Abstract
Objective To assist busy primary care providers caring for infants and young children and their families by providing them with the most recent recommendations and supportive evidence included in the 2024 edition of the Rourke Baby Record (RBR).
Quality of evidence Articles from pediatric preventive care literature (January 2019 to March 2023) were reviewed for relevance and quality of evidence. When available, evidence from systematic reviews, relevant clinical guidelines, and clinical trials were incorporated. In the absence of high-level evidence, observational studies and expert opinion on the topic were included. Primary research studies were reviewed and critically appraised using a modified protocol.
Main message Notable updates in the 2024 edition of the RBR include the promotion of early relational health for families; identification of targeted support and resources as opposed to labelling of high-risk groups; guidance on culturally safe care; clarification and evidence-based adjustments of the age of achievement of some developmental surveillance milestones; recommendations on plant-based beverages, vegetarian, and vegan diets; screening considerations for iron deficiency; dangers of ingestion of button batteries and cannabis edibles; literacy and socioemotional benefits of reading, singing, and storytelling; the importance of unstructured outdoor play; the environment’s effect on children’s health; the significance of sentinel injuries; acholic stools; and the normal presence and abnormal persistence of developmental (primitive) reflexes.
Conclusion Building on its 40-year history, the 2024 RBR provides freely available, evidence-informed recommendations to guide clinicians in providing effective, up-to-date, and comprehensive preventive pediatric care. Despite the challenging and evolving landscape of primary health care delivery, the RBR will continue to support primary care providers.
Primary health care is essential to maintaining the health of individuals and populations; it is a vital component for the provision of preventive health care and is at the centre of an effectively functioning health care system. For children in particular, primary care provides the foundation for monitoring growth and development, providing anticipatory guidance, and delivering timely vaccinations for preventable diseases. Primary prevention, through primary care and public health interventions, plays a key role in the reduction of many of the leading causes of death and morbidity in childhood (eg, injury remains the leading cause of death for Canadian children annually).1 When applied early in childhood, primary prevention may also reduce the risk of disease and morbidity in later adult life (eg, by identifying and treating risk factors for cardiovascular disease2) and may positively affect developmental trajectories (eg, by monitoring and supporting developmental progress).3 A robust and effective primary care system is associated with more equitable health in populations.4-6 Delays in, or failure to access, regular and timely primary care can lead to diagnostic and service gaps during a period of critical development for children and can further widen health inequities.7,8
For the past 4 decades, amid a changing primary care landscape, primary care providers (PCPs) across Canada have used the Rourke Baby Record (RBR) to guide the provision of evidence-informed preventive care for children younger than 6 years of age.9,10 The RBR has always been freely available and can be accessed online (https://www.rourkebabyrecord.ca). It is affiliated with the College of Family Physicians of Canada (CFPC) and the Canadian Paediatric Society (CPS), and is endorsed by the CFPC, CPS, and Dietitians of Canada. The RBR knowledge translation tools for PCPs help support and monitor well-baby and well-child visits. They include RBR visit forms (ie, Guides I to IV) in a printable version or embedded within electronic medical records, as well as a summary of supporting evidence and websites for the recommendations (ie, Notes 1 to 4, which were formerly called Resources 1 to 4). Updated resources for parents and caregivers, reflecting the 2024 edition of the RBR, include age-specific information and links.
This clinical review highlights the 2024 RBR updates by providing the most recent supportive evidence and recommendations for this newest edition of the RBR.
Quality of evidence
For the 2024 edition of the RBR, the literature search strategy, selection of relevant studies, and methodology review of each relevant study was conducted by McMaster Evidence Review and Synthesis Team (MERST) in Hamilton, Ont. MERST assisted with organizing and screening the literature using DistillerSR.11 A modified Shekelle approach was used for critical appraisal of the literature.12
The level of evidence was assigned based on the strength of the evidence and relevance to Canadian primary preventive care. Our RBR team established the strength of recommendation for each RBR reported item, which is reflected in the RBR guides and notes sections using the long-standing and clinician-friendly designation of good, fair, and inconclusive evidence (or consensus opinion), which are represented in bold, italic, or regular fonts, respectively.
