2020 edition of the Rourke Baby Record

Abstract

Objective

To update primary care providers practising well-child and well-baby clinical care on the evidence that contributed to the recommendations of the 2020 edition of the Rourke Baby Record (RBR).

Quality of evidence

Pediatric preventive care literature was searched from June 2016 to May 2019, primary research studies were reviewed and critically appraised using the GRADE (Grading of Recommendations Assessment, Development and Evaluation) methodology, and recommendations were updated where there was support from the literature.

Main message

Notable changes in the 2020 edition of the RBR include the recommendations to limit or avoid consumption of highly processed foods high in dietary sodium, to ensure safe sleep (healthy infants should sleep on their backs and on a firm surface for every sleep, and should sleep in a crib, cradle, or bassinette in the parents’ room for the first 6 months of life), to not swaddle infants after they attempt to roll, to inquire about food insecurity, to encourage parents to read and sing to infants and children, to limit screen time for children younger than 2 years of age (although it is accepted for videocalling), to educate parents on risks and harms associated with e-cigarettes and cannabis, to avoid pesticide use, to wash all fruits and vegetables that cannot be peeled, to be aware of the new Canadian Caries Risk Assessment Tool, to note new red flags for cerebral palsy and neurodevelopmental problems, and to pay attention to updated high-risk groups for lead and anemia screening.

Conclusion

The RBR endeavours to guide clinicians in providing evidence-informed primary care to Canadian children. The revisions are rigorously considered and are based on appraisal of a growing, albeit still limited, evidence base for pediatric preventive care.

Primary prevention, through primary care and public health interventions, plays a key role in preventing many of the leading causes of death and morbidity in childhood.^1-5 For example, each year, more children die in Canada from injuries than any single disease.¹ Motor vehicle–related deaths are the leading cause of injury in children, and numerous studies spanning several decades have demonstrated significantly reduced risk of death when children are properly restrained in car seats compared with children restrained by seat belts or unrestrained children.^2,3 Primary prevention in early childhood might also reduce the risk of disease and morbidity in later adult life. A compelling case for the latter is supported by longitudinal studies that have demonstrated how cardiometabolic risk factors in childhood such as high body mass index (BMI), blood pressure, lipid level, and blood glucose level can track into adulthood, resulting in further health issues including metabolic syndrome, type 2 diabetes, and atherosclerotic disease.^6,7

For the past 3 decades, primary care providers (PCPs) across Canada have used the Rourke Baby Record (RBR) to guide the provision of evidence-informed preventive care in children younger than 6 years of age.^8-10 The RBR can be accessed at no cost online (www.rourkebabyrecord.ca) and is endorsed by the College of Family Physicians of Canada, the Canadian Paediatric Society, and Dietitians of Canada. The RBR knowledge translation tools for PCPs to support well-baby and well-child visits include RBR structured forms (Guides I to IV) in a printable version or embedded within electronic medical records, an immunization chart (Guide V), and a summary of supporting evidence and websites for the recommendations (Resources 1 to 4). There are supplemental resources for parents and caregivers on the RBR website. The RBR is also a teaching tool for undergraduate and postgraduate trainees across Canada, as exemplified by LearnFM, a matrix of educational resources developed by the Canadian Undergraduate Family Medicine Education Directors and supported by the College of Family Physicians of Canada.¹¹

This current clinical review aims to highlight the updates of the 2020 RBR. Our goal is to update busy PCPs with the current evidence and recommendations included in this newest version of the RBR.

Quality of evidence

Although the number of pediatric clinical trials and studies has increased in recent years, many challenges remain in developing evidence-based recommendations for pediatric preventive care in the primary care setting.¹² The number of topics reviewed by the US Preventive Services Task Force and the Canadian Task Force on Preventive Health Care (CTFPHC) for adults still outweigh those for children, and most pediatric recommendations are inconclusive, mainly because of the lack of high-quality evidence to support child-related preventive maneuvers.^12,13 Faced with these limitations, the RBR team has continued to use multiple sources to incorporate the best available evidence and expert consensus into the updated recommendations, with a predilection for studies applicable to the Canadian context.

