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CPS Statements > Community Paediatrics > Flashcards

Community Paediatrics Flashcards

1
Q

What is primary nocturnal enuresis? secondary?

A
  • involuntary discharge of urine at night by children old enough to be expected to have bladder control
  • primary = bladder control has never been attained
  • secondary = incontinence recurs after at least 6 months of continence
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2
Q

When can you start saying a child has enuresis?

A

-regular bed wetting (more than 2x/wk) beyond age of 5 yrs

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3
Q

How common is bedwetting?

A
  • 10-15% of 5 yr olds
  • 6-8% of 8 year olds
  • 1-2% of 15 year old
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4
Q

When should you treat enuresis with pharmacotherapy and/or alarms?

A

-only if it poses a significant problem of the child

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5
Q

What routine tests should be ordered in a child with primary nocturnal enuresis?

A

-none if the hx and px are completely reassuring

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6
Q

What are RF for primary nocturnal enuresis?

A

positive family hx of the same

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7
Q

How does an alarm for nocturnal enuresis work?

A

-alarm goes off when the child starts to void and it will teach the child to wake up to the alarm and then by approximation to wake up to the sensation of a full bladder

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8
Q

How much do bed-wetting alarms cost?

A

$80

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9
Q

In which age group are bed-wetting alarms most effective?

A

kids >7-8 yrs

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10
Q

How would you tell a family to use a bed-wetting alarm?

A
  • continued use for 3-4 months
  • warn is often an initial improvement of decrease in urine output as opposed to being totally dry
  • continue until there have been 14 consecutive dry nights
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11
Q

What is the cure rate when using a bed-wetting alarm for primary nocturnal enuresis? What is the cure rate if pt relapses?

A

cure rate is 50%, rate is the same for relapses

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12
Q

What are down sides of the bed wetting alarm for primary nocturnal enuresis?

A
  • 50% cure rate

- needs a commitment from the entire family b/c can wake everybody up

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13
Q

In which pts should the bed wetting alarm for primary nocturnal enuresis be recommended?

A

-older, motivated children from motivated families for whom more simple measures are not successful

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14
Q

What is desmopressin?

A

-synthetic analogue of antidiuretic hormone

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15
Q

What are side effects of desmopressin?

A
  • headache
  • abdo pain
  • stuffiness
  • epistaxis
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16
Q

What is the dose of desmopressin for nocturnal enuresis?

A

-desmopressin acetate 200-600 microgram

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17
Q

For which populations do you need to use desmopressin with extreme caution?

A
  • kids with osmoregulation or fluid balance problems

- kids with CF

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18
Q

What instructions should you give to parents about desmopressin for their kids?

A

-avoid consuming fluids for one hour before and 8 hrs after taking desmopressin

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19
Q

When should desmopressin b prescribed for kids with primary nocturnal enuresis?

A
  • short-term only
  • camps
  • sleepovers
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20
Q

What are treatment options for patients with primary nocturnal enuresis?

A
  • alarm systems
  • desmopressin acetate
  • imipramine hydrochloride
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21
Q

For which patients with nocturnal enuresis could imipramine be prescribed to and at what dose? How long should they trial it before adjusting the dose?

A

Give to older, distressed kids if other treatments unsuccessful or contraindicated

  • kids 6-12 yrs = 25 mg (max 50 mg)
  • kids >12 yrs = 50 mg (max 75 mg)
  • give dose 1-2 hrs before bedtime
  • 2 week trial (maximal effect is noted within 1 wk)
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22
Q

What are side effects of imipramine?

A
  • personality changes
  • emotional lability
  • irritability
  • anxiety
  • disturbed sleep patterns
  • h/a
  • changes in appetite
  • RARE: sz, coma, cardiac arrhythmia from OD
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23
Q

Should you use sticker charts for rewarding dry nights in kids with nocturnal enuresis or ‘lifting’ (waking kid to void in the toilet)?

A
  • they may contribute to poor self esteem

- discuss with parents about potential adverse effects before instituting this

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24
Q

What are some behavioural modifications that can be recommended for primary nocturnal enuresis?

