Highlights of Revisions in the 2020 Rourke Baby Record

Download a version of the 2020 RBR with changes since 2017 shown in teal print

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Ontario version of the 2020 RBR



Changes in the 2020 Ontario RBR (shown in teal)

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Differences between 2020 National and Ontario RBR (shown in red)
About These Differences

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GENERAL ITEMS

1. Graphic design improvements: Changes of font, spacing, shading, and borders have been made on Guides I to V and Resources pages 1 – 4 to improve legibility, readability, and navigation.
2. Web links: Web links have been revised as per current evidence and provide a wealth of information for clinicians and families.  They are identified on Resources pages 1 - 4 with the title or topic followed by the organization or journal.  On the RBR website  the links are live for easy accessibility.
3. Order of Items: The order of items in some sections has been revised. 
- In the Nutrition and in the Education and Advice sections, we have attempted to list items in order of strength of recommendation – good evidence (bold) before fair evidence (italics) before inconclusive evidence/consensus (plain) - taking the flow of items into consideration
- In the Physical Exam section, we have attempted to list items from head to toe also taking the strength of recommendation into consideration - good evidence before fair evidence before inconclusive evidence/consensus."

GROWTH MONITORING

4. Growth Charts: The recommended growth charts remain the 2014 Canadian growth charts from the WHO Child Growth Standards, and the web link descriptor has been modified to show that BMI tables and calculator are freely available on this link.

NUTRITION SECTION

5. Breastfeeding: Wording has been revised to indicate that breastfeeding may reduce gastrointestinal and respiratory tract infections, as these associations noted in research studies could be due at least in part to the social determinants of health, which differ between women who breastfeed and those who do not.
6. Vitamin D supplementation: Lactating mothers are encouraged to consume a standard multivitamin/mineral supplement that contains vitamin D (400 IU/day).
7. Infant formula: As all infant formulas sold in Canada (save for a couple of very specialized items) now have enough iron to meet infants' needs, the wording “iron fortified” has been removed from all visits, and the following statement has been added: “Formulas generally contain iron: 0.4mg - 1.3mg/100ml.”
8. No bottles in bed: This item, already present at the 6 month and 9 month visits, has been added to the 12 and 15 month visits due to the importance of preventing dental caries at these ages.
9. Soy-based formulas: Wording has been revised in line with current evidence of minimal concern for adverse effects on development in infants who consume soy-based infant formula. Soy-based formula is not recommended for use in cow milk protein allergy or in preterm infants, and may interfere with absorption of T4 replacement therapy in infants with congenital hypothyroidism.
10. Introduction of solids: Wording has been revised to note that introduction of solids should be guided by infant readiness, starting between 4 and 6 months of age, and a link added to Feeding your baby in the first year - CPS Caring for Kids which lists the signs of readiness.
11. Allergenic foods: Evidence continues to increase that for all infants, including those at high risk for allergies, allergenic foods (especially eggs and peanut products) can be introduced with other solids around 6 months, but not before 4 months, as guided by the infant’s signs of readiness.  Once allergenic solids are introduced, they should be fed a few times a week to maintain tolerance.
12. Sugar and salt content of the diet of infants and young children: Wording has been revised to more widely address the issue of excess sugar and salt in foods as per current evidence to limit the consumption of foods (in addition to beverages) high in sugar as well as highly processed foods high in dietary sodium.

EDUCATION AND ADVICE SECTION

Injury prevention

13. Introductory wording: Due to the change in prevalence of causes of accidental death, the order of items in this section on Resources 1 has been changed to: Transportation in MVs, Bicycle, Safe sleep, Pacifiers, Choking, Drowning, Burns, Poisons, Falls, Firearms.  Note that this does not necessarily match the order on the Guides, which more closely follow the order of strength of recommendation.
14. Transportation in motorized vehicles including cars, ATVs, snowmobiles, etc.:
- Wording to never leave a child unattended in a vehicle has been added to address forgotten baby syndrome resulting in paediatric hyperthermia-related deaths.
- Car seat wording has been updated and streamlined, and now includes the recommendation to replace the car seat if in a collision.
- Children and youth younger than 16 years of age should not operate an ATV or a snowmobile, including youth models.
15. Bicycle: Wording has been added to replace the helmet if it has sustained an impact or is > 5 years old.
16. Safe sleeping environment:
- Sleep position, bed sharing and SIDS: Healthy infants should be positioned on their backs on a firm surface for every sleep.  Use of alcohol, or of illicit or sedating drugs have been added to the risk factors for SIDS.
- Crib safety: Wording has been revised for clarity.
- Swaddling: As there is not one age for all at which swaddling should be discontinued, the wording has been revised to: Swaddling is contraindicated once baby shows signs of attempting to roll.
17. Pacifier use: A statement to counsel on safe and appropriate use of pacifiers has been added for clarity.
18. Choking: The age for food choking risk has been increased from 3 years to 4 years in line with current recommendations.
19. Drowning: Wording has been added to specify pool fencing with self-closing and self-latching gates.
20. Burns: Information has been added re burns in general and scalds with hot liquids:
- For visits at 9 months to 5 years: The item “Burns” has replaced “Hot water <49C”.
- Wording has been added to be vigilant with hot liquids on countertops.
21. Poisons: Wording has been broadened to include toxic substances in general.

