Canadian Task Force on Preventive Health Care

Full Text Review

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

Up Contents

UpOverview

In 1990, the Canadian Task Force on the Periodic Health Examination reviewed the evidence on various elements of well-baby care <1> and found good evidence for immunization against diphtheria, measles, mumps, pertussis, poliomyelitis, rubella and tetanus and Hemophilus influenzae type B (HIB) infection during well-baby examinations (A Recommendation). Since that time the effectiveness of immunization against hepatitis B infection has been established. The subject of childhood immunization, however, is dealt with in a separate section and will not be covered here. (See section on Immunization of Children and Adults.) In its 1979 report, the Task Force found fair evidence to support inclusion of clinical examination for disorders of physical growth (serial measurement of height and weight) in the periodic health examination of well infants and children (B Recommendation). This recommendation is brought forward without evaluation of new evidence. In 1990, the Task Force concluded that there was good evidence to support counselling to reduce injury risk factors in the home, as well as anticipatory guidance for night-time crying. The subject of risk reduction is also dealt with in Chapter 28 on Prevention of Household and Recreational Injuries in Children. On the basis of good detection maneuvers, effective treatment, and the alleviation of the burden of suffering, an A Recommendation was given to certain components of the physical examination, specifically examination of the hips, the eyes, and of hearing during well-baby care in the first year of life. New evidence relating to screening for congenital hip disease <2,3> and deafness<4> has been published and is reviewed here. We also found fair evidence that enquiring about developmental milestones may lead to effective environmental stimulation in infants with developmental delay caused by environmental deprivation (B Recommendation) and no evidence that screening for potential child abuse is effective (C Recommendation). The subject of prevention of child abuse is currently reviewed in Chapter 29 on Primary Prevention of Child Maltreatment which reviews this topic in detail. For recommendations on various other issues in pediatric preventive health care see the section on Pediatric Preventive Care.

Up 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 behavioral 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. The morbidity rate is also considerable, although the true rate is impossible to ascertain since only in-patient data are gathered systematically. Disfigurement, disability, developmental delay and emotional problems are major sequelae of accidental injuries to children.

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.<5>

Hearing Problems

Severe bilateral congenital deafness is found in 1 of every 2,000 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

Controversy exists regarding the incidence of congenital hip dislocation, estimates varying from 2 to 50 per 1,000 live births.<6> These wide differences in estimates of incidence may be explained by differences in the infants’ ages at examination, in the thoroughness and skill of the examiners and by racial differences. The higher prevalence observed in the neonatal period is likely due to the transient laxity of ligaments during the first few weeks of life. Over diagnosis presents certain risks. First, a proportion of subluxatable hips become stable spontaneously during the first year of life. In addition, over-aggressive abduction treatment may be harmful, leading to avascular necrosis of the femoral head.

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 Child Maltreatment

The true incidence of parenting problems leading to child abuse in the first 2 years of life is unknown since it is not known what proportion of cases are reported. In the United States the estimated prevalence of maltreatment is 1% to 2% among children under 18 years of age. The outcomes of such maltreatment include death, disfigurement, disability, developmental delay and emotional problems. (See Chapter 29 on Primary Prevention of Child Maltreatment)

Up Maneuver

During the era in which healthy newborns were kept in hospital for 5-7 days the Task Force recommended six well-baby visits for healthy term infants born to primiparous women (one within the first month and then at 2, 4, 6, 12 and 18 months) to include 1) an assessment of growth and development as well as parenting skills; 2) counselling on nutrition, safety and common problems such as night-time crying; 3) physical examination, particularly for hearing impairment (parents were asked about their concerns regarding the infant’s hearing, and the response to the clap test is noted), strabismus (as determined through the cover test and the light reflex test) and congenital anomalies such as hip dislocation (as determined through the Ortolani test); and 4) immunization.<1>

Since the recent shift to early discharge of healthy full-term newborns at 1-3 days after birth from the previous discharge policy of 5-7 days of age, the optimum timing of the first well-baby visit has not been established in terms of effectiveness. Previously, problems such as feeding difficulties, jaundice, etc., were usually dealt with while infants were still in hospital. Now, such problems may arise after the baby has been discharged. For these reasons a well-baby visit during the first week or two may well be advisable for primiparous as well as multiparous women, although the effectiveness of this schedule has not been examined through clinical research studies.

