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.
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.
Sponsors
The Canadian Task Force on Preventive Health
Care developed this guideline with funding from Health Canada.
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.