Review ArticlePractice

Rourke Baby Record 2017

Clinical update for preventive care of children up to 5 years of age

Patricia Li, Leslie Rourke, Denis Leduc, Stephani Arulthas, Karen Rezk and James Rourke
Canadian Family Physician March 2019; 65 (3) 183-191;

Abstract

Objective To describe the process and evidence used to update preventive care recommendations in the 2017 Rourke Baby Record to assist primary care providers’ decisions around which maneuvers to prioritize and implement in practice.

Quality of evidence A search of the literature from June 2013 to June 2016 was conducted, using the GRADE (Grading of Recommendations Assessment, Development and Evaluation) methodology to critically appraise primary research studies, and recommendations were changed where there was substantial support from the new literature.

Main message The important changes in preventive care recommendations for children up to 5 years of age include the addition of body mass index monitoring as of 2 years of age; stronger evidence to support the introduction of allergenic foods without delay (strength of recommendation change from fair to good); the recommendation to ask validated questions regarding the effects of poverty; evidence showing no safe level of lead exposure in children; the recommendation of a daily sleep duration; the upgrade of recommendation strength from fair to good of items related to the prevention and detection of adverse childhood experiences, including assessment of bruising in babies younger than 9 months; and blood pressure monitoring only for children at risk.

Conclusion Early childhood exposures and habits have short- and long-term health consequences. The Rourke Baby Record will continue to publish updates to ensure that primary care providers are equipped to promote lifelong health and well-being through evidence-informed care in young children.

There is no doubt that the early years of a child’s life are crucial, not only for his or her potential for learning, but indeed for his or her lifelong physical, mental, social, and emotional health. Brain development in the first few years of life occurs sequentially, has sensitive periods, and is affected positively or negatively by experiences.1–3 Given this important window of opportunity to positively influence developmental outcomes, preventive care for families of young children assumes increasing importance, and is especially relevant when it is based on current best evidence.

The Rourke Baby Record (RBR) is a freely available evidence-informed health maintenance record for primary health care providers caring for infants and young children. Endorsed by the College of Family Physicians of Canada (CFPC), the Canadian Paediatric Society (CPS), and the Dietitians of Canada, the RBR has become the criterion standard in Canada for tracking health and development in children up to 5 years of age. First published in 1985,4 it has been validated5 and rigorously updated over the years.6–14 Available in English and French, in national and Ontario versions, it has also been adapted to various locales and unique populations (including Nunavut, Alberta First Nations, Northwest Territories, and Nova Scotia) with the permission of and review by the RBR authors.

The RBR consists of structured forms for well-baby and well-child visits (Guides I to IV), an immunization chart (Guide V), and a summary of current evidence for most items (Resources 1 to 4). Three fonts—bold, italics, and regular, bold being the strongest—indicate the strength of the recommendation for each item, and footnotes direct the user to the corresponding resource page (ie, one of Resources 1 to 4). It is an ideal tool for team-based and multidisciplinary care, and for teaching. The RBR website (www.rourkebabyrecord.ca) provides extensive resources for health care providers and parents. A Web application provides another format for reliable health information to answer parents’ common questions. The RBR has recently been translated into a teaching tool for medical students and other health care professionals through an open-access national curriculum (https://sites.google.com/site/sharcfm) devised by the Canadian Undergraduate Family Medicine Education Directors and supported by the CFPC.15

This article is a clinical review of the 2017 RBR, highlighting new evidence from the literature that has informed revisions from the 2014 edition of the RBR. By providing details of the process and evidence used to generate our preventive care recommendations, we aim to assist primary care providers in deciding which maneuvers to prioritize and implement in practice.

Quality of evidence

Our systematic approach to updating the RBR follows the framework of AGREE II (Appraisal of Guidelines for Research and Evaluation II; www.agreetrust.org).16 In general, we sought new or updated evidence regarding existing RBR items, as well as evidence to support the creation of new RBR items related to the preventive care of children up to 5 years of age in the key domains of growth monitoring, nutrition, education and advice (injury prevention, behaviour and family issues, environmental health, other), developmental surveillance, physical examination, investigations and screening, and immunization. The core RBR update team, consisting of a family physician (L.R.), a pediatrician (D.L.), a pediatric clinical epidemiologist (P.L.), and research assistants (S.A., K.R.), were involved in the literature search, appraisal of evidence, and final recommendations. We employed methods previously described14 to retrieve and appraise new or updated articles, reports, and position statements. For the current RBR, we searched the literature published from June 2013 (since the last RBR update) to June 2016. We used the GRADE (Grading of Recommendations Assessment, Development and Evaluation) methodology17 to critically appraise primary research studies. As the RBR is intended for primary care providers, stakeholders and advisory members involved in the update of the RBR were affiliated with the CFPC, the CPS, and the Dietitians of Canada. We collaborated with this team of knowledge users to ensure that key evidence and resources were reviewed and validated. We changed or modified recommendations where there was substantial support from the new literature. We classified recommendations using our long-standing and practical system consisting of good, fair, and consensus or inconclusive evidence, which appear in bold, italics, and regular font in the RBR, respectively.

