CTF Structured Abstract: Well Baby Care

Canadian Task Force on Preventive Health Care

Structured Abstract

Well-Baby Care in the First 2 Years of Life

Prepared by William Feldman, MD, FRCPC, Department of Pediatrics, University of Toronto

These recommendations were finalized by the Task Force in March 1994

Objective
Burden of Suffering
Options
Outcomes

Evidence
Values
Benefits, Harms, and Costs
Recommendations

Validation
Sponsors
Selected References

Objective

To make recommendations about well-baby care for Canadian infants during their first 2 years of life. The goals of well-baby care include immunization (see other guideline), provision of parental counselling on safety, nutrition and behavioural problems, and to identify and treat physical, developmental and parenting problems. This is an update of the 1990 Canadian Task Force report.

Burden of Suffering

The goals of visits for well-baby care are 1) to immunize, 2) to provide parents with reassurance and counselling on safety, nutrition and behavioural problems; and 3) to identify and treat physical, developmental and parenting problems.

Unintentional Injury
Trauma is the leading cause of death among children over 1 year of age. In developed countries injuries cause at least four times more childhood deaths than any disease. The leading cause of death among Canadian children is motor vehicle accidents; this is followed in descending order by drowning, burns, choking and falls.

Sleep Problems
Night-time awakening and crying in children beyond the age when infants require night-time feeding occurs in at least 20% of children in the first few years of life.

Hearing Problems
Severe bilateral congenital deafness is found in 1 of every 2000 newborns. If profound hearing loss is not identified within the first year of life the likelihood that the child will have intelligible speech and attain educational standards commensurate with intellectual ability will be greatly reduced.

Amblyopia
The prevalence of amblyopia depends on the criterion used to measure it. If a corrected visual acuity of 6/12 (20/40) or worse is used, 2% of the population is affected.

Congenital Hip Dislocation
Incidence estimates vary from 2 to 50 per 1,000 live births, depending on the thoroughness of the investigation, racial differences, and the transient laxity of ligaments during the first few weeks of life.

Developmental Delay
Mental retardation, defined for statistical purposes as an intelligence quotient at least two standard deviations below the mean as determined by a standard test of intelligence, occurs by definition in 2% to 3% of children.

Parenting Problems and Maltreatment
The prevalence of maltreatment in the U.S. is estimated at 1% to 2% among children under 18 years. The outcomes of such maltreatment include death, disfigurement, disability, developmental delay and emotional problems.

Options

Options include visiting schedules, frequency of visits, and proposed agenda items for each visit.

Outcomes

Prevention of childhood injuries, increased and early identification of diseases, disorders and problems in children, improved parenting skills and parenting satisfaction, and improved sleeping patterns of children.

Evidence

MEDLINE was searched for 1990 - May 1993 using MeSH terms hip dislocation, congenital; heart defects, congenital; mass screening; ocular motility disorders; hearing disorders; counselling; accident; child abuse; crying; sleep disorders; child development disorders and child behavior.

Recommendations were graded as:

A Good evidence to support the recommendation that the condition be specifically considered in a PHE.

B Fair evidence to support the recommendation that the condition be specifically considered in a PHE.

C Poor evidence regarding inclusion or exclusion of the condition in a PHE, but recommendations may be made on other grounds.

D Fair evidence to support the recommendation that the condition be specifically excluded from consideration in a PHE.

E Good evidence to support the recommendation that the condition be specifically excluded from consideration in a PHE.

Quality of evidence was rated according to 5 levels:

I Evidence from at least 1 properly randomized controlled trial (RCT).

II-1 Evidence from well-designed controlled trials without randomization.

II-2 Evidence from well-designed cohort or case-control analytic studies, preferably from more than 1 centre or research group.

II-3 Evidence from comparisons between times or places with or without the intervention. Dramatic results in uncontrolled experiments could also be included here.

III Opinions of respected authorities, based on clinical experience, descriptive studies or reports of expert committees.

Values

The 13-member Task Force of experts in family medicine, geriatric medicine, pediatrics, psychiatry and epidemiology used an evidence-based method for evaluating the effectiveness of preventive health care interventions. Recommendations were not based on cost-effectiveness of options. Patient preferences were not discussed.

