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RESOURCES 1: General (February 20, 2014)
GROWTH
Important: Corrected age should be used at least until 24 to 36 months of age for premature infants
born at <37 wks gestation.
Measuring growth - The growth of all term infants, both breastfed and non breastfed, and preschoolers should be evaluated using Canadian Growth Charts from the 2006 World Health
Organization Child Growth Standards (birth to 5 years) with measurement of recumbent length (birth
to 2-3 years) or standing height (≥ 2 years), weight, and head circumference (birth to 2 years).
CPS Position Statement
WHO Growth Charts Adapted for Canada
NUTRITION - Nutrition for healthy term infants
0-6 months
6-24 months
CPS Practice Point 0-6 months
-Ontario Society of Nutrition Professionals in Public Health
NutriSTEP®
Dietitians of Canada
Breastfeeding: Exclusive breastfeeding is recommended for the first six months of life for healthy
term infants. Breast milk is the optimal food for infants, and breastfeeding (with complementary
foods) may continue for up to two years and beyond unless contraindicated. Breastfeeding reduces
gastrointestinal and respiratory infections and helps to protect against SIDS. Maternal support (both antepartum and postpartum)
increases breastfeeding and prolongs its duration. Early and frequent mother-infant contact,
rooming in, and banning handouts of free infant formula increase breastfeeding rates.
Routine Vitamin D supplementation of 400 IU/day (800 IU/day in high-risk infants) is
recommended for all breastfed infants until the diet provides a sufficient source of Vitamin D
(~ 1-2 years). Breastfeeding mothers should continue to take Vitamin
D supplements for the duration of breastfeeding.
CPS Position Statement
Colic - CPS Position Statement
Introduction of solids should be led by the infant's signs of readiness - a few weeks before to just after 6 months.
Iron containing foods: At ~6 months, start iron containing foods to avoid iron deficiency.
Allergenic foods: Delaying the introduction of priority food allergens is not currently recommended to prevent food allergies,
including for infants at risk of atopy. CPS Position Statement
Avoid honey until 1 year of age to prevent botulism.
Dietary fat content: Restriction of dietary fat during the first 2 years is not recommended since it may compromise the intake of energy and essential fatty acids, required for growth and development. A gradual transition from the high-fat infant diet to a lower-fat diet begins after age 2 years as per Canada's Food Guide.
Encourage a healthy diet as per Canada's Food Guide
Vegetarian diets -
CPS Position Statement
Fish consumption: 2 servings/week of low mercury fish -
Health Canada
INJURY PREVENTION: In Canada, unintentional injuries are the leading cause of death in children
and youth. Most of these preventable injuries are caused by motor vehicle collisions, drowning,
choking, burns, poisoning, and falls.
Parachute, About Injuries
CPS Position Statement
Transportation in motor vehicles:
AAP article
Children < 13 years should sit in the rear seat. Keep children away from all airbags.
Install and follow size recommendations as per specific car seat model and keep child in each stage
as long as possible.
Use rear-facing infant/child seat that is manufacturer approved for use until age 2 years.
Use forward-facing child seat after 2 years for as long as manufacturer specifications will allow.
After this, use booster seat up to 145 cm (4'9").
Use lap and shoulder belt in the rear middle seat for children over 8 yrs who are at least 36 kg (80 lb) and 145
cm (4'9") and fit vehicle restraint system.
Bicycle: wear bike helmets and advocate for helmet legislation for all ages. Replace if heavy impact or sign of damage. CPS Position Statement
Drowning:
CPS Position Statement
- Bath safety: Never leave a young child alone in the bath. Do not use infant bath rings or bath seats.
- Water safety: Recommend adult supervision, training for adults, 4-sided pool fencing, lifejackets,
swimming lessons, and boating safety to decrease the risk of drowning.
Choking: Avoid hard, small and round, smooth and sticky solid foods until age 3 years. Use safe
toys, follow minimum age recommendations, and remove loose parts and broken toys.
Burns: Install smoke detectors in the home on every level.
Keep hot water at a temperature < 49°C.
Poisons: Keep medicines and cleaners locked up and out of child's reach. Have Poison Control
Centre number handy. Use of ipecac is contraindicated in children.
Falls: Assess home for hazards- never leave baby alone on change table or other high surface; use window guards and stair gates. Baby walkers are banned in Canada and should never be used. Ensure stability of furniture and TV. Advise against trampoline use at home.
CPS Position Statement
Safe sleeping environment:
CPS Position Statement
- Sleep position and SIDS/Positional plagiocephaly: Healthy infants should be positioned on
their backs for sleep. Their heads should be placed in different positions on alternate days.
Sleep positioners should not be used. While awake, infants should have supervised tummy
time. Counsel parents on the dangers of other contributory causes of SIDS such as overheating,
maternal smoking or second-hand smoke.
- Bed sharing: Advise against bed sharing which is associated with an increased risk for SIDS.
- Crib safety/Room sharing: Encourage putting infant in a crib, cradle or bassinette, that meets
current Health Canada regulations in parents' room for the first 6 months of life. Room sharing is protective against SIDS.
