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Growth Monitoring
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| Reference |
Methods |
Outcomes |
Evidence |
Promoting optimal monitoring of child growth in Canada: Using the new World Health Organization growth charts - Executive Summary
D Secker, C Armistead, L Corby, M de Groh, V Marchand, LL Rourke, E Misskey, Canadian Paediatric Society/Société canadienne de pédiatrie, Adolescent Health Committee/Comité de la santé de l'adolescent
http://www.pulsus.com/journals/
abstract.jsp?HCtype=Physician&
sCurrPg=abstract&jnlKy=5&
atlKy=9322&isuKy=897&isArt=t& |
Subjects: 0 to 5 years old
Design: Position statement
The WHO Growth Study was initiated in 1997 to follow a cohort of children’s who had been raised in six different countries (Brazil, Ghana, India, Norway, Oman and USA) under recommended nutritional and health practices. This position statement gives recommendations for physicians on how to properly use the growth charts. |
The WHO growth charts are now considered the gold standard for children’s growth and are recommended to physicians to use during well-baby and well-child visits. The WHO also recommends using calibrated and well-maintained quality equipment to ensure the accuracy of measurements. According to this report, physicians should be trained to use the new growth charts and should understand the differences between the WHO and CDC growth charts to be prepared to explain them to parents and caregivers. A table of cut-off points for possible growth problems is included and can be seen on the CPS website. |
III |
WHO Multicentre Centre Growth Reference Study Group. Assessment of differences in linear growth among populations in the WHO Multicentre Growth Reference Study. Acta Paediatr Supp 2006; 450(95): 56-65.
http://www.who.int/
childgrowth/standards/
Difference_linear_growth.pdf |
Subjects: 0 to 5 years old
Design: Population-based study (N=8,440)
Growth charts based on internationally sampled children (from Brazil, Ghana, India, Norway, Oman and the USA) with optimal feeding and living conditions (including exclusive breastfeeding for the first 4 to 6 months, no maternal smoking and environments supportive of unconstrained growth). |
This study looked at differences in length and height among the populations included in the Multicentre Growth Reference Study (MGRS). There were a total of 8,440 children sampled across all sites; 1,743 in the longitudinal sample and 6,697 enrolled in the cross-sectional sample. Results showed that variance in growth was 20 times more likely the result of individual variation within a population versus country variation (70% vs. 3%, respectively, of total variance). Ghana and the USA were representative of the pooled average, while Oman and India tended to have lower values and Brazil and Norway had higher values. |
II-2 |
WHO Multicentre Growth Reference Study Group. WHO Child Growth Standards: Growth velocity based on weight, length and head circumference: Methods and development. Geneva: World Health Organization, 2009 (242 pages).
WHO
http://www.who.int/
childgrowth/mgrs/en/ |
Subjects: 0 to 5 years old
Design: Population-based study (N=8,440)
Growth charts based on internationally sampled children with optimal feeding and living conditions (including exclusive breastfeeding for the first 4 to 6 months). Study conducted from 1997-2003. Longitudinal follow-up from birth to 24 months and cross-sectional data from 18 to 71 months. |
WHO velocity standards for weight are presented for 1-month increments from birth to 12 months and 2- to 6-month increments from birth to 24 months. An internationally-sampled cohort was prospectively followed to monitor growth patterns. Mothers and newborns visited at home 21 times; 882 of 1,743 (in the longitudinal sample) completely followed-up. This study reports that growth velocity must be interpreted by taking into account attained growth. One limitation to these methods is the community-based sampling strategy. |
II-2 |
De Onis M, Garza C, Onyango AW, Borghi E. Comparison of the WHO child growth standards and the CDC 2000 growth charts. The Journal of Nutrition. 2007; 137: 144-148.
PubMed |
Subjects: 0 to 5 years old
Design: Review
Compared 2006 WHO growth standards to 2000 CDC growth standards. Prepared descriptive comparisons using a pooled sample of 226 healthy infants from 7 studies in North America and Northern Europe |
Main difference in weight-for-age curves occurs during infancy. CDC sample seems to be generally heavier and WHO standards are taller. According to this review, CDC growth charts have been proven to be inadequate for monitoring the growth of breastfed infants. The review reports that the WHO standards are a better tool than the CDC 2000 growth charts for monitoring the growth of breastfed infants. The WHO standards were based on a prospective longitudinal study design while the CDC standards are based on data collected |
II-3 |
De Onis M, Habicht JP. Anthropometric reference data for international use: recommendations from a World Health Organization Expert Committee. Am J Clin Nutr 1996;64:650-8.
PubMed |
Subjects: All ages
Design: Review
Results of a review to reevaluate the use of anthropometry at all ages for assessing health, nutrition and social well-being. WHO formed a committee to assess reference data on anthropometric indexes and determine guidelines for use. |
The purpose of this paper is to study the evidence of the importance of measuring growth in children. The expert committee convened by the WHO to recommend guidelines and review references. According to this review, for the fetus and newborn infant, it is recommended to use a single, sex-specific multiracial international reference. For infants and children, the expert committee reaffirmed the WHO’s position of using a single international reference. However, they also recommended the replacement or update of the reference due to the limitations of the current one. For adolescents, the NCHA/WHO reference data were recommended for height-for-age. |
III |
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Nutrition - general
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| Reference |
Methods |
Outcomes |
Evidence |
Canadian Paediatric Society, Dietitians of Canada and Health Canada. Nutrition for Healthy Term Infants, Minister of Public Works and Government Services, Ottawa, 2005.
Health Canada |
Subjects: Infants
Design: Review
Statement compiled by the CPS Nutrition Committee, Health Canada and the Dieticians of Canada to provide health care workers with guidelines about infant nutrition to help counsel parents and caregivers to ensure optimal infant health. |
This review recommends breastfeeding for the first 6 months and vitamin D supplementation. Te review provides information about alternate milks, other fluid consumption, safety and feeding, transition to solid foods, and other issues in infant nutrition. The recommendations in this document are based on the available scientific evidence; however, few RCTs have been conducted as these are generally not feasible. Where no solid scientific evidence exists, the review relied on consensus recommendations. |
III
A |
Ontario Society of Nutrition Professionals in Public Health (OSNPPH). Pediatric Nutrition Guidelines for Primary Health Care Providers (revised May 2008).
OSNPPH |
Subjects: 0 to 6 years old
Pediatric nutrition guidelines
Produced by the Ontario Society of Nutrition Professionals in Public Health (OSNPPH). |
These guidelines provide various recommendations for feeding and nutrition for infants at certain age increments: birth to 6 months, 6 to 9 months, 9 to12 months, 12 to 18 months, 18 to 24 months, 2 to 3 years, and 3 to 6 years. They also report approximate amounts of fluid consumption as referenced in the Rourke Baby Record. They primarily used references from Health Canada and the Dieticians of Canada. |
III |
Health Canada. Eating Well with Canada’s Food Guide.
Health Canada |
Subjects: >2 years old |
The guide indicates that children aged >2 years old can obtain the nutrients and calories they need for healthy growth and development by following Canada’s Food Guide. |
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Atopy
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Greer FR, Sicherer S, Burks AW and the Committee on Nutrition and Section on Allergy and Immunology. Effects of Early Nutritional Interventions on the Development of Atopic Disease in Infants and Children: The role of maternal dietary restriction, breastfeeding, timing of introduction of complementary foods and hydrolyzed formulas. Pediatrics. 2008; 121:183-191
PubMed |
Subjects: Mothers and infants
Design: Clinical report
This statement replaces the AAP statement on hypoallergenic formulas (2000). Reviews the Cochrane Review (above) and other trials to assess nutritional options during pregnancy, lactation and the first year of infancy and any potential relation to the development of atopic disease. Many of the reviewed studies focus on high-risk children (i.e., 1 parent with atopic disease). |
According to this report, there is insufficient evidence to support a protective effect of delaying certain foods (e.g. eggs, milk, nuts) after the infant has reached the age of 6 months. Extensively hydrolyzed formulas may be more effective than partially hydrolyzed formulas in the prevention of atopic disease (modest evidence). The statement also notes that there is lack of evidence that antigen avoidance during pregnancy and lactation have a preventative effect on atopic disease. However, they do report that evidence exists for exclusive breastfeeding for at least 3 months and protection against wheezing in early life. They report that soy formula is not recommended for the purpose of allergy prevention. Many studies had limitations that compromised their conclusions (e.g. no concealment of allocation for RCTs). The power to detect differences was small in many studies. |
I, II-1, II-2, II-3
A |
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Breastfeeding (exclusive)
Strength of Recommendation = Good |
| Reference |
Methods |
Outcomes |
Evidence |
Boland M. Exclusive breastfeeding should continue to six months. Paediatrics & Child Health. 2005; 10(3): 148
PubMed |
Subjects: Mothers and infants
Design: Review
CPS position statement (reaffirmed in 2009)
Review of the literature on breastfeeding and current guidelines. |
This review reported that breast milk is the optimal food for healthy term infants and that breastfeeding can continue for up to 2 years. The recommendation is for exclusive breastfeeding for 6 months. These recommendations are consistent with recommendations from AAP, WHO and Health Canada. |
III
A |
American Academy of Pediatrics. Breastfeeding and the use of human milk. Pediatrics. 2005; 115: 496-506.
PubMed |
Subjects: Infants
Design: Policy statement (review article)
Review of the evidence from the literature to make evidence-based recommendations for infant feeding practices. |
This policy statement reported that breastfeeding is the optimal method of infant feeding. Out of 15 recommendations by the AAP, the use of human breast milk and breastfeeding are the most important means of infant feeding and achieving good nutrition. This report also recommends that supplements of any kind should not be given to the baby until after 6 months of age. Evidence is based on other policy statements from the American Academy of Pediatrics, American Dietetic Association and a study by Gartner (1994). |
III
A |
American Dietetic Association. Position of the American Dietetic Association: breaking the barriers to breastfeeding. J Am Diet Assoc. 2001; 101: 1213-1220.
PubMed |
Subjects: 0 to 6 months old
Design: Review
Review of evidence supporting the breastfeeding of infants. |
There is still some taboo about breastfeeding a baby beyond the age of 6 months in some cultures. The benefits of breastfeeding are numerous. The ADA recommends that women should breastfeed their children exclusively for 6 months or for 12 months or longer with complimentary food added at 6 months. Evidence comes from prospective cohort studies and policy statements from the AAP. |
III
A |
Kramer MS, Kakuma R. Optimal duration of exclusive breastfeeding. Cochrane Database Systematic Review. 2002(1): CD003517.
PubMed |
Subjects: Infants
Design: Systematic review
Performed searches in many databases (MEDLINE, CINAHL, HealthSTAR, BIOSIS, CAB Abstracts, EMBASE-Medicine, etc.). Total citations retrieved 2,668. |
Twenty-two studies met the inclusion criteria: 11 from developing countries (2 internally-controlled trials from Honduras) and 11 from developed countries (all observational studies). The review showed that infants who are exclusively breastfed for 6 months experience less morbidity from gastrointestinal infection than those who are mixed breastfed starting at 3 to4 months of age. As well, exclusive breastfeeding does not impair growth and can help the mother to lose weight. Exclusive breastfeeding is recommended for the first six months of life in both developed and developing countries. |
I
A |
O’Connor NR, Tanabe KO, Siadaty MS, Hauck FR. Pacifiers and Breastfeeding. A Systematic review. Arch Pediatr Adolesc. 2009; 163: 378-382.
PubMed |
Subjects: Mother-infant pairs
Design: Systematic review
Performed a literature review using the databases MEDLINE, CINAHL, the Cochrane Library, EMBASE, POPLINE and bibliographies of identified articles. |
Twenty-nine studies met the inclusion criteria: 4 RCTs, 20 cohort and 5 cross-sectional studies. Due to significant heterogeneity in the studies no meta-analysis could be performed. The RCTs showed no difference in weaning between using pacifiers and controls. However, observational studies have shown a strong association. Potential limitations in both these study designs might contribute to the mixed results. For example in one RCT, there might have been a problem with compliance. |
I
A |
Kramer MS, Barr RG, Dagenais S, Yang H, Jones P, Ciofani L, Jané F. Pacifier use, early weaning and cry/fuss counselling: A randomized controlled trial. JAMA. 2001; 286: 322-326.
PubMed |
Subjects: Healthy term breastfed infants and mothers
Design: Double blinded Randomized Controlled Trial
Participants (N=281) were randomized to 1 of 2 counselling interventions. Each group was counselled by a trained research nurse. The experimental group was different than control as they were counselled to avoid pacifier use and given alternative methods to calm a crying baby. |
Early weaning (i.e., within the first 3 months) was compared between groups. Detailed behaviour logs for each infant were maintained describing the frequency and duration of crying and pacifier use at 4, 6, and 9 weeks. Analysis based on random allocation showed no effect between experimental or control groups for either early weaning or cry/fuss behaviour (OR=1.0, 95% CI: 0.6-1.7). When random allocation was ignored a strong observational association was found (RR=1.9). Follow-up was completed by 91.8% of participants. Data strongly suggest that pacifier use is a marker of breastfeeding difficulties or reduced motivation to breastfeed rather than a cause of early weaning. |
I
A |
Collins CT, Ryan P, Crowther CA, McPhee AJ, Paterson S, Hiller JE. Effect of bottles, cups and dummies on breast feeding in preterm infants: a randomized controlled trial. BMJ. 2004 doi:10.1136/bmj.38131.675914.55
PubMed |
Subjects: Preterm infants (<34 weeks)
Design: RCT
Participants were randomized to 1 of 4 groups (cup/no dummy, cup/dummy, bottle/no dummy or bottle/dummy) and used block randomization to stratify infants based on gestational weeks. |
Main outcome was the proportion of infants fully breastfeeding by time of discharge. Secondary outcomes included length of hospital stay and prevalence of breastfeeding at 3 and 6 months after discharge. In this study, there was no effect between dummy use and breast feeding at discharge or after 3 and 6 months based on intention to treat analysis. However, there was a significant effect of cup feeding on full breastfeeding at discharge (OR=1.73, 95% CI:1.04-2.88). Also, cup feeds were significantly associated with longer hospital stay. |
>I
A |
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Vitamin D 400 IU/day (800 IU in northern areas)
Strength of Recommendation = Good |
| Reference |
Methods |
Outcomes |
Evidence |
Canadian Pediatric Society. Vitamin D supplementation: Recommendations for Canadian mothers and infants. Paediatrics & Child Health 2007; 12(7): 683-89.
PubMed |
Subjects: Infants
Design: Position statement (review)
Reviewed the literature for studies looking at vitamin D deficiency and rickets. Also reviewed intervention studies. |
The focus of research has shifted from rickets exclusively to the prevention of associated childhood and adult diseases. Vitamin D deficiency is very common, therefore according to this review, supplementation for mothers and infants, especially those in high risk groups such as Inuit and First Nations is recommended. Studies reviewed were mainly case-control and cohort study designs (no randomized controlled trials due to ethical implausibility.) |
II-1, II-2, II-3, III
A, B |
Wagner CL, Greer FR. American Academy of Pediatrics Committee on Nutrition. Prevention of rickets and vitamin D deficiency in infants, children and adolescents. Pediatrics 2008; 122: 1142-1152
PubMed |
Subjects: Mothers and infants
Design: Review
Reviewed the literature for studies looking at vitamin D deficiency and rickets. Also reviewed intervention studies. |
Extensive review of the literature revealed clinical trials, intervention studies and observational studies. According to this review, the new recommended daily intake of vitamin D is 400 IU/day for infants, children and adolescents starting in the first days of life. New evidence from clinical trials shows that both benefits and a lack of harmful effects are associated with giving infants, children and adolescents this dose. |
II-1, II-2, II-3, III
A |
Taylor SN, Wagner CL, Hollis BW. Vitamin D supplementation during lactation to support infant and mother. Journal of the American College of Nutrition. 2008; 27(6): 690-701.
PubMed |
Subjects: Mothers and infants
Design: Review
Reviewed the literature for studies and position statements looking at vitamin D deficiency and rickets in infants and mothers. Key words: human milk, lactation, infant, rickets, vitamin D. |
Many populations all over the world suffer from vitamin D deficiency. There was contrasting evidence about the benefits and harms of vitamin D supplementation; however it is now known to be very beneficial. This review reports that vitamin D supplementation for mothers and infants is recommended, especially for high risk groups (i.e., dark pigmented skin, Northern latitudes, whole-body covering). The authors are report that there is some evidence that supports giving breastfeeding mothers higher doses to eliminate direct supplementation to infants. |
II-1, II-2, II-3, III
A |
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Weaning
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| Reference |
Methods |
Outcomes |
Evidence |
Community Pediatrics Committee, Canadian Pediatric Society. Weaning from the breast. Paediatrics & Child Health 2004; 9(4), 249-253.
PubMed |
Subjects: Breastfeeding healthy term infants
Design: Policy statement
A review of the literature was done through databases such as MEDLINE and Cochrane as well as relevant websites such as WHO, CPS, AAP and Health Canada. |
This statement discusses issues involved in weaning such as: natural weaning (infant-led), planned weaning (mother-led), refusal to breastfeed, abrupt or emergency weaning and maternal guilt; exclusive breastfeeding for the first 6 months (with vitamin D). This statement advises slow, progressive, natural weaning whenever possible. The CPS also recommends that the physician provide information and support to the breastfeeding mother while ensuring adequate nutrition for the infant regardless of the timing of weaning. |
III
A |
|
Formula Feeding
Strength of Recommendation = Fair |
American Academy of Pediatrics Committee on Nutrition. Iron-fortification of infant formulas. Pediatrics 1999; 104(1):119-123.
PubMed |
Subjects: 0 to12 months old
Design: Policy statement
Review of the 1976 and 1989 statements on infant formulas as well as a scientific update and compilation of recommendations. |
The AAP recommends the use of iron-fortified infant formula to prevent iron-deficiency anemia. They also recommend that breastfeeding is optimal for all infants however, for parents who choose to formula feed, formula should contain 4-12 mg/L of iron for the first year of life. This statement reports that parents should be educated on the importance and role of iron for infant growth and development. |
III
B |
|
Colic
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| Reference |
Methods |
Outcomes |
Evidence |
Nutrition Committee, Canadian Pediatric Society. Dietary manipulations for infantile colic. Paediatrics & Child Health 2003;8(7):449-52.
