2025 update of the Greig Health Record

Abstract

Objective

To review a selection of new resources and updated recommendations from the third update of the Greig Health Record (GHR).

Sources of information

Pediatric preventive care literature was reviewed using PubMed and Google Scholar databases. Systematic reviews of subtopics were evaluated where available. Guidance and supporting evidence were reviewed from the Canadian Paediatric Society, the American Academy of Pediatrics, the Canadian Task Force on Preventive Health Care, the United States Preventive Services Task Force, the National Advisory Committee on Immunization, and the Centers for Disease Control and Prevention.

Main message

In this 2025 update the following topics have been added or revised: confidentiality, capacity, and consent in pediatric patients; developmental assessment; poverty screening; sexual health and consent; menstrual health history; contraception; guidance for detection and prevention of sexually transmitted infections; radon as an environmental hazard; updated ferritin standards; vaccine hesitancy; and updated dosing for human papillomavirus vaccination.

Conclusion

The third update of the GHR provides recent evidence-based recommendations and detailed guidance for clinicians providing pediatric preventive care.

The Greig Health Record (GHR) is an evidence-based care guide used in preventive care visits for children and adolescents aged 6 to 17 years old. It is available from https://greighealthrecord.ca, along with a comprehensive technical report that reviews the supporting evidence. This article provides an overview of a selection of the new resources and updated recommendations from the third update of the GHR.^1-3 This 2025 update also includes French translations of preventive care checklists and resources.

Sources of information

Searches for pediatric preventive care literature for the period of 2016 to 2025 were performed using PubMed and Google Scholar databases. Systematic reviews of subtopics were evaluated where available. Additionally, guidance and supporting evidence were reviewed from major Canadian and American agencies, including the Canadian Paediatric Society (CPS), the American Academy of Pediatrics, the Canadian Task Force on Preventive Health Care, the United States Preventive Services Task Force, the National Advisory Committee on Immunization (NACI), and the Centers for Disease Control and Prevention.

Main message

Confidentiality, capacity, and consent in pediatric patients. Confidentiality is central to a successful therapeutic relationship, particularly with adolescent patients.^4-6 Each physician is responsible for assessing their patient’s capacity to consent to the proposed medical intervention (including obtaining a history and performing physical examination). In the child and adolescent population, capacity may vary depending on the nature of the intervention and should be evaluated on a case-by-case basis.^7-9 The GHR now provides guidance in the form of definitions and resources (Box 1).^6,8,10,11

Box 1. Confidentiality, capacity, and consent.

This chart is not a comprehensive guide. See individual references for details and clarification.

Confidentiality

• The patient’s right to privacy in their medical care and health records is protected by federal legislation and no age is specified

Capacity

• Depends on ability to understand the medical problem; the proposed treatment; the alternatives (if any) to the proposed treatment; and the option of refusing treatment or of it being withheld or withdrawn

• Depends on the ability to appreciate the reasonably foreseeable consequences of accepting and refusing the proposed treatment

• Depends on the ability to make a decision that is not substantially based on delusions or depression

Consent

• Requirements include the following: the patient or decision maker must be capable (capacity); all relevant information must be given to make an informed decision; and it must be voluntary and without coercion

• No Canadian standard for age of consent. Legislation varies between provinces and territories

Data from Agostino et al,⁶ Canadian Medical Protective Association,⁸ Etchells et al,¹⁰ and Coughlin.¹¹

Developmental assessment. A new Canadian resource table is available for school-aged children. Generally, surveillance consists of questions about school performance and enjoyment as well as peer relationships. A table of developmental attainments for those aged 6 to 12 years is provided when a more in-depth assessment is needed (Table 1).¹²

Table 1.

Crucial skills in school-aged child development: At every age ask about academics. Is there a concern about the child’s writing, reading, or math?