As with previous updates, the 2020 RBR is guided by the AGREE II (Appraisal of Guidelines for Research and Evaluation II; www.agreetrust.org) framework.¹⁴ In addition, we engaged in a new partnership with the McMaster Evidence Review and Synthesis Team (MERST) to help streamline our literature review methods. The MERST has previously supported the work of other official bodies that produce guidelines, such as the CTFPHC.¹⁵ To update existing or integrate new recommendations into the 2020 RBR, we reviewed the latest evidence in the areas of growth monitoring, nutrition, education and advice (including injury prevention, behaviour and family issues, environmental health, and other issues), developmental surveillance, physical examination, investigations and screening, and immunization. We searched the literature from June 2016 (the last RBR literature update) to May 2019 using previously described methods.^9,10 We developed new search strategies for issues pertinent to early childhood health and primary care that have emerged since the last version of the RBR in 2017 (eg, e-cigarettes). We used the GRADE (Grading of Recommendations Assessment, Development and Evaluation) methodology to critically evaluate primary research studies.¹⁶ Based on new evidence, policy statements, and reviews, we modified or added recommendations using our longstanding and user-friendly categorization system of good, fair, and consensus or inconclusive evidence, which are represented in bold, italics, and regular fonts in the RBR tools, respectively.

The core 2020 RBR team initially included an FP (L.R.), a pediatrician (D.L.), a pediatric clinical epidemiologist (P.L.), and research assistants (S.A. and E.T.) who were involved in the literature search, evidence appraisal, and final recommendations. The MERST assisted with organizing and screening the literature using DistillerSR (https://www.evidencepartners.com/products/distillersr-systematic-review-software). In 2019, the team expanded to include further expertise in the clinical practice of family medicine (I.B. and B.K.) and pediatrics (A.R.L.). All of the latter members took part in reviewing pertinent evidence associated with the final recommendations and the knowledge translation tools associated with the final 2020 RBR. A team member (J.R.) has been continuously involved since the original development of the RBR and currently has an oversight role that includes publication input, review, and approval. Our team of stakeholders and advisory members from the College of Family Physicians of Canada, the Canadian Paediatric Society, and Dietitians of Canada reviewed, approved, and endorsed the final 2020 RBR. Furthermore, we created and collaborated with a users’ committee to ensure that the updated evidence was relevant, optimally incorporated, and accessible in the tools. The content of the 2020 RBR was finalized before the coronavirus disease 2019 (COVID-19) pandemic, and hence does not include literature or specific recommendations that might relate to COVID-19 and well-child care.

Main message

The main content revisions in the 2020 edition of the RBR are outlined below. Table 1 provides the accompanying details and rationale for the changes.^17-76 The RBR website includes a version of the 2020 RBR with wording revisions in teal print for easy identification of the changes, as well as a list of the revisions (www.rourkebabyrecord.ca/updates).

Table 1.

Revisions to the 2020 RBR: Modifications highlighted in bold.

General principles

• If a baby did not have a visit in the first month of life, it might be important to perform items that are typically part of the early visits, such as femoral pulse, palate, and spine and back examinations, whenever the initial assessment ultimately occurs, since these items are not performed again in later visits. This is particularly relevant if the infant was previously seen by another health care professional, or assessed via virtual care during the COVID-19 pandemic.

• Some items on the RBR are repeated at several visits. The PCP might elect to readdress items previously discussed where they perceive a risk or need.

• 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: items with good evidence appear first, followed by items with fair evidence, and items with inconclusive evidence or consensus appear last. Where possible, physical examination items have been organized from head to toe, taking into consideration the strength of recommendation.