Behaviour and Family Issues

22. Social determinants of health (SDH): Wording has been clarified re validated poverty identification questions as follows:
- On the Guides: “Difficulty making ends meet or food insecurity”
- On Resources 2:  “Within the past 12 months, did you worry that your food would run out before you got money to buy more, OR did the food not last and you didn’t have money to get more?”
23. Literacy: Evidence is accumulating about the effect of singing and music on literacy, attachment, and parental well-being.  Wording has been updated that reading and singing should ideally begin with young infants.
24. Family Healthy active living/sedentary behavior/screen time: In this digital age, screen use is no longer a black and white decision of all or nothing; the more realistic approach is to optimally manage it.  Video-chatting has been added to improve communication with family and friends.

Environmental Health

25. Second hand smoke/e-cigarettes/cannabis exposure: Wording has been expanded to educate parents on the health risks and harms associated with e-cigarettes and cannabis (including edibles), and on safe storage.
26. Sun exposure and insect bites/repellents: These have been split into two items on Resources 1 and include a recommendation to prevent mosquito bites.
27. Pesticide exposure: As obtaining pesticide-free foods is not realistic for many and evidence is lacking on its efficacy, this statement has been removed.  It has been replaced with asking about pesticide use and storage at home and advising washing of all fruits and vegetable that cannot be peeled.
28. Blood lead:
- As lead was banned from interior house paints in Canada in 1960, houses built before this time (rather than 1978 as on the 2017 RBR Resources 1) are higher risk. Exterior paint in Canada may have contained some lead until 1990.
- The following 3 risk factors have been added as new indications to consider blood lead screening.  Children who: i) have emigrated or been internationally adopted from a country where population lead levels are higher than in Canada; ii) are at risk of lead exposure from water pipes; or iii) require diagnostic investigations for neurodevelopmental delays/disorders. 

Other

29. Oral Health:
- A new item on management of teething discomfort has been added, advising gum massage with a cold facecloth/teething ring and appropriate use of oral analgesics (e.g. acetaminophen, or if > 6 months ibuprofen). Anaesthetics/ numbing gels and teething necklaces are contraindicated. 
- A new evidence-based Canadian caries risk assessment tool has been developed. It has been endorsed by the CPS.

DEVELOPMENT SECTION

30. The term “normal developmental milestones”, has been improved to “typical developmental milestones”.
31. A link to a table of general developmental assessment tools has been included. Assessment tools Table 4 (CPS)
32. Motor milestones: The milestones for developmental surveillance have been expanded to include the following items with evidence re early detection of cerebral palsy:
- At the 6-month visit, “No persistent closed/fisted hands”; and “reaches/grasps objects with both hands equally”.
- At the 9- and 12-month visits, “Uses both hands equally”.
33. Autism spectrum disorder: Additional risk factors of prematurity, and certain chromosomal, genetic and neurological disorders have been added.  Wording has been revised to broaden the choice and use of standardized evidence-based screening tools as per three new CPS Position Statements:
- ASD Early detection
- ASD Diagnostic assessment
- ASD Management

PHYSICAL EXAMINATION SECTION

34. The order of items in this section has been revised. Where possible, items have been placed from head to toe, also taking into consideration the strength of recommendation: good evidence (bold) before fair evidence (italics) before inconclusive evidence/consensus (plain).
35. Blood pressure: Common risk factors for elevated blood pressure in children > 3 years have been added and include those with obesity, sleep-disordered breathing, prematurity, renal disease, congenital heart disease, or diabetes, or those on medications that increase BP. The web link descriptor has been modified to indicate that the 2 linked resources include definitions of high blood pressure.
36. Vision: As examining for the corneal light reflex is most clinically relevant at and after 6 months of age, this item has been deleted from visits younger than 6 months of age.
37. Hearing inquiry/screening: Wording has been revised for clarity.
38. Palate: To rule out cleft palate, wording has been added to examine for an intact palate by inspection and palpation for visits up to 1 month of age. 
39. Tongue mobility: As tongue mobility becomes clinically relevant when there are breastfeeding problems, the qualifier “if breastfeeding problems” has been added to prevent overdiagnosis of clinically insignificant ankyloglossia.
40. Teeth: In line with current evidence, assessing risk for dental caries has been added as part of teeth examination for visits starting at 6 months of age, and a link has been added to the new CPS-endorsed Canadian Caries Risk Assessment Tool.
41. Heart/Lungs/Abdomen: This item has now been included on all visits, as it has been suggested that not including it implied that examination of the heart, lungs, and abdomen was not indicated.  The principle of the physical exam section, as stated on this heading on Guides I to IV, has always been that an appropriate age-specific physical examination is recommended at each visit. Evidence-based screening for specific conditions is highlighted.
42. Umbilicus: Umbilical cord care to gently pat dry and review S&S of infection has been added.
43. Hips: Wording has been expanded re physical examination assessment and consideration of selective imaging. Examination includes assessing limb length discrepancy and asymmetric thigh or buttock (gluteal) creases; performing Ortolani manoeuvre (usually negative after 3 mos); and testing for limited abduction (usually positive after 3 mos). Consider selective imaging between 6 wks and 6 mos if risk factor (i.e. breech, family history, hip instability on physical exam).
44. Motor exam: For early detection of cerebral palsy, “No head lag” has been added to the physical exam at 6 months, “Muscle tone” has been added at the 9- and 12-month visits; with a link to CP Features (DM&CN)
45. Muscle tone: Wording has been clarified that assessment should be performed for abnormal tone or deep tendon reflexes, or for asymmetric movements (moving one side more than other). These may be early signs of cerebral palsy or neuromotor disorder and suggest the need for further assessment.
46. Back/Spine: A new item has been added at visits up to 2 weeks of age to examine the spine for cutaneous signs of occult spinal dysraphism, along with a link to Congenital Brain and Spinal Cord Malformations (AAP)