AGE, Y	MOTOR	COMMUNICATION	COGNITIVE	SOCIAL-EMOTIONAL
6	Balances on 1 foot for 10 seconds Sees to catch tennis ball with 2 hands Buttons and unbuttons Dynamic mature pencil grasp	Makes back and forth conversation on partner’s topic Follows detailed 2-step directions (eg, “With your red crayon draw a line between the boys who are running”)	Sometimes follows rules without parent present Concentrates for 5-minute chore Does morning routine receiving 1 prompt per task	When calm, with parent help says a solution for problem Guesses friend’s feeling Understands right versus wrong with coaching
7	Skips forward Uses chopsticks without help Hooks and separates zipper	Follows embedded 2-step directions (eg, “Before you give me the paper, print your name on it”) Speaks with mostly correct grammar Hears for speech, with 90% or more understood	Verbally copies 5 digits forward, 3 digits backward	Draws or visualizes worries Knows how to be a good friend
8	Balances on 1 foot for 20 seconds Rides 2-wheel bicycle Uses knife and fork to cut	Shows understanding of familiar story	Generalizes rules to similar situations Ignores distractions; returns to task spontaneously after interruption	Self-calms using variety of strategies Says >1 solution for problem Guesses other’s intention
9	Hops forward then stops and balances on 1 foot Sees to throw tennis ball at wall and catch after 1 bounce, with 2 hands (6 of 10 tries) Copies vertical diamond and 3-dimensional cylinder	Detects implied meaning Describes experiences with main idea, thoughts, and feelings Talks about what they learned in school	With parent help when calm, says successful skill they used in difficult experience	Understands people can have different interpretations of events Responds soothingly to someone’s distress
10	Walks forward tandem Sees to throw and catch after 1 bounce (8 of 10)	Talks in group conversation Describes experiences with detail	Does morning routine without prompts	Knows what caused their negative emotion Remains calm when provoked Refrains from rude comments Adjusts quickly to unexpected change
11	Sees to throw and catch with no bounce (6 of 10)	Makes oral presentations interesting by using body language	When studying for tests, determines which information is important	Spontaneously chooses restitution Realistic about their strengths and weaknesses Receptive to coaching from parent and clinician
12	Sees to throw and catch with no bounce (7 of 10) Copies pre-drawn horizontal diamond	Thinks about how other feels from looking and listening during conversation	Sometimes thinks “what if” when choosing solutions for problem Sometimes generalizes rule to new situations Concentrates for 30-minute homework, 15-minute chore Remembers what to take to and from school	Might challenge their negative thoughts as coping strategy for distress Starts accurate perspective taking Considers intention when judging right from wrong Adjusts actions from seeing impact on other Does routine chores almost equally to parent

Adapted with permission by Dosman et al.¹²

Poverty screening. Approximately 1 in 5 children in Canada lives in poverty.¹³ Children growing up in low-income families have poorer physical and mental health outcomes.^14-19 Identifying children at risk and providing families with resources may improve long-term health. A validated screening tool to administer to parents and caregivers, as well as a link to the Centre for Effective Practice’s poverty tool, are included in the GHR.^20,21 The tool assists clinicians in guiding families to available resources (Box 2).^20,21

Box 2. Poverty screening tool: Ask “Do you ever have difficulty making ends meet by the end of the month?”.

• Screening recommendation: ask parents and caregivers

• If answer is yes, may be living below the poverty line (98% sensitivity, 40% specificity)

• Consider short- and long-term health consequences

• Offer assistance with accessing resources for filing taxes and collecting benefits

• Consult Centre for Effective Practice tool: https://cep.health/clinical-products/poverty-a-clinical-tool-for-primary-care-providers

Data from Centre for Effective Practice²⁰ and Persaud et al.²¹

Sexual health and consent. Sexual health history in pediatric populations should explore whether sex is consensual and free from exploitation and abuse, and confirm that the patient is capable of giving consent.^22-24 For the protection of young persons, Canadian laws provide detail regarding ability to consent to sexual activity by age and presence or absence of exploitation (Table 2).^23,25

Table 2.