A
  • clarify the goal of getting up at night and using the toilet
  • assure the child’s access to the toilet
  • avoid caffeine-containing foods and excessive fluids before bedtime
  • take the child out of diapers (training pants are ok)
  • incude the child in the morning cleanup in a non punitive manner
  • preserve their self-esteem
  • if the pt is not distressed then they do not need treatment
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25
Q

What is preferred to transport a threatened preterm labour in utero or after baby is born?

A

in utero

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26
Q

Why is there a need for a specialized neonatal transport team?

A
  • enhanced survival of neonate

- fewer adverse events

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27
Q

What is the typical make up of a neonatal transport team?

A

RT and RN
(better with an RN led team than a physician led team)
RTs more successful at incubations than residents

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28
Q

What equipment needs to be included for a neonatal transport?

A

-portable isolette
-ventilator
-medical air
-oxygen
iNO
-suction
-monitors for vital signs
-pulse oximetry
-capnography
-defibrillator
-point of care testing
-satellite or cell phone

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29
Q

What are physiological side effects of transport for the baby and how can these be prevented or minimized?

A
  • hypothermia - use a warming mattress
  • ambient noise - ear muffs
  • vibrations - air foam mattress and gel pillow
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30
Q

Who is legally responsible for the baby being transported from the community to a territory care setting?

A
  • tertiary institutions share the medicolegal responsibility as soon as they are aware of them
  • referral and transport team shares legal responsibility during stabilization
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31
Q

What is used for quality assurance of neonatal transport teams?

A
  • central access point

- database that captures severity of illness, transport times etc

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32
Q

What is tongue-tie?

A

ankyloglossia = abnormally short lingual frenulum which can cause decreased tongue mobility

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33
Q

What are the criteria to diagnose ankyloglossia?

A

-no universally accepted definition or criteria

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34
Q

How common is ankyloglossia?

A

4.2-10.7% of newborns

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35
Q

What are the concerns about ankyloglossia?

A
  • anecdotal reports linking it to poor latch, maternal nipple pain and trauma, suboptimal infant weight gain, infant breast refusal, low maternal milk supply due to poor milk removal
  • no absolute relationship btwn ankyloglossia and breastfeeding difficulties
  • remember to rule out other oral anomalies
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36
Q

What is the management of ankyloglossia?

A
  • usually conservative with some lactation support

- if there are signifiant breastfeeding difficulties then there is some evidence for frenotomy

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37
Q

What is a frenotomy and who should do it?

A
  • simple incision or snipping of tongue tie is most common
  • should be done by ENT or trained physician
  • give analgesia during procedure
  • some more complicated procedures exist
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38
Q

What are the complications of frenotomy for tongue-tie?

A
  • bleeding
  • infection
  • injury to Wharton’s duct
  • post operative scarring (which can limit tongue movement further)
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39
Q

What % of boys and what % of girls will have had a UTI by age 7 years?

A
  • 8% of girls

- 2% of boys

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40
Q

Which children should get antibiotic prophylaxis after a UTI?

A
  • not routinely recommended

- consider it for kids with grade IV or V VUR or significant urological abnormality

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41
Q

If you are going to use antibiotics for prophylaxis after UTI which one should you use and for how long?

A

-use for 3-6 months and reassess if the abnormality still exists
-TMP-SMX or nitrofurantoin
(nitrofurantoin needs to compounded into suspension in a special pharmacy)

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42
Q

What is the dose of prophylactic antibiotics for UTI?

A
  • septra or nitrofurantoin
  • no specific guidelines
  • traditionally used 1/4 to 1/3 of the daily total treatment dose but given once a day
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43
Q

What do you do with antibiotic prophylaxis in a child who grew a bug resistant to the prophylaxis?

A

-stop or change the prophylaxis even if you think the bug is a contaminant

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44
Q

What criteria should you use to do a UA and UCx in kids

A

-fever >39 without a source

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45
Q

What criteria should you use to do a UA and UCx in kids > 3 yrs?

A
  • dysuria
  • frequency
  • hematuria
  • abdo pain
  • back pain
  • new daytime incontinence
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46
Q

What is the contamination rate of bag samples for urine? What is the utility of a bag sample?

A

63%

-a negative bag culture rules out a UTI but a positive result is not useful

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47
Q

What do you look for on a dipstick (macroscopic urinalysis) that is suggestive of a UTI?