• Web links have been revised as per current evidence. They are identified on Resources 1 through 4 with the title or topic followed by the reference organization or journal. There are links on the RBR website for easy accessibility.

• A new landscape paper format has a larger font size and more writing space, enabling a double-sided, 3-visits-per-page format. This is similar to the pre-existing “stretched” version that stretches each guide vertically. The original 3 visits per page format is now available as a fillable PDF.

Growth monitoring. Since calculation of BMI is recommended for children older than 2 years of age, there is now a link to Dietitians of Canada BMI tables and calculator resources.¹⁷ Body mass index curves are available through the link for growth chart sets.

Nutrition. Several practical online resources for nutrition in children younger than 6 years of age have been added to Resources 1, including guidelines from the Ontario Dietitians in Public Health¹⁸ and the Baby-Friendly Initiative Strategy for Ontario,⁷⁷ and statements from the Canadian Paediatric Society on timing of allergenic food introduction²⁶ and dietary sodium.³¹ Content changes related to nutrition include the following: some qualification of the association between breastfeeding and gastrointestinal and respiratory infections to reflect the limitations of the evidence¹⁹; wording to emphasize that lactating mothers should continue a standard multivitamin supplement with at least 400 IU per day of vitamin D^20,21; removal of the words “iron fortified” to describe recommended infant formulas¹⁸; repeated advice at 12- and 15-month visits against bottles in bed^22,23; advice against using soy-based infant formula in preterm infants and in those with cow’s milk protein allergy, and to use caution in infants being monitored for congenital hypothyroidism²⁴; advice that introduction of solids should be guided by infant readiness, and should start between 4 and 6 months of age²⁵; addition of good strength of recommendation evidence (bold font) for introducing allergenic foods (especially eggs and peanut products) in infants at high risk of allergies, and for maintaining tolerance by continuing those foods several times a week^26-29; and advice to limit the consumption of foods (in addition to beverages) high in sugar³⁰ and to limit consumption of highly processed foods high in dietary sodium.³¹

Education and advice

Injury prevention: The list of preventable injuries in Resources 1 has been placed in order from most to least prevalent cause of accidental death in young children.³² Updates include the following advice: never leave a child unattended in a vehicle^33,34; replace any car seat involved in a collision³⁵ and any bicycle helmet if it has sustained an impact or is more than 5 years old³⁷; children and youth younger than 16 years of age should not operate an all-terrain vehicle or a snowmobile, including youth models³⁶; healthy infants should be positioned on their backs on a firm surface for every sleep; avoid use of alcohol or illicit or sedating drugs, as they are risk factors for sudden infant death syndrome; do not swaddle infants once they show signs of attempting to roll^38,39; do not introduce solid and sticky foods until 4 years of age because of choking risk (revised from 3 years of age)⁴⁰; pool fencing should include self-closing and self-latching gates⁴¹; and be vigilant with hot liquids on countertops because of the risk of burns.⁴²

Behaviour and family issues: Revised items include validated poverty identification questions about food security,^43,44 and advice that both reading and singing should begin with young infants^45,46; screen time should be optimally managed by children, parents, and caregivers; and videocalling can improve communication with family and friends.^47,48

Environmental health items: Updated items include revised wording to educate parents on the health risks and harms associated with e-cigarettes and cannabis (including edibles) and on their safe storage^49,50; advice on how to prevent insect bites⁵¹; omission of recommendation for using pesticide-free foods; recommendation to ask about pesticide use and storage at home⁵²; suggestion to wash all fruits and vegetables that cannot be peeled⁵³; and a list of changed and expanded risk factors for blood lead screening.^54,55

Oral health: Management of teething discomfort has been added^56-58 in addition to the Smiles for Life curriculum for non–dental health professionals (https://www.smilesforlifeoralhealth.org). There is a new Canadian Paediatric Society–endorsed Canadian Caries Risk Assessment Tool (http://umanitoba.ca/CRA_Tool_ENG_Version.pdf).