PubMed |
Subjects: Infants
Design: Policy statement
Performed a literature review on a variety of topics pertaining to possible causes and solutions to infantile colic. |
Topics included the hypoallergenic diets of breastfeeding mothers and the use of hypoallergenic, soy-based, low lactose and fibre-enriched formulas in bottle-fed infants. This statement reports that: 1) hypoallergenic diets for breastfeeding mothers may help reduce colic in infants; 2) hypoallergenic formulas may help with the management of some infants with colic; 3) soy formulas may be effective in reducing infantile colic however soy protein is an allergen in infancy and therefore should be avoided; 4) there is no evidence that low lactose or fibre-enriched formulas are effective for infantile colic. |
III
A |
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Ankyloglossia
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| Reference |
Methods |
Outcomes |
Evidence |
Community Paediatrics Committee, Canadian Pediatric Society. Ankyloglossia and breastfeeding. Paediatrics & Child Health 2002; 7(4), 269-70.
PubMed |
Subjects: Breastfeeding infants
Design: Position statement (review)
Reviewed the literature for evidence of the association between ankyloglossia and breastfeeding difficulties. |
According to this review, the incidence of ankyloglossia is about 4.8% in the newborn population. They report that restriction of tongue movement must be extreme to interfere with suckling and swallowing. According to this review, evidence suggests that despite newborn or infant ankyloglossia, most babies are able to breastfeed without too much difficulty and that surgical intervention is usually not warranted. |
III
A |
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Formula Feeding
Strength of Recommendation = Fair |
| Reference |
Methods |
Outcomes |
Evidence |
| Soy based formulas |
Canadian Paediatric Society. Concerns for the use of soy-based formulas in infant nutrition. Paediatrics & Child Health. 2009; 14(2): 109-113.
PubMed |
Subjects: Infants and mothers
Design: Practice point
Review of clinical and observational studies. |
Other studies have been done showing potential harmful effects of soy-based formulas because of the presence of phytoestrogens. According to this statement, mothers’ personal preference could be the main reason for use of soy-based formulas. This practice point reports that soy-based formula is not recommended for infants and that the recommendation for soy-based formula for infants with cow’s milk protein allergy (CMPA) or living a vegan lifestyle is no longer valid. One main limitation of studies on CMPA and soy-based formulas is failing to distinguish between IgE- and non-IgE- mediated CMPAs. |
III
B |
Bhatia J, Greer F. American Academy of Pediatrics Committee on Nutrition. Use of soy protein-based formulas in infant feeding. Pediatrics. 2008; 121: 1062-1068
PubMed |
Subjects: Infants and mothers
Design: Review
Reviewed literature on soy-based formulas for infants. Recommendations are based on a few randomized controlled trials, controlled clinical trials, observational studies and review articles. |
According to this review, soy-based formulas do not have adverse effects for normal term infants. However, the review reports that there is no added benefit over cow’s milk (unless the infant has CMPA) and that soy-based formulas should not be used for preterm babies. There is no evidence to support that soy-based formulas prevent atopic diseases or colic. This review reports that soy-based formula should only be used in infants with galactosemia or when a vegetarian diet is preferred. |
III
B |
Badger TM Gilchrist JM, Pivik RT, Andres A, Shankar K, Chen JR, Ronis MJ. The health implications of soy infant formula. American Journal of Clinical Nutrition. 2009; 89(Suppl): 1668S-72S.
PubMed |
Subjects: 0 to 6 months old
Design: Prospective longitudinal study
Arkansas Children’s Nutrition Center currently conducting a study comparing growth, development and health of breastfed children with formula-fed children. |
After 5 years of the study, all children are growing within the normal limits and no adverse effects have been seen. Many countries have recommended reduced use of soy formulas. According to this study, concerns about soy formulas are not supported by convincing data. Most of the evidence against soy formulas is based on RCTs using animal models and cannot be generalized to humans. The follow-up time of this study is adequate to determine any early developmental problems but not longer-term effects. |
II-2
B |
Osborn DA, Sinn JKH. Soy formula for prevention of allergy and food intolerance in infants (Review). Cochrane Database of Systematic Reviews. 2006, Issue 4 Art No.:CD003741. DOI:101002/14651858
PubMed |
Subjects: 0 to 6 months old
Design: Meta-analysis
Used the standard search strategy of the Cochrane Neonatal review group. Selected studies that compared the use of adapted soy formula to human milk, an adapted cow’s milk or a hydrolyzed protein formula. |
Only 3 randomized and quasi-randomized studies met the inclusion criteria. According to this meta-analysis, the use of soy formula cannot be recommended for the prevention of allergy or food intolerance in infants at high risk of these conditions. Ten to 14% of infants with CMPA allergy are also allergic to soy protein. |
I
A |
|
Canada's Food Guide
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| Reference |
Methods |
Outcomes |
Evidence |
Health Canada. Eating Well with Canada’s Food Guide.
Health Canada |
Subjects: >2 years old |
The guide indicates that children aged >2 years old can obtain the nutrients and calories they need for healthy growth and development by following Canada’s Food Guide. |
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Transportation in motor vehicles: Car seats (infant)
Strength of Recommendation = Good |
| Reference |
Methods |
Outcomes |
Evidence |
Canadian Pediatric Society. Transportation of infants and children in motor vehicles. Paediatr Child Health. 2008; 13: 313-318
PubMed |
Subjects: Infants and young children
Design: Position statement (reviewed by Transport Canada and the CPS Fetus and Newborn Committee)
Review of guidelines for child restraints for transportation in vehicles. Also looked at seating position, seat installation and placement of the child in the seat. |
This statement reports that there are 4 stages to child restraints: rear-facing (up to 10kg), forward-facing (up to 22kg), booster (up to 36kg) and finally seat belt (>36kg). Guidelines are based on age but height and weight limitations are more important. The CPS recommends that physicians should counsel parents on the appropriate use of child restraints, as parental misuse of equipment is a common source of harm. Children riding in rear seats in vehicles are 1.7 times less likely to incur a fatal or severe injury than front seat travelers. Recommendations are based on the most current knowledge from the literature and legislation. Evidence is good as the review is based on good methodological case-control studies and RCTs are not ethically feasible. |
III
A |
American Academy of Pediatrics. Car Safety Seats: A Guide for Families 2010.
American Academy of Pediatrics |
Subjects: Children
Guidelines for parents
Recommendations for parents on proper use, installation and type of child restraint for transportation of children in a vehicle. |
The report gives detailed descriptions of available restraint types for use at various ages, heights and weights. The AAP have similar recommendations as the CPS: rear-facing, forward-facing, booster and then seat belts should be sequentially used. |
III
A |
Winston FK, Durbin DR, Kallan MJ, Moll EK. The danger of premature graduation to seat belts for young children. Pediatrics. 2000;105:1179-1183
PubMed |
Subjects: 2 to 5 years old
Design: Case-control study (N=2,077)
Data obtained through the Partners for Child Passenger Safety child-focused crash surveillance system and from reported crashes to State Farm Insurance. Driver and parental reports were obtained through phone interviews using a validated survey. |
In this study, young children wearing seat belts are more likely to sustain an injury (particularly head injuries) in the event of a car crash than children in child restraint systems (CRS). Very few children 4 to 8 years old were in booster seats (i.e., the appropriate CRS) and were thus not properly restrained. According to this study, the authors report that the use of belt-positioning booster seats is recommended until the child is the appropriate height and weight for seat belt use. |
II-2
A |
Rice TM, Anderson CL. The effectiveness of child restraint systems for children aged 3 years or younger during motor vehicle collisions: 1996 to 2005. American Journal of Public Health. 2009; 99: 252-257.
PubMed |
Subjects: ≤3 years old
Design: Matched cohort study (N=6,303)
Data obtained from the Fatality Analysis Reporting System from 1996 to 2005. Identified crashes involving vehicles carrying a child ≤3 years and in which at least 1 person died from the matched pair. |
This cohort study reports that child safety seats are extremely effective in reducing the risk of death during severe traffic accidents and collisions. Restrained children were 67% less likely to suffer a fatal injury than children who were unrestrained. The authors suggest that parents of young children should be encouraged to use child safety seats instead of seat belts. |
II-2
A |
Durbin DR, Elliot MR, Winston FK. Belt-positioning booster seats and reduction in risk of injury among children in vehicle crashes. JAMA 2003;289:2835-2840.
PubMed |
Subjects: 4 to 7 years old
Design: Cross-sectional study
Sample taken from vehicle crash insurance claims. Eligible vehicles/drivers were then screened to partake in a full telephone interview. The type of restraint used for the child was determined during the phone interview. |
Among children in this study, 81% had been using some type of restraint. In this age group, odds of injury were 61% lower for children using belt-positioning booster seats than those wearing seat belts. This study reports that pphysicians should advocate the use of booster seats and educate parents. |
II-3
A |
Henary B, Sherwood CP, Crandall JR, Kent RW, Vaca FE, Arbogast KB, Bull MJ. Car safety seats for children: rear facing for best protection. Injury Prevention 2007; 13: 398-402.
PubMed |
Subjects: 0 to 23 months old
Design: Case-control study
(N=870)
U.S. National Highway Traffic Administration vehicle crash database for the years 1988-2003 was used to obtain data on children 0 to 23 months who were sitting in a rear-facing car seat (RFCS) or forward-facing car seat (FFCS) and involved in a car crash. |
This case-control study showed that RFCS are more effective than FFCS in restraining children 0 to 23 months old. Infants (<1 year old) were at an even greater risk of injury (5.32 [3.43-8.24]) when analyzed separately. Overall, children who suffered serious injuries were 1.76 (95% CI: 1.40-2.20) times more likely to be riding in a FFCS as compared to children riding in a RFCS. |
II-2
A |
Berg MD, Cook L, Corneli HM, Vernon DD, Dean JM. Effect of seating position and restraint use on injuries to children in motor vehicle crashes. Pediatrics. 2000; 105: 831-835.
PubMed |
Subjects: 0 to 14 years old
Design: Case-control study
(N=5,751)
Analyzed motor vehicle crash records from 1992 to 1996 from the Utah Department of Transportation. Study included crashes that resulted in injuries and crashes with damage costing over $750. |
Out of the 5,751 children involved in the accidents, 37% of children 0 to 4 years old were riding in the front seat and only 38% were optimally restrained. The odds ratio (OR) for being involved in a serious car accident is 1.7 (95% CI: 1.6-2.0) times higher for children sitting in the front as compared to the back of a vehicle. The OR for no restraint use was 2.7 (95% CI: 2.4-3.1) compared to restraint use. The investigators report that young children should be properly restrained and seated in the back seat of a vehicle. |
II-2
A |
Bull MJ, Engle WA, and the Committee on Injury, Violence and Poison Prevention and the Committee on Fetus and Newborn. American Academy of Pediatrics. Safe transportation of preterm and low birth weight infants at hospital discharge. Pediatrics 2009; 123: 1424-1429.
PubMed |
Subjects: Newborns
Design: Clinical report
Gives guidelines for physicians and other caregivers who counsel parents of preterm and low birth weight infants. |
The size of the infant being transported by vehicle is an important consideration. According to this report, any necessary medical equipment should be restrained during travel. Risks while traveling include oxygen desaturation, apnea or bradycardia. They report that families should be taught by trained hospital staff to correctly position the car safety seat. As well, proper positioning of the infant in the seat is important. It is suggested in this report that infants be placed in the car seat while still in the hospital and watched for 90 to 120 minutes to help ensure safe travel. |
III
A |
Strength of Recommendation = Good |
| Reference |
Methods |
Outcomes |
Evidence |
Thompson DC, Rivara FP, Thompson RS. Helmets for preventing head and facial injuries in bicyclists. Cochrane Database Syst Rev. 2000;(2):CD001855.
PubMed |
Subjects: All ages
Design: Systematic review
Searched databases such as CENTRAL, MEDLINE AND EMBASE. Checked reference lists of past reviews and review articles and contacted colleagues around the world. Searches were last updated November 2006. |
Five case-control studies met the inclusion criteria. This review reports that helmets provide a 63 to 88% reduction in the risk of head, brain and severe brain injury for all ages of bikers. Helmets also reduce head and facial injuries for all ages of bikers involved in all types of crashes (including crashes involving motor vehicles). All studies found a large protective effect of wearing helmets. |
II-2
A |
Thompson DC, Rivara, FP, Thompson RS. Effectiveness of bicycle safety helmets in preventing head injuries. A case-control study. JAMA 1996;276:1968-73.
PubMed |
Subjects: All ages
Design: Case-control study
Data was collected from 7 hospitals. Subjects were eligible for the study if they were injured while on a bicycle. Cases sustained head injuries and controls sustained any other injury. Questionnaires were sent out to subjects 7 to14 days after the initial ER visit. |
This study showed that controls were more likely to have been wearing helmets during the crash than cases (56.8% vs. 29.3%). The OR for the association between wearing helmets and sustaining a head injury was 0.31 (95% CI: 0.26-0.37), showing a protective effect of helmets. According to this study, bicycle helmets provide protection to bicyclists of all ages. They reduce the chance of severe head and brain injury. The study suggests that strategies to prevent bicycle injury should focus on the promotion of helmet use through legislation and education. |
II-2
A |
American Academy of Pediatrics, Committee on Injury and Poison Prevention. Bicycle helmets. Pediatrics. 2001; 108: 1030-1032
PubMed |
Subjects: Children
Design: Policy statement
This policy statement describes the role of the paediatrician in helping to attain universal helmet usage among children and teens. |
This policy statement reports that all bicyclists should wear a properly fitting helmet every time they are riding. Parents and children should also learn the essential aspects of bike safety. The AAP recommends that physicians should counsel parents and encourage bicycle helmet use during well-child visits as well as in the community. |
III
A |
David E. Wesson, MD, FRCSCa, Derek Stephens, MScb, Kelvin Lam, MScc, Daria Parsons, MScd, Laura Spence, BScNe and Patricia C. Parkin, MD, FRCPCb,f,g Trends in Pediatric and Adult Bicycling Deaths Before and After Passage of a Bicycle Helmet Law PEDIATRICS Vol. 122 No. 3 September 2008, pp. 605-610 (doi:10.1542/peds.2007-1776) http://pediatrics.aappublications.
org/cgi/reprint/122/3/605
http://www.ncbi.nlm.nih.gov/
pubmed?term=%22Pediatrics
%22[Jour]%20AND
%20122[volume]
%20AND%203[issue]
%20AND%20
bicycling[Title]&cmd=DetailsSearch |
Subjects: All ages
Design: Before and after study
This is a pre-post study to determine the effect of bike helmet legislation on bicycle-related mortality. Average numbers of deaths per year and mortality rates per 100 000 person-years were analyzed over a 12 year period from 1991 to 2002. Bicycle helmet legislation was passed in 1995 in Ontario. Analysis was done on deaths occurring in the age group 1-15 and 16 and over. Data was collected from database of the Office of the Chief Coroner of Ontario. |
Overall, there were 362 bicycle-related deaths in the 12 year period of this study (107 in the age group 1-15 years and 255 in the 16 year old and above group). After legislation, for bicyclists 1 to 15 years old, the average number of deaths per year decreased 52%. This reduction was not seen in the older age group. Due to the fact that legislation was enforced in the younger age group by fining the parents of the children and not enforced for the older age group, this study reported that legislation may have a positive effect on reducing the number of bicycle-related deaths. |
III
 A |
|
Bath Safety and Water Safety
Strength of Recommendation = Fair |
| Reference |
Methods |
Outcomes |
Evidence |
Byard RW, Donald T. Infant bath seats, drowning and near-drowning. J. Paediatr. Child Health 2004; 40: 305-307
PubMed |
Subjects: 0 to 2 years old
Design: Review
Reviewed files of the Forensic Science Centre and Child Protection Unit, Women’s and Children’s Hospital, Adelaide, South Australia, for immersion incidents in bathtub seats. |
Six cases of drowning and near-drowning were found over a 6-year period, three cases were reviewed in this article. One case of drowning occurred in a 7-month old boy who slipped from his bath seat. Two cases of near drowning happened in boys of the same age. The review reports that bathtub seats are associated with problems of trapping infants underwater if they slip down under the ring or seat. They have also been known to give parents false confidence to leave their children unattended. |
III
B |
Canadian Pediatric Society. Swimming lessons for infants and toddlers. Paediatric & Child Health 2003; 8(2): 113-114.
PubMed |
Subjects: Infants
Design: Position statement
Recommendations and guidelines for swimming lessons for infants and toddlers. |
The CPS statement reports evidence that swimming lessons improve swimming ability and deck behaviour but there is no evidence that it prevents drowning or near drowning. The CPS states that parental supervision and four-sided fencing are the best strategies for prevention against drowning. The CPS also states that swimming lessons should not be promoted as effective prevention against drowning and that there should be constant supervision for all children <4 years old who are swimming. |
III
B |
Brenner RA, Gitanjali ST, Haynie DL, Trumble AC, Qian C, Klinger RM, Klebanoff MA. Association between swimming lessons and drowning in childhood. A case-control study. Arch Pediatr Adolesc Med 2009;163(3):203-210.
PubMed |
Subjects: 1 to 19 years old
Design: Case-control study
Interviews were conducted with 61of the 88 families who had a child aged 1 to 4 years unintentionally drown. These were identified across specific jurisdictions in the U.S. through medical examiners or coroners. Cases were matched with 213 controls based on age, sex and area of residence by random-digit-dialling. |
Of the 61 cases interviewed, only 3% had taken formal swimming lessons as compared to 26% of the controls. There was an 88% reduction in the risk of drowning when 1 to 4 year olds participated in formal swimming lessons (95% CI: 0-.01-0.97). Informal swimming lessons did not significantly reduce the risk of drowning. The authors concluded that swimming lessons do provide some protective effect, however, due to the imprecise estimate (shown in the wide confidence intervals) the true magnitude of the effect remains unclear. |
II-2
B |
American Academy of Pediatrics Committee on Sports Medicine and Fitness and Committee of Injury and Poison Prevention. Swimming Programs for infants and toddlers. Pediatrics 2000;105:868-870.