Pacifier use may decrease risk of SIDS and should not be discouraged in the 1st year of life after breastfeeding is
well established, but should be restricted in children with chronic/recurrent otitis media. CPS Position Statement
Firearm safety: Advise on removal of firearms from home or safe storage to decrease risk of unintentional firearm injury, suicide, or homicide. CPS Position Statement
ENVIRONMENTAL HEALTH
Second-hand smoke exposure: contributes to childhood illnesses such as URTI, middle ear
effusion, persistent cough, pneumonia, asthma, and SIDS.
Sun exposure/sunscreens/insect repellents: Minimize sun exposure. Wear protective clothing,
hats, properly applied sunscreen with SPF ≥ 30 for those > 6 months of age. No DEET in < 6
months; 6-24 months 10% DEET apply max once daily; 2 - 12 yrs 10% DEET apply max TID.
Pesticides: Avoid pesticide exposure. Encourage pesticide-free foods.
OCFP review
Lead Screening is recommended for children who: CFP article: Lead and Children
- in the last 6 months lived in a house or apartment built before 1978;
- live in a home with recent or ongoing renovations or peeling or chipped paint;
- have a sibling, housemate, or playmate with a prior history of lead poisoning;
- live near point sources of lead contamination;
- have household members with lead-related occupations or hobbies;
- are refugees aged 6 mo - 6 yrs, within 3 months of arrival and again in 3-6 months.
Even for blood levels less than 10ug/dL, evidence suggests an association, and perhaps partial
causal relationship with lower cognitive function in children.
CPS article: Lead levels in Canadian children: Do we have to review the standard?
Websites about environmental issues:
OTHER
Advise parents against using OTC cough/cold medications.
Restricting Cough and Cold Medicines in Children
Complementary and alternative medicine (CAM): Questions should be routinely asked on the use of homeopathy and other complementary and alternative medicine therapy or products, especially for children with chronic conditions. CPS Position Statement
Fever advice/thermometers: Fever ≥ 38°C in an infant < 3 months needs urgent evaluation.
Ibuprofen and acetaminophen are both effective antipyretics. Acetaminophen remains the
first choice for antipyresis under 6 months of age; thereafter ibuprofen or acetaminophen may
be used. Alternating acetaminophen with ibuprofen for fever control is not recommended in
primary care settings as this may encourage fever phobia, and the potential risks of medication
error outweigh measurable clinical benefit. -
CPS Position Statement
Dental Care:
- Dental Cleaning: As excessive swallowing of toothpaste by young children may result in dental
fluorosis, children 3-6 years of age should be supervised during brushing and only use a small amount (e.g. pea-sized portion) of
fluoridated toothpaste twice daily. Children under 3 years of age should have their teeth and gums brushed twice daily by an adult
using either water (if low risk for tooth decay) or a rice grain sized portion of fluoridated toothpaste (if at carries risk).
- Systemic fluoride and/or fluoride varnish should be considered based on caries risk assessment
American
Academy Of Pediatric Dentistry Assessment tool, CDA Position Statement
- To prevent early childhood caries: avoid sweetened juices/liquids and constant sipping of milk or
natural juices in both bottle and cup.
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PHYSICAL EXAMINATION
Fontanelles - The posterior fontanelle is usually closed by 2 months and the anterior by 18 months.
Vision inquiry/screening:
CPS Position Statement
- Check Red Reflex for serious ocular diseases such as retinoblastoma and cataracts.
- Corneal light reflex/cover-uncover test & inquiry for strabismus: With the child focusing on a
light source, the light reflex on the cornea should be symmetrical. Each eye is then covered in
turn, for 2 - 3 seconds, and then quickly uncovered. The test is abnormal if the uncovered eye
"wanders"" OR if the covered eye moves when uncovered.
- Check visual acuity at age 3-5 years.
Hearing inquiry/screening - Any parental concerns about hearing acuity or language delay should
prompt a rapid referral for hearing assessment. Formal audiology testing should be performed
in all high-risk infants, including those with normal UNHS. Older children should be screened if
clinically indicated.
Inspect tongue mobility for ankyloglossia. CPS Position Statement
Tonsil size/sleep-disordered breathing - Screen for sleep problems (behavioural sleep problems and snoring in
the presence of sleep-disordered breathing which warrants assessment re obstructive sleep apnea). AAP article
Muscle tone - Physical assessment for spasticity, rigidity, and hypotonia should be performed.
Hips - There is insufficient evidence to recommend routine screening for developmental
dysplasia of the hips, but examination of the hips should be included until at least one year, or
until the child can walk.
AAP article
INVESTIGATIONS/SCREENING
Anemia screening: All infants from high-risk groups for iron deficiency anemia require screening
between 6 and 12 months of age, e.g. Lower SES; Asian; First Nations children; low-birth-weight and
premature infants, and infants fed whole cow's milk during their first year of life.
Hemoglobinopathy screening: Screen all neonates from high-risk groups: Asian, African & Mediterranean.
Universal newborn hearing screening (UNHS) effectively identifies infants with congenital hearing loss
& allows for early intervention & improved outcomes.
CPS Position Statement
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