With regard to screening for hearing, a recent National Institute of Health Consensus Statement on early identification of hearing impairment in infants and young children recommended universal screening by 3 months of age using auditory brainstem responses (ABR) or evoked otoacoustic emissions (OCE). The statement acknowledges a high false positive rate using either technique and that much of the evidence is descriptive. There are no randomized trials supporting the benefits of early identification and intervention<4>; until there is better evidence that universal screening using ABR or OCE is superior to enquiring of parents and the clap test in long-term outcome, the latter approaches continue to be recommended.

Counselling on safety should include a recommendation to maintain the temperature in the hot water heater at less than 54.46°C (120°F), to safety-proof cupboards and drawers containing medicines, cleaners and solvents, to put up gates across stairways and to prevent access to sharp objects or electric outlets.

Anticipatory guidance for persistent night-time crying involves enquiring at the 6-month visit whether the infant is sleeping through the night and, if not, whether this is distressing to the parents. If so, systematic ignoring is recommended.

Universal newborn screening for congenital hip disease using ultrasound is being done in a number of European centres, but the incidence of infants judged to be in need of treatment differs considerably in different centers, suggesting that the diagnostic methods and criteria need further study.<2> In another study, ultrasound was used only for those newborns whose hips were "doubtful" after clinical assessment; the authors report good results with this approach.<3> Until there is good evidence that routine ultrasound leads to better long-term outcome than physical exam of the hips, the latter approach continues to be recommended.

Up Effectiveness of Prevention and Treatment

In 1977 Dershewitz and Williamson<7> reported the results of a randomized controlled trial of the prevention of childhood household injuries through an educational program. They found no differences in the total household hazard scores between the experimental and control groups. However, the two groups were of above average socioeconomic status. Thus, a reasonably high level of safety may have existed in both groups prior to the intervention. More recent randomized controlled trials involving lower socioeconomic groups have shown that safety education during visits for well-baby care can lower the risk of injury.<8> However, very large samples are required to show significant differences in the actual rates of injury, and these studies did not have significant power to do so. Educational programs designed to enhance infant protection in cars do not appear to be effective in jurisdictions where such protection has not been legislated. This subject is reviewed in detail in Chapter 44 on Prevention of Motor Vehicle Accident Injuries.

In a randomized controlled trial involving low-income families prenatal and postnatal counselling with anticipatory guidance in 19 visits of 1 hour each during the first 3 years of life were compared with routine well-baby care in the control group. The intervention was associated with less anemia, better infant nutrition and fewer behavioral problems at 5 and 6 years of age. In current clinical practice, whether the schedule recommended by the Canadian Pediatric Society (eight visits in the first 2 years) or that of the American Academy of Pediatrics (nine visits) is followed, the amount of time spent in counselling and anticipatory guidance (usually a few minutes) is far less than was provided in the aforementioned study.<9> As a result of iron supplementation of food in Canada iron deficiency anemia is rare. The issue of iron deficiency is discussed in detail in Chapter 23 on prevention of Iron Deficiency Anemia in Infants.

Night-time crying, a particularly vexing problem, frequently arises as an issue during visits for well-baby care. There is now level I evidence (from a randomized controlled trial) that counselling significantly reduces the prevalence of this problem.<5> The early detection of certain physical problems, such as deafness, strabismus and congenital hip dislocation, can lead to effective interventions that prevent important physical and emotional difficulties. Although there have been no randomized controlled trials of the effectiveness of combined screening and intervention programs for such problems, the natural histories of undetected congenital deafness, strabismus and hip dislocation indicate considerable suffering and disability.

A study involving children with profound hearing loss (at least 70 dB in the speech frequencies) compared intervention with hearing aids and special training begun before and after 3 years of age. Sentence construction of those exposed to early (as opposed to late) intervention more closely matched that of control subjects with normal hearing. Unfortunately, confounding variables such as parent education were not assessed.

