Abstract
Objective To review a selection of new resources and updated recommendations from the third update of the Greig Health Record (GHR).
Sources of information Pediatric preventive care literature was reviewed using PubMed and Google Scholar databases. Systematic reviews of subtopics were evaluated where available. Guidance and supporting evidence were reviewed from the Canadian Paediatric Society, the American Academy of Pediatrics, the Canadian Task Force on Preventive Health Care, the United States Preventive Services Task Force, the National Advisory Committee on Immunization, and the Centers for Disease Control and Prevention.
Main message Recommendations for best practice are based on available evidence and guidance from various agencies; yet conflicting recommendations are often given. The GHR identifies 6 of these conflicts in pediatric preventive care recommendations, including depression screening; cannabis use counselling and screening; dietary recommendations for beverage selection and consumption of plant-based proteins; testicular self-examination; and meningococcal vaccination timing.
Conclusion Clinicians are advised to consider options for practice as they apply to their own patients and to be aware of changing guidance as new evidence emerges.
The Greig Health Record (GHR) is an evidence-based care guide used in preventive care visits for children and adolescents aged 6 to 17 years. It reviews and summarizes existing guidelines and presents the information in an easy-to-use format for clinicians. The GHR tool and its associated resources are available from https://greighealthrecord.ca.
Often guidelines on topics related to pediatric preventive care produce similar recommendations. However, conflicting recommendations from various agencies can occur due to differences in the methodology of literature evaluation, agendas and preferences of reviewers, targeted users, and proposed populations and settings for application.1 The GHR identifies 6 of these conflicts in pediatric preventive care recommendations, which include depression screening; cannabis use counselling and screening; dietary recommendations for beverage selection and consumption of plant-based proteins; testicular self-examination; and meningococcal vaccination timing. The GHR presents recommendations but leaves it to clinicians to consider options for practice and be aware of changing guidance as new evidence emerges.
Sources of information
Searches for pediatric preventive care literature for the period of 2016 to 2025 were performed using PubMed and Google Scholar databases. Systematic reviews of subtopics were evaluated where available. Additionally, guidance and supporting evidence were reviewed from major Canadian and American agencies, including the Canadian Paediatric Society (CPS), the American Academy of Pediatrics, the Canadian Task Force on Preventive Health Care (CTFPHC), the United States Preventive Services Task Force (USPSTF), the National Advisory Committee on Immunization (NACI), and the Centers for Disease Control and Prevention.
Main message
Should children and adolescents who are asymptomatic be screened for depression? Depression is a common symptom in adolescents and up to 1% to 2% of children aged 7 to 11 years suffer from depression.2 In 2023, 26% of Canadian adolescents rated their mental health as fair to poor.3
Most organizations that produce health guidelines recommend asking about mental health.4-7 In terms of population screening, the CPS recommends asking about emerging mental health problems at well-child visits and addressing social determinants of health, but no specific tools have been recommended. Systematic reviews have found insufficient evidence to make recommendations considering there have been no randomized clinical trials evaluating whether depression screening improves outcomes and no trials have addressed potential harms of screening.8,9 In 1994 the CTFPHC recommended against population screening. An updated recommendation is expected to be released in the near future.10
In contrast, the USPSTF recommends screening for major depressive disorder in adolescents (grade B recommendation) provided that there are resources for diagnosis and management.9 However, nonrandomized trials were included in their evaluation.9 The USPSTF has found insufficient evidence to recommend screening preadolescent children for depression or for suicide risk.11
The GHR recommends asking about mental health but does not recommend routine preventive screening with specific tools.12 An up-to-date recommendation will be made once the CTFPHC report is released. It should be emphasized that in children and youth who present with symptoms or behaviour suggesting depression or other mental health disorders that further investigation is recommended with validated screening tools. An anxiety and depression questionnaire is included for easy reference (Table 1).11,13-16
Patient Health Questionnaire-4
Should the focus be on screening or counselling for reducing cannabis risk in youth? Cannabis use is common in Canadian youth and has been increasing. In the 2019 Canadian Cannabis Survey, 44% of teens aged 15 to 19 reported using cannabis in the preceding 12 months, compared with 36% in 2018.17 For comparison, a 2015 survey of Ontario students in grades 7 to 12 reported 21.5% used cannabis in the previous year.18
While avoiding cannabis altogether is recommended, in practice, youth are not always willing to abstain. Counselling to prevent initiation, encouraging reduction or quitting, and promoting other harm-reduction strategies may be helpful.