A
  • positive nitrites test makes UTI very likely

- positive leukocyte esterase (as a indirect measure of pyuria)

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48
Q

What are nitrites and what causes false negative nitrites on a dipstick?

A
  • nitrites are a breakdown product of nitrates that are broken down by gram-negative bacteria
  • are very specific for UTI (98%)
  • False negatives: if bladder emptied frequently, if is gram-positive organism, if is a gram neg that does not metabolize nitrate
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49
Q

What is leukocyte esterase and what causes it to be falsely negative on dipstick?

A
  • indirect measure of pyuria

- falsely negative if leukocytes are present in low concentration

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50
Q

What is the definition of pyuria?

A
  • not a uniform definition

- 10 WBC per microL in uncentrifuged urine OR >5 WBC/hfp

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51
Q

What are the most frequent bugs that cause UTIs in kids > 2 months?

A
  • E coli
  • Klebsiella
  • Enterobacter
  • Citrobacter
  • Serratia
  • Staph saprophyticus (in female teens)
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52
Q

What is the minimum colony count indicative of a UTI with a midstream urine?

A

> or equal to 10^5 CFU/mL or > or equal to 10^8 CFU/L

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53
Q

What is the minimum colony count indicative of a UTI with a in and out cath urine?

A

> or equal to 5x 10^4 CFU/mL or > or equal to 5 x 10^7 CFU/L

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54
Q

What is the minimum colony count indicative of a UTI with a suprapubic aspiration urine?

A

any growth

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55
Q

What route for antibiotics is the first like for febrile UTI in a nontoxic child?

A

oral

-except in kids 2-3 months of age where some experts recommend starting with IV therapy

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56
Q

What is the best first line PO agent for febrile UTI?

A

Cefixime 8mg/kg/day as a single dose

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57
Q

What is the best first line IV agent for febrile UTI?

A 
Gentamicin IV (5-7.5mg/kg q24) +/- Ampicillin (200mg/kg/day div q6h)
--can use Cefotaxime instead of gent but these are broader spectrum so better to use Gent
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58
Q

What features suggest a complicated UTI?

What is the work up of a kid with suspected complicated UTI and what are you looking for?

A
  • hemodynamically unstable
  • elevated creatinine
  • bladder or abdominal mass
  • poor urine flow
  • not improving clinically within 24 hrs
  • fever not trending downward within 48h of appropriate abx

-do AUS looking for obstruction or abscess

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59
Q

What are the symptoms of cystitis (lower UTI) and how do you treat it?

A
  • UTI sx without fever; frequency and dysuria
  • most common in post pubertal girls
  • 2-4 day course of PO abx based on local E coli susceptibilities
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60
Q

When do you do an AUS for kids with first febrile UTI? When do you do it and why?

A

-age

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61
Q

When do you consider VCUG and what is it used for?

A
  • to diagnose VUR and for assessing the degree of VUR
  • do VCUG for kid with second episode febrile UTI or if AUS is suggestive of renal abnormality, obstruction or high grade VUR
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62
Q

What are the risks associated with VCUG?

A

expensive
exposure to radiation
risk of introducing infection
discomfort for the child

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63
Q

What is a DMSA scan? What is it used for? What are side effects?

A
  • used to diagnose acute pyelonephritis when done during acute illness and to identify renal scars when done months after an acute illness
  • involves radiation
  • useful when the diagnosis of acute UTI or of repeated UTIs is in doubt
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64
Q

How long should a child with febrile UTI be treated with abx?

A

7-10 days

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65
Q

Which infants are considered high risk for developing allergy?

A

-has a first degree relative (at least one parent or sibling) with atopic dermatitis, food allergy, asthma or allergic rhinitis

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66
Q

What foods should you avoid during pregnancy to help prevent allergy in the baby?

A

none

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67
Q

What foods should be restricted during breastfeeding to help prevent allergy in the baby? Which allergy is there possibly evidence for for restricting maternal diet?

A

No foods should be restricted but there is the possibility that restriction may help prevent atopic eczema.

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68
Q

When should you introduce allergenic foods (peanuts, fish, eggs, etc)?

A
  • do not delay bc this can actually increase the risk of allergy development
  • no convincing evidence to delay introduction beyond 4-6 months
  • CPS currently recommends exclusive breastfeeding until 6 months but evidence may change to say ok to introduce earlier
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69
Q

What principles are important when introducing foods such as peanuts, fish, eggs etc to babies?