PubMed |
Subjects: Infants and toddlers
Design: Policy statement
Review of swimming programs for infants and toddlers. Gives recommendations for parents and physicians. |
The AAP reports that children are not developmentally ready for swimming lessons until after their 4th birthday. There is no evidence that swimming programs reduce the risk of drowning. The AAP states that parents should not leave children unattended while swimming. |
III
B |
American Academy of Pediatrics. Committee on Injury and Poison Prevention. Drowning in Infants, Children and Adolescents. Pediatrics 1993;92;292-294.
PubMed |
Subjects: 0 to 19 years old
Design: Policy statement
Overview of causes and strategies to prevent drowning in children and adolescents. Provides recommendations for patient/parent and physicians. |
Effectiveness of swimming lessons at all ages for drowning prevention has not been determined. Four-sided fencing for home pools has been shown to reduce the number of pool immersion injuries by more than 50%. It is recommended by that AAP that children be taught how to swim and that they never swim without adult supervision. |
III
B |
Thompson DC, Rivara FP. Pool fencing for preventing drowning in children. Cochrane Database Systematic Review 2000;2:CD0001047
PubMed |
Subjects: 0 to 14 years old
Design: Systematic review
Searched databases such as CENTRAL, MEDLINE AND EMBASE. Checked reference lists of past reviews and review articles and contacted relevant organizations and experts. Searches were last updated in October 2006. |
Three case-control studies met the inclusion criteria. All 3 studies concluded that fenced pools are associated with a decreased risk of drowning compared to unfenced pools (OR 0.27 [95% CI: 0.16 to 0.47]). The study reports that isolation fencing (4-sided) is better than perimeter fencing (3-sided). Legislation and maintenance of pool fencing requires improvement in most communities. |
I
A |
|
Smoke detectors
Strength of Recommendation = Fair |
| Reference |
Methods |
Outcomes |
Evidence |
American Academy of Pediatrics. Committee on Injury and Poison Prevention. Reducing the number of deaths and injuries from residential fires. Pediatrics 2000; 105: 1355-1357.
PubMed |
Subjects: Children
Design: Review
Reports an overview of intervention strategies and prevention messages for reducing injury due to residential fires. |
The review reports that smoke alarms need to be installed and maintained in the home; they should be tested once a month and the batteries should be changed once a year; young children and older adults are at the highest risk for incurring serious injury and death due to residential fires. |
III
B |
DiGuiseppi C, Roberts I, Li L. Smoke alarm ownership and house fire death rates in children. J Epidemiol Community Health 1998; 52: 760-761.
PubMed |
Subjects: 0 to 14 years old
Design: Ecological study
Used data from the Office for National Statistics in England and Wales. Recorded all injury deaths of children 0 to14 years old from 1980-1995. |
Case-control studies have shown that smoke alarms are associated with a reduced risk of death. In this study, a 10% increase in smoke alarm ownership was associated with a 13% risk reduction of fire death in infants 0 to 4 years old (95% CI 0.81-0.94). The main limitation of this study is in its ecological design. There are other factors that might be contributing to the decrease in deaths that are not related to fire alarms such as reduced risk of fire occurrence or severity in this time period. |
II-3
B |
LeBlanc JC, Pless IB, King WJ, Bawden H, Bernard-Bonnin AC, Klassen T, Tenenbein M. Home safety measures and the risk of unintentional injury among young children: a multicentre case-control study. CMAJ 2006; 175(8): 883-887.
PubMed |
Subjects: 0 to 7 years old
Design: Case-control study
Investigators used records from 5 pediatric hospital emergency departments to look for cases of falls, burns or scalds, ingestions or choking. Matched control subjects were children who presented during the same period with acute non-injury related conditions. |
An investigator blinded to case/control status assessed 19 injury hazards at each child’s home. Overall, 17% percent of homes had no functioning smoke alarm and 51% had no functioning fire extinguisher. After controlling for siblings, maternal education and employment it was found that cases differed from controls for 5 hazards: presence of a baby walker, presence of choking hazards, no child-restraint lids in bathroom, no smoke alarm and no functioning smoke alarm. Compared to controls, cases were 3.2 (95% CI: 1.4-7.7). times more likely to have been injured in a house without a smoke alarm |
II-2
B Â |
|
Poisons PCC#
Strength of Recommendation = Good |
| Reference |
Methods |
Outcomes |
Evidence |
Tenenbein M, and the Committee on Injury, Violence, and Poison Prevention. AAP Policy Statement. Poison treatment in the home. Pediatrics 2003; 112: 1182-1185.
PubMed |
Subjects: Children
Design: Policy statement
Reviews the current literature on the prevention and treatment of poisonings in the home. |
The AAP statement reports that child-resistant closures and safer medications are recognized as the most effective measures for preventing domestic poisonings. Ipecac is no longer recommended for use in the home. The AAP recommends that physicians should inform parents about the proper storage of medications and poisons and that activated charcoal should not be used in the home. |
III
A |
McGregor T, Parkar M, Rao S. Evaluation and management of common childhood poisonings. American Family Physician 2009; 79: 397-403.
PubMed |
Subjects: Children
Design: Review
Reviews the literature on children evaluated for suspected toxin ingestion, commonly ingested substances and various treatments. |
Patients who have ingested toxins and who are presenting with respiratory, circulatory or neurological symptoms should be taken to the nearest ED. According to this study, use of ipecac is no longer recommended for treatment and the use of activated charcoal is discouraged, except if within one hour of ingestion. |
III
A |
|
Falls (stairs, walkers, change table and trampoline use)
Strength of Recommendation = Fair |
| Reference |
Methods |
Outcomes |
Evidence |
American Academy of Pediatrics. Committee on Injury and Poison Prevention. Falls from heights: windows, roofs, and balconies. Pediatrics. 2001; 107: 1188-1191.
PubMed |
Subjects: 0 to 15 years old
Design: Policy statement
Review of the literature to compile a policy statement on the epidemiology of falls from heights. Lists recommendations for preventive strategies for parent counselling. |
Preventive strategies for physicians include: parent counselling, community programs, building code changes and legislation. The AAP recommends a variety of tools (e.g. window guards and stops) to prevent accidental falls from windows. Also, parents are recommended not to place furniture on which children could climb near windows or balconies. |
III
B
|
American Academy of Pediatrics. Committee on Injury and Poison Prevention. Injuries associated with infant walkers. Pediatrics 2001; 108: 790-792.
PubMed |
Subjects: Children
Design: Review
Review of the literature on infant walkers and recommendations given by the AAP. |
From 1973 to 1998, there were 34 infant walker-related deaths, mainly from falls down the stairs. This review reports that walkers do not help infants learn to walk and can in fact delay normal development. Due to the high risk of injury, the AAP recommends a ban on the manufacture and sale of mobile infant walkers. If parents are determined to use them, they must meet the American Society for Testing and Materials standards. |
III
B |
Leduc S, Maurice P. Testimony of the Institut National de Santé Publique du Québec to the Board of Review Inquiring into the Nature and Characteristics of Baby Walkers. October 2006; pp. 1-9.
INSPQ |
Subjects: Children
Design: Review
Based on a recommendation from Health Canada, “the Governor in Council issued an Order under section 6 of the Hazardous Products Act that prohibited the advertising, sale and importation of baby walkers”. This is a review of that ban in light of the current literature. |
This review states that baby walkers are dangerous products and should not be sold or used. The authors report that they increase the risk of serious injury or death and also potentially delay psychomotor development. Not only are baby walkers dangerous but they can give parents a false sense of security when their infants are in them. The conclusion of the review is that the ban of April 7, 2004 must be maintained. |
III
A
|
Canadian Pediatric Society and the Canadian Academy of Sport Medicine. Trampoline use in homes and playgrounds. Paediatric & Child Health 2007;12(6):501-505.
PubMed |
Subjects: Children
Design: Position statement
A literature review was performed using the MEDLINE database from 1966 to 2006. Canadian injury data were provided by the Public Health Agency of Canada. |
This statement reviews the incidence, type and circumstance of injuries sustained as a result of using a home trampoline as well as the disposition of children after the injury. Trampoline injuries occur most frequently in children 5 to 14 years old. Fractures of the upper extremities are the most common injuries. This statement advised that trampolines should not be used for recreational purposes at home by children or adolescents. |
III |
|
Sleep position/bed sharing/room sharing
Strength of Recommendation = Good |
| Reference |
Methods |
Outcomes |
Evidence |
Canadian Pediatric Society. Recommendations for safe sleeping environments for infants and children. Paediatric & Child Health. 2004; 9(9): 659-663.
PubMed |
Subjects: Infants and young children
Design: Position statement
Reviewed the available scientific literature on the safety of various sleeping environments for infants and children. Gives recommendations for physicians  to counsel parents and caregivers. |
A few well-designed case-control studies and some case series were found. The case-control studies were large and population-based and conducted in several different countries. The studies reviewed in this CPS statement concluded that 1) prone sleeping and exposure to tobacco products are potential risk factors for SIDS; 2)“When infants sleep in their own crib, they are significantly safer than when they bed share.â€; and 3) a sudden change in sleeping pattern is associated with the highest risk of sudden death. |
III
A |
American Academy of Pediatrics. The changing concept of sudden infant death syndrome: diagnostic coding shifts, controversies regarding the sleeping environment, and new variable to consider in reducing risk. Pediatrics. 2005; 116: 1245-1255.
PubMed |
Subjects: Infants and young children
Design: Policy statement
Review of the current literature to update the previous AAP policy on SIDS from 2000. Certain topics that were not changed were left out of this statement. |
The AAP statement reports the following: 1) Placing the infant on their back to sleep is recommended; 2) the side position is no longer an alternative to prone position as it is associated with increased risk of SIDS; 3) Room sharing is associated with reduced risk while soft bedding is associated with increased risk of SIDS; 4) There is some evidence that pacifier use has a protective effect against SIDS; 5) The protective effect of breastfeeding on SIDS is inconclusive;6) It is important to recognize many risk factors for SIDS, not just prone sleeping position. |
III
A |
Vennemann MM, Bajanowski T, Brinkmann B, Jorch G, Sauerland C, Mitchell EA and the GeSID Study Group. Sleep environment risk factors for sudden infant death syndrome: The German sudden infant death syndrome study. Pediatrics. 2009; 123: 1162-1170
PubMed |
Subjects: Infants
Design: Population-based case-control study
Cases of SIDS (n=333) were collected from 1998 to 2001 from all over Germany. Controls (n=998) were matched for age, region, gender and sleep time and recruited from the same vital registry as the cases. |
This case-control study found that the  risk of SIDS is significantly higher when the infant’s last sleep was not in the parental home as well as when he/she is sleeping in the living room compared to the parents’ bedroom. They also found that sleeping prone, bed sharing, sleeping prone on sheepskin and duvets are associated with increased risk of SIDS. This study supports the statement from  the AAP and their recommendations for safe sleeping environments. Novel risk factors include sleeping outside the parents’ home, sleeping in the living room, and sleeping prone on sheepskin (high risk). |
II-2
A |
|
Positional plagiocephaly
|
Canadian Pediatric Society Statement Update. Positional plagiocephaly and sleep positioning: An update to the joint statement on sudden infant death syndrome. Paediatric & Child Health. 2001;6(10): 788-789.
PubMed |
Subjects: Infants
Design: Policy statement
Since the Back to Sleep campaign, there have been a few reports of an increased incidence of positional plagiocephaly. Positional plagiocephaly can occur if the infant consistently sleeps with their head in the same position. |
This policy statement reports that plagiocephaly can be prevented by ensuring that infants have supervised tummy time during the day (while awake), and by placing infants’ heads in different positions for sleep. |
III
A |
Persing J, James H, Swanson J, Kattwinkel J, Committee on Practice and Ambulatory Medicine, Section on Plastic Surgery and Section on Neurological Surgery. Prevention and Management of Positional Skull Deformities in Infants. Pediatrics. 2003; 112: 199-202.
PubMed |
Subjects: Infants
Design: Clinical report
This statement provides guidelines for the prevention, diagnosis and management of positional skull deformities in normal healthy infants. |
An increased incidence of positional plagiocephaly was observed from 1992 to 1994 which led to the AAP recommendation that all healthy infants be placed on their backs to sleep (i.e., the Back to Sleep campaign). The report states that the potential risk of plagiocephaly is outweighed by the reduced risk of SIDS from sleeping in the supine position (SIDS rates decreased more than 40% after the initiation of the Back to Sleep campaign). Finally, the authors report that while the infant is awake, there should be supervised tummy time and alternate head positioning during sleep. |
III
A |
|
Crib Safety
Strength of Recommendation = Good |
Moon RY, Kotch L, Aird L. State child care regulations regarding infant sleep environment since the healthy child care America-Back to Sleep campaign. Pediatrics. 2006; 118: 73-83.
PubMed |
Subjects: Infants
Design: Review
Reviewed the regulations in 50 states pertaining to SIDS, infant sleep position, crib safety, bedding safety, smoking and provision of information about sleep positioning policies and arrangements to parents before the infant is enrolled in child care. |
Eighty-one out of 101 state regulations have ≥ 1 crib safety standard. The review reports that the most common regulations pertain to the distance between slates and the firmness and fit of the mattress. The AAP recommends the use of cribs, bassinets or cradles that conform to the safety standards of the Consumer Product Safety Commission. |
III
A |
|
Firearm safety/removal
Strength of Recommendation = Good |
| Reference |
Methods |
Outcomes |
Evidence |
Canadian Pediatric Society. Youth and firearms in Canada. Paediatric & Child health. 2005; 10(8): 473-477.
PubMed |
Subjects: Children
Design: Policy statement
Reviewed the literature on youth and firearm safety from Canada and the United States. Mainly focuses on older children and adolescents, however there have been incidents involving children as young as 3 years old. |
The CPS statement reports that the presence of a firearm in the home increases the risk of domestic homicide, suicide and unintentional injury as compared to homes without a firearm and that non-powder firearms are also dangerous, especially for younger children. The Canadian Firearms Act states that firearms in the home have to be stored unloaded, in a locked container, separate from ammunition. The CPS strongly recommends removing firearms from the homes of depressed, potentially suicidal adolescents. Education programs for children have shown no benefit in preventing injury and death. |
III
A |
American Academy of Pediatrics Committee on Injury and Poison prevention. Firearm-related injuries affecting the pediatric population. Pediatrics. 2000; 105(4): 888-895.
PubMed |
Subjects: Children
Design: Position statement
Reviewed the literature on firearm-related injuries in children. Gives recommendations for possible interventions. |
Unintentional shootings account for 24% of firearm-related injuries in children <5 years old. The AAP recommends that the best prevention strategy is the absence of guns in the home. The statement reports that the high rate of firearm injury is most likely due to the ease of obtaining a gun in the U.S. compared to other industrialized countries. Educational interventions for children have been proven ineffective in preventing injury |
III
A |
Laraque D, and the Committee on Injury, Violence and Poison Prevention. American Academy of Pediatrics. Injury risk of nonpowder guns. Pediatrics. 2004; 114: 1357-1361.
PubMed |
Subjects: Children and adolescents
Design: Technical report review
Review of the literature on non-powder guns which include BB guns, pellet guns, air rifles and paintball guns. Launched projectiles can be made of lead, copper, brass, steel or paint. |
From 1990 to 2000, 32 deaths occurred in children <15 years old. Overall, non-powder guns are associated with serious injury, permanent disability and death. They are weapons and should never be characterized as toys. This review reports that injuries resulting from these guns should receive medical attention similar to firearm-related injuries. |
III
A |
|
Safety Info
|
| Reference |
Methods |
Outcomes |
Evidence |
Safe Kids Canada 2008.
Safe Kids Canada |
This website is a good reference to check up-to-date guidelines for basic injury prevention for infants and young children. The website provides information about public policy and advocacy from the municipal to the national level. |
|
Gardner HG and the Committee on Injury, Violence, and Poison Prevention. Office-based counselling for unintentional injury prevention. Pediatrics. 2007; 119: 202-206.
PubMed |
Subjects: 0 to 18 years old
Design: Clinical report
Reviews topics for office-based counselling. Topics covered are: traffic safety, burn prevention, fall prevention, choking prevention, drowning prevention, safe sleep environments, CPR, poison control and firearm safety. |
This clinical report gives recommendations for physicians to advise parents and children about unintentional injury risk and prevention which are consistent with AAP and CPS policy statements on these topics. Separate recommendations are given for different ages (i.e., infants, preschool-aged children, school-aged children, and adolescents). This is a consensus document put together by experts in the field of injury prevention. |
|
|
Shaken Baby Syndrome
|
| Reference |
Methods |
Outcomes |
Evidence |
Canadian Pediatric Society. Joint statement on shaken baby syndrome. Paediatr Child Health 2001;6(9):663-7
PubMed |
Subjects: Infants
Design: Position statement
Review of the evidence on shaken baby syndrome to inform the community and develop effective preventive strategies. |
Shaken baby syndrome is a condition that occurs in young infants when they are shaken violently by a parent or caregiver. The main injury is usually impact trauma to the head. The CPS states that the main preventive strategy is to disseminate information to the community to “Never shake a baby!”as well as to provide resources to parents who are angry or frustrated because of an infant’s crying or behaviour. |
III
A |
|
Night waking
Strength of Recommendation = Good |
| Reference |
Methods |
Outcomes |
Evidence |
Symon BG, Marley JE, Martin AJ, Norman ER. Effect of a consultation teaching behaviour modification on sleep performance in infants: A randomized controlled trial. MJA 2005; 182(5): 215-218.