INVESTIGATIONS/SCREENING SECTION

47. Anemia screening:
- Due to evolving evidence for the diagnosis of anemia, “Hemoglobin (if at risk)” has been revised to “Anemia screening (if at risk)”.
- Wording has been revised to reflect the high risk groups for iron deficiency anemia based on current evidence: Screening for iron deficiency anemia should be considered between 6 and 18 months of age for infants/children from high risk groups: E.g. Low SES; Indigenous communities; newly arrived refugee, internationally adopted and immigrant children from resource-poor countries; low-birth-weight and premature infants; infants/children fed whole cow’s milk before 9 months of age or at quantities > 500 mls/day; prolonged bottle feeding beyond 15 months of age; or sub-optimal intake of iron-containing foods. Beyond this age, anemia screening as per additional risk factors.  Note that Asian children are no longer considered to be a high-risk group.

IMMUNIZATION SECTION

48. Immunization pain reduction strategies: Giving the most painful vaccine last has been added as an additional pain reduction strategy. 

Vaccine notes: Revised wording includes:

49. dTap vaccine: Immunization with dTap should be offered to all pregnant women (>13 weeks of gestation, ideally at 27 – 32 weeks) to provide immediate protection to infants < 6 months of age.
50.  Hepatitis B vaccine: For children in medically high-risk groups (e.g. immunocompromising conditions, chronic renal failure, dialysis), see Hepatitis B chapter in the Canadian Immunization Guide for schedules re timing and number of Hep B vaccine doses and monitoring of HB antibody levels.
51. Influenza vaccine: 
- Influenza vaccine is recommended for all children, particularly those aged 6-59 months and other children at high risk.
- Children 2-18 years of age should be given QIV, or quadrivalent live attenuated influenza vaccine (LAIV) if not contraindicated. If a quadrivalent vaccine is not available, TIV should be used.
- LAIV is contraindicated for children i) with immune compromising conditions; ii) with severe asthma (defined as current active wheezing or currently on oral or high-dose inhaled glucocorticosteroids, or medically attended wheezing within the previous 7 days); or iii) on aspirin.

Highlights of Changes in the 2017 Rourke Baby Record

GENERAL ITEMS

  1. Domain headings: On the Guides, the headings have been incorporated above each domain to create more space and enable larger print.
  2. Problems & Plans domain: This has been expanded to include Current & New Referrals. E.g. medical specialists, speech and language pathologists, PT, OT, dietitians, audiologists, optometrists, dentists, social determinants resources, etc. There is now a table on the new Resources 4 to record contact information for these referrals and other local resources.
  3. Education & Advice domain: This is now qualified with the phrase: “Repeat discussion of items is based on perceived risk or need.” An item may need to be asked at more than one visit depending on risk or need. Likewise, every item does not need to be asked at every visit, especially if there has been no concern with it. This is particularly relevant for the RBR format that includes only one visit per page, as items are listed at all visits.
  4. Parent resources: A link to parent resources on the RBR website has been added to the top of each Guide and Resource page.
  5. Resource pages format: The Resources pages have been expanded from three to four to add evidence for more of the items, to add a table of local resource/referral contact information, and to increase font size.
    • Resources 1: Growth, Nutrition, Injury prevention, Environment, Other
    • Resources 2: Family, Behaviour, Development, Physical exam, Investigations/Screening
    • Resources 3: Immunizations
    • Resources 4: Early Child Development and Parenting Resource System and Local Resources/Referrals Table.
  6. Resource pages font: The fonts on most topic headings are now consistent with those corresponding to the Guides (bold, italics or regular).
  7. Web links: All web links have been updated, and are identified in the Resources pages with the title or topic followed by the organization or journal.

GROWTH MONITORING

  1. BMI: In line with the CTFPHC statement on Growth Monitoring, BMI has been added to the visits at ages 2 years and above.

