Evidence-based infant/child health maintenance guide
This annotated bibliography lists the literature which has been used to determine the strength of recommendation for selected items on the 2009 Rourke Baby Record. The references included in this review table are not exhaustive, and were selected by the authors for their relevance in supporting the evidence for the items included in the 2009 RBR. The strength of recommendation and levels of evidence are based on the classification system of the Canadian Task Force on Preventive Health Care . Click here for this system.
Thanks to Dr. Evelyn Constantin (MD CM, MSc(Epi), FRCPC, FAAP, CSPQ; Assistant Professor of Paediatrics McGill University), and Sarah Carsley (MSc(Epi) McGill University), for their exemplary work on this huge task. Thanks as well to Julie Matthews (BSc, MSc; Research Assistant Memorial University)who began the process; and to Lindsay Glynn (BA, MLIS;, Public Services Librarian, Memorial University of Newfoundland ) and Linda Horwood (MSc; Research Assistant Montreal Children’s Hospital) for their editing of the document.
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Growth Monitoring
Strength of Recommendation = Consensus |
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| Reference | Methods | Outcomes | Evidence |
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Promoting optimal monitoring of child growth in Canada: Using the new World Health Organization growth charts - Executive Summary |
Subjects: 0 to 5 years old |
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 |
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. | |
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). http://www.who.int/childgrowth/mgrs/en/ |
Subjects: 0 to 5 years old |
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. |
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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. |
Subjects: 0 to 5 years old |
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 | |
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 |
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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Breastfeeding (exclusive)
Strength of Recommendation = Good |
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| 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 |
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. | |
American Academy of Pediatrics. Breastfeeding and the use of human milk. Pediatrics. 2005; 115: 496-506. PubMed |
Subjects: Infants |
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). | |
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 |
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. |
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Kramer MS, Kakuma R. Optimal duration of exclusive breastfeeding. Cochrane Database Systematic Review. 2002(1): CD003517. |
Subjects: Infants |
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. | |
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Pacifiers
Strength of Recommendation = Fair |
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| Reference | Methods | Outcomes | Evidence |
O’Connor NR, Tanabe KO, Siadaty MS, Hauck FR. Pacifiers and Breastfeeding. A Systematic review. Arch Pediatr Adolesc. 2009; 163: 378-382. |
Subjects: Mother-infant pairs |
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. | |
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 |
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. | |
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) |
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. | |
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Weaning
Strength of Recommendation = Consensus |
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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 |
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. | |
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Ankyloglossia
Strength of Recommendation = Consensus |
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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 |
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. | |
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Vitamin D 400 IU/day (800 IU in northern areas)
Strength of Recommendation = Good |
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| 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 |
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.) | |
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 |
Subjects: Mothers and infants |
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. | |
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 |
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. | |
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Formula Feeding
Strength of Recommendation = Fair |
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| Reference | Methods | Outcomes | Evidence |
| Iron fortified formulas | |||
American Academy of Pediatrics Committee on Nutrition. Iron-fortification of infant formulas. Pediatrics 1999; 104(1):119-123. PubMed |
Subjects: 0 to12 months old |
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. | |
| 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 |
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. | |
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 |
Subjects: Infants and mothers |
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. | |
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. |
Subjects: 0 to 6 months old |
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. | |
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 |
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. | |
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Colic
Strength of Recommendation = Consensus |
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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 |
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. | |
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Atopy
Strength of Recommendation = Consensus |
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| Reference | Methods | Outcomes | Evidence |
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 |
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. | |
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Nutrition – general
Strength of Recommendation = Consensus |
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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 |
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. | |
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 |
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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Injury Prevention |
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| Reference | Methods | Outcomes | Evidence |
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Safe Kids Canada 2008. |
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. |
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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 |
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. |
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Transportation in motor vehicles: Car seats (infant)
Strength of Recommendation = Good |
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| 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 |
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. | |
American Academy of Pediatrics. Car Safety Seats: A Guide for Families 2010. |
Subjects: Children |
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. | |
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 |
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. |
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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 |
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. |
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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 |
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. | |
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 |
