Overview
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.
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)
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.
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.
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.
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).
Unanswered Questions (Research Agenda)
Full Citation
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.