The CPS guidance differs from Canada’s Lower-Risk Cannabis Use Guidelines (LRCUG), with the former focusing on screening for use, praising abstinence, and supporting quitting or decreasing use; and the latter on harm reduction. Both are included in the resource tables of the GHR to allow clinicians to choose the best approach for their patients.19-21 It is suggested that wider dissemination of the LRCUG may help to increase the impact of harm-reduction stategies.22 It is important to note that inadvertent ingestion of cannabis, especially in the form of edibles, is also a concern, especially for younger children. Safe storage is recommended.23,24
The GHR also includes substance use in the checklist pages for children aged 6 to 9 as a prompt for anticipatory guidance. Whether there is a positive impact for early abstinence counselling will require further study (Boxes 1 and 2).19,25
Cannabis risk reduction
Avoid risks by choosing not to use
Delay starting cannabis use for as long as possible; there are more harms for teens, especially those younger than 16 years
Choose products with lower tetrahydrocannabinol content, or higher ratio of cannabidiol compared to tetrahydrocannabinol
Do not use synthetic cannabis products
Non-smoking options are less dangerous
If smoking, avoid inhaling deeply or holding your breath
Limit use, and try for infrequent, occasional use, or at most once per week
Do not drive when using, avoid driving for at least 6 hours, avoid combining with alcohol
Avoid if you or your family have a history of psychosis or substance use issues
Do not use if pregnant
Avoid inadvertent ingestion of edibles. Label clearly and place in locked storage
Data from the Canadian Research Initiative in Substance Matters and Centre for Addiction and Mental Health.25
Cannabis counselling guidelines
Provide a safe and confidential environment to screen for cannabis use
Ask about use of cannabis
Praise non-users for choosing to abstain from using cannabis
Consider cannabis as a contributing factor when youth complain of fatigue, low mood, and sleep issues
Provide support to decrease or stop use in cases of problematic use
Counsel about the impact on the developing brain (up to age 25 years)
Counsel about cannabis effects on mood and the potential for causing resurgence of depression or anxiety in those who have already experienced mood issues
Data from Bélanger and Grant.19
Should water be the beverage of choice? Are plant-based protein foods preferred? The nutritional recommendations chart in the supplemental pages of the GHR has been updated to reflect changes in Canada’s Food Guide. Recommendations include consuming plant-based protein foods and making water the beverage of choice.26 Water is specifically recommended but unsweetened low-fat cow’s milk and unsweetened soy and almond beverages are optional alternatives.27 Plant-based proteins are recommended to be consumed daily; the rationale is that these foods offer more fibre and less saturated fat than other protein foods.28 While the Canadian Guidelines are similar to updated guidelines from the United States and the United Kingdom, only the Canadian guidelines specifically state that water is the beverage of choice and that plant-based proteins should be chosen more often.29,30 The US guideline update recommends water to satisfy thirst and lower-fat dairy for calcium and other nutrients.29,31 The UK guidelines state the best drinks for children are water and milk but milk can be served as a main drink.32 The Canadian Guidelines do not address adequate calcium intake for bone health. The Canadian guidelines are summarized on the checklist pages of the GHR and Health Canada’s recommendations for calcium and vitamin D intake are in the resource pages to ensure clarity (Box 3 and Table 2).26,33-35
Nutritional recommendations
Eat vegetables, fruit, whole grains, and protein foods
Protein: Among protein foods consume plant-based more often. Protein foods include legumes, nuts, seeds, tofu, fortified soy beverage, fish, shellfish, eggs, poultry, lean red meat including wild game, lower-fat milk, lower-fat yogurts, lower-fat kefir, and cheeses lower in fat and sodium
Choose foods with mostly unsaturated fats rather than mostly saturated fats
Water should be the beverage of choice
Eating together (eg, family meals) can foster healthy eating habits
Energy needs are individual and should be adjusted to maintain a healthy weight
Processed or prepared items with excessive sodium, free sugars (such as sugary drinks and confectioneries), or saturated fat should not be consumed regularly. Unsweetened nutritious foods and beverages should be promoted instead of sugar substitutes
Cooking and preparing food at home can help support healthy eating. Food labels can help in making informed food choices
Nutrition recommended daily intake: No adjustment for latitude, pregnancy, or lactation.
