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."
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.
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
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.
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.
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.
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)
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.
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.
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.
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.
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.
Behaviour and Family Issues
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.
Rourke Baby Record: 2009 edition - Summary of major changes from the 2006 RBR
Education & Advice - Anticipatory Guidance
Injury prevention issues
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)
The major changes to the September 2000 version found in the May 2006 version of the Rourke Baby Record are as follows: