Regaining birth weight: Time to regain birth weight depends on mode of delivery (cesarean delivery vs vaginal) and milk source (breast vs formula). Nomograms exist: eg, Newborn Weight Loss Tool

New evidence and nomograms on normative patterns of growth in the first week, which reference evidence-informed nomograms^15,16

Breastfeeding: Support exclusive breastfeeding for the first 6 mo of life for healthy-term infants. Breastfeeding is associated with better health outcomes (eg, fewer gastrointestinal and respiratory illnesses, lower incidence of SIDS). Early and frequent parent-infant skin-to-skin contact, rooming in, and banning handouts of free infant formula increase breastfeeding rates

Additional evidence on the health benefits associated with breastfeeding^17-21

Maternal-infant skin-to-skin contact updated to parent-infant to be more inclusive of all parents

Evidence supporting the reduction of allergies through the early introduction of potentially allergenic foods has not demonstrated reduced breastfeeding duration. The optimal age of introduction of complementary foods has not been established but current evidence suggests at around 6 mo but not before 4 mo²²

Vitamin D supplementation: Breastfeeding mothers should consume a daily supplement that contains at least 400-600 IU of vitamin D

Recent evidence suggests that breastfeeding mothers should consume a daily supplement that contains at least 400-600 IU vitamin D, which may be associated with improved infant vitamin D status²³

Plant-based beverages are not a nutrition-equivalent replacement for milk, especially for infants or children <2 y due to low protein, energy, and nutrient content. If a parent chooses not to provide breast milk or cow’s milk at 9-12 mo, a soy-based formula is recommended until 2 y

Per recent evidence: After 2 y of age, fortified unsweetened soy milk is an acceptable alternative to cow’s milk, but other plant-based beverages (eg, almond, oat, rice) remain nutritionally inadequate unless specifically fortified^24,25

Vegetarian and vegan diets: Children <2 y fed a vegan diet may be at risk for nutrient deficiencies

Earlier discussion of this topic is now recommended during the introduction of solid food, and new parent and clinician resources have been added

Milk consumption in excess of 750 mL per day poses a risk for iron deficiency

This recommendation follows the Health Canada Nutrition for Healthy Term Infants. Community-based research findings on iron deficiency and feeding practices in young children have been incorporated

Uncomplicated gastroesophageal reflux is frequent, improves with conservative measures, and usually resolves by 1 y. Avoid medication unless poor growth, respiratory problems, or gastrointestinal bleeding

Per updated evidence: Based on 2022 Canadian Paediatric Society Practice Point²⁶

Limit or avoid consuming highly processed foods and foods that are high in dietary sodium. Choose foods with healthy fats and limit foods containing saturated fat

High dietary sodium and saturated fats are risk factors for heart disease and hypertension in adulthood. New resources added^27-29

Allergenic foods: Recent evidence has shown that tolerance is maintained by feeding allergenic foods at least once a week or a few times a month

Per new evidence³⁰

Exposure to pesticides is associated with adverse neurodevelopmental outcomes

Evidence revised from fair to good and added to visits under 2 mo of age, per evidence that exposure to pesticides is associated with adverse neurodevelopmental outcomes^31,32

Well water should be tested regularly for contamination

Contamination by chemicals, naturally occurring toxic substances, or pathogenic organisms can cause illness in children³³

Safe sleeping environment: Counsel parents on the dangers of contributory risk factors for SIDS, such as bed sharing in parents’ bed, sleeping on a sofa or cushioned chair or in a car seat or swing, overheating, maternal smoking, second-hand smoke, alcohol, and illicit or sedating drug use

Risk factors for SIDS have been expanded as per recent evidence and clarified to be risk factors rather than causal factors^21,34,35

Choking: Avoid hard, small, smooth, and gummy foods under 4 y of age. Conforming items like latex balloons can cause choking. Use safe toys that are age appropriate and remove loose or broken parts. Encourage caregivers to learn choking first aid

New evidence adds latex balloons as a choking hazard and encourages caregivers to learn choking first aid

Poisoning or ingestion: Cannabis edibles and button batteries have been added. Ensure safe storage and disposal of button batteries. Canada-wide poison control number added: 844-POISON-X (844-764-7669)

New evidence regarding harms from accidental ingestion of cannabis^36-39 and button batteries⁴⁰

