Table 1.

Main changes and additions to the 2017 RBR: Important changes are shown in bold.

CHANGE OR ADDITIONDETAILS OR RATIONALE
Growth monitoring
  • Calculation of BMI for visits at ≥ 2 y of age• Addition of BMI calculation is based on the 2015 CTFPHC statement on growth monitoring.18 Although the CTFPHC based their decision on very low-quality evidence, the strength of the recommendation for growth monitoring was strong. They deemed the preventive maneuver to be a “long-standing, feasible, low-cost intervention that is unlikely to result in harms”18 and that might help identify children at risk of weight-related problems, including hypertension, dyslipidemia, diabetes, and nonalcoholic fatty liver disease
• Growth monitoring includes the measurement of recumbent length (birth to 2 to 3 y) or standing height (≥ 2 y), weight, head circumference (birth to 2 y), and calculation of BMI (2 to 5 y). The RBR endorses the WHO growth charts adapted for Canada, available from the Dietitians of Canada (www.dietitians.ca/growthcharts), which include BMI curves for boys and girls aged 2 to 19 y, along with BMI calculators
Nutrition
  • The use of homemade infant formulas is discouraged• Homemade formula is discouraged owing to nutrition and safety concerns19
  • Statement removed: breastfeeding is contraindicated for HIV-1 infected mothers even if they are receiving antiretroviral therapy• Emerging evidence shows that the breastfeeding contraindication is no longer absolute. It is currently a more complex issue20
  • Vitamin D supplementation of 400 IU/d (800 IU/d in high-risk infants) is recommended for infants and children for as long as they are breastfed (previous RBR recommended this until the diet provided a sufficient source of vitamin D at about 1 to 2 y)• Recent evidence shows low vitamin D levels in breastfed infants and children eating solid foods, and particularly in those > 1 y of age, along with difficulty in knowing when the diet of a breastfed infant or child contains sufficient vitamin D2123
  • Introduction to solids: a few weeks before to just after 6 mo, start iron-containing foods to avoid iron deficiency. A variety of soft-texture foods, ranging from purees to finger foods, can be introduced• Addition is based on the 2014 joint statement on nutrition for healthy term infants produced by Health Canada, the CPS, the Dietitians of Canada, and the Breastfeeding Committee for Canada.22,23 Specific timing of introduction is based on signs of infant readiness, which include that the infant transitions from sucking to swallowing from a spoon, holds head up well, sits with little help, opens mouth when food is offered, and turns head to refuse food. Early participation of the infant in the feeding process might avoid feeding difficulties and poorer nutrition in childhood24
   • Allergenic foods: delaying the introduction of priority food allergens is not currently recommended to prevent food allergies, including for infants at risk of atopy (good evidence; previously fair)• Early introduction and repeated ingestion of food allergens, such as egg, fish, and peanut products, starting at 6 mo of age or earlier is associated with a statistically significant reduction in risk of these respective food allergies2529
   • Avoid hard, small, round, smooth, and sticky solid foods until 3 y of age. Encourage child to remain seated while eating and drinking• Further strategies provided for the prevention of choking23
   • Avoid sweetened juices and liquids (good evidence; previously consensus)• Limit sweetened drinks or juice to prevent dental caries and obesity, and because these liquids take the place of more nutritious foods23
  • Avoid all sweetened fruit drinks, sport drinks, energy drinks, and soft drinks; restrict fruit juice consumption to a maximum of 1/2 cup (125 mL) per d
  • Promote family meals with independent feeding or self-feeding while offering a variety of healthy foods• A healthy approach to eating promotes a parent-child division of responsibility in feeding. The parent decides what, where, and when, whereas the child decides how much23
Education and advice: repeat discussion of items is based on perceived risk or need
Injury prevention
  • Assessment of bruising: unexplained injuries (eg, fractures, bruising, burns) or injuries that do not fit the rationale provided or developmental stage raise concern of child maltreatment• Caregiver frustration with infant crying can lead to child maltreatment or inflicted injury (eg, head injury, fractures, bruising)30
  • Motorized vehicle safety recommendations now include all-terrain vehicles and snowmobiles31,32NA
  • Use rear-facing infant or child seat that is approved by the manufacturer for use until at least 2 y of age. After this, use booster seat for children 18 to 36 kg (40 to 80 lbs) and up to 145 cm (4 ft 9 in)• Car seat wording has been updated according to Transport Canada recommendations33
  • Crib safety or room-sharing: infants should sleep in a crib, cradle, or bassinet, without soft objects, loose bedding, and similar items that meet current 2015 Health Canada regulations, in the parents’ room for the first 6 mo of life.34,35 Room-sharing is protective against SIDSNA
  • While supine for sleep, the orientation of the infant’s head should be varied. After the umbilical cord stump has detached, infants should have supervised “tummy time” while awake• These recommendations were updated for the prevention of positional plagiocephaly36
  • Swaddling must be done properly and is not recommended after the first 2 mo of life (change from 6 mo). A swaddled infant must always be placed supine, with free movement of hips and legs, and the head uncovered• Although proper swaddling of the infant for the first 2 mo of life might promote longer sleep periods, it can be associated with adverse events (hyperthermia, SIDS, or development of hip dysplasia) if misapplied, and is not recommended beyond 2 mo of life37,38
Behaviour and family issues
  • Recommended sleep duration per 24 h: 12 to 16 h for infants 4 to 12 mo of age; 11 to 14 h for children 1 to 2 y of age; 10 to 13 h for children 3 to 5 y of age; 9 to 12 h for children 6 to 12 y of age; and 8 to 10 h for children 13 to 18 y of age• Normal sleep (quality and quantity for age) is associated with normal development and leads to better health outcomes3941
  • Turn off computer or television screens 60 min before bedtime. No computer or television screens should be in the bedroom
  • Inquire about effects of poverty: “Do you have difficulty making ends meet? Do you have trouble feeding your family?”• There is increasing evidence of the importance of addressing SDH to optimize early child development and long-term health outcomes4244
  • Discipline and parenting skills programs are advised (good evidence)• Adverse childhood experiences have negative outcomes and there is strong evidence to support positive parenting2,4549
  • Inform parents that warm, responsive, flexible, and consistent discipline techniques are associated with positive child outcomes. Overreactive, inconsistent, cold, and coercive techniques are associated with negative child outcomes. Use of any physical punishment, including spanking, should be discouraged in all ages
  • Risk factors for child maltreatment are categorized as follows:
  • -Parent (low socioeconomic status, maternal age < 19 y, child is in a single-parent family, child has nonbiologic parents, abused as child, substance abuse, lack of social support, unplanned pregnancy or negative parental attitude toward pregnancy)

