand smoke exposure less than 3 meters away from the infant was associated with the highest risk of admission for infectious illness (hazard ratio 1.14, 95% CI: 1.00-1.31). This association was strongest for infants 0 to 6 months years old. Exposure of infants to second-hand smoke within 3 meters increased their risk of serious illness, both respiratory and other infections. This study also showed that young infants (<6 months) as well as low birth weight and preterm infants are at high risk.

DiFranza JR, Aligne CA, Weitzman M. Prenatal and postnatal environmental tobacco smoke exposure and children’s health. Pediatrics. 2004;113:1007-1015. Abstract available from: PubMed

Methods

Subjects: Children

Design: Review

Methods: Reviewed the literature for the most up-to-date data on environmental tobacco smoke (ETS) and the effects on infants and children.

Outcomes

Studies since 1967 suggest that ETS exposure is associated with decreased lung growth, respiratory tract infection, asthma, otitis media, SIDS, neurocognitive decrements and behavioural problems. This review reported that the greatest risk of adverse health effects occurs during pregnancy and the first few years of life; there is a potential causal relationship between maternal smoking and SIDS; the risk of hospitalization for respiratory illness is greatest in the first 6 months of life.

American Academy of Pediatrics Committee on Environmental Health. Environmental tobacco smoke: A hazard to children. Pediatrics. 1997; 99: 639-642. Abstract available from: PubMed

Methods

Subjects: Children

Design: Policy statement

Methods: Review of epidemiological studies on the association between environmental tobacco smoke (ETS) and respiratory infections in children and infants.

Outcomes

Studies were found that evaluated the effects of ETS on lower respiratory infections, middle ear effusions, asthma, SIDS, lipid profiles and cancer. The statement reports that there is strong evidence that exposure to ETS is associated with an increased risk of lower respiratory infections, middle ear effusions, SIDS and asthma. The AAP recommends that physicians should counsel parents against the hazards of second-hand smoke.

Sun Exposure/Sunscreen/Insect Repellents Recommendation Strength of Recommendation
  1. Minimize sun exposure. Wear protective clothing, hats, and 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 yrs 10% DEET apply max TID.

Consensus

Sun Exposure/Sunscreen/Insect Repellents References
ReferenceMethods and OutcomesFormer CTFPHC GRADE

American Academy of Pediatrics Committee on Environmental Health. Ultraviolet light: A hazard to children and adolescents. Pediatrics. 1999; 104: 328-333. Revised March 2011. Available from: Pediatrics

Methods

Subjects: Children

Design: Review

Methods: Reviews recommendations for physicians to counsel their patients on sun exposure, appropriate use of sunscreen and effective ways to prevent skin cancer.

Outcomes

There are no clinical trials on the effectiveness of sunscreen in the prevention of skin cancer. However, sunscreen does prevent the skin from burning.  According to the AAP, children should be protected from intense sun exposure early in life to prevent skin cancer; children <6 months of age should not be exposed to direct sunlight and should instead be placed in the shade and/or covered by clothes; children >6 months of age should wear sunscreen that is SPF 15 or above and well rubbed into their skin. The AAP recommends that physicians should counsel parents on sun protection. The revised version further highlights the lack of evidence supporting recommendations on sun behaviour in children and includes discussions on vitamin D and outdoor physical activity. The AAP recommendations are largely based on evidence from epidemiologic studies that UVR causes skin cancer. Recommendation: 1) Paediatricians should incorporate advice about UVR exposure into health-supervision practices. 2) Advice includes keeping infants < 6 months out of direct sunlight and/or covered by clothes, avoiding sun burning and sun tanning, wearing clothing and hats with brims, and applying and reapplying sunscreen when a child might sunburn. 3) Advice should be framed in the context of promoting outdoor physical activity in a sun-safe manner.

Meurer LN, Jamieson B. What is the appropriate use of sunscreen for infants and children? The Journal of Family Practice. 2006;55(5):437, 440, 444. Abstract available from: PubMed

Methods

Subjects: Children

Design:  Clinical inquiry

Methods: An evidence-based answer to the question “What is the appropriate use of sunscreen for infants and children?” using the SORT grades of evidence.