Consent for sexual activity: All sexual activity without consent is a criminal offence, regardless of age. Sexual activity ranges from kissing and fondling to intercourse.

AGE OF CONSENTER	MAY LEGALLY GIVE CONSENT
18 y or older	In cases of potentially exploitative situations (eg, involving prostitution, pornography, or in relationships where there is a difference in authority or dependence)
16 y or older	Must be non-exploitative
Exceptions for close in age
• Age 14 or 15 y	Partner is <5 y older and non-exploitative
• Age 12 or 13 y	Partner is <2 y older and non-exploitative
• Younger than 12 y	Cannot consent

Data from Johnson²³ and Department of Justice Canada.²⁵

Menstrual health history. Adolescent females are often reluctant to raise menstrual concerns with health care providers.^26,27 Dysmenorrhea is the most common gynecologic concern and a leading cause of absenteeism from school and work in this age group.^28,29 A table regarding normal menarche, cycle regularity, and flow, as well as signs and symptoms requiring further inquiry, is now included in the GHR (Box 3).^30-33

Box 3. Menstrual health topics to ask about.

• Age of menarche—average is 12 to 13 years

• Cycles and regularity—may take 2 to 3 years to establish regular cycles after menarche, initial cycles are 20 to 45 days vs 24 to 38 for adults

• Length of periods—average duration is 5 days, >7 days is prolonged

• Heavy bleeding or clotting—average volume is 40 mL, heavy >80 mL. A saturated pad or tampon absorbs 5 to 15 mL

• Clots larger than a quarter are excessive. A menstrual chart is available from https://www.betteryouknow.org/sites/default/files/2022-08/BetterYouKnow-Menstrual-Chart-Scoring-System.pdf

• Symptoms related to cycle include mood, irregular bleeding, fatigue, and shortness of breath

• Consider screening for anemia or iron deficiency for heavy, prolonged, or frequent bleeding or for those with symptoms of fatigue or shortness of breath

• Dysmenorrhea

• Amenorrhea: primary, no period by age 16; secondary, no period for 6 months

Data from Peacock et al,³⁰ Centers for Disease Control and Prevention,³¹ United States Preventive Services Task Force,³² and Graham et al.³³

Contraception for adolescents. The GHR updates contraception recommendations from the CPS and the Society of Obstetricians and Gynaecologists of Canada. These include specific guidance for adolescents regarding bone mineral density, thromboembolic events, extended-use oral contraceptives, quick-start regimens, and year-long prescriptions. Long-acting reversible contraceptives are the preferred option. When choosing combined oral contraceptive pills, those with ethinyl estradiol below 30 μg per day should be avoided due to possible impact on bone mineralization in adolescents (Box 4).^34-36 Emergency contraception should be discussed where applicable. In Canada, emergency oral contraception is available in most regions without a prescription.³⁸ Options including oral contraceptives, intrauterine devices, and intrauterine systems are outlined (Box 5).^37-40

Box 4. Contraception recommendations: Recommendations for contraception do not address sexually transmitted infection prevention.

Recommend contraceptives in order of effectiveness:

1. LARCs: IUD, IUS, or implantable etonogestrel device

2. Hormonal plus time of intercourse method

3. Hormonal: OCPs, transdermal patch, vaginal ring, injectable

4. Used at time of intercourse: male and female condoms, diaphragms, cervical caps, sponges, and spermicide

History and physical examination

• Take a complete medical history

• Ask about migraines with aura, which is an absolute contraindication to estrogen use. Progesterone-only methods may be used

• Examination—weight and blood pressure

• Provide contraception without a pelvic examination unless required (eg, for IUD insertion)

Prescribing

• Quick-start approach—do not wait for next menses if reasonable certainty they are not pregnant; use a back-up method for 7 days after starting an OCP or implantable etonogestrel device outside of days 1 to 5 of the menstrual cycle