A

-early introduction and regular exposure to induce tolerance (several times per week)

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70
Q

If you are choosing a formula for a baby which should you choose to minimize allergy risk?

A

-hydrolyzed cow’s milk based formula b/c has preventative effect against atopic dermatitis

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71
Q

What is the role for skin testing or specific IgE blood test in infants?

A

-routine screening without a history of the child ever ingesting the food is discouraged b/c of high risk of potentially confusing false-positive results

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72
Q

What is the latest solid foods should be introduced and why?

A
  • 6 months at the latest b/c delaying it further puts baby at risk for iron deficiency anemia and other micronutrient deficiencies
  • introduce iron rich foods first (iron fortified cereal, meat, fish, tofu)
  • if delay beyond this consider iron supplementation
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73
Q

What are the 2 types of weaning from the breast?

A

infant led (usually complete btwn 2-4 yrs) and mother led

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74
Q

What is a nursing strike (breastfeeding) and what are ways to overcome it?

A

-nursing strike is a sudden temporary refusal to nurse and can result from many causes including infant illness, change in mothers soap, diet, onset of menses etc

  • make feeding time special and quiet
  • increase cuddling time
  • offer breast when babe is very sleepy or just waking up
  • offer breast frequently, in different positions, in different rooms
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75
Q

If an infant refuses to take a bottle from the mum after breastfeeding has ceased or is being ceased what are some strategies?

A
  • can offer milk in a cup

- may need to be fed milk or other foods by an alternate caregiver

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76
Q

If abruptly wean breastfeeding what should you counsel the mother?

A
  • take analgesics
  • express just enough milk that her breasts feel comfortable
  • cold gel packs, cold cabbage leaves or breast massages may relieve engorgement
  • watch for signs of a plugged duct (isolated pea sized hard or tender area without local heat) b/c can lead to mastitis
  • normal to feel guilt or sadness
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77
Q

For how long should a baby be breastfed?

A

-exclusively for 6months and continued breastfeeding until 2 yrs and beyond

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78
Q

What are early childhood caries?

A
  • presence of one or more decayed, missing (due to caries) or filled tooth surfaces in any primary tooth in a preschool-aged child
  • prevalence in urban areas is 6-8%, up to 90% in some indigenous communities
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79
Q

What are the 4 different ways canadians can pay for dental care?

A

1) third-party insurance (employment-related)
2) private dental insurance
3) paying out of pocket
4) government subsidized programs (eg. veterans or first nations)

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80
Q

What factors contribute to early childhood caries?

A
  • diet
  • bacteria
  • host
  • social determinants of health
  • frequent, prolonged bottle feeding
  • excessive juice consumption
  • low SES
  • new immigrant
  • aboriginal or first nations
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81
Q

What measures are there to help prevent early childhood caries?

A
  • fluoridation of water
  • promote proper feeding
  • dental sealants
  • topical fluorides (varnish on teeth you paint on)
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82
Q

Which organism is most associated with early childhood caries?

A
  • Streptococcus mutans

- window for infectivity is btwn 19-31 months of age

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83
Q

Which branch of government is responsible for dental benefits?

A

provincial/territorial

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84
Q

When should a child first go see a dentist?

A

between 6-12 months of age

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85
Q

What is the most common type of neonatal hearing loss?

A
  • sensorineural
  • genetic cause found in 50%
  • 70% have nonsyndromic deafness
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86
Q

What are risk factors for neonatal sensorineural hearing loss?

A
  • FHx of permanent hearing loss
  • craniofacial abnormalities including those involving the external ear
  • congenital infections (meningitis, CMV, roxo, rubella, herpes, syphilis)
  • physical findings consistent with an underlying syndrome associated with hearing loss
  • NICU stay >2 days OR with any of ECMO, assisted ventilation, ototoxic drug use, hyperbili requiring exchange transfusion
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87
Q

If not screened at what median age are children diagnosed with hearing loss? With screening was is the age?

A
  • without screening 24 months

- with screening 3 months or younger (intervention by 6 mo)

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88
Q

Parental concern about hearing loss is predictive of true hearing loss. True or False.

A

True

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89
Q

What are otoacoustic emission (OAE) tests?