Outcomes

According to this report, infants <6 months of age should be kept out of direct sunlight or be covered to avoid sunburn and  children >6 months of age should wear a liberal amount of sunscreen that is SPF 15 or above and  reapplied every 2 hours, especially if swimming. 

Canadian Paediatric Society. Insect repellents for children. Available from: Caring for Kids

Methods

Subjects: Children

Design: Website

Methods: General information on insect repellent use in children <6 months, 6 months to 2 years, 2 to 12 years and >12 years of age.

Outcomes

According to this CPS report, 1) Children should not apply their own repellent; 2) Parents should remember to read the entire label before using. 3) Repellent should not be used on infants <6 months old; 4) Overall, the recommendations from the CPS are as follows: children <12 years old can use a product with 10% DEET; children >12 years old can use 30% DEET; children 6 months to 2 years old should use a product with no more than 10% DEET applied only once per day.

Pesticide Use Recommendation Strength of Recommendation
  1. Avoid pesticide exposure. Encourage pesticide-free foods.

Consensus

Pesticide Use References
ReferenceMethods and OutcomesFormer CTFPHC GRADE

Council On Environment And Health. Pesticide exposure in children. Pediatrics 2012;130;e1757. Abstract available from: Pediatrics

Methods

Subjects: Children

Design: Policy statement

Methods: This policy statement presents the position of the American Academy of Pediatrics on exposure pesticides. It discusses steps that paediatricians should take to identify pesticide poisoning, evaluate patients for pesticide-related illness, provide appropriate treatment, and prevent unnecessary exposure and poisoning. A thorough review of these topics can be found in the technical report.  

Outcomes

Based on an in-depth review of pesticide exposure in children, this position statement reported that pesticide exposures are common and has both acute and chronic deleterious effects on health. Recommendation: The AAP recommends that paediatricians acquire the knowledge and the skills in pesticide identification, counselling, and management.

Roberts JR, Karr CK; American Academy of Pediatrics, Council on Environmental Health. Technical report—pesticide exposure in children. Pediatrics. 2012:130(6). Abstract available from: Pediatrics

Methods

Subjects: Children

Design: Review and technical report

Methods: This review focuses on select insecticides, herbicides, and rodenticides and specific chemical classes within these groups that have the greatest acute and chronic toxicity for children on the basis of historical experience and/or emerging evidence. 

Outcomes

This report reviews the evidence about health outcomes associated with both acute and chronic exposure to pesticides. The sources of pesticides, the mechanism of toxicity, the clinical manifestations, the chronic health effects of pesticide exposures and the state of pesticide knowledge among pediatricians are among several topics presented. Authors note that children are uniquely vulnerable to uptake and adverse effects of pesticides because of developmental (e.g. hand-to-mouth activity), dietary, and physiologic factors (e.g. greater intake of food or fluids per pound of body weight). The recommendations issued are similar to those found in the AAP policy statement. Recommendation:  Pediatricians should be familiar with the common pesticide types, signs and symptoms of acute toxicity, and chronic health implications, and that efforts should be made to limit children’s exposure as much as possible. 

Bassil KL, Vakil C, Sanborn M, Cole DC, Kaur JS, Kerr KJ. Cancer health effects of pesticides: Systematic review. Can Fam Physician. 2007;53:1704-1711. Abstract available from: PubMed

Methods

Subjects: Adults and children exposed to pesticides

Design: Systematic review

Methods: Performed a search of electronic databases MEDLINE, PreMedline, CancerLit and LILACS for studies On non-Hodgkin lymphoma, leukemia and 8 solid-tumour cancers published between 1992 and 2003. Studies were reviewed by 2 trained reviewers and rated on methodologic quality according to a 5-page assessment tool. Studies rates below a score of 4 out of 7 were excluded. 