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. | |
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 |
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. | |
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 |
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. | |
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Bike helmets
Strength of Recommendation = Good |
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| 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 |
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. | |
Thompson DC, Rivara, FP, Thompson RS. Effectiveness of bicycle safety helmets in preventing head injuries. A case-control study. JAMA 1996;276:1968-73. |
Subjects: All ages |
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. | |
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 |
Subjects: Infants and mothers |
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. | |
American Academy of Pediatrics, Committee on Injury and Poison Prevention. Bicycle helmets. Pediatrics. 2001; 108: 1030-1032 PubMed |
Subjects: Children |
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. | |
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. pubmed?term=%22Pediatrics %22[Jour]%20AND %20122[volume] %20AND%203[issue] %20AND%20 bicycling[Title]&cmd=DetailsSearch |
Subjects: All ages |
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. | |
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Sleep position/bed sharing/room sharing
Strength of Recommendation = Good |
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| 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 |
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.”; and 3) a sudden change in sleeping pattern is associated with the highest risk of sudden death. | |
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 |
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. | |
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 |
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). | |
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Positional plagiocephaly
Strength of Recommendation = Consensus |
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| Reference | Methods | Outcomes | Evidence |
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 |
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. |
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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 |
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. | |
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Crib Safety
Strength of Recommendation = Good |
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| Reference | Methods | Outcomes | Evidence |
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 |
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. | |
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Firearm safety/removal
Strength of Recommendation = Good |
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| Reference | Methods | Outcomes | Evidence |
Canadian Pediatric Society. Youth and firearms in Canada. Paediatric & Child health. 2005; 10(8): 473-477. |
Subjects: Children |
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. | |
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 |
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 | |
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 |
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. | |
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Smoke detectors
Strength of Recommendation = Fair |
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| 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 |
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. | |
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 |
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. | |
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 |
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 | |
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Poisons PCC#
Strength of Recommendation = Good |
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| 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 |
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. | |
McGregor T, Parkar M, Rao S. Evaluation and management of common childhood poisonings. American Family Physician 2009; 79: 397-403. PubMed |
Subjects: Children |
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. | |
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Falls (stairs, walkers, change table and trampoline use)
Strength of Recommendation = Fair |
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| 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 |
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. |
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American Academy of Pediatrics. Committee on Injury and Poison Prevention. Injuries associated with infant walkers. Pediatrics 2001; 108: 790-792. PubMed |
Subjects: Children |
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. | |
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 |
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. | |
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 |
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. | |
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Bath Safety and Water Safety
Strength of Recommendation = Fair |
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| 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 |
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. | |
Canadian Pediatric Society. Swimming lessons for infants and toddlers. Paediatric & Child Health 2003; 8(2): 113-114. PubMed |
Subjects: Infants |
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. | |
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 |
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. | |
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 |
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. | |
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 |
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. | |
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 |
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. | |
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Night waking
Strength of Recommendation = Good |
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| Reference | Methods | Outcomes | Evidence |
|---|---|---|---|
Canadian Pediatric Society. Joint statement on shaken baby syndrome. Paediatr Child Health 2001;6(9):663-7 PubMed |
Subjects: Infants |
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. | |
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 |
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. | |
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Swaddling
Strength of Recommendation = Consensus |
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| 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 |
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. | |
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. |
Subjects: Infants |
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. | |
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Discipline/Parenting education programs/Parenting skills
Strength of Recommendation = Fair |
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| Reference | Methods | Outcomes | Evidence |
Canadian Pediatric Society. Effective discipline for children. Paediatric & Child Health. 2004; 9(1): 37-41. PubMed |
Subjects: Children |
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. | |
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 |
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. | |
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 |
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. |
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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. |
Subjects: 3 years old |
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. | |
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. |
Subjects: 0 to 3 years old |
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. | |