Although there is some controversy surrounding the exact age at which correction of congenital esotropia is essential to prevent amblyopia or failure of binocular vision,<10> current ophthalmological practice has been influenced by a cohort study in which infants whose eyes were aligned before 24 months of age had significantly fewer problems with binocularity.<11>

In a study of congenital hip dislocation the amount of open surgery required was much less and the long-term results much better among infants whose condition has been diagnosed at birth and treated with abduction splints before 1 month of age than among those diagnosed later in the first year.<6>

Other than the specific instances of phenylketonuria and hypothyroidism (usually diagnosed in the neonatal period) few measures to prevent mental retardation are available. For environmentally deprived infants an enriched environment may enhance mental development.

Frequency of Visits for Well-baby Care

A recent randomized controlled trial in Canada, involving healthy term neonates in intact families from all social classes, showed that the goals of well-baby care were achieved as well in a group randomly allocated to 5 or 6 visits coinciding with immunizations, as compared with a group allocated to 10 visits during the first 2 years. There were no differences in 1) physical status (assessed by a pediatrician blinded to group assignments); 2) developmental status at 2 years of age (assessed by the Mental Development Index of the Bayley scales of infant development; 3) maternal knowledge of child-rearing or maternal anxiety (as measured by the Hulka Infancy Questionnaire); 4) safety and infant stimulation in the home (determined by the Home Observation for Measurement of the Environment test); and 5) parent-initiated visits as a result of illness. The sample size provided adequate statistical power to detect any clinically significant differences.

Up Recommendations of Others

In 1990 the College of Family Physicians of Canada, concurred with the recommendations of the Task Force for an additional visit within the first month for infants of primiparous women. The Canadian Pediatric Society also recommended a visit within the first month as well as an additional visit at nine months for all well babies.

In 1989, the U.S. Preventive Services Task Force recommended that clinical prudence should be used to provide counselling on measures to reduce the risk of unintentional household or environmental injuries from falls, drownings, fires or burns, poisoning, and firearms. They also recommended that clinicians should be alert for signs of ocular misalignment when examining infants and that the height and weight of children should be measured regularly and plotted on a growth chart throughout infancy and childhood.<12> Their recommendation on screening for hearing impairment is currently under review.

Up Conclusions and Recommendations

There is good evidence for counselling about risk factors for accidental injury in the home during all well-baby visits. (A Recommendation) Anticipatory guidance particularly with regard to night-time crying beyond the expected age is also recommended (A Recommendation). Although repeated examination of hips and hearing is recommended, (A Recommendation) there is insufficient evidence at this time to recommend that routine use of ABR or OCE for hearing screening of healthy babies should replace regular assessment of hearing during well-baby visits using parental questioning and the clap test. Additionally, there is insufficient evidence at this time to recommend that routine ultrasound examination of the hips should replace clinical assessment of the hips in the nursery and during well-baby visits. Repeat examination of the eyes for strabismus is recommended during well-baby visits, especially during the first six months (A Recommendation). There is fair evidence to assess developmental milestones at each visit, since, for infants with developmental delay due to lack of stimulation, an enriched environment may be effective (B Recommendation). There is fair evidence for serial measurements of height, weight and head circumference (B Recommendation).

 Up Unanswered Questions (Research Agenda)

  1. Is routine hearing screening of healthy babies using ABR or OCE more effective than traditional means during well-baby visits, in terms of the long-term outcome of oral language development?
  2. Is routine hip screening using ultrasound more effective than clinical assessment in terms of long-term outcome?
  3. The optimum frequency and timing of well baby visits needs to established.

Up Evidence

A MEDLINE search from 1990 to May 1993 was conducted for the mesh headings 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. This review was undertaken in May 1993 and updates a report published in 1990. Recommendations were finalized by the Task Force in March 1994.

 Full Citation

Link to Structured Abstract of this review

Link to Summary Table of this review

Link to Selected References list of this review

Link to New Evidence-Based Rourke Baby Records

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