Outcomes

Eighty-three studies were found. Most studies on non-Hodgkin lymphoma and leukemia showed a positive association with pesticide exposure. There was an association between kidney cancer in children and parents with occupational exposure. The 8 solid-tumour cancers included: brain, breast, kidney, lung, ovarian, pancreatic, prostate and stomach cancer. This review of evidence shows an association between pesticide exposure and cancer, particularly brain, prostate, kidney and non-Hodgkin lymphoma and leukemia. Children had an increased risk of cancer during critical periods of exposure (both prenatal and postnatal) and with parental exposure at work. Recommendation:  Reduced exposure to all pesticides.

Ma X, Buffler PA, Gunier RB, Dahl G, Smith MT, Reinier K, Reynolds P. Critical windows of exposure to household pesticides and risk of childhood leukemia. Environmental Health Perspectives. 2002;110:955-960. Abstract available from: PubMed

Methods

Subjects: 0 to 14 years old

Design: Case-control study

Methods: Used the study population for the Northern California Childhood Leukemia Study (NCCLS). Matched cases with controls from the population birth registry. Exposure was the use of pest control services from 1 year before birth to 3 years after birth.

Outcomes

In this study, professional pesticide use was associated with leukemia (OR=2.8, 95% CI 1.4-5.7). The highest risk of childhood leukemia was exposure to pesticides during pregnancy and also, early life exposure had higher risk than exposure in later life. Indoor pesticides were more harmful than outdoor pesticides. Also, there was higher risk with greater frequency of exposure. This study showed that the timing, location and frequency of exposure to pesticides may be associated with the risk of developing leukemia. 

Buckley JD, Meadows AT, Kadin ME, Le Beau MM, Siegel S, Robison LL. Pesticide exposures in children with non-Hodgkin lymphoma. Cancer. 2000;89:2315-2321. Abstract available from: PubMed

Methods

Subjects: ≤20 years old

Design: Case-control study

Methods: Data from the Children’s Cancer Group. Used matched, randomly selected, regional population controls. Assessed pesticide exposure through telephone interviews with mothers.

Outcomes

This study found a significant association between the risk of non-Hodgkin lymphoma (NHL) and increased frequency of pesticide use in the home. Use of professional extermination services and postnatal exposure were also significant predictors of NHL. However, due to some limitations of the study (self-report of pesticide exposure can lead to potential for recall bias), no causal trend can be determined and further investigation is warranted.

Mercury and Lead Recommendations Strength of Recommendation
  1. Lead Screening is recommended for children who: 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 mo - 6 yrs, within 3 months of arrival and again in 3-6 months.

Fair

  1. Even for blood levels less than 10ug/dL, evidence suggests an association, and perhaps partial causal relationship with lower cognitive function in children.

Fair

Mercury and Lead References
ReferenceMethods and OutcomesFormer CTFPHC GRADE

Abelsohn AR, Sanborn M.

Lead and children: Clinical management for family physicians. Canadian Family Physician. 2010; 56:531-5. Abstract available: PubMed

Methods

Subjects: Children

Design: Narrative review

Methods: MEDLINE search of English-language articles published in 2003 to 2008.

Outcomes

The review paper reiterates the lead screening guidelines as reported by the CDC. The paper reports that a new action level of 0.24 μmol/L (5 μg/dL) has been proposed in the United States. No guidelines or changes in action level have been proposed for Canada. The authors report that “interventions that reduce high blood lead levels have not been proven effective for preventing neurocognitive deficits”.  Office-based approach to prevention and public education campaigns are important.  Specifically, physicians can counsel at all visits, including preconception counseling, antenatal and well-baby visits.  Physicians can inquire about lead paint exposure (housing, occupation) and drinking water, and especially be more vigilant in screening for high-risk groups.

Centers for Disease Control. CDC lead poisoning prevention in newly arrived refugee children: tool kit. Atlanta, GA: Centers for Disease Control; 2009. Available from: Centers for Disease Control.

 

Centers for Disease Control. CDC lead poisoning prevention tips. Atlanta, GA: Centers for Disease Control; 2009. Available from: Centers for Disease Control.