Background papers providing critical appraisal of the evidence and tentative recommendations prepared by the chapter author were pre-circulated to the members. Evidence for this topic was presented and deliberated upon in 1- to 2-day meetings, 2 to 3 times per year from January 1993 to June 1993. Consensus was reached on final recommendations.

Benefits, Harms, and Costs

Some, but not all RCTs have shown that safety instruction for parents reduces injuries for their children. 1 RCT of low-income families showed that prenatal and postnatal counselling was associated with less anemia, better nutrition, and fewer behavioural problems at 5 to 6 years. An RCT showed that counselling reduced the prevalence of night-time crying.

A cohort study showed that children with profound hearing loss had better sentence construction if hearing aids and training were introduced before 3 years of age. Another cohort study showed that infants who had their eyes aligned for correction of congenital esotropia before they were 24 months old had fewer problems with binocularity. A cohort study also showed that less surgery was required and long-term results were better for children who had their congenital hip dislocation fixed before the age of 1 month compared with repair at 1 year.

Few measures to prevent mental retardation exist but environmentally challenged infants may have enhanced mental development with an enriched environment.

In terms of frequency of well-baby care visits, an Canadian RCT showed that infants who received 5 to 6 visits in their first 2 years did not differ for most outcomes when compared with infants who received 10 visits in their first 2 years.

Recommendations

Recommendation grade [A, B, C, D, E] and level of evidence [I, II-1, II-2, II-3, III] are indicated after each recommendation. Citations in support of individual recommendations are identified in the guideline text.

Good evidence exists to include counselling to reduce risk factors in the home in the PHE of families with well babies [A, I]. (Topics include: safety gates, cupboard and drawer locks, hot water temperature, and isolation of sharp objects and electrical outlets) .
Good evidence exists to include counselling for anticipatory guidance for night-time crying in the PHE of families with well babies [A, I].
Good evidence exists to include repeated examinations of the hips, eyes, and hearing in the PHE of well babies, especially in the first year [A, II-2, III].
Link to Recommendation Table of 2001 update: Screening and management of developmental dysplasia of the hip in newborns
Fair evidence exists to include enquiries about the achievement of developmental milestones at each visit of families with well babies [B, II-2].
Fair evidence exists to include serial measurements of height, weight, and head circumference in the PHE of well babies [B, II-2, III].

Validation

This report was externally peer reviewed. The College of Family Physicians of Canada recommended an extra visit during the first month because of the pattern of early discharge. The Canadian Pediatric Society also recommended a visit in the first month plus another visit at 9 months. In 1989 the United States Preventive Services Task Force recommended clinical prudence should be used to provide counselling on reducing the risk of unintentional household or environmental injuries from falls, drowning, fires or burns, poisoning, and firearms and that clinicians be alert for ocular misalignment, measure the height and weight of children, and plot these on a growth chart throughout infancy and childhood.

Selected References

Source Document

Feldman W. Well-Baby care in the first 2 years of life. In: Canadian Task Force on the Periodic Health Examination. Canadian Guide to Clinical Preventive Health Care. Ottawa: Health Canada, 1994; 258-66.

Other

Canadian Task Force on the Periodic Health Examination: The periodic health examination, 1990 update: 4. Well-baby care in the first 2 years of life. Can Med Assoc J. 1990;143:867-72.

Link to Full Text of this review

Link to Summary Table of Recommendations of this review

Link to Selected References list of this review

Link to New Evidence-Based Rourke Baby Records

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A	Good evidence to support the recommendation that the condition be specifically considered in a PHE.
B	Fair evidence to support the recommendation that the condition be specifically considered in a PHE.
C	Poor evidence regarding inclusion or exclusion of the condition in a PHE, but recommendations may be made on other grounds.
D	Fair evidence to support the recommendation that the condition be specifically excluded from consideration in a PHE.
E	Good evidence to support the recommendation that the condition be specifically excluded from consideration in a PHE.

I	Evidence from at least 1 properly randomized controlled trial (RCT).
II-1	Evidence from well-designed controlled trials without randomization.
II-2	Evidence from well-designed cohort or case-control analytic studies, preferably from more than 1 centre or research group.
II-3	Evidence from comparisons between times or places with or without the intervention. Dramatic results in uncontrolled experiments could also be included here.
III	Opinions of respected authorities, based on clinical experience, descriptive studies or reports of expert committees.