Barlow J, Stewart-Brown D. Behaviour problems and group-based parent education programs. J Dev Behav Pediatr 2000;(21)5:356-70. |
Subjects: 3 to 10 years old |
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. | |
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Parental/Family issues – High risk infants/Assess home visit need
Strength of Recommendation = Good |
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| Reference | Methods | Outcomes | Evidence |
Canadian Pediatric Society. Psychosocial Paediatrics Committee. Maternal depression and child development. Paediatr Child Health 2004;9(8):575-583. |
Subjects: Mothers and children |
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. |
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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 |
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. | |
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 |
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). | |
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. |
Subjects: Families |
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. |
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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. |
Subjects: Mothers with at least one risk factor |
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. |
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Fetal alcohol spectrum disorder
Strength of Recommendation = Consensus |
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| 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 |
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. | |
Benz J, Rasmussen C, Andrew G. Diagnosing fetal alcohol spectrum disorder: History, challenges and future directions. |
Subjects: Mothers and Infants |
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. | |
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Non parental child care
Strength of Recommendation = Fair |
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| 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. |
Subjects: 6 to 36 months old |
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. | |
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. |
Subjects: 6 to 36 months old |
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. | |
American Academy of Pediatrics. Quality early education and child care from birth to Kindergarten. Pediatrics 2005; 115: 187-191. PubMed |
Subjects: <5 years old |
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. | |
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. |
Subjects: <5 years old |
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. | |
Zoritch B, Roberts I, Oakley A. Day care for pre-school children. Cochrane Database of Systematic Reviews 2000, Issue 3:CD000564 |
Subjects: 0 to 5 years old |
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. | |
Canadian Pediatric Society. Well Beings: A Guide to Health in Child Care. |
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. | ||
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Second-hand smoke
Strength of Recommendation = Good |
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| Reference | Methods | Outcomes | Evidence |
|---|---|---|---|
American Academy of Pediatrics Committee on Environmental Health. Environmental tobacco smoke: A hazard to children. Pediatrics 1997; 99: 639-642. |
Subjects: Children |
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. | |
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. |
Subjects: 0 to 8 years old |
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. | |
DiFranza JR, Aligne CA, Weitzman M. Prenatal and postnatal environmental tobacco smoke exposure and children’s health. Pediatrics 2004;113:1007-1015. |
Subjects: 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. |
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No OTC cough/cold medication
Strength of Recommendation = Good |
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| Reference | Methods | Outcomes | Evidence |
Health Canada’s Decision on Cough and Cold Medicines. Information December 2008. |
Subjects: 0 to 12 years old |
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. | |
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 |
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. | |
Rimsza ME, Newberry S. Unexpected infant deaths associated with use of cough and cold medications. Pediatrics 2008;122:e318-e322. |
Subjects: 0 to 10 months old |
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 | |
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. |
Subjects: 0 to 12 years old |
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. | |
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Inquiry on complementary/alternative medicine
Strength of Recommendation = Fair |
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| 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 |
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. |
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Canadian Pediatric Society. Homeopathy in the pediatric population. Paediatrics & Child Health. 2005;10:173-177. |
Subjects: Children |
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. | |
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 |
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. | |
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Counsel on Pacifier Use
Strength of Recommendation = Fair |
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| Reference | Methods | Outcomes | Evidence |
Canadian Pediatric Society. Recommendations for the use of pacifiers. Paediatric & Child Health 2003; 8: 515-519. |
Subjects: 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. | |
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 |
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. | |
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. |
Subjects: 0 to 4 years old |
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. | |
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Sun exposure/sunscreen/insect repellents
Strength of Recommendation = Consensus |
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| Reference | Methods | Outcomes | Evidence |
American Academy of Pediatrics Committee on Environmental Health. Ultraviolet light: A hazard to children. Pediatrics 1999; 104: 328-333. |
Subjects: Children |
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. | |
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. |
Subjects: Children |
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. |
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Canadian Paediatric Society. Insect repellents for children. Caring for Kids |
Subjects: Children |
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. | |
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Fever advice/thermometers
Strength of Recommendation = Consensus |
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| Reference | Methods | Outcomes | Evidence |
Canadian Pediatric Society. Temperature measurement in paediatrics. |
Subjects: Children |
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. | |
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 |
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. | |
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. |
Subjects: 6 months to 10 years old |
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. | |
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. |
Subjects: 0 to 18 years old |
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. | |
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 |
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. | |
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Footwear
Strength of Recommendation = Consensus |
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| Reference | Methods | Outcomes | Evidence |
Canadian Pediatric Society. Footwear for children – summary. Paediatric & Child Health. 2009;14:119. PubMed |
Subjects: Children |