Methods

Subjects: Infants

Design: Lead poisoning prevention guidelines

Methods: Developed guidelines for preventing lead poisoning in children. There are a variety of screening questions that can be asked during well-baby visits to target potentially high-risk infants for blood tests.

Outcomes

Recommendations: Lead screening recommended for children who: Lead Screening is recommended for children who: 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 mo - 6 yrs, within 3 months of arrival and again in 3-6 months. There are other guidelines that are not included in the CFP study but are quite vague.

Chandramouli K, Steer CD, Ellis M, Emond AM. Effects of early childhood lead exposure on academic performance and behaviour of school age children. Arch Dis Child. 2009;94(11):844-8. Abstract available from: PubMed

Methods

Subjects: Children

Design: Cohort

Methods: This study aimed to determine whether early lead exposure at levels below 10 microg/dl has an impact on educational and behavioural outcomes at school. Venous samples were taken from a subgroup of the Avon Longitudinal Study of Parents and Children (ALSPAC) attending a research clinic at 30 months of age (n = 582), and lead levels were measured by atomic absorption spectrometry. Developmental, behavioural and standardised educational outcomes (Standard Assessment Tests, SATs) were collected on these children at age 7-8 years. In the analysis, blood lead concentration was investigated both as a continuous covariate and as a categorical variable.

Outcomes

488 cases (84%) had complete data on confounders and outcomes. After adjustment for confounders and using a log dose-response model for lead concentration, blood lead levels showed significant associations with reading, writing and spelling grades on SATs, and antisocial behaviour. A doubling in lead concentration was associated with a 0.3 point (95% CI -0.5 to -0.1) decline in SATs grades. Treating lead levels categorically, with the reference group 0-2 microg/dl, no effects on outcomes were apparent at 2-5 microg/dl, but levels of 5-10 microg/dl were associated with a reduction in scores for reading (OR 0.51, p = 0.006) and writing (OR 0.49, p = 0.003). Lead levels >10 microg/dl were also associated with increased scores for antisocial behaviour (OR 2.9, p = 0.040) and hyperactivity (OR 2.82, p = 0.034). Conclusion: Exposure to lead early in childhood has effects on subsequent educational attainment, even at blood levels below 10 microg/dl. 

Lee R, Middleton D, Caldwell K, Dearwent S, Jones S, Lewis B, Monteilh C, Mortensen ME, Nickle R, Orloff K, Reger M, Risher J, Rogers HS, Watters M. A review of events that expose children to elemental mercury in the United States. Environ Health Perspect. 2009;117(6):871-8. Abstract available from: PMC

Methods

Subjects: Children

Design: Review

Methods: Comprehensive review of the existing exposure data sources and the scientific literature to identify and quantify common sources of mercury exposure for children in the United States and to describe the location, demographics, and proportion of children affected by such exposures. The numerous mercury exposure prevention initiatives were also reviewed. 

Outcomes

Federal, state, and regional programs with information on mercury releases along with published reports of children exposed to elemental mercury in the United States were identified and reviewed. All mercury-related events that were documented to expose (or potentially expose) children were selected. Primary exposure locations were at home, at school, and at other locations such as industrial property not adequately remediated or medical facilities. Conclusions: 1) Exposure to small spills from broken thermometers was the most common scenario; however, reports of such exposures are declining. 2) Childhood exposures to elemental mercury often result from inappropriate handling or cleanup of spilled mercury. 3) Most releases do not lead to demonstrable harm if the exposure period is short and the mercury is properly cleaned up.

Recommendation: Primary prevention to reduce human exposure to heavy metals such as mercury should include health education and policy initiatives.

Bellinger DC. Very low lead exposures and children’s neurodevelopment. Current Opinion in Pediatrics. 2008;20(2):172-177. Abstract available from: PubMed

Methods

Subjects: Children

Design: Review

Methods: Reviewed the literature for studies that show adverse outcomes when children are exposed to blood lead levels <10µg/dL (the current screening guideline).