Should adolescent males receive testicular self-examination counselling? Testicular cancer is the most common cancer in males aged 15 to 35 years.36,37 In 2004, and reaffirmed in 2011, the USPSTF recommended against counselling for testicular self-examination or routine clinical examination in individuals at average risk, in light of the low incidence of testicular cancer and favourable outcomes in the absence of screening.37 Time spent counselling for self-examination might be better spent on other topics. By contrast, the Canadian Cancer Society and the American Cancer Society recommend regular health visits and self-examination. Concern has been raised about a missed opportunity for early diagnosis and better outcomes, both medical and psychological.38,39 A description for self-examination is available.40 Provision of education in-person works better than written materials only.41
Despite these conflicting recommendations, patients should be advised to be aware of changes in their testicles and seek medical advice for any changes. Tables in the GHR are included to assist with counselling those who ask for more information (Box 4).40
Testicular self-examination
Who: Adolescent males or persons with testicles
Why: Most common cancer in adolescent males
Self-examination: Check for any changes such as a lump or tenderness (https://cancer.ca/en/cancer-information/cancer-types/testicular/finding-cancer-early and https://testicularcancersociety.org/pages/self-exam-how-to?)
Other symptoms: Feeling of heaviness in scrotum or lower abdomen; pain, possibly mild, in the testicle or scrotum
Next steps: See your doctor if you notice a change
Data from the Canadian Cancer Society.40
When should meningococcal vaccines be given? Creating a uniform recommendation for meningococcal vaccination for Canada is challenging as the epidemiology of invasive meningococcal disease (IMD) continues to change substantially and vary by age group and province or territory. Most IMD is caused by serotypes A, C, Y, and W135 combined but meningococcal B (MenB) strains account for the largest proportion of cases by single strain.42-44
Incidence of IMD in 11- and 12-year-olds is low. Recommendations for children younger than 12 years old are under review. Some studies indicate that carriage of meningococcus peaks around 19 years.45,46 Vaccine protection is of short duration; experts in the United States are considering whether later vaccination, such as in 16- and 17-year-olds, may be more efficacious.47 These considerations must be evaluated in the Canadian context.
Regarding MenB, there are currently 2 preparations of serogroup B meningococcal vaccine authorized for use in Canada. Neither has an effect on carriage, and as a result neither is effective in providing herd immunity. The NACI recommends MenB vaccination for persons at higher risk and advises MenB vaccines be considered on an individual basis.42,43 Following local public health guidelines is recommended. Ongoing evaluation of local serotypes and changing epidemiology will be necessary for future vaccination recommendations.48 A reminder to discuss immunization for MenB has been added to the GHR, although no specific recommendation for vaccination has been made at this time.
Conclusion
Conflicting recommendations may be the result of differing agendas for various agencies that produce guidelines. As evidence is evolving, lack of uniformity among guidelines may be the result of lag time in implementing new recommendations. Primary care providers are advised to stay abreast of new evidence. The GHR will be updated regularly and new recommendations will be explored.
Notes
Editor’s key points
▸ The Greig Health Record (GHR) is an evidence-based care guide used in preventive care visits for children and adolescents aged 6 to 17 years old.
▸ Conflicting guidelines and recommendations from various agencies can occur due to differences in the methodology of literature evaluation, agendas and preferences of reviewers, targeted users, and proposed populations and settings for application. The GHR covers 6 conflicts in pediatric preventive care recommendations: depression screening; cannabis use counselling and screening; dietary recommendations for beverage selection and consumption of plant-based proteins; testicular self-examination; and meningococcal vaccination timing.
▸ The GHR presents differing recommendations but leaves it to clinicians to consider options for practice and be aware of changing guidance as new evidence emerges.
Points de repère du rédacteur
▸ Le Relevé médical Greig (RMG) est un guide sur les soins de santé fondé sur des données probantes à utiliser lors des rendez-vous en santé préventive avec des enfants et des adolescents de 6 à 17 ans.
▸ Les lignes directrices et les recommandations provenant de diverses organisations peuvent être conflictuelles en raison de différences dans la méthodologie d’évaluation de la littérature scientifique, les mandats et les préférences des réviseurs, les utilisateurs ciblés et les populations et milieux proposés pour leur mise en application. Le RMG porte sur 6 divergences dans les recommandations sur les soins préventifs pédiatriques : le dépistage de la dépression; le counseling et le dépistage liés à la consommation de cannabis; les recommandations alimentaires entourant le choix des boissons et la consommation des protéines à base de plantes; l’autoexamen des testicules; et le calendrier de vaccination contre les méningocoques.
▸ Le RMG présente des recommandations divergentes, mais laisse aux cliniciens le choix d’envisager les options pour leur pratique et les incite à se tenir au fait des orientations changeantes au fur et à mesure de l’émergence de nouvelles données probantes.
Footnotes
Acknowledgment
We thank Éliane Sauvé Greig for her work on the French language translations.
Contributors
All authors contributed to conducting the literature review and to preparing the manuscript for submission.
Competing interests
None declared
This article has been peer reviewed.
- Copyright © 2026 the College of Family Physicians of Canada
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