PubMed |
Subjects: Infants
Design: RCT
Families with newborn infants were randomized to a control group or an intervention group consisting of a consultation with a nurse 2 to 3 weeks after birth. The consultation included a tutorial discussion on normal sleep patterns as well as related written material. |
Out of 1,001 families contacted, 346 were randomized to the control or intervention groups and 268 were included in the statistical analysis (i.e., reached 6- or 12-week follow-up). The intervention group had greater mean total hours of sleep, hours of night sleep and hours of daytime sleep per 24hour period, both at 6 and 12 weeks. The study found that a single consultation 2 to 3 weeks after a child’s birth can significantly improve a child’s sleep performance, and this effect is maintained at 3 months of age. |
I
A |
|
Swaddling
|
| Reference |
Methods |
Outcomes |
Evidence |
van Sleuwen BE, Engelberts AC, Boere-Boonekamp MM, Kuis W, Schulpen TWJ, L’hoir MP. Swaddling: A Systematic Review. Pediatrics. 2007; 120: e1097-e1106.
PubMed |
Subjects: Infants
Design: Systematic review
Performed an electronic search of PubMed, PsycINFO, Embase, Cochrane Library and Blackwell Synergy. The articles looked at 10 topics associated with swaddling: sleep and arousal, temperature control, motor development, SIDS, rickets and developmental dysplasia of the hip (DDH), respiratory infections, pain control, crying behaviour, breastfeeding as well as swaddling start and duration. |
Seventy-eight articles, including 9 RCTs, met the inclusion criteria. The review reports that there are potential benefits and harms of swaddling. Healthy infants have less startles, less arousals and longer sleep when swaddled. Swaddling can also benefit preterm infants, decrease crying and does not negatively impact breastfeeding. Potential harms include an increased risk for DDH, SIDS (when infant placed prone), and overheating. Because of the potential benefits and harms, the authors did not reach conclusions regarding recommendations for swaddling. |
I
C
|
Gerard CM, Harris KA, Thach BT. Spontaneous arousals in supine infants while swaddled and unswaddled during rapid eye movement and quiet sleep. Pediatrics. 2002; 110(6):e70.
PubMed |
Subjects: Infants
Design: Non-randomized cross-over controlled trial
Infants were observed during nap times in alternate swaddled and unswaddled (left in a free state) conditions. Behavioural cues determined whether the infant was in REM or quiet sleep (QS). |
Outcomes were sighs, startles and full arousals. This study found that swaddling had a significant effect in preventing the progression of arousals in QS. It also decreased spontaneous arousals in QS and increased duration of REM sleep. The study reports that this could potentially help the baby return to sleep without parent intervention and that a safe form of swaddling (allowing for hip flexion and chest wall excursion) may be beneficial. |
II-1
C |
|
Discipline/Parenting education programs/Parenting skills
Strength of Recommendation = Fair |
| Reference |
Methods |
Outcomes |
Evidence |
Canadian Pediatric Society. Effective discipline for children. Paediatric & Child Health. 2004; 9(1): 37-41.
PubMed |
Subjects: Children
Design: Position statement
Review of evidence for effective discipline of children, role of the physician, developmental considerations, forms of discipline, setting rules and applying consequences. |
The CPS recommends that physicians should ask non-judgmentally about discipline techniques used in the home and should counsel parents on forms appropriate to the child’s developmental level. Discipline is about changing behaviour and not punishing the child. Spanking and other forms of physical punishment are associated with negative child outcomes therefore the CPS strongly discourages spanking. |
III
B |
|
Discipline/Parenting education programs/Parenting skills
Strength of Recommendation = Fair |
| Reference |
Methods |
Outcomes |
Evidence |
Jones K, Daley D, Hutchings J, Bywater T, Eames C. Efficacy of the Incredible Years programme as an early intervention for children with conduct problems and ADHD: long-term follow-up. Child: care, health and development. 2008;34(3):380-390.
PubMed |
Subjects: 3 to 5 years old
Design: RCT
Participants for this study were drawn from an existing sample of 133 families from an on-going RCT, 79 were eligible for inclusion. Fifty were randomized into intervention and 29 into control group. The intervention received the Incredible Years parenting programme (a 2-hour session once a week for 12 weeks) |
In the short-term, mean scores on the Conners rating scale decreased from 20.56 to 14.6. 52% of children in the intervention group showed improvements compared to 21% in the control group. These results remained stable over time. There was a significant reduction in ADHD symptoms at post-intervention assessment. Intervention gains were maintained for at least a year after the programme’s completion. According to the authors, these results show good potential for the Incredible Years Parenting Program. |
I
B |
Fergusson D, Stanley L, Horwood J. Preliminary data on the efficacy of the Incredible Years Basic Parent Programme (IYBPP) in New Zealand. Australian and New Zealand Journal of Psychiatry 2009; 43:76-79.
PubMed |
Subjects: 2½ to 8 years old
Design: Non-randomized controlled trial
Participants attended IYBPP session. Data was gathered from parents using self-completed questionnaires. Outcomes included pre-test-post-test comparisons and parental satisfaction. |
Based on preliminary data (from agency records rather than based on a systematic research design) the results of the pre-test-post-test comparisons are positive. There was significant improvement in test scores at post-test assessment. Effect sizes were in the range of moderate to large. Parents’ responses to the program were positive overall. This study found that there seem to be improvements in scores after a minimum of 9 sessions of the IYBPP. A more rigorous evaluation of the IYBPP is needed. |
II-1
B |
Melhuish E, Belsky J, Leyland AH, Barnes J, and the National Evaluation of Sure Start Research Team. Effects of fully-established Sure Start Local Programmes on 3-year-old children and their families living in England: a quasi-experimental observational study. Lancet 2008;372 :1641-1647.
PubMed |
Subjects: 3 years old
Design: Quasi-randomized controlled trial
Children were randomly selected from the Millennium Cohort study and compared to controls. All participants were from low socioeconomic status (SES) families. The authors looked at 14 outcomes. |
In this trial, five of the 14 outcomes showed beneficial effects of the SSLP intervention: better social development, more positive social behaviour, greater independence, less negative parenting and a better home-learning environment. Overall, children in the intervention group had more benefits than those in the control group. This study showed the effects of SSLP to be positive with no adverse effects. According to this study, early interventions may improve the life course of many children living in low SES families. |
II-1
B |
Minkovitz CS, Hughart N, Strobino D, Scharfstein D, Grason H, Hou W, et al. A practice-based intervention to enhance quality of care in the first 3 years of life: the Healthy Steps for Young Children Program. JAMA 2003;290(23):3081-91.
http://www.ncbi.nlm.nih.gov/pubmed/14679271 |
Subjects: 0 to 3 years old
Design: Prospective controlled clinical trial
Children enrolled at birth and followed up until 3 years old. There were 6 randomization sites and 9 quasi-randomized sites (pediatric practices) across the US. The intervention (Healthy Steps Program) included incorporating developmental specialists and enhanced developmental services into pediatric care. The control group was given standard pediatric care. |
In total 5565 families were enrolled, 88% completed interviews at 2 to 4 months and 67.2% completed interviews at 30 and 33 months. There were 4 main domains to determine quality care: effectiveness, patient-centeredness, timeliness and efficiency. Measures included: discussing more than 6 anticipatory guidance topics, being highly satisfied with care provided, receiving timely well-child visits and vaccinations and remaining at the practice for 20 months or longer. Overall, families that participated in the Healthy Steps Program had greater odds of receiving 4 or more Healthy Steps related services compared to controls. Parenting skills also improved with reduced odds of severe discipline (slapping or spanking with object). Possible limitations are that parents that completed the 30 to 33 month interview were more socially advantaged than the average enrolled population. This would lead to an overestimation if families lost to follow up would require more intensive interventions. |
II-1
B |
Barlow J, Stewart-Brown D. Behaviour problems and group-based parent education programs. J Dev Behav Pediatr 2000;(21)5:356-70.
http://www.ncbi.nlm.nih.gov/pubmed/11064964 |
Subjects: 3 to 10 years old
Design: Review article
An electronic review of the literature was performed from 1970 to 1997. Inclusion criteria for studies included: randomized trials, study participants from age 3 to 10, the intervention had to include at least one group-based parent education program and at least one standardized child behaviour outcome measures (parent report or independent observation). |
A total of 255 primary studies were retrieved but only 16 studies met the inclusion criteria. Six of the 16 studies used rigorous methods for randomization, whereas several other studies were methodologically flawed. Examples of the types of programs studied were verbal instruction with manual or pamphlet supplementation and Webster-Stratton’s video-tape modelling. Of the five studies that used parent report to determine effect sizes, all programs showed a positive change in parent perception of child behaviour. Group-based programs produced better results than individual or self-administered programs. All studies but one showed long term beneficial effects of programs on children’s behaviour. |
III
B |
|
Parental/Family issues – High risk infants/Assess home visit need
Strength of Recommendation = Good |
| Reference |
Methods |
Outcomes |
Evidence |
Canadian Pediatric Society. Psychosocial Paediatrics Committee. Maternal depression and child development. Paediatr Child Health 2004;9(8):575-583.
PubMed |
Subjects: Mothers and children
Design: Position statement
Review of the current knowledge and literature on the consequences of maternal depression on children. Performed a literature search on MEDLINE over the past 15 years. Included mainly longitudinal prospective cohort studies. |
There is a negative impact of maternal depression on a child’s cognitive development. The CPS suggests screening for postpartum depression at 2-, 6- and 12-month well-baby care visits. There is fair evidence against routine testing for maternal depression, however, it is strongly suggested that physicians maintain a high degree of clinical suspicion for depression among their patients. The CPS also recommends that patients with symptoms should be referred to psychiatric services. |
III
A |
Fetal alcohol spectrum disorder
|
| Reference |
Methods |
Outcomes |
Evidence |
Chudley AE, Conry J, Cook JL, Loock C, Rosales T, LeBlanc N. Fetal alcohol spectrum disorder: Canadian guidelines for diagnosis. CMAJ 2005; 172(5 suppl):S1-S21.
PubMed |
Subjects: Children
Design: Review
Reviews the epidemiology, risk factors, diagnosis, screening and referral practices for FASD. |
This review provides recommendations for screening and referral, the physical examination and differential diagnosis, growth and facial features, neurobehavioral assessment, treatment and follow-up, maternal alcohol history in pregnancy and diagnostic criteria for FAS, partial FAS and ARND for physicians to counsel mothers and their partners on the risks and treatment of FASD. |
III
A |
Benz J, Rasmussen C, Andrew G. Diagnosing fetal alcohol spectrum disorder: History, challenges and future directions.
Paediatr Child Health Vol 14 No 4 April 2009
Paediatrics & Child Health |
Subjects: Mothers and Infants
Design: Review
Reviews the history of fetal alcohol spectrum disorders and discusses future directions and implications of diagnostic strategies. |
The clinical use of the term fetal alcohol effects (FAE) has been abandoned for the umbrella term fetal alcohol spectrum disorder (FASD). There were 5 separated classes of prenatal alcohol effects determined by the US Institute of Medicine (IOM). In 1999, a 4-digit code was developed to enhance accuracy and clarity of diagnosis which was updated in 2004. Canadian guidelines recommend assessment pre- or post-natal growth against appropriate norms and controlling for confounding variables. This review reports that evaluation of cognitive performance along with prenatal and postnatal factors is required to make an FASD diagnosis. |
III
A |
|
Parental/Family issues – High risk infants/Assess home visit need
Strength of Recommendation = Good |
| Reference |
Methods |
Outcomes |
Evidence |
MacMillan HL and the Canadian Task Force on Preventive Health Care. Preventive health care, 2000 update: prevention of child maltreatment. CMAJ 2000;163(11):1451-1458.
PubMed |
Subjects: Children
Design: Review
Review of the evidence for the effectiveness of interventions to prevent child maltreatment. Searched MEDLINE, PSYCINFO, ERIC etc. and consulted experts. |
The review reports that the harms of screening for child maltreatment outweigh its potential benefits because of the high rate of false positives. Two RCTs showed reduced child maltreatment with nurse home-visiting interventions from pregnancy to age 2 in high-risk mothers. There is good evidence to recommend nurse home-visits to target high-risk mothers (i.e., less than 19 years old, unmarried and of low socioeconomic status). There is insufficient evidence to recommend education programs for the prevention of sexual abuse. |
III
A |
American Academy of Pediatrics. The role of home-visitation programs in improving health outcomes for children and families. Pediatrics 1998;101(3):486-489.
PubMed |
Subjects: Children
Design: Review
Reviews the current research on home-visitation programs and gives recommendations for the role of physicians in supporting home-visitation programs and identifying children at high-risk. |
The review reports that some long-term effects of home visitation programs include: decrease in use of welfare, decrease in verified incidents of child abuse and neglect, fewer subsequent pregnancies, reduced maternal criminal behaviour. The beneficial effects of home-visitation programs are seen in high-risk children/families (i.e. mothers who are teenagers, unmarried, poor or having a history of abuse and preterm and low birth weight babies). |
III
A |
MacMillan HL, Thomas BH, Walsh CA, Boyle MH, Shannon HS, Gafni A. Effectiveness of home visitation by public-health nurses in prevention of the recurrence of child physical abuse and neglect: a randomized controlled trial. Lancet 2005; 365 : 1786-1793.
PubMed |
Subjects: Families
Design: RCT
Enrolled 163 families with a history of at least one child being exposed to physical abuse or neglect. The control group received the standard of care, which included routine follow-up by CPA (child protection agency) caseworkers. The intervention group was treated with the standard of care and a program of home visitation by nurses. |
Incidents of physical abuse and neglect were measured by CPA records and hospital records. There was no difference in the recurrence of physical abuse and neglect between the control and intervention groups using CPA records. However, hospital records showed a significantly higher recurrence of physical abuse or neglect among the intervention group. One possible explanation for this is potential ascertainment bias when nurses visited the homes of the intervention group. This study failed to show positive results for an intervention to reduce recurrence of physical abuse or neglect. This study underlines the importance of initiating prevention strategies against child maltreatment before a pattern of abuse can be established in the family. |
I
A |
Zielinki DS, Eckenrode J, Olds DL. Nurse home visitation and the prevention of child maltreatment: Impact on the timing of official reports. Development and Psychopathology 2009; 21: 441-453.
PubMed |
Subjects: Mothers with at least one risk factor
Design: RCT
Families were randomized into a control group and an intervention group that had nurse home-visits from the onset of the mother’s pregnancy until the child was 2 years of age. Participants were followed for 15 years. Outcome ascertainment was measured using Child Protective Services official reports. |
In the intervention group, 76% of children “survived” until the age of 15 without a CPS report compared to 68% of children in the comparison group. Intervention and control groups were similar until ages 5 to 6. After age 6 the two curves separated and a significant difference was seen in the intervention and comparison group. The control group continued to generate new reports of maltreatment until children were age 15, while there were practically none in the intervention group. This study found that home-visits have an effect on the onset of child maltreatment. This study also supports the current evidence that the Nurse Family Partnership, a program to reduce child maltreatment in high-risk families can be successful. |
I
A |
|
Non parental child care
Strength of Recommendation = Fair |
| Reference |
Methods |
Outcomes |
Evidence |
NICHD Early Child Care Research Network. Child-care effect sizes for the NICHD study of early child care and youth development. Am Psychol 2006;61(2):99-116.
http://www.ncbi.nlm.nih.gov/pubmed/16478355 |
Subjects: 6 to 36 months old
Design: Cohort study
Early Child Care Research Network started in 1991 and followed children from birth independent of parents’ decision for child care. The objective of this study was to look at exclusive maternal care versus non parental child care. For children in child-care, type, quality and quantity of child-care were measured. |
In this study, higher quality care was related to advanced cognitive, language and pre-academic outcomes at every age (15, 24, 36 and 54 months). Exclusive maternal care was not predictive of any child outcomes. Better socio-emotional and peer outcomes were seen at some ages. Generally, higher quality care is correlated with better behavioural outcomes and higher income level of the families. In terms of quantity of child care, the evidence is weak and inconsistent. |
II-2
B |
NICHD Early Child Care Research Network. Child Outcomes when child care center classes meet recommended standards for quality. Am J Public Health 1999;89:1072-7.
http://www.ncbi.nlm.nih.gov/pubmed/10394318 |
Subjects: 6 to 36 months old
Design: Cohort study
Early Child Care Research Network started in 1991 and followed children from birth independent of parents’ decision for child care. The objective was to determine the outcomes of children who attended child care centres that meet recommended care standards. |
The total sample size of this study was 1526. 1364 (89%) completed a 1 month visit, out of those 1216 (89%) continued to 36 months. The measures for quality of non parental child care were: child-staff ratio, observed group size, caregiver training and caregiver education. The average child-staff ratio and average group size was higher than recommended at ages 6, 15 and 24 months. At 36 months the ratio and group size were approximately equal to the recommended numbers. Caregiver training and education were at recommended levels at all 4 ages. Fewer behaviour problems, higher school readiness and language comprehension scores were reported in children that attended classes that met more of the recommended standards. |
II-2
B |
American Academy of Pediatrics. Quality early education and child care from birth to Kindergarten. Pediatrics 2005; 115: 187-191.
PubMed |
Subjects: <5 years old
Design: Policy statement
Review and recommendations written by expert committee. No definitive methods section. |
The AAP reports that it is important for early education and child care to be of high quality. Given its limited availability, the AAP recommends that physicians should work with parents and the community to facilitate access to the best child care possible. Evidence shows that high quality (i.e., developmentally sound and emotionally supportive) early education has a positive effect on both the child and their family. The AAP recommends that physicians are encouraged to ask families about their child care situation. |
III |
Canadian Pediatric Society. Health implications of children in child care centres. Part A: Canadian trends in child care, behaviour and developmental outcomes. Paediatr Child Health 2008 13(10): 863-867.