Outcomes

Many studies have shown adverse effects, such as cognitive deficits and behavioural problems, in children with “low” blood lead levels. According to this review, there is no level of lead exposure that is considered to be safe. The authors highlight that in order to prevent exposure it is important to keep parents of young children informed of all sources of lead in their child’s environment. 

Téllez-Rojo MM, Bellinger DC, Arroyo-Quiroz C, Lamadrid-Figueroa H, Mercado-Garcia A, Schnaas-Arrieta L, Wright RO, Hernandez-Avila M, Hu H. Longitudinal associations between blood lead concentrations lower than 10 µg/dL and neurobehavioral development in environmentally exposed children in Mexico City. Pediatrics. 2006;118:e323-e330. Abstract available from: PubMed

Methods

Subjects: Infants

Design: Prospective cohort study

(N=294)

Methods: Healthy mother –infants pairs were recruited from Mexican maternity hospitals.  Infants were included if their blood lead levels at both 12 and 24 months of age were <10 µg/dL. Outcome measures were Bayley Scales of Infant Development II, specifically: 1) the Mental Development Index (MDI) and 2) the Psychomotor Development Index (PDI) at 12 and 24 months.

Outcomes

At 12 months, there was no significant association between MDI and PDI scores and blood lead levels. At 24 months, blood lead levels were inversely associated with both MDI and PDI scores Blood lead levels at 12 months were inversely associated with PDI scores at 24 months. These relationships were not altered by adjustment for cord lead blood levels or 12-month MDI and PDI scores.  Results of this study suggest that exposure to lead, even in the range of <10 µg/dL (the current screening guideline), may adversely impact the neurodevelopment of infants in a dose-dependent manner.

Tsekrekos SN, Buka I. Lead levels in Canadian children: Do we have to review the standard? Paediatr Child Health. 2005;10(4):215-220. Abstract available from: PubMed

Methods

Subjects: Children

Design: Review

Methods: Reviewed literature from searches of MEDLINE and Web of Science database using key words: Canada, child, lead poisoning, blood lead, and paediatrician.

Outcomes

There has been limited surveillance for blood lead levels among children and little research on the effects of low-level lead poisoning. Neurodevelopmental damage has been seen in children with blood lead levels lower than the current standards (i.e., 0.48 μmol/L). The authors conclude that the current regulations might be inadequate to protect children against lead poisoning. The review reports that physicians should be aware of screening tools for use in high-risk children and inform parents about the symptoms of lead poisoning.

Lanphear BP, Dietrich K, Auinger P, Cox C. Cognitive deficits associated with blood lead concentrations <10 µg/dL in US children and adolescents. Public Health Reports. 2000;115(6):521-529. Abstract available from: PubMed

Methods

Subjects: 6 to 16 years old

Design: Prospective cohort study

Methods: Used data from the Third National Health and Nutrition Examination Survey (NHANES III). Assessed relationship between blood lead concentrations and performance on cognitive tests (arithmetic, reading, nonverbal reasoning, and short-term memory).

Outcomes

After performing a multivariate analysis to control for potential confounders, there was an inverse relationship between blood lead concentration and scores on the 4 cognitive tests. Children were dichotomized to two groups for comparison: those with blood levels <5 and those with blood levels of 5 and over. Children with blood levels <5 µg/dL had decreased scores in reading and math. This study suggests that cognitive deficits are associated with blood lead concentrations <5 µg/dL. These findings are important given that current standards are set at 10 µg/dL.

Mercury and Lead Recommendations Strength of Recommendation
  1. Lead Screening is recommended for children who: 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 mo - 6 yrs, within 3 months of arrival and again in 3-6 months.

Fair

  1. Even for blood levels less than 10ug/dL, evidence suggests an association, and perhaps partial causal relationship with lower cognitive function in children.

Fair

Mercury and Lead References
ReferenceMethods and OutcomesFormer CTFPHC GRADE

Abelsohn AR, Sanborn M.

Lead and children: Clinical management for family physici