The CPS reports that using footwear for correction of foot or leg ‘deformities’ in children is common but lacks evidence of effectiveness. The conclusions from the statement are that 1) infants do not need shoes until they are walking, and 2) shoes are necessary for protection and should be well-fitting, soft, light weight and should have cushioned soles. | |
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Pesticide Use
Strength of Recommendation = Consensus |
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| 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. |
Subjects: Adults and children exposed to pesticides |
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. |
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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. |
Subjects: 0 to 14 years old |
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. | |
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. |
Subjects: ≤20 years old |
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. |
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Lead Screening
Strength of Recommendation = Fair |
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| 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 |
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. | |
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 |
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. |
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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. |
Subjects: Infants |
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. | |
Bellinger DC. Very low lead exposures and children’s neurodevelopment. Current Opinion in Pediatrics 2008;20(2):172-177. PubMed |
Subjects: Children |
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. | |
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Websites about environmental issues: |
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http://www.ocfp.on.ca/local/files/Communications/Current%20Issues/Pesticides/Final%20Paper%2023APR2004.pdf |
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Encourage Reading
Strength of Recommendation = Fair |
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| 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 |
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. | |
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 |
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. | |
Duursma E, Augustyn M, Zuckerman B. Reading aloud to children: the evidence. |
Subjects: Children |
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. | |
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. |
Subjects: 2 to 5.9 years old |
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. | |
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. |
Subjects: 6 to 72 months old |
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. | |
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Healthy active living/Media use
Strength of Recommendation = Consensus |
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| Reference | Methods | Outcomes | Evidence |
Canadian Pediatric Society. Healthy active living for children and youth. Paediatr Child |
Subjects: 5 to 18 years old |
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. | |
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 |
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. | |
Canadian Pediatric Society. Impact of media use on children and youth. Paediatr Child Health 2003;8(5):301-306. |
Subjects: All ages |
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. | |
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Dental cleaning/fluoride
Strength of Recommendation = Good |
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| Reference | Methods | Outcomes | Evidence |
CDA Position on Use of Fluorides in Caries Prevention. Approved by the CDA Board of Directors November 2008 |
Subjects: All ages |
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. | |
American Academy of Pediatrics Section on Pediatric Dentistry and Oral Health. Preventive oral health intervention for pediatricians. Pediatrics 2008;122:1387-1394. |
Subjects: Children |
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. | |
Canadian Pediatric Society Nutrition Committee. The use of fluoride in infants and children. Paediatr Child Health 2002;7(8):569-72. |
Subjects: 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. | |
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 |
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.” | |
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: |
Subjects: 0 to 16 years old |
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. | |
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Toilet learning
Strength of Recommendation = Consensus |
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| 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. |
Subjects: <4 years old |
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. | |
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 |
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. | |
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Eyes (red reflex)
Strength of Recommendation = Good |
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| 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 |
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. | |
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 |
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. | |
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. |
Subjects: 0 to 5 years old |
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. |
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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 |
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. | |
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Ears (TMs) Hearing inquiry/screening
Strength of Recommendation = Fair |
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| 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 |
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. | |
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. |
Subjects: Infants |
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. | |
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Hips
Strength of Recommendation = Consensus |
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| 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 |
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. | |
US Preventive Services Task Force. Screening for Developmental Dysplasia of the Hip: Recommendation Statement. Pediatrics 2006; 117(3):898-902. |
Subjects: Infants |
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. | |
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Adenotonsillar hypertrophy and presence of sleep-disordered breathing
Strength of Recommendation = Consensus |
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| 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 |
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. | |
| 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. |
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. |
Subjects: 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. | |
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Meningococcal vaccine schedule
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| 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 |
Subjects: Infants and children 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. |
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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 |
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. | |
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Other resources for information on immunization
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National Advisory Committee on Immunization (NACI) http://www.phac-aspc.gc.ca/naci-ccni/ |
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| 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. | |
Canadian Task Force on Preventive Health Care. New grades for recommendations from the Canadian Task Force on Preventive Health Care. CMAJ 2003;169:207-8.