PubMed |
Subjects: <5 years old
Design: Position statement
Searched MEDLINE (1950 to Aug. 2008), EMBASE (1988 to Aug. 2008), PsycInfo (1985 to 2008) and Cochrane Reviews. Keywords: day care, child day care centres AND child development or cost analysis or health care costs. |
Most child care studies are longitudinal or cross-sectional. Randomization and blinding are hard to achieve in child care research, lowering the quality of RCTs. Also, it is difficult to control for confounding variables. Quality of child care is optimized when keeping with AAP-recommended ratios of staff to children (strength of recommendation A). Low child to caregiver ratios have been associated with high cognitive and language scores. |
III
A |
Zoritch B, Roberts I, Oakley A. Day care for pre-school children. Cochrane Database of Systematic Reviews 2000, Issue 3:CD000564
http://www.ncbi.nlm.nih.gov/pubmed/10796726 |
Subjects: 0 to 5 years old
Design: Systematic Review
An extensive literature review was performed using 7 electronic databases (i.e., Medline, Embase, etc.)Eligibility criteria for inclusion in the review: trials had to be randomized or quasi-randomized. Intervention was non parental day-care for pre-school education. |
This review looks at the relation between non parental child-care and various outcomes. A total of 8 trials were found with a total of 2203 children randomized to receive day care or be in the control group. Length of follow-up ranged from 6 months to 27 years. Authors concluded that out of home day-care is beneficial in important areas of children’s well-being such as enhancing cognitive development and preventing later school failure. Authors also concluded that it is beneficial for children’s behaviour. This review was methodologically rigorous in their inclusion criteria and assessed the possibility for bias. They concluded that there is potential for some interview bias in certain studies included. |
I
A |
Canadian Pediatric Society. Well Beings: A Guide to Health in Child Care.
Well Beings Online |
This book provides information on the daily care, health and safety of children from birth to preschool. It is an excellent resource for child care centers, agencies, home-based providers and public-health professionals. |
|
|
Second-hand smoke
Strength of Recommendation = Good |
| Reference |
Methods |
Outcomes |
Evidence |
American Academy of Pediatrics Committee on Environmental Health. Environmental tobacco smoke: A hazard to children. Pediatrics 1997; 99: 639-642.
PubMed |
Subjects: Children
Design: Policy statement
Review of epidemiological studies on the association between environmental tobacco smoke (ETS) and respiratory infections in children and infants. |
Studies were found that evaluated the effects of ETS on lower respiratory infections, middle ear effusions, asthma, SIDS, lipid profiles and cancer. The statement reports that there is strong evidence that exposure to ETS is associated with an increased risk of lower respiratory infections, middle ear effusions, SIDS and asthma. The AAP recommends that physicians should counsel parents against the hazards of second-hand smoke. |
III
A |
Kwok MK, Schooling CM, Ho LM, Leung SS, Mak KH, McGhee SM, Lam TH, Leung GM. Early life second-hand smoke exposure and serious evidence from Hong Kong’s “Children of 1997” birth cohort. Tobacco Control 2008;17:263-270.
PubMed |
Subjects: 0 to 8 years old
Design: Prospective,
population-based cohort study
Using data from the 1997 birth cohort from April and May in Hong Kong, investigators followed up with infants and parents at 3, 9 and 18 months. Based on self-reported smoking data, families were classified as no exposure, smoking more than 3 meters and less than 3 meters away from the child. |
In this study, second-hand smoke exposure less than 3 meters away from the infant was associated with the highest risk of admission for infectious illness (hazard ratio 1.14, 95% CI: 1.00-1.31). This association was strongest for infants 0 to 6 months years old. Exposure of infants to second-hand smoke within 3 meters increased their risk of serious illness, both respiratory and other infections. This study also showed that young infants (<6 months) as well as low birth weight and preterm infants are at high risk. |
II-2
A |
DiFranza JR, Aligne CA, Weitzman M. Prenatal and postnatal environmental tobacco smoke exposure and children’s health. Pediatrics 2004;113:1007-1015.
PubMed |
Subjects: Children
Design: Review
Reviewed the literature for the most up-to-date data on environmental tobacco smoke (ETS) and the effects on infants and children. |
Studies since 1967 suggest that ETS exposure is associated with decreased lung growth, respiratory tract infection, asthma, otitis media, SIDS, neurocognitive decrements and behavioural problems. This review reported that the greatest risk of adverse health effects occurs during pregnancy and the first few years of life; there is a potential causal relationship between maternal smoking and SIDS; the risk of hospitalization for respiratory illness is greatest in the first 6 months of life. |
III
A |
|
No OTC cough/cold medication
Strength of Recommendation = Good |
| Reference |
Methods |
Outcomes |
Evidence |
Health Canada’s Decision on Cough and Cold Medicines. Information December 2008.
Full Text at Health Canada |
Subjects: 0 to 12 years old
Design: Information update
After reviewing the evidence supporting the effectiveness of over-the-counter (OTC) cough and cold medicines in children, it was determined that these medicines do not work the same in children as in adults. |
According to this report, children <2 years old are most vulnerable to the adverse side-effects of OTCs. Lower weight children aged 2 to 6 years old are also at risk. Younger children are less able to communicate any adverse side-effects therefore are at heightened risk. According to Health Canada, certain cough and cold medicines should not be used in children <6 years old. Reports of misuse, overdosing and serious side-effects prompted the Health Canada advisory. |
III
A |
Sharfstein JM, North M. Over the counter but not longer under the radar- pediatric cough and cold medications. New England Journal of Medicine. 2007; 357:2321-2324.
PubMed |
Subjects: 0 to 12 years old
Design: Review
Article describing the most recent actions of an advisory committee looking at over-the-counter cough and cold medicine use in children. |
Six RCTs have been done since 1985 on cough and cold medication efficacy in children <12 years old. The review reported that there have been no meaningful differences found between active drugs and placebo. The committee voted in favour of immediate action against the use of cough and cold medication in children <6 years old. According to this review, cough and cold medication should not be used to sedate a child. |
III
A |
Rimsza ME, Newberry S. Unexpected infant deaths associated with use of cough and cold medications. Pediatrics 2008;122:e318-e322.
PubMed |
Subjects: 0 to 10 months old
Design: Case review
The Arizona Child Fatality database was reviewed for cases of infants who died unexpectedly in 2006. Post-mortem and toxicology reports were then reviewed. |
Ten infants died unexpectedly in Arizona in 2006. They were between 17 days and 10 months of age. All of the cases had apparent cough and cold medications in their blood. Nine out of 10 of the parents did not seek physician counsel prior to administering the medication. The authors report that OTC cough and cold medications should not be given to children <6 years old and that education campaigns are needed to inform parents |
II-3
A |
Dart RC, Paul IM, Bond GR, Winston DC, Manoguerra AS, Palmer RB, Kauffman RE, Banner W, Green JL, Rumack BH. Pediatric fatalities associated with over the counter cough and cold medications. Ann Emerg Med. 2009;53:411-417.
PubMed |
Subjects: 0 to 12 years old
Design: Case review article
A panel of 8 experts reviewed all fatalities gathered from 5 different sources to assess a causal relationship between the ingestion of cough and cold medication (CCM) and deaths in children <12 years old. Other inclusion criteria included U.S. residence, and use of 1 or more of 8 CCMs. |
Out of 189 cases included, the deaths of 118 were judged possibly, likely or definitely related to a CCM ingredient. The review reports that risk factors included; age <2 years old, use of CCM for the purpose of sedation, use of CCM in a day care setting, use of 2 or more CCMs with the same ingredient, no use of a measuring device, use of product intended for adult use only and product misidentification. |
III
A |
|
Inquiry on complementary/alternative medicine
Strength of Recommendation = Fair |
| Reference |
Methods |
Outcomes |
Evidence |
Canadian Pediatric Society. Children and natural health products: what a clinician should know. Paediatric & Child Health. 2005;12:227-232.
PubMed |
Subjects: Children
Design: Position statement
Reviews the literature and gives recommendations to physicians on how to advise parents interested in complementary and alternative medicine (CAM) and natural health products (NHPs). |
Many RCTs have been done looking at NHP use in the pediatric population however they are of poor methodological quality. Only 20-30% of NHPs are FDA approved for pediatric use. The CPS recommends that where possible, physicians should try and follow an evidence-based rationale for therapy and that it is important for physicians to maintain an open mind and nonjudgmental attitude towards both CAM and NHPs. |
III
B |
Canadian Pediatric Society. Homeopathy in the pediatric population. Paediatrics & Child Health. 2005;10:173-177.
Paediatrics & Child Health |
Subjects: Children
Design: Position statement
Reviewed the literature for studies on homeopathy in the pediatric population. |
Two well-designed studies were found: an RCT and a meta-analysis, conducted by the same author. Both showed a positive effect of homeopathy on diarrhea. Homeopathy is a common form of CAM. Adverse events from properly prepared medicines are uncommon. The CPS statement reports that parents who use homeopathic remedies may be resistant to vaccinating their child, which may negatively affect the child’s health. |
III
B |
Kemper KJ, Vohra S, Walls R, the Task Force on Complementary and Alternative Medicine, the Provisional Section on Complementary, Holistic and Integrative Medicine. The use of complementary and alternative medicine in pediatrics. Pediatrics. 2008;122:1374-1386.
PubMed |
Subjects: Children
Design: Clinical report
From 2000 to 2002 the AAP formed a task force to look at issues relating to CAM for children. This report gives current statistics on the frequency of use and most common types of CAM, its users and related research implications. |
More people than ever are using CAM. According to this report, users include 20 to 40% of healthy children seen in outpatient clinics and >50% of children with chronic, recurrent or incurable conditions. This report states that it is increasingly important for physicians to be “aware of the necessity to have an open, respectful relationship and clear communication with families”. The Task Force also reports that physicians can best provide good advice if they regularly ask about the CAM therapies that parents and children are using. |
III
B |
|
Counsel on Pacifier Use
Strength of Recommendation = Fair |
| Reference |
Methods |
Outcomes |
Evidence |
Canadian Pediatric Society. Recommendations for the use of pacifiers. Paediatric & Child Health 2003; 8: 515-519.
PubMed |
Subjects: Infants
Design: Policy statement
Reviewed literature on pacifier use in infants and its association with breastfeeding, otitis media, dentition, SIDS, infection and analgesic effects. Also reviewed product safety guidelines and pacifiers use in preterm infants. |
According to the CPS statement, 1) the decision to use pacifiers is the choice of the parents; 2) physicians should counsel parents on the potential benefits (reduced risk of SIDS) and potential harms (increased risk of recurrent otitis media). The CPS recommends that “Health care professionals should recognize pacifier use as a parental choice determined by the needs of their newborn, infant or child.” They also report that early pacifier use might be associated with breastfeeding difficulties and infants with recurrent otitis media should not use pacifiers. |
III
B |
Hauck FR, Omojokun OO, Siadaty MS. Do pacifiers reduce the risk of sudden infant death syndrome? A meta-analysis. Pediatrics. 2005; 116: e716.
PubMed |
Subjects: Infants
Design: Meta-analysis
Performed a systematic review of the literature by searching the MEDLINE database. All studies that met the inclusion criteria (published articles with data on the relationship between pacifier use and SIDS risk) as well as a test for homogeneity were included in the meta-analysis. |
Nine studies were found during the systematic review however only 7 of the 9 case-control studies were included in the meta-analysis due to two of the studies being heterogeneous. The meta-analysis showed a reduced risk of SIDS with pacifier use when used for sleep (OR=0.71, 95% CI: 0.59-0.85). Based on this evidence, the authors recommend that pacifiers be used for infants less than 1 year of age. This is a US Preventive Services Task Force level B strength of recommendation, meaning the beneficial effects will outweigh any potential negative effects. |
II-2
B |
Rovers MM, Numans ME, Langenbach E, Grobbee DE, Verheij TJM and Schilder AGM. Is pacifier use a risk factor for acute otitis media? A dynamic cohort study. Family Practice 2008; 25: 233–236.
PubMed |
Subjects: 0 to 4 years old
Design: Prospective cohort study (N=476)
Followed a cohort of infants from 2000 to 2005 from Leidsche Rijn, a residential area in Utrecht, The Netherlands. Parents completed a questionnaire on pacifier use at baseline and GPs diagnosed acute otitis media (AOM) events. |
The odds ratio for pacifier use and a single AOM event was 1.3 (95% CI: 0.9-1.9) and was therefore not significant. However, for recurrent AOM, the odds ratio was 1.9 (95% CI: 1.1-1.3). According to this study, pacifier use appears to be a risk factor for recurrent AOM. The authors report that physicians should counsel parents on the risks of pacifier use once their child has received their first diagnosis of AOM. |
II-2
B |
O’Connor NR, Tanabe KO, Siadaty MS, Hauck FR. Pacifiers and Breastfeeding. A Systematic review. Arch Pediatr Adolesc. 2009; 163: 378-382.
PubMed |
Subjects: Mother-infant pairs
Design: Systematic review
Performed a literature review using the databases MEDLINE, CINAHL, the Cochrane Library, EMBASE, POPLINE and bibliographies of identified articles. |
Twenty-nine studies met the inclusion criteria: 4 RCTs, 20 cohort and 5 cross-sectional studies. Due to significant heterogeneity in the studies no meta-analysis could be performed. The RCTs showed no difference in weaning between using pacifiers and controls. However, observational studies have shown a strong association. Potential limitations in both these study designs might contribute to the mixed results. For example in one RCT, there might have been a problem with compliance. |
I
A |
Kramer MS, Barr RG, Dagenais S, Yang H, Jones P, Ciofani L, Jané F. Pacifier use, early weaning and cry/fuss counselling: A randomized controlled trial. JAMA. 2001; 286: 322-326.
PubMed |
Subjects: Healthy term breastfed infants and mothers
Design: Double blinded Randomized Controlled Trial
Participants (N=281) were randomized to 1 of 2 counselling interventions. Each group was counselled by a trained research nurse. The experimental group was different than control as they were counselled to avoid pacifier use and given alternative methods to calm a crying baby. |
Early weaning (i.e., within the first 3 months) was compared between groups. Detailed behaviour logs for each infant were maintained describing the frequency and duration of crying and pacifier use at 4, 6, and 9 weeks. Analysis based on random allocation showed no effect between experimental or control groups for either early weaning or cry/fuss behaviour (OR=1.0, 95% CI: 0.6-1.7). When random allocation was ignored a strong observational association was found (RR=1.9). Follow-up was completed by 91.8% of participants. Data strongly suggest that pacifier use is a marker of breastfeeding difficulties or reduced motivation to breastfeed rather than a cause of early weaning. |
I
A |
Collins CT, Ryan P, Crowther CA, McPhee AJ, Paterson S, Hiller JE. Effect of bottles, cups and dummies on breast feeding in preterm infants: a randomized controlled trial. BMJ. 2004 doi:10.1136/bmj.38131.675914.55
PubMed |
Subjects: Preterm infants (<34 weeks)
Design: RCT
Participants were randomized to 1 of 4 groups (cup/no dummy, cup/dummy, bottle/no dummy or bottle/dummy) and used block randomization to stratify infants based on gestational weeks. |
Main outcome was the proportion of infants fully breastfeeding by time of discharge. Secondary outcomes included length of hospital stay and prevalence of breastfeeding at 3 and 6 months after discharge. In this study, there was no effect between dummy use and breast feeding at discharge or after 3 and 6 months based on intention to treat analysis. However, there was a significant effect of cup feeding on full breastfeeding at discharge (OR=1.73, 95% CI:1.04-2.88). Also, cup feeds were significantly associated with longer hospital stay. |
I
A |
|
Fever advice/thermometers
|
| Reference |
Methods |
Outcomes |
Evidence |
Canadian Pediatric Society. Temperature measurement in paediatrics.
Reference No. CP00-01
*Reaffirmed February 2009
Canadian Pediatric Society |
Subjects: Children
Design: Position statement
Examination of the current types of measurements and methods for taking a child’s temperature properly. |
The CPS recommends that 1) children <2 years old should have their temperature taken rectally to obtain accurate and reliable measurements; 2) children <5 years old should have their temperature taken with a rectal thermometer (gold standard) and that axillary or tympanic measurements could be used for screening purposes (less precise); 3) For children >5 years old the recommended technique is using an oral thermometer. The CPS reports that mercury thermometers should no longer be used. |
III
A |
Hay AD, Costelloe C, Redmond NM, Montgomery AA, Fletcher M, Hollinghurst S, Peters TJ. Paracetamol plus ibuprofen for the treatment of fever in children (PITCH): randomized controlled trial. BMJ 2008; 337:a1302.
PubMed |
Subjects: 6 months to 6 years old
Design: RCT
Participants from primary care settings and households in England were randomized to 1 of 3 intervention arms: paracetamol alone, ibuprofen alone or a combination of both. |
The outcome measures were 1) the amount of time without fever in the first 4 hours after the first dose was given and 2) the proportion of children not experiencing discomfort (i.e., normal on the discomfort scale) after 48 hours. For amount of time with fever in the first 4 hours, the combination intervention arm was more effective than paracetamol alone and as good as ibuprofen. Combination therapy also cleared fever faster than paracetamol alone but showed no difference compared to ibuprofen alone. No difference was found for discomfort or other symptoms. The authors report that physicians should recommend ibuprofen for fever reduction. |
I
A |
Erlewyn-Lajeunesse MDS, Coppens K, Hunt LP, Chinnick PJ, Davies P, Jigginson IM, Benger JR. Randomised controlled trial of combined paracetamol and ibuprofen for fever. Arch Dis Child 2006;91:414-416.
PubMed |
Subjects: 6 months to 10 years old
Design: RCT
Three arm, open label randomized trial in a Children’s ED, London, England. Participants received suspensions of paracetamol (15 mg/kg), ibuprofen (5 mg/kg) or both. |
Using an intention-to-treat analysis, a significant difference between the 3 groups was found (p=0.023). There was a difference between the combined and paracetamol treatments, but not between combined and ibuprofen treatments. The combined treatment was better at reducing fever than paracetamol alone. Although the difference was significant, the study was carried out in a paediatric emergency room therefore only one third of the patients had their temperature recorded post-dose. This RCT reports that there is not enough benefit to warrant routine use of combined therapy for rapid fever reduction. |
I
A |
Perrott DA, Piira T, Goodenough B, Champion D. Efficacy and safety of acetaminophen vs. ibuprofen for treating children’s pain or fever: a meta-analysis. Arch Pediatr Adolesc Med. 2004;158:521-526.