NUTRITION SECTION

  1. Vitamin D supplementation: In line with recent evidence of low Vitamin D levels in breastfed infants/children, and the difficulty in knowing when the diet of a breastfed infant/child contains sufficient vitamin D, Vitamin D supplementation of 400 IU/day (800 IU/day in high-risk infants) is now recommended for infants/children for as long as they are breastfed.
  2. Homemade infant formulas: Due to nutrition and safety issues, a statement to discourage the use of homemade infant formulas has been added to Resources 1.
  3. Allergenic foods: There is now good evidence for not delaying introduction of priority food allergens. In fact, the early introduction of some food allergens, such as egg, fish and peanut products, is associated with significantly lower prevalence of these respective food allergies.
  4. Variety of food textures: This item has been added to the 9 month and 12 – 13 month visits and to Resources 1.
  5. Dietary fat content: The wording is clarified that the transition starting at age 2 years refers to that from a high fat milk diet.
  6. Independent/self-feeding: This has been added to the 9 to 18 month visits and to Resources 1.

EDUCATION AND ADVICE SECTION

Injury prevention
  1. Injury prevention: A statement has been added on Resources 1 that unexplained injuries or injuries that do not fit the rationale provided or developmental stage raise concern for child maltreatment.
  2. Motorized vehicle safety: This has been expanded to motorized vehicle safety, to include ATVs and snowmobiles. Car seat wording has been updated.
  3. Choking: Encouraging children to eat and drink while seated has been added to the factors to avoid choking.
  4. Safe sleeping:
    1. Crib safety wording has been expanded on Resources 1.
    2. Positional plagiocephaly prevention: Supervised tummy time while awake has been added to Guides I and II; with expanded wording on Resources 1.
    3. Swaddling: Due to emerging evidence re adverse events associated with swaddling, this item has been moved from the sleep section.
Behaviour and Family Issues
  1. Crying: Wording on Resources 2 has been revised to highlight the risk of maltreatment from caregiver frustration related to infant/child crying.
  2. Recommended sleep duration: Information has been added on Resources 2, along with a statement to turn off TV/computer screens at least 60 minutes before bedtime.
  3. Parenting: Given the growing evidence on childhood adverse experiences and positive parenting, the items parenting/bonding/discipline/parenting skills are now in bold font (good evidence). A statement against physical punishment has been added on Resources 2.
  4. Maternal depression: Evidence has gone from fair to good re the significance of maternal, and to a lesser extent paternal, depression on infant/child health outcomes.
  5. Social determinants of health (SDH): There is increasing evidence of the importance of addressing SDH to optimize early child development and long term health outcomes. The validated questions “Do you have difficulty in making ends meet or feeding your family?” have thus been added to all Guides and to Resources 2.
  6. Care of immigrant and refugee children: Information has been added on Resources 2.
  7. Care of aboriginal children: Information has been added on Resources 2
  8. Prevention of child maltreatment: Wording on Resources 2 has been revised to consolidate risk factors for physical and sexual abuse, give parent advice re appropriate/inappropriate touch and normal sexual behaviour for age, and highlight the harms of violence against children. Resources on abusive head trauma, and on bruising in suspected maltreatment cases have been added.
  9. Screen time: Screen time has now been included in the item “Family healthy active living/sedentary behaviour/screen time” on the Guides and Resources 2, and the evidence for restricting screen time has gone from fair to good.
Environmental Health
  1. Blood lead: This item wording has been corrected from “serum” lead.
  2. Second hand smoke: Wording on Resources 1 has been expanded and clarified.
Other
  1. Complementary and alternative medicine (CAM): The CPS position statement on chiropractic care has been added to Resources 1.
  2. Oral Health:
    1. Wording on Resources 1 has been expanded to list caries risk factors, to clarify parental assistance with brushing teeth, to explain the different indications for fluoride varnish vs. systemic fluoride supplements, to begin flossing daily when teeth touch (which can be as early as 3 years of age), and to consider the first dentist visit by 6 months after the eruption of the first tooth or at age 1 year.
    2. The teeth graphic has been moved to the Physical exam section on Resources 2.
    3. Smiles for life – A Canadian version of the Smiles for Life program has been developed and endorsed by the Canadian Paediatric Society.

DEVELOPMENT SECTION

  1. “Sucks well on nipple”: This item has been added to the visit within 1 week of age, both as surveillance of development and as a red flag for hydration.
  2. Milestones related to self-feeding: Evidence for red flag ages of milestones was reviewed and the following fine motor control milestones clarified: opposes thumb and fingers at 9 months; uses pincer grasp at 12 – 13 months.
  3. Speech milestones: With publication of evidence-based milestone ages, the red flag for speech acquisition at the 18 month visit has been changed from 20 words, to 15 words.
  4. Autism spectrum disorder (ASD): Social/emotional and communication skills at the 18 month visit and development milestones at age 2 years have been labelled with a footnote (2) to indicate information on Resources 2 related to screening for autism spectrum disorder.
  5. Early child development and parenting resource system location and content: This chart has been moved to Resources 4 along with a table for adding local resource and referral contact information. With the2016 publication of the Developmental Delay Guidelines by the Canadian Task Force on Preventive Health Care, the box recommending Developmental Screening has been changed to Developmental Surveillance to avoid any misinterpretation.

PHYSICAL EXAMINATION SECTION

  1. Physical examination section location in the Resources pages: To more closely follow the domain order on the RBR Guides, this section has been moved to Resources 2.
  2. Dry skin: The item dry skin has been deleted (1 and 2 week visits) as it is not a reliable sign of dehydration and is not a significant part of the physical exam.
  3. Bruising: Bruising has been added to the physical exam of visits from 1 week to 6 months of age, and an item added to Resources 2 that unexplained bruising warrants evaluation re child maltreatment or medical illness. Bruising is rare (<1%) in infants prior to 9 months of age, in contrast to being common (40 – 90%) in those 9 months of age and older.
  4. Jaundice: An item has been added to Resources 2 to advise bilirubin testing (total and conjugated) if jaundice persists beyond 2 weeks of age. The item “jaundice” has been added to the 2 month visit and a reference added to Resources 2 re prolonged jaundice caused by biliary atresia.
  5. Blood pressure: In line with current evidence, measurement of blood pressure at the 2 to 5 year visits has been qualified as fair evidence for children at risk, rather than for all children.
  6. Dental: Examination of the teeth has been added at the 6 and 9 month visits, as the average age for first tooth eruption is 6 months. An explanatory item has been added to the physical examination box on Resources 2 to accompany the teeth graphic, which is now more appropriately relocated to this section.
  7. Neck/torticollis: This item has been added to visits up to 4 months in association with positional plagiocephaly and orientation of the infant’s head while sleeping.
  8. Abdomen: An age specific physical examination is recommended at each visit. To be consistent with the inclusion of the examination of the heart until 2 months of age for the diagnosis of congenital heart disease, abdominal exam has been added for the detection of a congenital or acquired renal lesion presenting as an abdominal mass.
  9. Hips: The techniques for proper hip exam have been added: Barlow/Ortolani at the 1 week to 2 month visits; and limited hip abduction at the 4 to 15 month visits (until walking).
  10. Examination of genitalia: At the visits up to 2 weeks, “genitalia” has been added to the item “testicles” to include genitalia exam for all infants.

INVESTIGATIONS/SCREENING SECTION

  1. Location: To more closely follow the domain order on the RBR Guides, this section has been moved to Resources 2.
  2. Anemia screening: On Resources 2, the high risk groups for iron deficiency anemia have been expanded to include infants/children fed whole cow’s milk before 9 months or at quantities > 750 mls/day, or if iron containing foods are not provided. Hemoglobin (if at risk) has been added to the 18 month visit.
  3. Blood lead testing: This has been moved from the environmental health section to the Investigations/screening domain. The rationale remains in the Environmental Health portion of the Education and Advice domain on Resources 1.
  4. TB skin testing: TB skin testing and guidelines have been moved to this section.

IMMUNIZATION SECTION

  1. Immunization schedules: These have been updated on Guide V and on Resources 3.
  2. Pregnant women: In order to protect the infant, pregnant women have been included in the statement on Resources 3 to reflect the recommended immunization schedule of the Canadian Immunization Guide. Recommendations for pregnant women have also been included in the dTap and influenza vaccine notes.
  3. Antipyretic use: In keeping with emerging evidence, a statement that acetaminophen or ibuprofen should not be given prior to, but after vaccination as required has been added to Resources 3.
  4. Vaccine notes: These have been updated and/or clarified on Resources 3 for all vaccines.
  5. Human papilloma virus vaccine: The HPV vaccine is not given in the 1 week to 5 year age range of the RBR, and the schedule is evolving. Thus the qualifier on the Immunization table (Guide V) has been revised to: “HPV: Starting at 9 years of age, as per provincial/territorial guidelines”. The HPV vaccine notes on Resources 3 have been deleted from this edition of the RBR as the current content may become outdated during 2017.
  6. Respiratory syncytial virus vaccine: Vaccine notes have been added to Resources 3.
  7. HIV moms and breastfeeding: This statement has been deleted as there is emerging evidence that the contraindication may no longer be absolute. It is currently a more complex issue.
  8. Selected Infectious Disease Recommendations: This section has been deleted. The updated content is now found in vaccine notes on Resources 3, and in the investigations/screening section of Resources 2.

EARLY CHILD DEVELOPMENT ALGORITHM – RESOURCES 4

  1. Areas of concern for development: Problems with feeding have been added to problems with vision or hearing in the sensory impairment areas of concern.

Highlights of Changes in the 2014 Rourke Baby Record

GENERAL ITEMS

Riverin B, Li P, Rourke L, Leduc D, Rourke J. Rourke Baby Record 2014: Evidence-based tool for the health of infants and children from birth to age 5. Canadian Family Physician. 2015; 61: 949-955.
http://www.cfp.ca/content/61/11/949.full.pdf+html

A version of the 2014 national English RBR highlighting all the changes from the previous edition can be downloaded for viewing here. Changes in content in the 2014 RBR are shown in aqua print.