• Provide 1-year prescriptions to increase adherence (ie, for non-LARC)

• Choose OCP with 30 or 35 μg of ethinyl estradiol—lower levels may have negative effects on bone mineral density for adolescents

• For OCPs extended cycles and continuous use of active pills are effective

Precautions and contraindications

• For individuals >90 kg—certain contraceptives may have reduced effectiveness

• Combined OCP contraindications: containing estrogen, migraine with aura, history of venous thromboembolism or pulmonary embolus, systemic lupus erythematosus with antiphospholipid antibodies, factor V Leiden deficiency, estrogen-sensitive tumours

• Use SOGC guidelines to inform contraceptive choice

Discuss emergency contraception and condom use as appropriate

IUD—intrauterine device, IUS—intrauterine system, LARC—long-acting reversible contraception, OCP—oral contraceptive pill, SOGC—Society of Obstetricians and Gynaecologists of Canada.

Data from Di Meglio et al³⁴ and Black et al.^35,36

Box 5. Emergency contraception options.

1. Emergency over-the-counter hormonal pills (easiest to obtain, but reduced efficacy for patients weighing >75 kg)

   • Oral levonorgestrel

   • Ulipristal acetate

   • Combined OCP (lower efficacy than above)

2. Copper IUD (most effective)

3. Levonorgestrel IUS

When prescribing,

• Ask about timing of unprotected intercourse (determine if within window of effectiveness)

• Assess risk of pre-existing pregnancy

• Ask if unprotected intercourse was coerced

• Assess for STI risk and need for postexposure prophylaxis; offer testing for STIs

• Consider a pregnancy test 3 weeks post use

IUD—intrauterine device, IUS—intrauterine system, OCP—oral contraceptive pill, STI—sexually transmitted infection.

Data from the Society of Obstetricians and Gynaecologists of Canada,³⁷ Bancsi and Grindrod,³⁹ and the Society of Obstetricians and Gynaecologists of Canada.⁴⁰

Newer guidance for detection and prevention of sexually transmitted infections. Vaginal self-swabs for the detection of chlamydia and gonorrhea are recommended owing to evidence that detection of chlamydia may be improved and the ease and privacy of collecting a vaginal self-swab makes this a preferred option.^40,41 Sampling from other sites, such as from rectal and oropharyngeal areas, is recommended based on practices and sexual history, with self-swabs as an option with equal sensitivity.^42-44 Pre-exposure vaccination is recommended for persons at risk for Mpox due to practices and local epidemiology.^45,46 Guidance is provided for pre-exposure prophylaxis for individuals at higher risk for human immunodeficiency virus exposure, including those who report condomless anal sex and higher-risk situations. Counselling patients who are at risk should include discussion of pre- and postexposure prophylaxis (Boxes 6 and 7).^47-55

Box 6. PrEP for HIV.

PrEP indications

• MSM and transgender women, who may report condomless anal sex and other risk factors⁵⁴

• Heterosexual partner reporting condomless vaginal or anal sex with a partner with a substantial or non-negligible risk of transmissible HIV

• People who inject drugs and share injection paraphernalia with a person with a non-negligible risk of HIV infection

Medication: 300 mg of tenofovir disoproxil fumarate with 200 mg of emtricitabine in a single tablet (TDF-FTC)

Regimen

• Recommended: 1 tablet of TDF-FTC daily⁴⁸

• Alternative on demand: 2 tablets of TDF/FTC 2 to 24 hours prior to first sexual exposure, followed by 1 pill daily until 48 hours after last sexual activity⁵³

Postexposure prophylaxis requires additional medications and dosing

HIV—human immunodeficiency virus, MSM—men who have sex with men, PrEP—pre-exposure prophylaxis.

Box 7. PEP for HIV.