PubMed |
Subjects: 0 to 18 years old
Design: Meta-analysis
Searched electronic databases (MEDLINE, EMBASE, Cochrane Library, Biological Abstracts etc). Studies had to include random allocation to treatment arms and have blinded participants. |
Seventeen studies met the inclusion criteria. Primary outcomes were pain, fever and safety. Both ibuprofen and acetaminophen were equally effective for pain. Ibuprofen was superior for fever relief. There was no evidence that the drugs differed in safety. There was no difference between ibuprofen and acetaminophen for pain and safety; however, ibuprofen was superior for fever reduction, especially at 4 and 6 hours after treatment. There is no clear preference as both treatments are more effective than placebo. |
I
A |
Sarrell EM, Wielunsky E, Cohen HA. Antipyretic treatment in young children with fever: Acetaminophen, ibuprofen or both, alternating in a randomized, double-blind study. Arch Pediatr Adolesc Med. 2006;160:197-202.
PubMed |
Subjects: 6 to 36 months old
Design: RCT
Double-blinded randomized controlled trial with three parallel groups. Patients were randomized to 3 intervention groups: acetaminophen, ibuprofen and an alternating regime of both. |
Outcome measures included temperature, stress score, number of days absent from day care or work. There was a significant difference between combined and acetaminophen, as well as combined and ibuprofen treatments (all differences were statistically significant P<.001) but no difference between the mono-therapies. The alternating regimen was more effective at reducing temperature than either mono-therapy. One limitation of the combination therapy is due to the different doses of each treatment, there is potential for parental confusion and possible adverse events. |
I
A |
|
Healthy active living/Media use
|
| Reference |
Methods |
Outcomes |
Evidence |
Canadian Pediatric Society. Healthy active living for children and youth. Paediatr Child
Health 2002;7(5):339-345.
PubMed |
Subjects: 5 to 18 years old
Design: Position statement
Reviews many of the adverse effects of having a non-active and healthy lifestyle including obesity, hypertension, type 2 diabetes, osteoporosis, mental health problems and poor school performance. |
The CPS statement reports the following: 1) The prevalence of obesity has increased 3-fold from 1981 to 1996, likely due to poor diet and decreased levels of physical activity. 2) Other diseases resulting from this are type 2 diabetes, osteoporosis and hypertension in later adulthood. 3) Physicians should encourage adequate physical activity and nutrition for their patients and their parents. 4) Counselling families to reduce sedentary behaviour and participate in family physical activity is also important. |
III |
American Academy of Pediatrics Council on Sports Medicine and Fitness and Council on School Health. Active Healthy Living: Prevention of childhood obesity through increased physical activity. Pediatrics 2006;117(5):1834-1842.
PubMed |
Subjects: All ages
Design: Policy statement
Reviews evidence and strategies for physicians to encourage, monitor and advocate increased physical activity for children and adolescents. |
According to the AAP, for infants and toddlers, there is insufficient evidence to recommend exercise programs to promote increased physical activity. AAP recommends no TV watching for children <2 years old. The AAP also recommends that physicians should encourage appropriate outdoor play and activity with proper supervision for children <5 years old. As well, parents should reduce sedentary transportation (by car or stroller) and limit screen time (TV and computer) to <2 hours a day. |
III
I |
Canadian Pediatric Society. Impact of media use on children and youth. Paediatr Child Health 2003;8(5):301-306.
PubMed |
Subjects: All ages
Design: Position statement
Review of guidelines for physicians to discuss with parents about their child’s exposure to media (television, internet, radio, music and video games). |
The CPS statement reports that the negative effects of watching TV include increased violent behaviour and offensive language, and inappropriate sexuality. The CPS recommends that physicians can help to improve children’s TV viewing habits; that physicians should regularly inquire about media habits and be familiar with the types of media that their patients may be exposed to; that TV early in a child’s life should be restricted and parents should have clearly established rules; and finally, that there are also dangers to allowing a child to use the internet unsupervised. |
III |
|
Sun exposure/sunscreen/insect repellents
|
| Reference |
Methods |
Outcomes |
Evidence |
American Academy of Pediatrics Committee on Environmental Health. Ultraviolet light: A hazard to children. Pediatrics 1999; 104: 328-333.
PubMed |
Subjects: Children
Design: Review
Reviews recommendations for physicians to counsel their patients on sun exposure, appropriate use of sunscreen and effective ways to prevent skin cancer. |
There are no clinical trials on the effectiveness of sunscreen in the prevention of skin cancer. However, sunscreen does prevent the skin from burning. According to the AAP, children should be protected from intense sun exposure early in life to prevent skin cancer; children <6 months of age should not be exposed to direct sunlight and should instead be placed in the shade and/or covered by clothes; children >6 months of age should wear sunscreen that is SPF 15 or above and well rubbed into their skin. The AAP recommends that physicians should counsel parents on sun protection. |
III |
Meurer LN, Jamieson B. What is the appropriate use of sunscreen for infants and children? The Journal of Family Practice 2006;55(5):437, 440, 444.
PubMed |
Subjects: Children
Design: Clinical inquiry
An evidence-based answer to the question “What is the appropriate use of sunscreen for infants and children?” using the SORT grades of evidence. |
According to this report, infants <6 months of age should be kept out of direct sunlight or be covered to avoid sunburn and children >6 months of age should wear a liberal amount of sunscreen that is SPF 15 or above and reapplied every 2 hours, especially if swimming. |
III
B |
Canadian Paediatric Society. Insect repellents for children.
Caring for Kids |
Subjects: Children
Design: Website
General information on insect repellent use in children <6 months, 6 months to 2 years, 2 to 12 years and >12 years of age. |
According to this CPS report, 1) Children should not apply their own repellent; 2) Parents should remember to read the entire label before using. 3) Repellent should not be used on infants <6 months old; 4) Overall, the recommendations from the CPS are as follows: children <12 years old can use a product with 10% DEET; children >12 years old can use 30% DEET; children 6 months to 2 years old should use a product with no more than 10% DEET applied only once per day. |
III |
|
Pesticide Use
|
| Reference |
Methods |
Outcomes |
Evidence |
Bassil KL, Vakil C, Sanborn M, Cole DC, Kaur JS, Kerr KJ. Cancer health effects of pesticides: Systematic review. Can Fam Physician 2007;53:1704-1711.
PubMed |
Subjects: Adults and children exposed to pesticides
Design: Systematic review
Performed a search of electronic databases MEDLINE, PreMedline, CancerLit and LILACS for studies On non-Hodgkin lymphoma, leukemia and 8 solid-tumour cancers published between 1992 and 2003. Studies were reviewed by 2 trained reviewers and rated on methodologic quality according to a 5-page assessment tool. Studies rates below a score of 4 out of 7 were excluded. |
Eighty-three studies were found. Most studies on non-Hodgkin lymphoma and leukemia showed a positive association with pesticide exposure. There was an association between kidney cancer in children and parents with occupational exposure. The 8 solid-tumour cancers included: brain, breast, kidney, lung, ovarian, pancreatic, prostate and stomach cancer. This review of evidence shows an association between pesticide exposure and cancer, particularly brain, prostate, kidney and non-Hodgkin lymphoma and leukemia. Children had an increased risk of cancer during critical periods of exposure (both prenatal and postnatal) and with parental exposure at work. The authors recommend reduced exposure to all pesticides. |
I-2
B |
Ma X, Buffler PA, Gunier RB, Dahl G, Smith MT, Reinier K, Reynolds P. Critical windows of exposure to household pesticides and risk of childhood leukemia. Environmental Health Perspectives 2002;110:955-960.
PubMed |
Subjects: 0 to 14 years old
Design: Case-control study
Used the study population for the Northern California Childhood Leukemia Study (NCCLS). Matched cases with controls from the population birth registry. Exposure was the use of pest control services from 1 year before birth to 3 years after birth. |
In this study, professional pesticide use was associated with leukemia (OR=2.8, 95% CI 1.4-5.7). The highest risk of childhood leukemia was exposure to pesticides during pregnancy and also, early life exposure had higher risk than exposure in later life. Indoor pesticides were more harmful than outdoor pesticides. Also, there was higher risk with greater frequency of exposure. This study showed that the timing, location and frequency of exposure to pesticides may be associated with the risk of developing leukemia. |
II-2
B |
Buckley JD, Meadows AT, Kadin ME, Le Beau MM, Siegel S, Robison LL. Pesticide exposures in children with non-Hodgkin lymphoma. Cancer 2000;89:2315-2321.
PubMed |
Subjects: ≤20 years old
Design: Case-control study
Data from the Children’s Cancer Group. Used matched, randomly selected, regional population controls. Assessed pesticide exposure through telephone interviews with mothers. |
This study found a significant association between the risk of non-Hodgkin lymphoma (NHL) and increased frequency of pesticide use in the home. Use of professional extermination services and postnatal exposure were also significant predictors of NHL. However, due to some limitations of the study (self-report of pesticide exposure can lead to potential for recall bias), no causal trend can be determined and further investigation is warranted. |
II-2
I |
|
Lead Screening
Strength of Recommendation = Fair |
| Reference |
Methods |
Outcomes |
Evidence |
Tsekrekos SN, Buka I. Lead levels in Canadian children: Do we have to review the standard? Paediatr Child Health 2005;10(4):215-220.
PubMed |
Subjects: Children
Design: Review
Reviewed literature from searches of MEDLINE and Web of Science database using key words: Canada, child, lead poisoning, blood lead, and paediatrician. |
There has been limited surveillance for blood lead levels among children and little research on the effects of low-level lead poisoning. Neurodevelopmental damage has been seen in children with blood lead levels lower than the current standards (i.e., 0.48 μmol/L). The authors conclude that the current regulations might be inadequate to protect children against lead poisoning. The review reports that physicians should be aware of screening tools for use in high-risk children and inform parents about the symptoms of lead poisoning. |
III
B |
Lanphear BP, Dietrich K, Auinger P, Cox C. Cognitive deficits associated with blood lead concentrations <10 µg/dL in US children and adolescents. Public Health Reports 2000;115(6):521-529.
PubMed |
Subjects: 6 to 16 years old
Design: Prospective cohort study
Used data from the Third National Health and Nutrition Examination Survey (NHANES III). Assessed relationship between blood lead concentrations and performance on cognitive tests (arithmetic, reading, nonverbal reasoning, and short-term memory) |
After performing a multivariate analysis to control for potential confounders, there was an inverse relationship between blood lead concentration and scores on the 4 cognitive tests. Children were dichotomized to two groups for comparison: those with blood levels <5 and those with blood levels of 5 and over. Children with blood levels <5 µg/dL had decreased scores in reading and math. This study suggests that cognitive deficits are associated with blood lead concentrations <5 µg/dL. These findings are important given that current standards are set at 10 µg/dL. |
II-2
B |
Téllez-Rojo MM, Bellinger DC, Arroyo-Quiroz C, Lamadrid-Figueroa H, Mercado-Garcia A, Schnaas-Arrieta L, Wright RO, Hernandez-Avila M, Hu H. Longitudinal associations between blood lead concentrations lower than 10 µg/dL and neurobehavioral development in environmentally exposed children in Mexico City. Pediatrics 2006;118:e323-e330.
PubMed |
Subjects: Infants
Design: Prospective cohort study
(N=294)
Healthy mother –infants pairs were recruited from Mexican maternity hospitals. Infants were included if their blood lead levels at both 12 and 24 months of age were <10 µg/dL. Outcome measures were Bayley Scales of Infant Development II, specifically: 1) the Mental Development Index (MDI) and 2) the Psychomotor Development Index (PDI) at 12 and 24 months. |
At 12 months, there was no significant association between MDI and PDI scores and blood lead levels. At 24 months, blood lead levels were inversely associated with both MDI and PDI scores Blood lead levels at 12 months were inversely associated with PDI scores at 24 months. These relationships were not altered by adjustment for cord lead blood levels or 12-month MDI and PDI scores. Results of this study suggest that exposure to lead, even in the range of <10 µg/dL (the current screening guideline), may adversely impact the neurodevelopment of infants in a dose-dependent manner. |
II-2
B |
Bellinger DC. Very low lead exposures and children’s neurodevelopment. Current Opinion in Pediatrics 2008;20(2):172-177.
PubMed |
Subjects: Children
Design: Review
Reviewed the literature for studies that show adverse outcomes when children are exposed to blood lead levels <10µg/dL (the current screening guideline). |
Many studies have shown adverse effects, such as cognitive deficits and behavioural problems, in children with “low” blood lead levels. According to this review, there is no level of lead exposure that is considered to be safe. The authors highlight that in order to prevent exposure it is important to keep parents of young children informed of all sources of lead in their child’s environment. |
III
B |
|
Dental cleaning/fluoride
Strength of Recommendation = Good |
| Reference |
Methods |
Outcomes |
Evidence |
CDA Position on Use of Fluorides in Caries Prevention. Approved by the CDA Board of Directors November 2008
Canadian Dental Association |
Subjects: All ages
Design: Position statement
The statement is a review of the recommendations for the use of fluoride in cavity prevention. |
The CDA recommends the use of fluoridated toothpaste twice a day with a minimum amount of water for rinsing after brushing. The CDA also recommends that children <3 years old should have their teeth brushed by an adult using a minimal amount (“smear”) of toothpaste; children 3 to 6 years old should be assisted so that only a small (“pea-sized”) amount of toothpaste is used; fluoride supplements such as chewable tablets, lozenges or drops are not recommended; fluoride mouth rinsing is not recommended for children under 6 years of age. |
III
A
|
American Academy of Pediatrics Section on Pediatric Dentistry and Oral Health. Preventive oral health intervention for pediatricians. Pediatrics 2008;122:1387-1394.
PubMed |
Subjects: Children
Design: Policy statement
This statement reviews the recommendations for primary care pediatric practitioners on oral health. |
According to the AAP statement, it is important for physicians to be aware of the preventive strategies for dental caries because more infants see a physician many times before they have their first dental check-up. The AAP recommends that: physicians evaluate dental caries risk and suggest prevention strategies; oral health anticipatory guidance should be part of counselling during well-child visits. The AAP recommends that infants be scheduled for an initial oral examination within 6 months of the eruption of the first primary tooth and no later than 1 year of age. |
III
A |
Canadian Pediatric Society Nutrition Committee. The use of fluoride in infants and children. Paediatr Child Health 2002;7(8):569-72.
*Revision in progress February 2009.
Paediatrics & Child Health |
Subjects: Infants and children
Design: Position statement
Review of the evidence for the use of fluoride in infants and children. |
Fluoride is supplemented in drinking water and toothpaste. Too much fluoride can result in fluorosis. According to the CPS statement, 1) no fluoride should be given before teeth have erupted; 2) no supplemental fluoride should be given to children <6 months old; 3) only children >6 months of age should receive supplemental fluoride if they are at high-risk for caries, or if the concentration of fluoride in the drinking water is <0.3ppm, or if they do not brush their teeth twice a day. |
III
A |
Kagihara LE, Niederhauser VP, Stark M. Assessment, management, and prevention of early childhood caries. Journal of the American Academy of Nurse Practitioners 2009.21:1-10
PubMed |
Subjects: Infants and children
Design: Review
Searched MEDLINE, PubMed, AAP and American Dental Association websites. Keywords: dental caries prevention, caries process, dental home, etc. |
Dental caries is a preventable infectious disease, however, it is remains the most common chronic disease of childhood. According to this review, there has been a 15.2% increase in caries among children 2 to 5 years old. The authors report that physicians need to be informed in areas of caries risk assessment, intervention, education and referral. The review emphasizes that “The importance of early identification and intervention for infants and toddlers at high risk cannot be overestimated.” |
III
A |
Marinho VCC, Higgins JPT, Logan S, Sheiham A. Fluoride toothpastes for preventing dental caries in children and adolescents. Cochrane Database of Systematic Reviews 2003, Issue 1. Art. No.: CD002278. DOI:
10.1002/14651858.CD002278.
PubMed |
Subjects: 0 to 16 years old
Design: Systematic review and meta-analysis
Searched the Cochrane Oral Health Group’s Trials Register, The Cochrane Central Register of Controlled Trials, MEDLINE, and several other databases. |
Seventy-four studies were included in the systematic review, and 70 in the meta-analysis. The results of the review reaffirm the benefits of fluoride toothpastes in preventing caries. The authors report that “Children who brush their teeth at least once a day with toothpaste that contains fluoride will have less tooth decay.” However, as the AAP suggests, twice a day can increase the benefit. |
I
A |
|
Encourage Reading
Strength of Recommendation = Fair |
| Reference |
Methods |
Outcomes |
Evidence |
Canadian Paediatric Society. Read, speak, sing: Promoting literacy in the physician’s office. Paediatric & Child Health. 2006;11(9):601-606.
Paediatrics & Child Health |
Subjects: 0 to 18 years old
Design: Position statement
Performed a search of electronic databases MEDLINE and Psych INFO from 1995 to June 2006. Keywords: reading, literacy and illiteracy. |
Recommendations and strategies to promote reading and literacy in young children are discussed. Quantity and quality of language exposure are important. The CPS reports that book exposure among infants and toddlers promotes the development of early literacy skills. The CPS recommends that physicians should include literacy promotion in their routine clinical practice. |
III
B |
High PC, LaGasse L, Becker S, Ahlgren I, Gardner A. Literacy promotion in primary care pediatrics: can we make a difference? Pediatrics. 2000;105:927-934.
PubMed |
Subjects: 5 to 11 months old
Design: RCT
Low-income families were randomized to intervention or control groups. At baseline. The intervention group received children’s books, educational materials and advice from pediatricians about sharing books with children. Follow-up included family interviews and child language testing. A Child-Centered Literacy Orientation was defined as a stated enjoyment of reading and/or report of usual reading together at bedtime. |
At follow-up (an average of 3.4 well-child visits later; mean age 18.4 months), there was a 40% increase in Child-Centered Literacy Orientation among the intervention families compared to 16% among controls. In older intervention toddlers, receptive and expressive vocabulary scores were higher, but not for younger intervention toddlers. When reading aloud was added to a multivariate analysis, the effect of the intervention was no longer evident. The authors concluded that this simple intervention changed parental attitudes, and as they increasingly read to their children older toddlers in particular experienced enhanced language development. |
I
B |
Duursma E, Augustyn M, Zuckerman B. Reading aloud to children: the evidence.
Arch Dis Child 2008;93:554-557.