  • -Family (spousal violence, poor marital relations, poor child-parent relationship, unhappy family life)

  • -Child (behaviour problems, disability)

Environmental health
  • Lead: there is no safe level of lead exposure in children• Evidence suggests that even low blood lead levels can have adverse health effects on a child’s cognitive function50,51
  • Blood screening for lead is recommended for children who ...
  • -in the past 6 mo lived in a house or apartment built before 1978,

  • -live in a home with recent or ongoing renovations or peeling or chipped paint,

  • -have a sibling, housemate, or playmate with a history of lead poisoning,

  • -live near point sources of lead contamination,

  • -have household members with lead-related occupations or hobbies, or

  • -are refugees aged 6 mo to 6 y. Testing should be done within 3 mo of arrival and again in 3 to 6 mo

• Blood lead level, not serum lead level, should be measured
  • Second-hand smoke exposure: there is no safe level of exposure
  • -Advise caregivers to stop smoking or reduce second-hand smoke exposure. Offer smoking cessation resources

• Second-hand smoke exposure contributes to childhood respiratory illnesses, SIDS, and neurobehavioural disorders5254
Other
  • Dental cleaning: as excessive swallowing of toothpaste by young children might result in dental fluorosis, children < 3 y of age should have their teeth and gums brushed twice daily by an adult using either water (if at low risk of tooth decay) or a rice grain–sized portion of fluoridated toothpaste (if at risk of caries). Children 3 to 6 y of age should be assisted during brushing and only use a small amount (eg, pea-sized portion) of fluoridated toothpaste twice daily.
Caregiver should brush a child’s teeth twice daily until they develop the manual dexterity to do this alone, and should continue to intermittently supervise brushing after children assume independence. Begin flossing daily when teeth touch
• Recommendations in keeping with the CPS-endorsed Canadian version of the Smiles for Life oral health online education tool (www.smilesforlifeoralhealth.org)55
  • Caries risk factors include caries or enamel defects, concerns about hygiene or diet, parent has caries, premature or low-birth-weight infant, or no water fluoridation
  • Fluoride varnish should be used for those at risk of caries. Consider dietary fluoride supplements only for high-risk children who do not have access to systemic community water fluoridation
  • Consider the first dentist visit by 6 mo after eruption of first tooth, or at age 1 y
Developmental surveillance: ongoing monitoring of development, identification of risk factors, and elicitation of parental concerns56,57
Assess the following:
  • Within 1 wk: Sucks well on nipple• Updated for surveillance of development and as a red flag for inadequate hydration
  • 9 mo: Opposes thumb and fingers when grasping objects and finger foods• Updated in keeping with evidence-informed milestones58
  • Added at 12 mo: Has pincer grasp to pick up and eat finger foods
  • 18 mo: Says 15 or more words (words do not have to be clear) (previously 20 or more words)
Physical examination
  • Within 1 wk to 1 mo: skin (jaundice, bruising)• “Dry skin” was removed as it is not a reliable assessment of dehydration
  • Up to 6 mo old: assessment of bruising• Unexplained bruising warrants evaluation for child maltreatment or medical illness. Bruising is rare (< 1%) in infants < 9 mo of age, in contrast to common (40% to 90%) in those ≥ 9 mo of age59
  • Assessment of jaundice up to 2 mo of age (previously 1 mo)• To assess the possibility of biliary atresia60
  • Jaundice: bilirubin testing (total and conjugated) if jaundice persists beyond 2 wk of age