With every iteration of the RBR, there is an accompanying literature review table to document the main evidence appraised to support our recommendations. In the current table, we included additional resources and any substantial evidence published from June 2016 to November 2017, although these did not necessarily contribute to the recommendations owing to the lead time required to send the updated tool for external review. We also archived old policy statements and clinical practice points that were either published more than 10 years ago and no longer pertinent or withdrawn by the professional bodies that originally endorsed them.

Main message

The main content changes in the RBR 2017 are outlined below. Further details and rationale for the changes are found in Table 1.2,18–68

View this table:
Table 1.

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

A version of the 2017 national RBR showing all changes since the 2014 RBR in teal text and a list of all revisions can be found on the RBR website in the “Updates/Changes” section (www.rourkebabyrecord.ca/updates).

Growth monitoring.

The calculation of body mass index is now recommended for children aged 2 years and older, in keeping with the 2015 Canadian Task Force on Preventive Health Care statement on growth monitoring.18

Nutrition.

Content changes in the 2017 RBR related to nutrition include advising against the use of homemade infant formulas,19 deletion of the absolute contraindication to breastfeeding by all mothers with HIV-1 infection,20 vitamin D supplementation for all breast-fed infants and children regardless of age and diet,21–23 encourage a variety of soft-texture foods,24 stronger evidence to support the introduction of allergenic foods without delay,25–29 expansion of choking avoidance strategies,23 and expansion of the statement on juices and sweetened liquids.23

Education and advice.

In the guides, the “Education and Advice” domain title is now qualified with the phrase: “Repeat discussion of items is based on perceived risk or need.” This is meant to clarify that an item might require discussion at more than 1 visit depending on risk or need. Likewise, an item does not need to be automatically readdressed, especially if there has been no concern with it and no change in care. This is particularly relevant for RBR formats that list all anticipatory guidance items at each visit.

Injury prevention items with updates include unexplained or inconsistent injuries,30 motorized vehicle injuries,31–33 crib safety,34,35 prevention of positional plagiocephaly,36 and the age limit for swaddling.37,38

Revised behaviour and family items include addition of recommended daily sleep duration with no screen time 60 minutes before bedtime,39–41 the recommendation to ask the parents validated questions about the effects of poverty,42–44 and the recommendation upgrade from fair to good of items related to the prevention and detection of adverse childhood experiences and support of positive parenting.2,45–49

The update to the environmental health items states there is no safe level of exposure to lead50,51 or secondhand smoke.52–54

The oral health section in Resources 1 has been expanded to list caries risk factors, to explain assistance with brushing and flossing teeth, and to clarify indications for fluoride use. A Canadian version of a module of the American “Smiles for Life” oral health online education tool has been developed and has been endorsed by the CPS.55 Currently it is found at www.smilesforlifeoralhealth.org (click on “Teach Curriculum” and select course 11, “Canadian Modules”).

Developmental surveillance.

Developmental surveillance, as used in the RBR, involves the “ongoing monitoring of development, identification of risk factors and elicitation of parental concerns,” whereas screening is the “use of a standardized tool to search for developmental delay in asymptomatic populations.”56 The strength of recommendations for developmental surveillance items on the RBR has not changed. However, the Canadian Task Force on Preventive Health Care now recommends against screening for developmental delay with standardized tools in children 1 to 4 years of age who have no signs of developmental delay, and when caregivers and clinicians have no developmental concerns (strong recommendation; low-quality evidence).56 The CPS continues to endorse an enhanced 18-month well-child visit, in which they promote the use of an evidence-informed health supervision guide such as the RBR, as well as a developmental screening tool (common ones include the Nipissing District Developmental Screen, Ages and Stages Questionnaire, Parents’ Evaluation of Developmental Status, and Parents’ Evaluation of Developmental Status: Developmental Milestones) to encourage discussion of a child’s development.57

Revisions regarding specific developmental milestones have been made including sucking ability, fine motor control items, and 18-month speech acquisition.58

Physical examination.

Several physical examination maneuvers have been revised in the 2017 RBR: removal of examining for dry skin in the neonate, emphasis on the importance of prolonged jaundice up to 2 months of age,60 assessment for bruising in infants younger than 9 months of age,59 risk factors requiring blood pressure assessment,61,62 age for examining teeth, assessment for torticollis up to 4 months of age,63 abdominal examination, techniques of hip examination,64 and genitalia examination for all infants.

Investigations and screening.

Anemia screening indications and timing have been revised.65,66

Immunizations.

The recommended immunization schedule according to the National Advisory Committee on Immunization (NACI) has been updated in Guide V and Resources 3.

Changes in this version of the RBR include inclusion of immunization recommendations for pregnant women,67 restriction of use and timing of antipyretics during vaccination,68 and human papillomavirus vaccine recommendations.