Practise inclusive, antiracist, culturally safe care. Practise cultural humility through reflection of personal biases to deliver patient- and family-centred antiracist and culturally safe care where patients feel respected and safe^41-43

Racism is a social determinant of health that has profound lifelong effects on children and families^44-46

Practise trauma-informed care. Trauma-informed care is defined as practices that promote a culture of safety, empowerment, and healing

New resources highlight the importance of integrating trauma-informed approaches to well-child care^14,47

Observe, discuss, model, and praise specific parenting behaviour and healthy routines that promote ERH. Build on each family’s relational strengths and protective factors, reinforce healthy routines, use anticipatory guidance to prepare parents for developmentally normal (and possibly challenging) behaviour, and help modify specific behaviour or skills when needed

Family approaches to crying, sleep, and behaviour vary culturally, and navigating points of variance with sensitivity is key to providing culturally safe care

ERH is the emotional connection between children and trusted adults that promote health and development. Evidence has shown that it leads to positive experiences, can help mitigate negative effects of trauma and adversity, and build resilience (ability to recover from stressors and negative experiences)^13,48

Be aware of prevention, recognition, and assessment of mental health problems in children as well as of parental depression

Evidence has shown that depression in either parent is a risk factor for the safety of children as well as for their socioemotional and cognitive development⁴⁹

Social determinants of health: Inquire about the impact of poverty (eg, housing or food insecurity) and offer resources to families with unmet social needs

New evidence supports inquiring about poverty and directing families with unmet social needs to appropriate resources.^50,51 Provide links to Canadian resources^52,53

Unexplained injuries (eg, fractures, burns), sentinel injuries, or injuries that do not fit either the explanation provided or developmental stage raise concern for child maltreatment

Consider more support or resources for parents with low socioeconomic or educational status, younger maternal age, single parent family, history of abuse, mental health or substance use, unplanned pregnancy; families with intimate partner violence, high conflict relationships, isolation or lacking social connectedness, caregivers who use corporal punishment; children with behavioural or mental health conditions or with special needs

Discuss with parents of preschoolers about teaching names of genitalia, appropriate and inappropriate touch, teaching age-appropriate principles of consent and permission, and normal sexual behaviour for age

Wording now includes unexplained and sentinel injuries,⁵⁴ principles of consent, and consideration for support and resources rather than merely labelling groups as high risk^14,47,55-57

Colic definition added: Recurrent and prolonged periods of infant crying, fussing, or irritability onset <5 mo old that occur without obvious cause and cannot be prevented or resolved by caregivers

Colic has been appropriately added to the Crying item in the Family functioning and behaviour issues section

Read, speak, and sing to the infant or child

Encourage caregivers to read, speak, tell stories, and sing to or with their infants and children in their language of choice to promote language and early literacy skills, as well as socioemotional and relational development

Children at risk of reading difficulties: History of early speech or language delay, trouble identifying letters of the alphabet, difficulty with letter-sound correspondence or rhyming, family history of reading difficulty or disability

This is now in bold print (good evidence) on all visits, and has been expanded to include singing and telling stories in addition to reading. New evidence has shown benefits to socioemotional development and relational health in addition to literacy.⁵⁸ Identifying children at risk of reading difficulties prior to school with early implementation of evidence-based and closely monitored reading interventions can improve literacy^58,59

Family healthy active living, sedentary behaviour, screen time: Decrease sedentary pastimes and encourage daily and frequent physical activity, with parents as role models, through interactive floor-based play for infants, and free and unstructured outdoor active play for young children

Based on new guidance on the importance of free play, especially outdoor risky play.⁶⁰ Risky play is different from hazardous play. The benefits of risky play include physical health, mental, and social-emotional health

Ages, wording, or reclassification of the level of evidence for the acquisition of certain milestones have been revised

The milestones are now consistently listed in the following order: gross motor, fine motor, communication, cognitive, social-emotional

Further assessment of development is merited by the absence of any milestones, loss of attained milestones, or parental or caregiver or clinician concern

Users should ensure that milestones have been achieved for any missed visits, and to recognize that parental familiarity with particular milestones may be culturally dependent

Guidance on developmental surveillance has been updated based on 2 major evidence-based papers on developmental milestone acquisition and collaboration with Dr Cara Dosman et al.^61,62 As in prior editions of the RBR, tasks are red flags, as they are set after the time of typical milestone acquisition so that absence of any item or parental concern suggests consideration for further assessment of development