  • 2 to 3 y and 4 to 5 y of age: blood pressure measurement if at risk (instead of all children)• Current evidence suggests low-risk children up to 5 y of age do not need their blood pressure measured. Children with the following conditions should have their blood pressure measured: history of prematurity, very low birth weight, or other neonatal complication requiring intensive care; congenital heart disease (repaired or unrepaired); recurrent urinary tract infections, hematuria, or proteinuria; known renal disease or urologic malformations; family history of congenital renal disease; history of solid organ transplant; history of malignancy or bone marrow transplant; treatment with drugs known to raise blood pressure; other systemic illnesses associated with hypertension (neurofibromatosis, tuberous sclerosis, etc); evidence of elevated intracranial pressure; obesity; and any symptoms or concerns61,62
  • Assess teeth from 6 mo onward (previously ≥ 12 mo)• Revised to be consistent with the average age of first tooth eruption
  • Assess torticollis from < 1 wk to 4 mo• Recommended to be done in association with positional plagiocephaly and orientation of the infant’s head while sleeping63
  • Assess abdomen until 2 mo• To be consistent with the inclusion of the examination of the heart until 2 mo of age for the diagnosis of congenital heart disease, we added an abdominal examination until 2 mo for the detection of a congenital or acquired renal lesion presenting as an abdominal mass
  • Hip examination details added: Barlow-Ortolani test (up to 2 mo) and limited hip abduction (4 to 15 mo)• Appropriate examination technique varies with age64
  • Genitalia examination added to examination of testicles (up to 2 wk)• Genitalia examination should be done for both female and male infants
Investigations and screening
  • All infants and children from high-risk groups for iron deficiency anemia require screening between 6 and 18 mo of age (eg, low socioeconomic status; Asian ethnicity; First Nations children; low-birth-weight and premature infants; infants or children fed whole cow’s milk before 9 mo of age or at quantities greater than 750 mL/d, or if iron-containing foods are not provided)• Children continue to be at risk of iron deficiency anemia beyond 12 mo of age65,66
Immunizations: see Guide V and Resources 3 pages for updated schedule according to NACI
  • See the Canadian Immunization Guide (www.canada.ca/en/public-health/services/canadian-immunization-guide.html) for recommended immunization schedules for infants, children, youth, and pregnant women• To protect the infant, immunization recommendations for pregnant women are included. However, the 2017 RBR does not contain the most recent (February 2018) recommendations for Tdap in pregnancy, which recommends that the Tdap vaccine be offered in every pregnancy, irrespective of previous immunization history67
  • Acetaminophen or ibuprofen should not be given before, but can be given after vaccination as required• Prophylactic antipyretics are not recommended owing to the possibility of a reduced antibody response to vaccine antigens68
  • The qualifier on the immunization table (Guide V) for HPV has been revised to “starting at 9 years of age, as per provincial/territorial guidelines,” and the HPV vaccine notes have been deleted• The HPV vaccine is not given in the birth-to-5-y age range of the RBR, and the schedule is evolving
  • BMI—body mass index; CPS—Canadian Paediatric Society; CTFPHC—Canadian Task Force on Preventive Health Care; HPV—human papillomavirus; NA—not applicable; NACI—National Advisory Committee on Immunization; RBR—Rourke Baby Record; SDH—social determinants of health; SIDS—sudden infant death syndrome; Tdap—tetanus toxoid, reduced diphtheria toxoid, and acellular pertussis; WHO—World Health Organization.