In February 2018, NACI and the Society of Obstetricians and Gynaecologists of Canada revised the recommendation on immunization in pregnancy with tetanus toxoid, reduced diphtheria toxoid, and acellular pertussis (Tdap) vaccine: immunization with Tdap vaccine should be offered in every pregnancy, irrespective of previous Tdap immunization history (strong NACI recommendation); NACI concludes that there is good evidence to recommend immunization (high-quality evidence). Immunization in pregnancy is safe and protects infants until they can receive the pertussis vaccine at 2 months of age.67 Note that this is not reflected in the content of the 2017 RBR.

Format changes.

The RBR resource pages, which provide a summary of current evidence for items in the RBR guides, have been expanded and now more closely follow their order in the RBR guides.

  • Resources 1 includes growth, nutrition, injury prevention, environment, and other items.

  • Resources 2 includes family, behaviour, development, physical examination, investigations, and screening.

  • Resources 3 includes immunizations.

  • Resources 4 includes early child development, a parenting resource system, and a local resources and referrals table.

In the guides, the “Problems and Plans” domain has been expanded to include “Current and New Referrals,” with a new table in Resources 4 listing contact information for these referrals or other local resources.

All Web links have been updated and are more clearly and consistently identified in the resource pages with the title or topic followed by the associated organization or journal, and a link has been added to the guides and resource pages to associated parent resources.

A new paper format, the “stretched” version, has a larger font size and more writing space while maintaining the 3-visits-per-page format by stretching each guide vertically onto 2 pages.

Increasingly, through licence agreements with the authors, the RBR is being incorporated in electronic medical records. These ideally incorporate interactive components.

Conclusion

This clinical review reports the process and evidence behind the updated 2017 RBR. The important changes in preventive care recommendations for children up to 5 years of age include the addition of body mass index monitoring as of age 2; stronger evidence to support the introduction of allergenic foods without delay (strength of recommendation upgrade from fair to good); the recommendation to ask validated questions regarding social determinants of health; evidence showing no safe level of lead exposure in children; the recommendation of daily sleep duration; the upgrade of recommendation strength from fair to good of items related to the prevention and detection of adverse childhood experiences, including assessment of bruising in babies younger than 9 months; and blood pressure monitoring only for children at risk. With cumulative research demonstrating the effects of early childhood exposures and habits on short- and long-term outcomes, the RBR will continue to publish updates to ensure that primary care providers are equipped to promote lifelong health and well-being through evidence-informed care in young children.

Acknowledgments

Financial support for the 2017 Rourke Baby Record (RBR) comes from the Government of Ontario and is administered through McMaster University in Hamilton. The licensing fee for electronic medical record use of the RBR (for electronic medical record firms not licensed in Ontario) goes to the Memorial University of Newfoundland Rourke Baby Record Development Fund. No royalties are received for the RBR, and there are no honoraria from commercial interests. In-kind support comes from Memorial University of Newfoundland and the 3 endorsing organizations: the Canadian Paediatric Society, the College of Family Physicians of Canada, and the Dietitians of Canada.

Notes

Editor’s key points

  • ▸ The 2017 Rourke Baby Record (RBR) is an update of the 2014 edition and incorporates the most recent evidence for the health supervision of infants and children up to 5 years of age. Tools to aid in knowledge translation and clinical decision making are available on the RBR website (www.rourkebabyrecord.ca).

  • ▸ The most substantial revisions in the 2017 RBR for children up to 5 years of age include the addition of body mass index monitoring as of 2 years of age; stronger evidence to support the introduction of allergenic foods without delay (change in strength of recommendation from fair to good); the recommendation to ask parents validated questions regarding the effects of poverty; evidence showing no safe level of lead exposure in children; the recommendation of a daily sleep duration; the strength of recommendation upgrade from fair to good of items related to the prevention and detection of adverse childhood experiences, including assessment of bruising in babies younger than 9 months; and blood pressure monitoring only for children at risk.

  • ▸ The “Interactive RBR” section of the website displays Guides I to V with shading that links to the summary of evidence, to selected guidelines, and to parent resources for each topic. The “Literature Review” section lists the critically appraised references supporting the items included in the 2017 RBR (www.rourkebabyrecord.ca/literature_review).

Footnotes

  • Contributors

    Drs Li, L. Rourke, and Leduc, and Ms Arulthas and Ms Rezk contributed to the literature review and interpretation. All authors contributed to development of the Rourke Baby Record and to preparing the manuscript for submission.

  • Competing interests

    None declared

  • This article is eligible for Mainpro+ certified Self-Learning credits. To earn credits, go to www.cfp.ca and click on the Mainpro+ link.

  • This article has been peer reviewed.

  • La traduction en français de cet article se trouve à www.cfp.ca dans la table des matières du numéro de mars 2019 à la page e99.

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Patricia Li, Leslie Rourke, Denis Leduc, Stephani Arulthas, Karen Rezk, James Rourke
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