What are they useful for?

A
  • sound stimulus sent to newborn’s auditory system via probes put in external ear canal; the probe simultaneously records emissions returning from the outer hair cells of the cochlea via the middle ear
  • good for diagnosing hearing loss of 30dB or greater; detects conductive and cochlear hearing loss
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90
Q

What is auditory baronets response (ABR) screening for hearing? What are they useful for?

A
  • sounds are transmitted to infant via earphones and then records brainstem electrical activity in response to the sounds presented to the infant
  • can identify conductive, cochlear and neural hearing loss from external ear to level of brainstem including CN VIII
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91
Q

Who should be tested with ABR as opposed to OAE?

A
  • infants who fail the OAE

- infants with risk factors for sensorineural hearing loss

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92
Q

How is newborn screening usually done?

A

Usually do OAE first and if fail do the ABR

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93
Q

If a child is identified as having hearing loss, who should be involved as part of the team?

A
  • pediatrician
  • GP
  • audiologist
  • ENT
  • SLP
  • also need prompt vision assessment and referral to geneticist to determine underlying aetiology may be necessary
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94
Q

What is the false positive rate of hearing screening?

A

2-4%

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95
Q

What are short falls of universal newborn hearing screening programs?

A
  • does not detect less severe congenital hearing loss

- does not detect progressive, or late-onset hearing loss (e.g. from CMV)

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96
Q

Children with cochlear implants have increased risk of meningitis and specific recommendations for preventive vaccination have been made. True or false.

A

True

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97
Q

A vegetarian diet can provide for the needs of a growing child. True or false.

A

True if it is well-balanced

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98
Q

What is a lacto-ovo-vegetarian? What is a vegan?

A
  • lacto-ovo-vegetarian - no meat, fish, fowl or products containing these but do eat eggs and dairy.
  • vegans - no meat, fish, dairy or eggs - no animal products at all
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99
Q

What adjustments need to be made for protein intake for children who are vegan and why?

A

increase protein due to lower digestibility of plant protein

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100
Q

What adjustments need to to be made for iron intake in vegetarians and vegans and why?

A

-increased iron (1.8x intake) b/c of different bioavailability and vitamin c and other components enhance the absorption of nonheme iron

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101
Q

What foods are iron rich?

A

iron-fortified cereals
grain products (iron-fortified)
dried beans and peas

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102
Q

What part of our diet provides zinc? When do breastfed infants start to need zinc from sources from non-breastmilk?

A
  • 50% of our zinc intake comes from animal protein
  • zinc also found in legumes, nuts, yeast-leavened breads, fermented soy
  • breastmilk has enough since for infants up to 7 months
  • we do not supplement with zinc
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103
Q

What is the effect of a maternal vegan diet on a breast-fed infant’s calcium? What is the effect of vegan diet on a child’s calcium?

A
  • calcium in breastmilk is unaffected by a maternal vegan diet
  • many vegan kinds have low calcium levels so may need supplmentation
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104
Q

Which foods are good sources of calcium?

A
  • calcium fortified foods (soy products, cereals, juices, leafy vegetables)
  • bok choy
  • chinese cabbage
  • kale
  • collards
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105
Q

Vegan diets are relatively deficient in long-chain omega-3 fatty acids (DHA and EPA) b/c are mostly found in fish, seafood and eggs. What can you tell them to include in their diet to make up for this?

A
  • precursor of linolenic acid which are then converted to EPA and DHA
  • flaxseed
  • canola oil
  • walnuts
  • soy products
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106
Q

What deficiency are vegans most at risk for? And what are the implications for children?

A
  • Vitamin B12
  • breastfed infants need to be supplemented
  • for kids sources of B12 include: fortified soy formula, and cereals, yeasts,
  • need 3 servings of Vit B12 rich foods a day or supplement with 5-10 micrograms per day
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107
Q

What is considered adequate sun exposure in a light skinned child for vitamin D?

A

20-30 minutes 3x/wk

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108
Q

What founds contain vitamin A and how many servings do vegans need to have of these a day?

A
  • yellow and orange vegetables, leafy greens, fruits rich in beta-carotene
  • 3 servings of these vegetables and fruits per day
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109
Q

What is the recommended fibre intake a day?