PEP indications

• Needs to be started within 72 h (the sooner the better)

• Recommended for HIV-negative individuals after moderate- to high-risk exposure of HIV transmission with a person who has a substantial risk of having transmissible HIV

• Can be considered for HIV-negative individuals after an exposure that is moderate or high risk for HIV transmission with a person who has a low but non-negligible risk of having transmissible HIV

HIV—human immunodeficiency virus, PEP—postexposure prophylaxis.

Data from Tan et al⁵⁴ and Billick et al.⁵⁵

Radon as an environmental hazard. A new national study about radon estimates that 17.8% of Canadian homes have high levels of radon. Previous estimates were lower, at 7%. Radon gas is found naturally in soil and rock and can seep in through building foundations. Long-term radon exposure, especially in children, increases the risk of lung cancer.^56,57 The GHR has added radon to its list of environmental hazards with links to a Canadian guide for radon reduction (Box 8).⁵⁸

Box 8. Radon exposure and radon reduction.

Parachute Canada—poisoning: https://parachute.ca/en/injury-topic/poisoning/

Health Canada—radon reduction: https://www.canada.ca/en/health-canada/services/health-risks-safety/radiation/radon/resources.html

Updated ferritin standards. Ferritin level standards in children are different from adults. New guidelines state that, for pediatric populations, the following values warrant treatment: less than 20 μg/L or between 20 and 30 μg/L if accompanied by anemia, microcytosis, or other risk factors.⁵⁹

Vaccine hesitancy. Counselling vaccine-hesitant patients and parents presents a challenge to providers. Guidance suggests strategies that can be used to deliver evidence-based information in a way that promotes understanding.^60,61 Counselling resources are provided (Box 9).⁶⁰

Box 9. Counselling vaccine-hesitant parents.

Start early, even antenatally

Present vaccination as the default approach

Build trust

• Spend time

• Be respectful, validate concerns

• Be knowledgeable

• Be honest about side effects

• Provide reassurance on a robust vaccine safety system

Focus on protection of the child and the community

Tell stories (of own children, vaccine successes, non-vaccination consequences)

Address pain and fear

Vaccination handouts and fact sheets: https://www.ontario.ca/document/immunization-well-child-toolkit

Data from Shen et al.⁶⁰

Updated dosing for human papillomavirus vaccination. The NACI strongly recommends all individuals aged 9 to 26 years be vaccinated. Individuals aged 9 to 20 years now require only 1 dose and those aged 22 to 26 years require 2 doses.^62,63

Conclusion

This update to the GHR provides recent evidence-based recommendations and detailed guidance for clinicians providing pediatric preventive care.

Editor’s key points

• ▸ The Greig Health Record (GHR) is an evidence-based care guide used in preventive care visits for children and adolescents aged 6 to 17 years old.

• ▸ In this third update, the following topics are new or revised: confidentiality, capacity, and consent; developmental assessment; poverty screening; sexual health and consent; menstrual health history; contraception; guidance for detection and prevention of sexually transmitted infections; radon as an environmental hazard; updated ferritin standards; vaccine hesitancy; and updated dosing for human papillomavirus vaccination.

Points de repère du rédacteur

• ▸ Le Relevé médical Greig (RMG) est un guide sur les soins de santé préventifs fondés sur des données probantes à utiliser lors des rendez-vous avec des enfants et des adolescents de 6 à 17 ans.

• ▸ Dans cette troisième actualisation, les sujets suivants sont nouveaux ou révisés : la confidentialité, la capacité et le consentement; l’évaluation développementale; le dépistage de la pauvreté; Ia santé sexuelle et le consentement; les antécédents en santé menstruelle; la contraception; des conseils sur la détection et la prévention des infections transmises sexuellement; le radon en tant que danger environnemental; les normes actualisées pour la ferritine; l’hésitation vaccinale; et le dosage actualisé pour la vaccination contre le virus de papillome humain.