  1. The wording on the printed Resources 1 - 3 pages has been simplified by hyper-linking the words that describe each web link instead of the actual URL itself. This has allowed a larger print font for easier reading. 
     All web links have been updated where appropriate.
  2. Strength of recommendation:  " Strength of recommendation is based on literature review using the classification: Good (bold type); Fair (italic type); Inconclusive evidence/Consensus (plain type). See literature review table at www.rourkebabyrecord.ca"
    • The regular font on the RBR Guides has been clarified to refer to items with either inconclusive evidence or consensus opinion.
    • There is no change to the system used in the 2014 RBR for evaluating the strength of recommendation: Good (bold type)Fair (italic type); Inconclusive evidence/Consensus (plain type)).  The Canadian Task Force on Preventive Health Care (CTFPHC), however, recently changed its classification system from the one above to the GRADE system, in which the grade of recommendation is either strong or weak.  Extensive discussion occurred to determine whether the RBR should follow suit.  This included discussions with members of the CTFPHC.  It was determined that the GRADE system is not appropriate for all the literature under review for the RBR.  Where appropriate, individual articles have been reviewed using both the GRADE and the former CTFPHC classification system, and can be found in the literature review table on the RBR website.
  3. The Ontario College of Family Physicians is no longer the fund administrator of the Government of Ontario funding support.
  4. To more clearly identify whether or not there are concerns with each item recommended for discussion, the following has been added in a horizontal shaded bar above the Nutrition section on Guides I to IV: “For each o item discussed, indicate “v” for no concerns, or “X” if concerns”.
  5. For the first time, the Dietitians of Canada (DC) has joined the College of Family Physicians of Canada (CFPC) and the Canadian Paediatric Society (CPS) in endorsing the RBR.

GROWTH MONITORING

  1. The 2014 RBR continues to recommend growth monitoring using growth charts from the 2006 World Health Organization (WHO) Child Growth Standards (birth to 5 years).  The Canadian WHO Growth Charts were revised in early 2014 to address concerns raised by the Canadian Paediatric Endocrinology Group (CPEG) regarding change in shaded percentile range lines; and omission of weight for age curves over 10 yrs of age.  The new web link for the Canadian WHO Growth Charts is www.whogrowthcharts.ca
    The CPEG growth charts, if they remain in use, can be found in the literature review table on the RBR website.
  2. The word "percentiles" has been changed to "age" in the Growth cell on the left column of each Guide so that it reads: Correct age until 24 - 36 months if
  3. In all visits up to and including 18 months (on Guides I to IV), the word "Height" has been changed to "Length" in the Growth boxes.

NUTRITION

  1. Vitamin D:
    • On the RBR Guides, a bullet symbol has been added in front of Vitamin D, indented under breastfeeding, as an additional prompt.
    • To be consistent with the revised Nutrition for Healthy Term Infants 0 - 6 months and 6 – 24 months, the following revisions have been made:
      • + Vitamin D 400 IU/day in regular font has been added to visits at 12 – 13, 15, and 18 months; and Resources 1 revised to include Vitamin D supplementation for all breastfed infants until the diet provides a sufficient source of Vitamin D (~ 1 – 2 years).  This is in regular font as the evidence is not as strong as it is for under one year of age.
      • Resources 1 statement about use of 800 IU vit D/day has been revised from “northern communities” to “high risk infants”.
      • The following statement has been removed from Resources 1: “Formula may only supply a portion of the recommended daily vitamin D intake if less than 1000 mL (33 oz) is consumed daily.”
  2. Introduction of Solids
    • Significant changes have occurred to the nutrition section of the 6 month and 9 month visits to allow the timely introduction of more solids, including allergenic foods, starting at 6 months.  The word "initial" has been deleted from "introduction of solids" at the 6 month visit as evidence is accumulating that introduction of solids should be considered depending on the infant’s signs of readiness, and may be a few weeks before to just after 6 months.  Introduce iron-rich foods first (to prevent iron deficiency anemia), then add fruits, vegetables and milk products such as yogurt and cheese.  Cow’s milk as the primary milk source should be delayed to sometime between 9 and 12 months.
    • An item has been added at the 4 month visit to discuss the future introduction of solids.
  3. New information and/or web links have been added on Resources 1 for the following topics:
    • Nutrition for Healthy Term Infants (NHTI), formerly for 0 - 24 months, has now been split into 2 documents:  0 to 6 months, and 6 to 24 months; and the CPS Practice Point on NHTI 0 – 6 months included.
    • NutriSTEP web link
    • Baby friendly initiative web link
    • safe infant formula preparation and handling
    • expansion of the positive effects of breastfeeding to include protection against sudden infant death syndrome (SIDS).
    • expansion of the statement on dietary fat content explaining its importance in the first 2 years of life
    • addition of: i) a statement on introduction of solids, ii) new information on the introduction of allergenic foods; and iii) CPS Position Statement on dietary exposures and allergy prevention
    • addition of a statement on iron containing foods
    • addition of a statement on honey avoidance until 1 year of age
    • info on mercury in fish has been expanded to fish consumption in general
  4. Clarification that promotion of cup use at the 12 – 13 and 15 month visits should be an “open” cup.
  5. Avoidance of sweetened juices/liquids has been continued for the 2 – 5 year visits.
  6. Skim milk has been added to 1% and 2% milk as appropriate for children starting at age 2 years.  This is consistent with the literature and with Canada’s Food Guide.
  7. Breastfeeding has been added to the 2 – 3 yr visit in regular font (the evidence isn’t as strong as for younger ages) to be consistent with the Nutrition for Healthy Term Infants document.

EDUCATION AND ADVICE

General
A new section of Environmental health items has been created on all the RBR Guides and on Resources.  These items in past RBR editions were generally scattered throughout the “Other” section of the Education and advice section.