A

0.5g/kg/day

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110
Q

What is the recommended for vitamin D in pregnant and lactating mums?

A

2000 IU per day through the winter

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111
Q

What deficiencies are vegans at risk for?

A
  • vit b12
  • zinc
  • need increased iron
  • omega-3-fatty acids (precursors)
  • calcium
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112
Q

What is the Greig Health Record?

A
  • evidence-based health supervision guide for clinicians caring for kids age 6 to 17 years
  • template for periodic health visits and anticipatory guidance
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113
Q

What % of kinds in Canada are affected by ADHD?

A

1 in 20 (5%)

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114
Q

What are down sides of prescribing immediate release stimulant medications?

A
  • require repeated doses during the day
  • stigma of taking drug at school
  • disrupts school routine
  • less compliance
  • more likely to be sold/diverted and misused
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115
Q

Why do we treat ADHD with medication?

A
  • better academic and social outcomes
  • decreases risk of substance abuse if treated
  • less likely to visit an ED or be admitted due to injury
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116
Q

What type of stimulant medication should be considered first line for ADHD treatment?

A

Extended release preparations

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117
Q

A patient with ADHD on treatment is at increased risk for substance abuse. True or false

A

False

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118
Q

Which is more efficacious in treating the symptoms of ADHD, extended release or immediate release?

A

-they both work well but it is the abuse potential and repeated dosing etc that makes extended release meds the better choice

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119
Q

What % of kids who have an out-of-hospital arrest survive?

A

1.9%

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120
Q

What are the most common causes of out-of-hospital arrest?

A
  • respiratory emergency

- trauma

121
Q

What is the most successful intervention to help with gas exchange?

A

-bag and mask ventilation (with self-inflating bag)

122
Q

What can you do in your office to improve readiness for an outpatient emergency?

A
  • do office mock codes
  • keep up your BLS and PALS
  • have office protocols
  • have the appropriate equipment (the further from EMS you are the more things you should have available to you)
123
Q

What are the recommended circulation, drug, trauma and airway supplies for a physicians’ office?

A

CIRCULATION

  • backboard
  • BP cuffs
  • IO needles
  • IV fluid and tubing
  • NS (2x 500ml bags)

MEDS

  • dosing cards or tapes
  • epi for anaphylaxis (1:1000 solution, 0.01 mg IM)
  • ventolin (0.5 ml of 5mg/ml solution diluted in 3 ml NS (2.5 mg neb) for infants/toddlers, and 1ml diluted in 3 ml NS for older kids)
  • epi (1:1000) for nebulization (0.5 ml/kg to max 5 ml)
  • compressor with nebulizers and masks

TRAUMA

  • stiff neck collars
  • dressings, bandages, splints
  • emergency equipment container/cart
  • latex-free gloves

AIRWAY

  • bag-valve mask (self-inflating with reservoir)
  • oxygen masks
  • O2 tank and valve with flow meter
  • oxygen tubing

(O2 sat is on the ‘desirable’ not the ‘recommended’ list)

124
Q

What % of preschoolers will have problems with visual acuity if not recognized?

A

5-10%

125
Q

What is the most effective test for amblyopia?

A

visual acuity by noninvasive testing

126
Q

What is the risk of missing or not treating amblyopia?

A

risk for total blindness, in the case of injury or disease, in the better functioning eye

127
Q

Which kids should be referred for further evaluation based on history alone?

A
  • if have RF like ROP, T21, et

- if have concerning FHx (congenital glaucoma, strabismus)

128
Q

What is amblyopia? What are the 2 most common causes?

A

Reduced vision in the absence of ocular disease, which occurs when the brain does not recognize input from the eye.

-2 most common causes: strabismus and difference in refractive error

129
Q

What is refractive error?

A

inability of the eye to focus the image, usually correctable with a lens

130
Q

What is strabismus?

A

-misalignment of the eye in any direction, can be constant or intermittent

131
Q

What is pseudo strabismus and how can you differentiate it from true strabismus?

A

-most common when broad nasal bridge covers the nasal sclera unequally, can tell by symmetric corneal light reflex that it is pseudostrabismus

132
Q

What is a cataract?