PubMed |
Subjects: Children
Design: Review
The authors compiled evidence to support parents and caregivers reading aloud to children and participating in shared book reading to promote language development. |
This review reports that children who are read to aloud from an early age tend to have higher scores on language measures later in life. Socioeconomic status, race/ethnicity and parental education are factors that can affect the development of literacy and oral language skills. The authors report that parents should take into account their child’s personal interests and physicians should encourage reading aloud. |
III
B |
Sharif I, Rieber S, Ozuah PO. Exposure to Reach Out and Read and vocabulary outcomes in inner city preschoolers. J Natl Med Assoc 2002;(94)3:171-7.
http://www.ncbi.nlm.nih.gov/pubmed/11918387 |
Subjects: 2 to 5.9 years old
Design: Cross-sectional survey
Two federally funded health centres were used as the two sites of comparison. Subjects attending clinic A had a 3 year Reach Out and Read (ROR) intervention while attendants of clinic B had no ROR exposure. The ROR program included counselling parents about reading to children and parents received an age-appropriate book at each well-child visit. |
The sample size for this study was 200 parent/child pairs with mean age of children of 3.8 years. The outcome measures were expressive and receptive one word picture vocabulary tests, a home literacy orientation scale created by the authors, and the STIMQ-READ subscale. Comparing English-speaking children, there was a statistically significant difference (p=0.01) between ROR-exposed children and controls. A positive association between the Reach Out and Read program and better receptive vocabulary scores were reported. Higher scores were also found on measures of home reading activities. Limitations of this study include the cross-sectional design’s inability to determine a causal relationship and parental reports of home reading activity may have lead to a degree of recall bias. |
II
B |
Needleman R, Toker KH, Dreyer BP, Klass P, Mendelsohn AL. Effectiveness of a primary care intervention to support reading aloud: a multicenter evaluation. Ambul Pediatr 2006;(5)4:209-215.
http://www.ncbi.nlm.nih.gov/pubmed/16026185 |
Subjects: 6 to 72 months old
Design: Before-after intervention study
19 clinical sites were included in 10 states. At each site a convenience sample was interviewed before the implementation of the Reach Out and Read (ROR) program, which served as the control group. A separate convenience sample was interviewed after the program which served as the experimental group. |
The total sample size was 1,647 subjects. Main outcome measures were parental interviews based on questions from validated questionnaires about their attitudes and practices related to reading out loud. There was a significant association (p < 0.001) between exposure to ROR and reading aloud as a favourite parenting activity, at bedtime, 3 or more days a week and ownership of >= 10 picture books. Limitations to this study are taking a convenience sample of subjects and sites that were different before and after. This can limit the ability to generalize the findings to the population and can introduce selection bias. There is also possibility for social desirability bias from parents’ answers to the questions. |
II
B |
|
Toilet learning
|
| Reference |
Methods |
Outcomes |
Evidence |
Canadian Pediatric Society Community Paediatrics Committee. Toilet learning: Anticipatory guidance with a child-oriented approach. Paediatrics & Child Health 2000;5(6):333-335.
Paediatrics & Child Health |
Subjects: <4 years old
Design: Position statement
Review of issues surrounding toilet training in children. Includes appropriate timing, using a child-oriented approach, assessing a child’s readiness, toilet refusal and children with special needs. |
Reaching developmental milestones can be difficult for the child and their parents. According to the report, there is a wide range of timing for toilet training that is considered normal, usually between 24 and 48 months. After 48 months, referral to a general or developmental pediatrician is recommended. The CPS recommends that physicians should inform parents and encourage the child-oriented approach; differences in cultures need to be taken into consideration (i.e., 24 to 48 months in a Western norm); moreover, motor, language and social milestones should also be considered when assessing a child’s readiness for toilet learning. |
III |
Russell K, Lang ME. Among healthy children, what toilet-training strategy is most effective and prevents fewer adverse events (stool withholding and dysfunctional voiding)? Paediatric & Child Health 2008; 13(3):201-204.
PubMed |
Subjects: Infants >18 months old
Design: Review (Part A: Evidence-based answer and summary; Part B: Clinical commentary.)
Reviews the literature on the best method to toilet-train an infant. Searched databases MEDLINE, EMABSE, ERIC, PsycINFO and Cinahl. |
The current CPS and AAP guidelines recommend a child-oriented approach starting between 18 and 24 months and not beginning before the child displays interest. The two main methods are the child-oriented approach and the Foxx and Azrin Method of Toilet Training in Less Than One Day. According to this review, neither method has conclusive evidence that makes it better than the other. |
III |
|
Eyes (red reflex)
Strength of Recommendation = Good |
| Reference |
Methods |
Outcomes |
Evidence |
Canadian Pediatric Society. Vision screening in infants, children and youth. Paediatr Child Health 2009; 14:246-248.
Paediatrics & Child Health |
Subjects: 0 to 5 years old
Design: Position statement
Revision of the position statement on vision screening from 1998. Performed searches of the Cochrane Library from 1966 to 2005. |
This CPS statement reported that there are no robust randomized trials to detect the impact of vision screening. However, longitudinal cohort studies have shown that eyes should be checked regularly by physicians during well-child visits starting from birth. The CPS also recommends that high-risk patients should be referred to an ophthalmologist for further testing. |
III
A |
American Academy of Pediatrics. Section on Ophthalmology. Red reflex examination in neonates, infants and children. Pediatrics 2008; 122(6):1401-1404.
PubMed |
Subjects: Infants and children
Design: Policy statement
This statement is a revision of the previous policy statement that was published in 2002. It reviews reasons for testing, the proper technique to use and when to refer to a specialist. |
The AAP recommends the following: 1) red reflex assessment should be part of the eye evaluation in the neonatal period and during all subsequent routine health visits; 2) children who are at high risk of vision and potentially life-threatening eye abnormalities should be referred to an ophthalmologist regardless of the status of red reflex; 3) any abnormalities should be referred to an ophthalmologist directly by the physician with proper follow-up. |
III
A |
Kemper A, Harris R, Lieu TA, Homer CJ, Whitener BL. Screening for visual impairment in children younger than age 5 years: a systematic evidence review for the U.S. Preventive Services Task Force. Rockville, MD: Agency for Healthcare Research and Quality (AHRQ). 2004.
http://www.ncbi.nlm.nih.gov/pubmed/15209205 |
Subjects: 0 to 5 years old
Design: Recommendation statement
US Preventive Task Force recommendation on screening for visual impairment. This review is limited to the most common causes of visual impairment: amblyopia and its risk factors, as well as refractive error. |
Visual impairment is a common condition among young children affection 5-10% of all preschoolers. The USPSTF recommends visual impairment screening to detect amblyopia, strabismus, and defects in visual acuity. There is no evidence in the literature of harm due to screening: potential for harm is small and the benefits of screening will likely outweigh any potential harm. |
III
B
|
Tingley DH. Vision screening essentials: Screening today for eye disorders in the pediatric patient. Pediatrics in Review 2007; 28(2):54-61.
PubMed |
Subjects: Infants
Design: Review
This article discusses the role of screening for vision problems, as well as guidelines for screening patients with age-appropriate tests. |
This review states that the red reflex testing should be the first eye examination that is done at birth and at all subsequent well-child visits; corneal light reflex should start to be tested at 6 months and visual acuity at 3 years. In order to catch possible abnormalities early and allow for the best chance of successful treatment, the authors report that visual screening should be done at each well-child visit and that abnormalities or high risk patients should be referred to a specialist. |
III
A |
|
Ears (TMs) Hearing inquiry/screening
Strength of Recommendation = Fair |
| Reference |
Methods |
Outcomes |
Evidence |
Nelson HD, Bougatsos C, Nygren P. Universal newborn hearing screening: Systematic review to update the 2001 US Preventive Services Task Force recommendation. Pediatrics 2008;122:e266-e276.
PubMed |
Subjects: Newborn infants
Design: Systematic review
Searched key databases (MEDLINE and Cochrane) for articles published since the 2001 recommendation. |
Twenty studies were found. Overall, children who were universally screened as newborns were diagnosed and received hearing aids at younger ages than those not screened. Children with hearing loss who had universal hearing screening at birth had better language outcomes at school-age than those not screened. This was due to earlier referral, diagnosis and treatment. |
II-1, II-2, II-3
B |
Vohr BR, Carty LM, Moore PE, Letourneau K. The Rhode Island Hearing Assessment Program: experience with state-wide hearing screening 1993-1996. J Pediatr 1998;133(3):353-7.
http://www.ncbi.nlm.nih.gov/pubmed/9738715 |
Subjects: Infants
Design: Retrospective cohort study
Hearing screen/rescreen referral data were collected prospectively for 53,121 infants born in Rhode Island over a 4 year period. Eight Rhode Island birthing hospitals were included in the sample. |
Outcomes included: first-stage referral rates, rescreen compliance, diagnostic referral rates, identification rates and the age of amplification. Of infants who received the TEOAE (Transient evoked otoacoustic emissions) stage 1 screen, 10% were referred for the second-stage. Specificity was 90% for stage 1 and 87% for stage 2. No infants passed the TEOAE and were subsequently diagnosed with hearing loss. Mean age of identification for permanent hearing loss was 20 months. This study concluded that two stage hearing screening is effective to screen, track, identify and habilitate infants in NICUs and normal nurseries for permanent hearing loss. |
II
B |
|
Hips
|
| Reference |
Methods |
Outcomes |
Evidence |
Patel H and the Canadian Task Force on Preventive Health Care. Preventive health care, 2001 update: screening and management of developmental dysplasia of the hip in newborns. CMAJ 2001; 164(12):1669-77.
PubMed |
Subjects: Newborns and high-risk infants
Design: Review
Reviews evidence to give recommendations for screening and management of developmental dysplasia of the hip (DDH) in newborns. |
This review used rates of operative intervention, abduction splinting, delayed diagnosis of DDH (beyond 3 to 6 months), treatment complications and false diagnosis labelling. Long-term functional outcomes were considered important. The harm associated with some screening tools and resource consumption is substantial. There is fair evidence supporting the inclusion of a serial clinical examination of the hips for all infants. However, there is fair evidence against the use of general ultrasound screening. |
III
B (physical exam)
D (ultrasound screening) |
US Preventive Services Task Force. Screening for Developmental Dysplasia of the Hip: Recommendation Statement. Pediatrics 2006; 117(3):898-902.
PubMed |
Subjects: Infants
Design: Review
Recommendations for screening infants for developmental dysplasia of the hip (DDH). |
The USPSTF reports that screening tests for DDH have limited accuracy with poor sensitivity or specificity. USPSTF concludes there is insufficient evidence to recommend routine screening for DDH in infants. |
III
I |
|
Adenotonsillar hypertrophy and presence of sleep-disordered breathing
|
| Reference |
Methods |
Outcomes |
Evidence |
American Academy of Pediatrics. Clinical Practice Guideline: Diagnosis and Management of Childhood Obstructive Sleep Apnea Syndrome. Pediatrics 2002;109(4): 704-712.
PubMed |
Subjects: Children
Design: Clinical practice guidelines
Guidelines were generated based on available medical literature. Performed computerized search of PubMed database with keywords: sleep apnea syndrome, apnea, sleep disorders, snoring, polysomnography, airway obstruction, adenoidectomy, tonsillectomy (adverse effects mortality), and sleep-disordered breathing. |
There were very few RCTs. The AAP recommendations include the following: 1) all children should be screened for snoring; 2) complex or high-risk patients should be referred to a specialist; 3) thorough diagnostic evaluation should be performed; 4) adenotonsillectomy is the first line of treatment for children with OSAS; 5) all surgical patients should receive post-operative re-evaluation to determine whether additional treatment is necessary. |
III |
|
Immunization Information
|
| Reference |
Methods |
Outcomes |
Evidence |
Gold, R. Your Child’s Best Shot. Ottawa: Canadian Paediatric Society, 3rd edition:2006. 392 pp.
Blaine, KA. Your child’s best shot: a parent’s guide to vaccination, 2nd edition. CMAJ 2003;168(2):199.
CMAJ |
For parents and caregivers with questions about vaccines |
From Blaine review: “This is a well-written and informative book, with an appealing cover design and children’s drawings throughout. A clear introduction delivers what is promised. In the disease-specific chapters, credible information is provided, often in the form of statistically accurate and visually convincing table and graphs. Vaccine histories, side effects and associated risks are discussed in detail. Primary health care providers would do well to have this information at their fingertips.” Note that a new edition has been published since this review. |
|
Diekema DS and the Committee on Bioethics. Responding to parental refusals of immunization of children. Pediatrics 2005;115(5):1428-1431.
PubMed |
Subjects: Children
Design: Clinical report
The objective of this report is to help pediatricians understand the various reasons why parents might refuse a vaccine. As well, it gives them appropriate guidelines on how to deal with parents who refuse immunizations for their children. |
Three issues are discussed in this report: 1) if the parents are withholding medical care this constitutes medical neglect and child services have to be called; 2) if not immunizing poses harm to the community, this becomes a public health issue; and 3) how the physician should respond to a refusing parent. Due to the high rates of immunization in most communities and low prevalence of vaccine-preventable disease, the authors report that many unimmunized children can be covered by herd immunity. The report highlights that physicians should counsel parents on the benefits of vaccines and address their concerns. |
III |
|
Other resources for information on immunization
|
National Advisory Committee on Immunization (NACI) http://www.phac-aspc.gc.ca/naci-ccni/
Provincial guidelines are available online: http://www.phac-aspc.gc.ca/im/ptimprog-progimpt/table-1-eng.php
American Academy of Pediatrics. Immunization Initiatives. http://www.cispimmunize.org/
Facts for parents about vaccine safety: http://www.caringforkids.cps.ca/immunization/index.htm and http://pediatrics.aappublications.org/cgi/reprint/115/5/1428 and http://www.cps.ca/english/statements/ID/DispellingMyths.pdf |
|
Meningococcal vaccine schedule
|
| Reference |
Methods |
Outcomes |
Evidence |
CPS position statement. A new meningococcal conjugate vaccine: What should physicians know and do? Paediatr Child Health 2009;14(8):515-517
http://www.cps.ca/english/statements/ID/ID09-02.htm. |
Subjects: Infants and children
Design: Position Statement
Review and recommendations for physicians about the new quadrivalent meningococcal conjugate vaccine for serogroups A, C, Y and W135 (MCV4). |
The CPS recommends that 1) physicians should encourage and promote immunization programs for infants starting at two months of age; 2) children who are at increased risk should be given a meningococcal C conjugate vaccine during infancy and then a MCV4 booster at 2 years of age; 3)the MCV4 vaccine may also be used for HIV-positive children at two years of age and older; 4)finally, at 12 years old a booster dose of MCV4 or the meningococcal C conjugate vaccine should be offered. |
|
National Advisory Committee on Immunization (NACI). Meningococcal C conjugate vaccination recommendations for infants.
http://www.phac-aspc.gc.ca/publicat/ccdr-rmtc/07vol33/acs-11/index-eng.php |
Subjects: Infants and children
Design: Advisory Committee Statement (ACS)
The NACI provided the Public Health Agency of Canada with ongoing medical, scientific and public health advice relating to immunization. These recommendations are based on the best current available scientific knowledge. |
Studies have shown that effectiveness of the meningococcal C conjugate vaccine decreases after 1 year following the completion of the infant vaccination series. Therefore, the NACI recommends a booster shot in the second year of life, if the infant received their first shot at less than 1 year old. |
II-2
A |
| Table 1. Recommendations Grades for Specific Clinical Preventive Actions |
|---|
| A |
There is good evidence to recommend the clinical preventive action. |
| B |
There is fair evidence to recommend the clinical preventive action. |
| C |
The existing evidence is conflicting and does not allow to make a recommendation for or against use of the clinical preventive action; however, other factors may influence decision making. |
| D |
There is fair evidence to recommend against the clinical preventive action. |
| E |
There is good evidence to recommend against the clinical preventive action. |
| I |
There is insufficient evidence (in quantity or quality) to make a recommendation; however, other factors may influence decision making. |
| The CTF recognizes that in many cases patient specific factors need to be considered and discussed, such as the value the patient places on the clinical preventive action; its possible positive and negative outcomes; and the context and /or personal circumstances of the patient (medical and other). In certain circumstances where the evidence is complex, conflicting or insufficient, a more detailed discussion may be required. |
| Table 2. Levels of Evidence - Research Design Rating |
| I |
Evidence obtained from at least one properly randomized trial. |
| II-1 |
Evidence obtained from a well-designed, controlled trial without randomization. |
| II-2 |
Evidence obtained from a well-designed cohort or case-controlled analytic studeis, preferably from more than one centre or research group. |
| II-3 |
Evidence obtained from comparisons between times and places, with or without the intervention; dramatic results in uncontrolled experiments could also be included in this category. |
| III |
Opinions of respected authorities, based on clinical experience, descriptive studies or reports of expert committees. |
| Table 3. Levels of Evidence - Quality (Internal Validity) Rating (see Harris et al., 2001) |
| Good |
A study (including meta-analyses or systematic reviews) that meets all design-specific criteria* well. |
| Fair |
A study (including meta-analyses or systematic reviews) that does not meet (or it is not clear that it meets) at least one design-specific criterion* but has no known "fatal flaw". |
| Poor |
A study (including meta-analyses or systematic reviews) that has at least one design-specific* "fatal flaw", or an accumulation of lesser flaws to the extent that the results of the study are not deemed able to inform recommendations. |
| |
*General design-specific criteria are outlined in Harris et al., 2001. |
Current Evidence
Click the LitReview button to view an annotated table of the literature reviewed with the level of evidence of each article resulting in the strength of recommendation for various topics in the 2009 RBR. Level of evidence and strength of recommendation follows the classification system of the Canadian Task Force on Preventative Health Care.
Growth
Measuring growth - The growth of all full term infants, both breastfed and non breastfed, and
preschoolers should be evaluated using growth charts from the 2006 World Health Organization
Child Growth Standards (birth to 5 years) with measurement of recumbent length (birth to 2-3 years)
or standing height (≥ 2 years), weight, and head circumference (birth to 2 years).
www.who.int/childgrowth/standards/en/ LitReview
Important: Corrected age should be used at least until 24 to 36 months of age for premature infants
born at <37 wks gestation.