Developmental surveillance. Revisions regarding specific developmental milestones have been made, including changing the term normal developmental milestones to typical developmental milestones, and expanding motor milestones for early detection of cerebral palsy.^59,60 The evidence and full list of associated publications supporting this recommendation on cerebral palsy is available at https://www.childhooddisability.ca/early-detection-of-cp/.

Additional risk factors have been added for autism spectrum disorder, as well as new standardized evidence-based screening tools for autism spectrum disorder detection, assessment, and management.^61-63

Physical examination. Examination of the heart, lungs, and abdomen is now included in all visits. This corrects a misperception that not including these items implied they were not indicated. The principle of the physical examination section, as stated on this heading in 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.

Other revised maneuvers include listing risk factors for elevated blood pressure in children older than 3 years of age⁶⁴; deleting corneal light reflex from the examination of infants younger than 6 months of age⁶⁵; examining for intact palate⁶⁶; examining for tongue mobility only if there are breastfeeding problems⁶⁷; outlining umbilical cord care⁶⁸; detailing hip assessment and consideration of selective imaging⁶⁹; expanding muscle tone and motor maneuvers^59,60; and examining the back and spine at 1- and 2-week visits.⁷⁰

Investigations and screening. Anemia screening has been revised to reflect the high-risk groups for iron deficiency anemia based on current evidence.^71,72

Immunizations. Guide V and Resources 3 have been updated with the latest recommendations from the National Advisory Committee on Immunization. Changes in this edition of the RBR include the recommendation to give the most painful vaccine last as an additional pain reduction strategy,⁷³ and revisions to recommendations for diphtheria and tetanus toxoids and acellular pertussis,⁷⁴ hepatitis B,⁷⁵ and influenza vaccines.⁷⁶

Conclusion

The 2020 edition of the RBR continues its tradition of updating its recommendations for the preventive care of infants and young children based on new evidence. We have increased the rigour of our process of evidence review and appraisal with new partnerships for this 2020 edition. In outlining the rationale and evidence underlying the updates and changes in the RBR recommendations in this article, we hope to help educate clinicians who provide primary care to children on best practices.

In the future, the RBR group is planning an end-user (clinicians and parents) satisfaction evaluation with the RBR guides and resources. This feedback would direct further development to optimize the usability, accessibility, and effectiveness of the tools.

Finally, primary care has dramatically changed since the COVID-19 pandemic onset, with increased reliance on virtual, as opposed to in-person, visits. We will seek ways to support PCPs with the implementation of the RBR within the challenging and shifting landscape of current health care delivery to ensure that infants and children continue to receive high-quality primary care.

Editor’s key points

▸ The 2020 edition of the Rourke Baby Record (RBR) is an update of the 2017 edition and provides updated recommendations for the primary care of children younger than 6 years of age. The knowledge translation tools and supporting literature are available at www.rourkebabyrecord.ca.

▸ Important revisions include the recommendations to limit or avoid consumption of highly processed foods high in dietary sodium, to ensure safe sleep (healthy infants should sleep on their backs and on a firm surface for every sleep, and should sleep in a crib, cradle, or bassinette in the parents’ room for the first 6 months of life), to not swaddle infants after they attempt to roll, to inquire about food insecurity, to encourage parents to read and sing to infants and children, to limit screen time for children younger than 2 years of age (although it is accepted for videocalling), to educate parents on risks and harms associated with e-cigarettes and cannabis, to avoid pesticide use, to wash all fruits and vegetables that cannot be peeled, to be aware of the new Canadian Caries Risk Assessment Tool, to note new red flags for cerebral palsy and neurodevelopmental problems, and to pay attention to updated high-risk groups for lead and anemia screening.

▸ The 2020 edition of the RBR was completed before the onset of the coronavirus disease 2019 pandemic, and thus does not include recommendations regarding virtual care. The RBR will continue to find ways to support primary care providers within the shifting landscape of health care delivery.