A

opacification of the crystalline lens

133
Q

At what age should a baby do the following:

a) face to follow:
b) visual following:
c) Visual acuity measurable with the appropriate chart:

A

a) face to follow: - birth-4 weeks
b) visual following: 3 months
c) Visual acuity measurable with the appropriate chart: 42 months

134
Q

What is a red reflex, how do you perform it and what tells you that it is normal?

A
  • reflection of orange-red light from retina through the pupil
  • set ophthalmoscope to 2 diopters and look from 0.5 m distance
  • should see equal brightness and colour, pupil should fill completely
135
Q

What is corneal light reflex and what is normal?

A

-small focal bright white reflection of light on cornea, should be symmetrically positioned close to the centre of each cornea

136
Q

What is the cover-uncover test and what result is normal?

A

-cover one eye at a time while the child fixates on a target. The uncovered eye should not move. The covered eye should NOT reposition when exposed (providing fixation is maintained) - if it does then refer

137
Q

What screening eye charts exist and for what ages should you use them? At what distance from the chart should the pt stand?

A
  • HOTV - from 36 mo
  • Snellen - after age 6 yrs
  • allen chart (pictograms) - too culturally specific to be helpful
  • patient should be 3 m from the chart, one eye at a time (better eye first)
138
Q

What age do you stop checking red reflex?

A

age 5 yrs

139
Q

What are the recommended ratios (child to adult) of kids in daycare?

A

3:1 for kids 36 mo

140
Q

What is the national average annual child care expenditure per household in Canada?

A

$2500

141
Q

What is the evidence around child care centres and behavioural and cognitive outcomes?

A
  • high quality child care centres may have a positive effect

- ideally want the staff to have some Early Childcare Education training

142
Q

Who is at higher risk for unintentional injury, kids in daycare or kids under parental care?

A

-kids under parental care are higher risk for injuries

143
Q

What are the most common types of injuries associated with daycares?

A
  • cuts, bruises, abrasions,

- fewer burns, ingestions, poisoning, foreign body insertion

144
Q

When can a kid with a respiratory condition return/attend daycare?

A

-when they are well enough to participate fully in all activities

145
Q

When can a kid with bacterial conjunctivitis or streptococcal pharyngitis return to daycare?

A

-after 24 h of antibiotic therapy

146
Q

Which kids with diarrhea should be excluded from daycare?

A
  • if their stool cannot be contained in a diaper
  • if stool cannot be controlled by a toilet trained child
  • if there are signs of bacterial enteritis (fever, blood or mucus)
147
Q

What are barriers to health care for kids in foster care?

A
  • lack of or inadequate medical records
  • lack of consistent care or follow-up due to temporary placements
  • difficulty accessing services
148
Q

What is foster care?

A
  • provision of care and supervision by a family other than a biological parent or guardian and is approved and arranged by a child welfare authority
  • can be temporary or permanent
149
Q

What are risk factors for foster care?

A
  • drug and alcohol addiction
  • extreme poverty
  • homelessness
  • violence
  • previous involvement with the child welfare system
  • prenatal dug and/or alcohol exposure
  • FHx of mental health disorders
  • severe behaviours
  • complex medical problems
  • cognitive or functional impairment of parents with little resources or support
150
Q

What is Jordan’s Principle?

A

-child-first principle that ensures the needs of the child are met by the government of first contact until the jurisdictional dispute is resolved

151
Q

What are the recommendations for timing and frequency of medical visits for a kid in foster care?

A
  • initial visit as soon as possible after placement
  • more comprehensive follow up visit within 30 days of placement with routine screening
  • need to be seen more often than other kids
152
Q

What are some common issues that arise medically for kids in foster care?

A
  • underimmunization
  • dental neglect
  • poor hygiene
  • contraceptive needs for teens
153
Q

What should be done on the first and second visits for a kid in foster care?

A

FIRST VISIT

  • physical exam
  • screen and treat acute conditions (e.g. acute illness, infection, pregnancy, etc),
  • assess need for vision, hearing and dental
  • decide about screening BW

SECOND VISIT

  • review medical hx, immunization status
  • complete physical
  • complete or review referrals
  • review labs
  • consider psychoeducational assessment
  • consider talking to principal or school for support
154
Q

What screening bloodwork should you consider for a child in foster care?

A
  • CBC
  • ferritin
  • lead level
  • HIV
  • hepatitis B and C titres
  • BHCG
  • cervical or urethral swabs for STIs
155
Q

What are parts of aircraft technology to minimize the change of airborne illness spread?