Injury prevention

  • Safe Kids Canada web link has been changed to Parachute (new organization).
  • Bicycle safety has been expanded to include advocating for helmet legislation for all ages, and the web link for the new CPS Position Statement has been added to Resources page 1.
  • Firearm safety has been expanded to include safe storage.
  • "Falls" item has been expanded to include unstable furniture and TVs.
  • Pacifier use has been moved from "Other" section to "Injury prevention" section due to evidence that pacifier use may decrease the risk of SIDS.
  • Transportation in motor vehicles has been updated to:
    • recommend rear-facing infant/child seats until age 2 years as per recent recommendations;
    • replace the outdated CPS Position Statement (currently under revision) with a more up to date statement by the American Academy of Pediatrics (AAP).

Behaviour and Family Issues

  • Adoption has been added to foster care statement on Resources 2: Adoption/foster care: Children newly adopted or entering foster care ..."
  • Swaddling item on Resources 2 has been changed from 6 months to 2 months because of safety concerns re SIDS (although no conclusive evidence in the literature).
  • New information has been added on healthy sleep habits
  • The term "shaken baby syndrome" has been changed to "abusive head trauma".
  • Expansion of information on Resources 2 for prevention of child maltreatment
  • The item "Healthy active living/sedentary behaviour" has been expanded and moved from Resources 1 Other Section to Resources 2 Behaviour/Family Issues, and has been renamed “Family healthy active living/sedentary behaviour".  A web link to the Canadian Society for Exercise Physiology (CSEP) guidelines for physical activity and sedentary behaviour has been added to Resources page 2.

Other
Oral health

  • Expansion of information to include 1) fluoride varnish, and 2) a caries risk assessment tool (AAP).
  •  

DEVELOPMENTAL MILESTONES

  1. There is no change to the items in this section on the RBR Guides.
  2. Two new web links have been added to Resources 2 for new CPS Position Statements:
    • Getting it right at 18 months
    • Measuring in support of early childhood development
  3. On Resources 2, the Modified Checklist for Autism in Toddlers (M-CHAT) has been revised and the follow-up questions for initial positive screening questions incorporated in a single document:
    M-CHAT-R/F.  The M-CHAT-R is also available in an electronic format for parents to complete.

PHYSICAL EXAMINATION

  1. On all Guides (I to IV), the Physical Examination column wording has been clarified to: "An appropriate age-specific physical examination is recommended at each visit.  Evidence-based screening for specific conditions is highlighted. "
  2. Checking visual acuity at age 3 - 5 years has been added to Resources 1.
  3. The wording for "obstructive sleep apnea" has been updated to "sleep disordered breathing".
  4. "Tongue mobility" has been added to Guide 1 (visits 1 wk 2 wk and 1 mo) and "Inspect tongue for ankyloglossia" has been added to Resources 1. 
  5. “Patency of anus” has been added to the physical examination within 1 week.

IMMUNIZATION

  1. The format of the Guide V Immunization chart has been improved with a new column to separate the date from the name of the vaccine.
  2. A direct link to the Canadian Immunization Guide (in addition to the NACI homepage) has been added to the Guide V Immunization chart and to Resources page 3.
  3. Meningococcal vaccine terminology has been updated from MenC-C to MVC-C and MCV-4.
  4. “Females” has been removed from the HPV vaccine item on Guide V: Immunization chart as HPV vaccine is now recommended for both genders.
  5. MMR wording has been clarified on Resources page 3 re the timing of the second dose.
  6. Vaccine notes on Resources page 3 now indicates that live attenuated influenza vaccine can be used at age 2 years and above if no contraindication.
  7. Regarding TB, web links to the Canadian TB Standards have been added, and more simplified wording has been used on Resources page 3.

Highlights of Changes in the 2011 Rourke Baby Record

Rourke L, Leduc D, Constantin E, Carsley S, Rourke J, Li P. Getting it right from birth to kindergarten What’s new in the Rourke Baby Record? Canadian Family Physician 2013;59:355-359.

A version of the 2011 national English RBR highlighting all the changes from the previous edition can be downloaded for viewing here. Changes in content in the 2011 RBR are shown in magenta (pink) print and new web links in the 2011 RBR are in green print.

Growth

  1. Growth monitoring: the strength of the evidence has improved from fair to good with use of the WHO growth charts.
  2. "Regains birth weight between 1 and 3 wks" has been added to the 2 week visit.

Nutrition

  1. Change from bottle to cup discussion occurs earlier at 9 months.
  2. Vegetarian diets: new topic and resources.  
  3. Breastfeeding mothers are advised to continue vitamin D supplements for the duration of breastfeeding.
  4. New resources on:
    - infant formulas,
    - medications during breastfeeding,
    - mercury in fish.

Education and Advice

  1. Safe sleep wording expanded to include:
    - advice against using sleep positioners,
    - stronger advice against bed sharing,
    - cradle and bassinette safety statement.
  2. Lead screening risk factors and resources expanded.
  3. Children entering foster care: new topic and resources.
  4. Updated resources on:
    - health and the environment,
    - shaken baby syndrome,
    - fetal alcohol spectrum disorder.