The core 2024 RBR team includes 3 family physicians (L.R., I.B., B.K.), 3 general pediatricians (D.L., P.L., A.R.L.), and 2 pediatric clinical epidemiologists (P.L., I.B.), all of whom contributed to the literature search, evidence appraisal, and final recommendations. A senior team member (J.R.) has been continuously involved since the original development of the RBR and has provided strategic planning and project support, including publication input, review, and process for this RBR 2024 edition, and the content of this article.
Our team of clinical user group stakeholders and advisory members from the CFPC, CPS, and Dietitians of Canada extensively reviewed and provided feedback prior to its endorsement and release.
Main message
The 2024 RBR provides an updated evidence-based synthesis of recommendations for well-infant and well-child preventive care. RBR guides for well-baby and well-child visits include the following domains: parental concerns; growth; nutrition; education and advice on common concerns such as injury prevention, healthy routines, behaviour and family issues, and environmental health; developmental surveillance; physical examination; investigations and screening; and immunizations. The RBR guides are accompanied by notes pages with supporting evidence and resources for health care providers.
Notable revisions in the 2024 RBR guides and notes section include the following:
Inclusion of a section on antiracist, inclusive, and culturally safe care.
Promotion of early relational health (ERH) for families, along with a shift from labelling high-risk groups to identifying targeted support and resources.
Healthy routines: further evidence on the benefits of reading, singing, and telling stories, and of unstructured outdoor play.
New information and resources on growth and nutrition topics, including regaining of birth weight, growth measurement, plant-based beverages, baby-led weaning, gastroesophageal reflux management, vegetarian and vegan diets, and age-appropriate forms of peanut products.
Injury prevention: dangers of ingestion of button batteries and cannabis edibles, and awareness of choking risks and prevention.
Evidence and resources on the effect of the environment on children’s health including air quality, climate change, well water testing, and pesticide exposure.
Evidence-based modifications to improve clarity and to adjust the age of achievement of some developmental surveillance red flag milestones (developed in collaboration with Dr Cara Dosman et al).
Physical examination: awareness of the significance of sentinel injuries in the context of child maltreatment, acholic stools in the infant, developmental (primitive) reflexes, and hip examination techniques.
Immunizations: Given the dynamic developments inherent in the vaccination sphere, the Guide V Immunization Chart has been deleted and users are referred to current National Advisory Committee on Immunization (NACI) and the Canadian Immunization Guide recommendations. New information is included on vaccine hesitancy and evidence-based interventions to improve vaccine confidence.
Consideration of screening for iron deficiency in at-risk children.
Expanded and updated resource links with information for health care professionals and families.
Reflective of recent policy statements from the CPS13 and the American Academy of Pediatrics,14 the 2024 RBR includes a renewed emphasis on the centrality of ERH. Abundant evidence has demonstrated the foundational importance of safe, strong, and nurturing relationships (SSNRs), and their critical role in supporting children in developing resilience and mitigating the impact of childhood adversity. The focus on ERH is based on the important recognition that trauma-informed, culturally safe, and antiracist care has the potential to improve access to care, reduce health inequities, and to improve health outcomes for children and their caregivers. ERH begins with clinicians’ self-assessment of and reflection on their own biases and a commitment to providing compassionate, nonjudgmental, and culturally safe care that honours each family’s culture and background. It is strengths-based, building on family protective factors rather than emphasizing deficits, such as by reinforcing positive back-and-forth interactions between parents and children; encouraging empathetic, nonjudgmental active listening; eliciting parental observations on what works best for their child; and commenting on examples of positive interactions observed between caregiver and child.
Table 1 outlines specific changes, rationale, and supporting evidence for the 2024 edition of the RBR.13-71 A detailed review of the supporting evidence is available in the evidence table on the RBR website (https://www.rourkebabyrecord.ca/literature-review).
Specific Rourke Baby Record 2024 updates and rationale
The RBR website has been relaunched with improved functionality on mobile devices, greater accessibility for users with disabilities, and a more modern and consistent design. The RBR visit guides and associated notes are available on the website in an interactive format or as downloadable forms. Relevant resources for parents and caregivers include age-specific well-baby and well-child information handouts based on RBR content, and links to reliable resources on common health issues researched and curated by pediatric health care professionals.