The algorithm for early child development and resources found on Notes 4 has been revised

The revision was based on feedback received on the 2020 RBR. Note that the Ontario version of the 2024 RBR also includes links to province-specific resources

Sentinel injuries (such as bruising, subconjunctival hemorrhages, or intraoral trauma to the frenulum, lips, oral mucosa, gingiva, or tongue) or other unexplained injuries warrant evaluation regarding child maltreatment or medical illness

This term was added to the physical examination section of the visits up to 9 mo, to the general injury prevention statement, and to the prevention of child maltreatment statement. Addition of the term sentinel injuries raises awareness of injuries such as subconjunctival hemorrhages and intraoral trauma, which are uncommon but can be more specific findings for maltreatment⁶³

Acholic stools

Acholic stools and prolonged jaundice (predominately conjugated) in the newborn can be signs of BA. Early identification of BA with surgical management (Kasai procedure) reduces the need for liver transplantation⁶⁴

Developmental (primitive) reflexes: Testing for developmental reflexes (also called primitive reflexes) has been added to the physical examination section at the first visit (within 1 wk to 2 wk), and noting their absence by the 6-mo visit

The persistence of some primitive reflexes (eg, Moro, asymmetric tonic neck, palmar grasp) may be early signs of neuromotor disorder, suggesting the need for further assessment⁶⁵

Hip screening for developmental dysplasia: The revised wording clarifies the physical examination screening maneuvers of choice for infants at different ages and the considerations for selective imaging. Consider selective imaging between 6 wk and 6 mo for infants with normal hip examination if breech or family history, and for all infants with positive findings on physical examination

Whereas the hip examination for detecting hip dysplasia at 0 to 3 mo includes the Barlow and Ortolani tests, the Ortolani is the most sensitive clinical test. (The Barlow test detects laxity of the hip joint rather than an existing dislocation.) Between 3-12 mo, limited or asymmetric abduction is the most sensitive clinical maneuvers

Anemia or iron deficiency screening: Screening should be considered between 6 and 18 mo of age for infants or children at risk due to factors including low birth weight and prematurity; social determinants of health; recently arrived from countries with limited resources; or diet (infants or children fed whole cow’s milk before 9 mo of age or at quantities >500 mL/d; prolonged bottle feeding beyond 15 mo of age; or suboptimal intake of iron-containing foods). Beyond this age, screening as per additional risk factors

Consideration for anemia screening has been broadened to include iron deficiency. Recent evidence has shown that iron deficiency without anemia has impacts on health including development and brain functioning⁶⁶

Consider hemoglobinopathy screening for neonates from high-risk groups

The revised wording reflects consideration for screening depending on risk. At-risk ethnic groups vary with different types of hemoglobinopathy

The term tuberculosis screening has replaced TB skin testing

Based on updated evidence⁶⁷

Immunization pain reduction: During vaccination, pain-reduction strategies with good evidence include breastfeeding, use of expressed breast milk or use of sweet-tasting solutions, encouraging parents to hold their child, avoiding aspiration during IM injections, giving the most painful vaccine last, and consideration of topical anesthetics

Pain-reduction strategies have been expanded in keeping with current evidence⁶⁸

Vaccine hesitancy: Vaccine hesitancy was identified by WHO in 2019 as 1 of the 10 threats to global health. Evidence-based interventions to improve vaccine confidence include nonjudgmental parent education and communication (face-to-face, pamphlet, video, applications, texts), anticipatory guidance including prenatally, team-based approaches and tracking or recall systems, and community-wide collaborations

This new item on vaccine hesitancy has been added due to its increasing importance. Evidence-based interventions are included^69-71

The Immunization Chart (Guide V) has been deleted

Due to changing immunization schedules and the widespread use of electronic and other methods of recording immunizations, the Guide V Immunization Chart has been deleted

HPV vaccine has been deleted from the vaccine notes

As HPV vaccine is not given under age 6 y, it is not relevant to the RBR

COVID-19 vaccine has been added with recommendation to reference the NACI and the Canadian Immunization Guide for details regarding dosage and schedules

Due to evolving immunization recommendations regarding schedules and dosage, we refer to the NACI and the Canadian Immunization Guide for current advice