Physical Examination

  1. Fontanelle examination and closure wording has been clarified.
  2. Hip exam recommended until at least one year of age, or until the child can walk.
  3. Obstructive sleep apnea wording includes the presence of snoring.

Investigations/Screening

  1.  Premature infants: included in the at-risk group for anemia screening.
  2.  Universal newborn hearing screening: included with good strength of evidence.

Immunization/Infectious diseases

  1. Immunization pain reduction strategies and resources: included with good strength of evidence.
  2. Immunization info web links for parents and physicians have been expanded.
  3. Rotavirus vaccine has been added to the RBR Immunization chart (Guide V) along with resources.
  4. Varicella vaccine schedule has been updated on the RBR Immunization chart (Guide V).
  5. Statements have been updated for:
    - varicella vaccine,
    - pneumococcal conjugate vaccine,
    - meningococcal conjugate vaccine.

Miscellaneous

  1. One month visit is no longer optional: to insure adequate growth, nutrition and parent adjustment.

Changes in the 2009 Rourke Baby Record 

Rourke L, Leduc D, Constantin E, Carsley S, Rourke J. Update on well-baby and well-child care from 0 to 5 years: What’s new in the Rourke Baby Record? Canadian Family Physician 2010; 56: 1285-90.

 

Rourke Baby Record: 2009 edition - Summary of major changes from the 2006 RBR

General

  1. No major format changes.
  2. Same endorsement by the CFPC and CPS as for the 2000 and 2006 editions of the RBR.
  3. Web links updated.
  4. Paper hard copies are no longer being distributed by McNeil Consumer Healthcare. The 2009 edition of the RBR may be downloaded from the Rourke Baby Record website (www.rourkebabyrecord.ca) and from various organization websites such as the CFPC and CPS.
  5. See the Rourke Baby Record website (www.rourkebabyrecord.ca) for pending updates including proposed new section for literature review with levels of evidence and new section for parent resources.

Growth

  1. Change from the CDC 2000 growth charts to the WHO 2006 growth standards.
  2. Update in recommendations for correction of growth measurement for premature infants.

Nutrition

  1. Addition of suggested daily volumes of milk intake as an approximate guide at different ages.
  2. Update re vitamin D supplementation.
  3. Change in the recommended fat content in milk given to 2 to 5 year olds.
  4. New recommendations on the indications for using soy-based formula.

Education & Advice - Anticipatory Guidance

Injury prevention issues

  1. Update in information/evidence regarding transportation in motor vehicles, bicycle helmets, hazards re choking and falls, aspects of water safety.
  2. Clarification of safe sleeping terminology.

Behaviour/Family/Development issues

  1. New guidelines for screening for autism spectrum disorder including use of the MCHAT.
  2. Update in information/evidence regarding non-parental childcare, facilitating literacy, and crying and the risk of shaken baby syndrome.
  3. The inclusion of recommendations for infant swaddling and on parenting programs.

Other issues

  1. Update in information/evidence regarding pacifiers, antipyretics, insect repellents, and dental care/oral health statements.
  2. New evidence and recommendations on OTC cough/cold medications and on serum lead levels

Development Milestones

  1. External reviews of levels of evidence for various developmental milestone items with subsequent revision of some items.
  2. Update in recommendations for correction of developmental milestones for premature infants.

Physical Examination

  1. Revision in level of evidence for vision screening and for screening for developmental dysplasia of the hips.
  2. New evidence and statements on hearing screening including universal newborn hearing screening.
  3. Clarification of the expected norms for fontanelle examination.

Immunization

  1. Update of immunizations as per NACI recommendations.
  2. New evidence and statements on rotavirus vaccine.
  3. Updated schedule for meningococcal vaccine.
  4. New resources for parents regarding immunizations.

2009 Rourke Baby Record: National and Ontario versions
As in the 2006 edition, the only differences between the Ontario and National versions of the 2009 edition of the RBR are found on Guide IV and its reverse (Healthy Child Development Selected Guidelines/Resources)

  1. On the Ontario version, the 128 month visit development section includes the following statements not on the national version:
    "Enhanced inquiry after Nipissing Developmental Screen™ (NDDS™)**
    List NDDS™ items not yet attained: _______________"
  2. 2. The 2009 Early Child Development and Parenting Resource System found on the reverse of Guide IV (Healthy Child Development Selected Guidelines/Resources) are either national or Ontario specific.

Changes in the 2006 Rourke Baby Record

The major changes to the September 2000 version found in the May 2006 version of the Rourke Baby Record are as follows:  

  • Expansion of visits from 3 guides to 4 to allow more writing space, with an optional 15-month visit to accommodate some immunization preferences/schedules.
  • Major emphasis on the 18-month visit as a critical time for assessing development.
  • Use of the Centers for Disease Control’s full-page growth charts.
  • Creation of an immunization chart to more easily document immunization.
  • Reorganization of the Education & Advice section to avoid omitting issues if a visit is missed.
  • Incorporation of selected evidence-based environmental, literacy, and healthy active living issues.
  • More detail on child development, including new evidence-based information on the reverse of Guide 4.
  • Incorporation of web-based resources for further information.