Nutrition
Pediatric nutrition guidelines – Nutrition for Healthy Term Infants: LitReview
- Breastfeeding: Exclusive breastfeeding is recommended for the first six months of life for healthy term infants. Breast milk is the optimal food for infants, and breastfeeding (with complementary foods) may continue for up to two years and beyond unless contraindicated. Breastfeeding reduces gastrointestinal and respiratory infections. Maternal support (both antepartum and postpartum) increases breastfeeding and prolongs its duration. Early and frequent mother-infant contact, rooming in, and banning handouts of free infant formula increase breastfeeding rates.LitReview
- Routine Vitamin D supplementation of 400 IU/day (800 IU/day in northern communities) is recommended for all breastfed full term infants until the diet provides a sufficient source of Vitamin D (~ 1 year of age). Formula may only supply a portion of the recommended daily vitamin D intake if less than 1000 mL (33 oz) is consumed daily.LitReview
- Resources:
- Milk consumption range is consensus only & is provided as an approximate guide.
- Soy-based formula is not recommended for routine use in term infants as an equivalent alternative to cow’s milk formula, or for cow milk protein allergy, and is contraindicated for preterm infants.
- Transition to lower fat diet: A gradual transition from the high-fat infant diet to a lower-fat diet begins after age 2 years as per Canada’s Food Guide.
- Encourage a healthy diet as per Canada's Food Guide
Education and Advice
Injury Prevention
In Canada, unintentional injuries are the leading cause of death in children and youth. Most of these preventable injuries are caused by motor vehicle collisions, drowning, choking, burns, poisoning, and falls.
- Transportation in motor vehicles: LitReview
- www.cps.ca/english/statements/IP/IP08-01.htm
- www.safekidscanada.ca/SKCPublicPolicyAdvocacy/custom/
BoosterSeatLegislationChart.pdf
- Children < 13 years should sit in the rear seat. Keep children away from all airbags.
- Install and follow size recommendations as per specific car seat model and keep child in each stage as long as possible.
- Use rear-facing infant seat until at least 1 year of age AND 10 kg (22 lb).
- Use forward-facing child seat from at least 1 year of age AND 10 - 22 kg (22 - 48 lb) and up to 122 cm (48”). Maximum ht/wt may vary with car seat model.
- Use booster seat from at least 18 - 36 kg (40 - 80 lb) and up to 145 cm (4’9”).
- Use lap and shoulder belt in the rear seat for older children over 8 yrs who are at least 36 kg (80 lb) and 145 cm (4’9”) and fit vehicle restraint system.
Bicycle: wear bike helmets. Replace if heavy impact or sign of damage. LitReview- Drowning:
- www.cps.ca/english/statements/IP/IP03-01.htm
- Bath safety: Never leave a young child alone in the bath. Do not use infant bath rings or bath seats.
- Water safety: Recommend adult supervision, training for adults, 4-sided pool fencing, lifejackets, swimming lessons, and boating safety to decrease the risk of drowning.LitReview
- Choking: Avoid hard, small and round, smooth and sticky solid foods until age 3 years. Use safe toys, follow minimum age recommendations, and remove loose parts and broken toys.
- Burns: LitReview
- Install smoke detectors in the home on every level
- Keep hot water at a temperature < 49° C.
- Poisons: Keep medicines and cleaners locked up and out of child’s reach. Have Poison Control Centre number handy. Use of ipecac is contraindicated in children.LitReview
- Falls: Assess home for hazards- never leave baby alone on change table or other high surface; use window guards and stair gates. Baby walkers are banned in Canada and should never be used. Advise against trampoline use at home. LitReview
- Safe sleeping environment: www.cps.ca/english/statements/CP/cp04-02.htm
LitReview
Sleep position and SIDS/Positional plagiocephaly: Healthy infants should be positioned on their
backs for sleep. Their heads should be placed in different positions on alternate days. While
awake, infants should have supervised tummy time. Counsel parents on the dangers of other
contributory causes of SIDS such as overheating, maternal smoking or second-hand smoke.- Bed sharing: Advise against bed sharing.
- Room sharing: Encourage putting infant in a crib that meets current Canadian safety regulations
in parents’ room for the first 6 months of life. Room sharing is protective against SIDS.
- Firearm safety/removal: There is evidence-based association between a firearm in the home and
increased risk of unintentional firearm injury, suicide, or homicide.LitReview
- For more safety information: LitReview
Behaviour and Family Issues
Crying: Excessive crying may be caused by behavioral or physical factors or be the upper limit
of the normal spectrum. Evaluation of these etiological factors and of the burden for parents is
essential and raises awareness of the potential for the shaken baby syndrome.- Shaken baby syndrome: LitReview
- Night waking: occurs in 20% of infants and toddlers who do not require night feeding. Counselling
around positive bedtime routines (including training the child to fall asleep alone), removing
nighttime positive reinforcers, keeping morning awakening time consistent, and rewarding good
sleep behaviour has been shown to reduce the prevalence of night waking, especially when this
counselling begins in the first 3 weeks of life. LitReview
- Swaddling: Proper swaddling of the infant for the first 6 months of life may promote longer sleep
periods but could be associated with adverse events (hyperthermia, SIDS, or development of hip
dysplasia) if misapplied. A swaddled infant must always be placed supine with free movement of
hips and legs, and the head uncovered. LitReview
- Parenting/discipline: Inform parents that warm, responsive, flexible & consistent discipline techniques are assoc with
positive child outcomes. Over reactive, inconsistent, cold & coercive techniques are assoc with
negative child outcomes. LitReview
Refer parents of children at risk of, or showing signs of, behavioral or conduct problems to
structured parenting programs which have been shown to increase positive parenting, improve
child compliance, and reduce general behavior problems. Access community resources to
determine the most appropriate and available research-structured programs.
(eg. The Incredible Years, Right from the Start, COPE program). LitReview
- Parental/Family Issues - high risk infants/children
- Maternal depression - Physicians should have a high awareness of maternal depression, which
is a risk factor for the socio-emotional and cognitive development of children. Although less
studied, paternal factors may compound the maternal-infant issues. LitReview
- Fetal alcohol spectrum disorder (FASD) - Canadian Guidelines: LitReview
- Assess home visit need: There is good evidence for home visiting by nurses during the perinatal
period through infancy for first-time mothers of low socioeconomic status, single parents or
teenaged parents to prevent physical abuse and/or neglect. LitReview
- Risk factors for physical abuse:
- low SES
- young maternal age (< 19 years)
- single parent family
- parental experiences of own physical abuse in childhood
- spousal violence
- lack of social support
- unplanned pregnancy or negative parental attitude towards pregnancy
- Risk factors for sexual abuse:
- living in a family without a natural parent
- growing up in a family with poor marital relations between parents
- presence of a stepfather
- poor child-parent relationships
- unhappy family life
- Inquire about current child care arrangements. High quality child care is associated with improved
paediatric outcomes in all children.
Factors enhancing quality child care include: LitReview
Other Issues
- Second-hand smoke exposure: contributes to childhood illnesses such as URTI, middle ear
effusion, persistent cough, pneumonia, asthma, and SIDS. LitReview
- Advise parents against using OTC cough/cold medications. LitReview
- Complementary and alternative medicine (CAM):Questions should be routinely asked on the use of
homeopathy and other complementary and alternative medicine therapy or products, especially
for children with chronic conditions. LitReview
- Pacifier use may decrease risk of SIDS and should not be discouraged in the 1st year of life after
breastfeeding is well established, but should be restricted in children with chronic/recurrent otitis
media. LitReview
- Fever advice/thermometers: Fever ≥ 38oC in an infant < 3 months needs urgent evaluation.
Ibuprofen and acetaminophen are both effective antipyretics. Acetaminophen remains the
first choice for antipyresis under 6 months of age; thereafter ibuprofen or acetaminophen may
be used. Alternating acetaminophen with ibuprofen for fever control is not recommended in
primary care settings as this may encourage fever phobia, and the potential risks of medication
error outweigh measurable clinical benefit. LitReview
- Footwear: Shoes are for protection, not correction. Walking barefoot develops good toe
gripping and muscular strength. LitReview
- Healthy Active Living: Encourage increased physical activity and decreased sedentary pastimes
with parents as role models. LitReview
Sun exposure/sunscreens/insect repellents: Minimize sun exposure. Wear protective clothing,
hats, properly applied sunscreen with SPF ≥ 30 for those > 6 months of age. No DEET in < 6
months; 6-24 months 10% DEET apply max once daily; 2 - 12 yrs 10% DEET apply max TID. LitReview- Pesticides: Avoid pesticide exposure. Encourage pesticide-free foods. LitReview
- Lead Screening is recommended for children who:
- Websites about environmental issues: LitReview
- Dental Care:
- Dental Cleaning: Fluoridated
toothpaste should be used
twice per day with a minimum
amount of water used to rinse
the mouth after brushing.
As excessive swallowing of
toothpaste by young children
may result in dental fluorosis,
children under 6 years of age
should be supervised during
brushing and only use a small
amount (e.g. pea-sized portion)
of toothpaste. Children under
3 years of age should have
their teeth brushed by an
adult using only a smear of
toothpaste.
- Fluoride supplements are not recommended under 6 yrs of age unless the child is considered
at high risk for dental caries.
- To prevent early childhood caries: avoid sweetened liquids and constant sipping of milk or
natural juices in both bottle and cup. LitReview
Development
Maneuvers are based on the Nipissing District Development Screen™ (www.ndds.ca) and other
developmental literature. They are not a developmental screen, but rather an aid to developmental
surveillance. They are set after the time of normal milestone acquisition. Thus, absence of any one
or more items is considered a high-risk marker and indicates the need for further developmental
assessment, as does parental or caregiver concern about development at any stage.
- “Best Start” website contains resources for maternal, newborn, and early child development
- OCFP Healthy Child Development: Improving the Odds publication is a toolkit for primary healthcare providers
- www.cdc.gov/ncbddd/child/screen_provider.htm
- Centre of Excellence for Early Childhood Development
Literacy: Encourage parents to read to their children within the first few months of life and to limit TV, video
and computer games to provide more opportunities for reading. LitReview
Toilet Learning : The process of toilet learning has changed significantly over the years and within different
cultures. In Western culture, a child-centred approach, where the timing and methodology of
toilet learning is individualized as much as possible, is recommended. LitReview
Autism Spectrum Disorder: Specific screening for ASD at 18 - 24 months using the M-CHAT should be performed on all
children with any of the following: failed items on the social/emotional/communication skills
inquiry, sibling with autism, or developmental concern by parent, caregiver, or physician.
If the M-CHAT is abnormal, use the M-CHAT Follow-up Interview to reduce the false positive rate
and avoid unnecessary referrals and parental concern. The M-CHAT tool and follow-up interview
are found at:
Physical Examination
- Vision screening: www.cps.ca/english/statements/cp/cp09-02.htm
- Check Red Reflex for serious ocular diseases such as retinoblastoma and cataracts.
- Corneal light reflex/cover-uncover test & inquiry for strabismus: With the child focusing on a
light source, the light reflex on the cornea should be symmetrical. Each eye is then covered in
turn, for 2 – 3 seconds, and then quickly uncovered. The test is abnormal if the uncovered eye “wanders” OR if the covered eye moves when uncovered. LitReview
- Hearing screening/inquiry – Universal newborn hearing screening (UNHS) effectively identifies
infants with congenital hearing loss & allows for early intervention. Any parental concerns about
hearing acuity or language delay should prompt a rapid referral for hearing assessment. Formal
audiology testing should be performed in all high-risk infants, including those with normal
UNHS. Older children should be screened if clinically indicated. LitReview
- Muscle tone – Physical assessment for spasticity, rigidity, and hypotonia should be performed.
- Hips – There is insufficient evidence to recommend routine screening for developmental
dysplasia of the hips, but examination of the hips should be included in the periodic health exam. LitReview
- Adenotonsillar hypertrophy and presence of sleep-disordered breathing warrant assessment re.
obstructive sleep apnea. LitReview
Problems and Plans
- Anemia screening: All infants from high-risk groups for iron deficiency anemia require screening
between 6 and 12 months of age, e.g. Lower SES; Asian; First Nations children; low-birth-weight
infants, and infants fed whole cow’s milk during their first year of life.
- Hemoglobinopathy screening: Screen all neonates from high-risk groups, e.g. Asian, African, and Mediterranean.
Immunization
- National Advisory Committee on Immunization (NACI) recommended immunization schedules for infants, children and youth can be found at the following website: www.phac-aspc.gc.ca/naci-ccni/.
- Provincial/territorial immunization schedules may differ based on funding differences. For provincial/territorial immunization schedules, see Canadian Nursing Coalition on Immunization chart on the website of the Public Health Agency of Canada: www.phac-aspc.gc.ca/im/ptimprog-progimpt/table-1_e.html
- Additional information for parents on vaccinations can be accessed through: LitReview
Vaccine Notes (Adapted from NACI)
- Diphtheria, Tetanus, acellular Pertussis and inactivated Polio virus vaccine (DTaP-IPV): DTaP-IPV vaccine is the preferred vaccine for all doses in the vaccination series, including completion of the
series in children < 7 years who have received ≥ 1 dose of DPT (whole cell) vaccine (e.g., recent immigrants).
- Haemophilus influenzae type b conjugate vaccine (Hib): Hib schedule shown is for the Haemophilus b capsular polysaccharide – PRP conjugated to tetanus toxoid (Act-HIBTM) or the Haemophilus
b oligosaccharide conjugate - HbOC (HibTITERTM) vaccines. This vaccine may be combined with DTaP in a single injection.
- Measles, Mumps and Rubella vaccine (MMR): A second dose of MMR is recommended, at least 1 month after the first dose for the purpose of better measles protection. For convenience, options
include giving it with the next scheduled vaccination at 18 months of age or at school entry (4-6 years) (depending on the provincial/territorial policy), or at any intervening age that is practical.
The need for a second dose of mumps and rubella vaccine is not established but may benefit (given for convenience as MMR). The second dose of MMR should be given at the same visit as DTaPIPV
(± Hib) to ensure high uptake rates. MMR and varicella vaccines should be administered concurrently (at different sites if the combined MMR/varicella vaccine is not available) or separated by
at least 4 weeks.
- Varicella vaccine: Children aged 12 months to 12 years who have not had varicella should receive one dose of varicella vaccine. Unvaccinated individuals ≥ 13 years who have not had varicella
should receive two doses at least 28 days apart. Varicella and MMR vaccines should be administered concurrently (at different sites if the combined MMR/varicella vaccine is not available) or
separated by at least 4 weeks.
- Hepatitis B vaccine (Hep B): Hepatitis B vaccine can be routinely given to infants or preadolescents, depending on the provincial/territorial policy. For infants born to chronic carrier mothers, the
first dose should be given at birth (with Hepatitis B immune globulin), otherwise the first dose can be given at 2 months of age to fit more conveniently with other routine infant immunization
visits. The second dose should be administered at least 1 month after the first dose, and the third at least 2 months after the second dose, but again may fit more conveniently into the 4- and
6-month immunization visits. A two-dose schedule for adolescents is an option.
(See also SELECTED INFECTIOUS DISEASES RECOMMENDATIONS below.)
- Pneumococcal conjugate vaccine - 7-valent (Pneu-Conj): Recommended schedule, number of doses and subsequent use of 23 valent polysaccharide pneumococcal vaccine depend on the age of
the child, if at high risk for pneumococcal disease, and when vaccination is begun.
- Meningococcal conjugate vaccine (Men-C): Monovalent vaccine to Type C (Men-C-C) is indicated for all ages, and quadravalent to Types A/C/W/Y (Men-C-ACWY) for age 2 yrs and over.
Recommended vaccine, schedule and number of doses of meningococcal vaccine depend on the age of the child and vary between provinces/territories.
Possible schedules include:
- Men-C-C: 2 - 3 doses under 12 mos of age AND booster dose between 12 - 24 mos age.
OR
- Men-C-C: 1 dose at 12 mos of age.
Men-C-C or Men-C-ACWY booster dose should also be given at 12 yrs of age or during adolescence. LitReview
- Diphtheria, Tetanus, acellular Pertussis vaccine - adult/adolescent formulation (dTap): a combined adsorbed “adult type” preparation for use in people ≥ 7 years of age, contains less diphtheria
toxoid and pertussis antigens than preparations given to younger children and is less likely to cause reactions in older people. This vaccine should be used in individuals > 7 years receiving their
primary series of vaccines.
- Influenza vaccine: Recommended for all children between 6 and 23 months of age, and for older high-risk children. Previously unvaccinated children up to 9 years of age require 2 doses with an
interval of at least 4 weeks. The second dose is not required if the child has received one or more doses of influenza vaccine during the previous immunization season.
- Rotavirus vaccine: Universal rotavirus vaccine is being considered by NACI and CPS.
Selected Infectious Diseases Recommendations
See CPS position statements of the Infectious Diseases and Immunization Committee: www.cps.ca/english/publications/InfectiousDiseases.htm
- Hepatitis B immune globulin and immunization: Infants with HBsAg-positive parents or siblings require Hepatitis B vaccine at birth, at 1 month, and 6 months of age. Infants of HBsAg-positive mothers also require Hepatitis B immune globulin at birth.
Hepatitis B vaccine should also be given to all infants from high-risk groups, such as:
- infants where at least one parent has emigrated from a country where Hepatitis B is endemic;
- infants of mothers positive for Hepatitis C virus;
- infants of substance-abusing mothers.
- Human Immunodeficiency Virus type 1 (HIV-1) maternal infections: Breastfeeding is contraindicated for an HIV-1 infected mother even if she is receiving antiretroviral therapy.
- Hepatitis A or A/B combined (when Hepatitis B vaccine has not been previously given): These vaccines should be considered when traveling to countries where Hepatitis A or B are endemic.
- Tuberculosis - TB skin testing: TB skin testing should be done if the infant is living with anyone being investigated or treated for TB. TB skin testing should also be considered in high-risk groups, including Aboriginal people,
immigrants and long-term travellers from areas with a high prevalence of TB.