Discussion
Over the past 40 years, the RBR has responded to the challenges of a changing primary care landscape and has adjusted and evolved to remain relevant. The past decade has brought remarkable change and challenges to clinical care provision. Currently, 1 in 6 Canadians report not having a regular family physician.72 Numerous factors are involved: more family physicians retiring since the height of the COVID-19 pandemic, an aging workforce, reduced working hours, fewer medical students choosing a career in family medicine, and fewer family physicians choosing to work in comprehensive longitudinal practice.73 Furthermore, virtual care has become integrated into routine care, with increased uptake during and since the COVID-19 pandemic.
The impact of virtual care during the pandemic was welcomed by both parents and clinicians.74,75 However, the impact of the increasing use of virtual care remains unclear for the current and future status of primary care surveillance in infancy and childhood.76 For those children who require in-person visits for growth monitoring, vision screening, physical examination, and routine vaccinations, this care can only be provided partially, at best, in a virtual setting. With these current challenges, the RBR offers an up-to-date, evidence-informed guide that is well-known to many primary care providers. It is a practical tool for use by new primary care clinicians of different disciplines, for team-based care, and for teaching pediatric preventive health care to learners.
As a surveillance tool, the RBR has the potential to be interpreted as simply a checklist focused on identifying red flags or deficits. Despite its checklist framework, it is intended to be a clinical tool to provide a basis for a personalized reciprocal interaction with the patient, family, and provider. For example, when adopting a strengths-based approach when inquiring about a child’s developmental trajectory, the provider may ask “What does your child enjoy?” or “What is he or she good at?” This strengthens the therapeutic relationship and expands the clinical context more broadly than a checklist of soliciting information and providing recommendations. Further, critical to the domain of ERH, a care provider can observe attachment and parental responsiveness during clinical interactions, and model positive reciprocity and encouragement for an infant or child.
Lastly, the RBR is designed as a general surveillance tool for Canadian children. We acknowledge that many questions or recommendations may not apply to all children, families, or cultures. We respect that providers and families are engaged in relationships of trust and that these topics are individualized and discussed in comfortable and welcoming environments.
Conclusion
The 2024 edition of the RBR presents an updated evidence-based synthesis of recommendations for well-infant and well-child preventive care. This is the most comprehensive revision in the history of the RBR. The redesigned and updated website also offers an accessible and easily navigable repository of information for clinicians, parents, and caregivers. We will continue to 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. We look forward to engaging with PCP user groups to identify ways of evolving the RBR. Consideration will also be given to more frequent dynamic updates of preventive health topics of the RBR that have developing evidence as opposed to more major revisions of the entire content at a single point in time.
Acknowledgment
We thank Dr Cara Dosman and her multidisciplinary team for their revisions to the developmental surveillance domain of the 2024 Rourke Baby Record.
Notes
Editor’s key points
▸ The 2024 edition of the Rourke Baby Record (RBR) 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 https://www.rourkebabyrecord.ca.
▸ Notable updates in the 2024 edition of the RBR include the promotion of early relational health for families; identification of targeted support and resources as opposed to labelling of high-risk groups; guidance on culturally safe care; clarification and evidence-based adjustments of the age of achievement of some developmental surveillance milestones; recommendations on plant-based beverages, vegetarian, and vegan diets; screening considerations for iron deficiency; dangers of ingestion of button batteries and cannabis edibles; literacy and socioemotional benefits of reading, singing, and storytelling; the importance of unstructured outdoor play; the environment’s effect on children’s health; the significance of sentinel injuries; acholic stools; and the normal presence and abnormal persistence of developmental (primitive) reflexes.
▸ The 2024 edition of the RBR is the most comprehensive revision in the history of the RBR. The redesigned and updated website offers an accessible and easily navigable repository of information for clinicians, parents, and caregivers. Consideration will also be given to more frequent dynamic updates of preventive health topics of the RBR that have developing evidence as opposed to more major revisions of the entire content at a single point in time.
Footnotes
Contributors
All authors contributed to conceptualizing and designing the study; to collecting, analyzing, and interpreting the data; and to preparing the manuscript for submission.
Competing interests
The Rourke Baby Record team receives unrestricted financial support from the Government of Ontario, which has no input into the review process or content of the Rourke Baby Record.
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This article has been peer reviewed.
La traduction en français de cet article se trouve à https://www.cfp.ca dans la table des matières du numéro de septembre 2025 à la page e205.
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