The Rourke Baby Record (RBR), first developed in 1979 by Drs Leslie and James Rourke and published in Canadian Family Physician in 1985 (1), promotes comprehensive, evidence-based well-baby and well-child care by acting as an aide mémoire, allowing for efficient use of time, encouraging a team approach and providing an ideal teaching tool.
The RBR is widely used by Canadian family doctors. A 2005 Ontario survey found that 78% of family physicians who provide well-baby care in Toronto, Ottawa and London, Ontario, use the RBR.
The 2006 RBR represents a major revision. Over the past 20 years, several updates have been published in Canadian Family Physician (2–5) and, more recently, in Paediatrics & Child Health (6). As with the last version, this revision was a collaboration between Drs Leslie Rourke, Denis Leduc and James Rourke. It is endorsed by The College of Family Physicians of Canada (CFPC) and by the Canadian Paediatric Society (CPS). Financial support for this revision came from the Strategic Initiatives Division of the Ontario Ministry of Children and Youth Services, with funds administered by the Ontario College of Family Physicians.
The pertinent literature has been extensively reviewed to reaffirm or modify the levels of evidence attached to the recommendations and advice given. A substantial proportion of this evidence was derived through critical appraisal of CPS position statements. Additional expertise was obtained through consultation with other organizations, including the Canadian Dental Association, the Ontario College of Family Physicians Environmental Health Committee, the CFPC, and the specialty committees and sections of the CPS.
As in previous versions of the RBR, evidence to support the inclusion of various items in well-child health supervision is graded according to the classification outlined by the Canadian Task Force on Preventive Health Care (7). Based on the quality of the evidence (levels I through III), items classified as grade A recommendations are printed in bold type, those classified as grade B are printed in italics, and those items judged important to include because of consensus or inconclusive evidence (usually owing to inadequate research) appear in plain type.
Major changes from the previous version are described below.
FORMAT
The periodic health supervision visits from zero to five years of age have been expanded from three guides to four. This provides additional writing space, as well as a new, optional visit at 15 months to accommodate some immunization preferences or schedules.
THE 18-MONTH VISIT
The 18-month visit is a critical time for assessing development. Substantial evidence-based modifications to the format and content of this visit have been made, which are consistent with the report of the Ontario Expert Panel on the 18-Month Well Baby Visit, entitled “Getting it Right at 18 Months...Making it Right for a Lifetime” (8). There is more information to expand the development section, including evidence-based guidelines and resources on the back of the fourth guide. This expansion includes information on parenting and discipline, toilet learning, autism spectrum disorder, fetal alcohol spectrum disorder, literacy, and parental and family issues affecting child development. Interventional pathways for identified areas of concern are outlined.
GROWTH PARAMETERS
At the time of publication of the 2000 RBR, the Centers for Disease Control and Prevention growth data were available only in chart form, and therefore those data were converted to graph form on the reverse of the RBR. In the 2006 RBR, these smaller growth graphs have been replaced by full-size, free-standing Centers for Disease Control and Prevention growth charts. Further modifications may occur in the future to reflect the recent release of child growth standards by the World Health Organization <www.who.int/childgrowth/standards/en/>.
EDUCATION AND ADVICE SECTION
Anticipatory guidance included in the Education and Advice section has also undergone several changes. Items have been grouped by age range and realigned horizontally; thus, items will be considered, if applicable, at every visit. This avoids duplication of items on each guide and helps to prevent the omission of issues if a visit is missed or if discussion of items that are not applicable are repeated unnecessarily.
New evidence has resulted in the incorporation of several items in this section. New injury prevention items include firearm safety and removal, updated Transport Canada car seat recommendations and an expansion of safe sleeping issues. The literature on the importance of children’s environmental health is growing; sun exposure, sunscreen use, insect repellent use and pesticide exposure are now discussed. The importance of healthy active living is introduced to set the stage for lifelong activity and the prevention of obesity. Miscellaneous new items include a discussion on pacifier use, complementary and alternative medicine, fever advice and thermometers and footwear.
IMMUNIZATION RECORD
In the past few years, the development of new vaccines for such diseases as varicella, and pneumococcal and meningococcal infections has resulted in the need for more space in the RBR for immunizations. In addition, guidelines on the timing, schedule and inclusion of recommended immunizations often differ among provinces depending on local funding issues. A major improvement of the 2006 RBR is the development of the ‘Guide V: Childhood Immunization Record’ to record all immunizations. This sheet follows the recommendations of the National Advisory Committee on Immunization and is easily modified for specific provincial schedules. On the reverse of this record are guidelines for, and resources about, immunization and selected infectious diseases.
INTERNET-BASED INFORMATION
The availability of almost unlimited information on the Internet has resulted in the ability to incorporate evidence, background information and supporting links in a condensed format as part of the selected guidelines and resources on the back of Guides I, IV and V. These Internet-based resources allow users of the RBR to easily access further information on most items, which is particularly helpful when they are used as part of an electronic medical record. This obviates the need for an accompanying manual whose content is fixed at the time of printing. Many of the chosen Web sites are CPS position statements that are reviewed every three years.
DISTRIBUTION
The 2006 RBR is available on the Web sites of the CFPC <www.cfpc.ca/English/cfpc/programs/patient%20care/rourke%20baby/default.asp?s=1> and the CPS <www.cps.ca/english/statements/CP/Rourke/RourkeBabyRecord.htm>. Hard copies are available through McNeil Consumer Healthcare at 1-800-265-7323.
FUTURE INITIATIVES
Translation of the 2006 RBR into French will occur as soon as possible. Until a French version of the new RBR is available, the 2000 RBR is available in French on the CPS and CFPC Web sites. Mechanisms to adapt the 2006 RBR for electronic medical records are currently underway. The process for regular and consistent updates of the RBR is also being developed to facilitate and enhance the preventive care of infants and young children in Canada.
ACKNOWLEDGEMENTS
The authors thank the Ontario Ministry of Children and Youth Services for their financial support of this update, and the Ontario College of Family Physicians for fund administration. The authors also thank Ms Sarah Pearce for providing literature review. Many members of the CFPC and CPS reviewed the present document and offered valuable feedback. Most important, the authors thank their families for their support and patience for the many hours that this project required.
Footnotes
This article also appears in the October 2006 issue of Canadian Family Physician. Internet addresses are current at time of publication.
REFERENCES
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