A
  • high-efficiency particulate filters that remove 99.9% of bacteria and viruses
  • air is exchanged 15-20x per hour
  • airflow is top to bottom with little front to back flow
  • passengers who appear to have a communicable disease can be denied boarding
156
Q

What are the effects of airline cruising altitudes on the oxygen saturations of healthy children?

A
  • cruise 9150m to 13,000m usually
  • pressurized to atmostpheric pressure of 2440m
  • saturations decreased by 4% on a 7 hour flight
157
Q

Which children are at risk for complications related to altitude while flying and what should you do before they travel?

A

-kids with CF, hypoemia (known or suspected), hypercapnia, COPD or restrictive lung disease, pts on O2, pts with hx of difficulty with air travel, pts with recent exacerbation of chronic lung disease,

  • some may need spirometry and hypoxic challenge tests
  • check CO2 b/c if elevated suggests poor pulmonary reserve and may need oxygen
158
Q

What medical conditions are contraindications to commercial airline flights?

A
  • uncontrolled HTN
  • uncontrolled SVT
  • Eisenmenger’s syndrome
159
Q

Which kids are at risk for thromboembolic disease on airline flights? How might they be treated?

A
  • thrombophilia
  • preve thromboembolism
  • malignancy or major surgery within 6 wks

-may be treated with ASA or low-molecular weight heparin

160
Q

What are the risks of flying for pts with sickle cell trait? Sickle cell disease? What should be done as prevention?

A
  • no risks with sickle cell trait
  • with sickle disease can be at risk for crisis
  • have medical oxygen available
  • if >7600ft consider O2 for sickle cell pts esp if have splenomegaly or high blood viscosity
161
Q

What is barotrauma and how can you reduce it while flying?

A
  • due to inability to equilibrate the pressure differential in the middle ear compared to ambient pressure
  • causes otalgia
  • worst with take off and landing
  • can do valsalva, chew, yawn etc
162
Q

What is barotitis media?

A
  • inflammatory change (acute or chronic) of middle ear due to barotrauma
  • characterized by sudden ear pain, impaired hearing, vertigo and can have rupture of TM
163
Q

What can be done in kids with recurrent otitis media or adenoidal hypertrophy to prevent barotrauma while flying?

A

-treat with topical nasal decongestant at least 30 mins before take off and landing

164
Q

Can a child with AOM fly?

A
  • ideally best to wait 2 weeks from diagnosis

- if AOM dx within 48 hrs of flight then ensure adequate analgesia and use nasal decongestant

165
Q

What should you counsel parents of kids with allergies about air travel?

A
  • alert airline crew that child is allergic

- carry an epiPen and antihistamines on board

166
Q

What considerations need to be made for kids with type 1 DM regarding traveling overseas/flying/changing time zones?

A
  • insulin may need to be adjusted if crossing time zones
  • if going east and day shortened by more than 2 hrs may need to decrease the intermediate or long-acting insulin
  • if day is lengthened by more than 2 hrs (going west) may need to increase insulin
167
Q

What do you warn parents of kids with epilepsy or seizures about air travel?

A
  • travel with anti seizure meds and have them readily available in carry on
  • jet lag, delayed meals, hypoxia, fatigue related to travel can lower seizure threshold
168
Q

What can you do to help a child with air sickness?

A
  • dimenhydrinate
  • cool vented air on face
  • gaze at horizon
  • select a seat away from the rear of the cabin
169
Q

What can you tell parents of a kid with behavioural problems about how to prepare for air travel?

A
  • show kids books about planes
  • take practice trips to the air port
  • learn relaxation techniques
170
Q

What can do you tell parents of kids with medical devices (eg. G-tubes, urinary catheters) for air travel?

A
  • gas expansion can introduce air into hollow viscus

- cap feeding and infusion tubes during takeoff and landing

171
Q

What precautions need to be taken during air travel for kids in casts?

A
  • trapped gas beneath a cast can expand during flight
  • if traveling within 48 hrs of getting a cast on the cast should be bivalved
  • provide adequate analgesia
  • elevate the limb
  • pneumatic splints usually not allowed
172
Q

What is the best way for young kids (

A
  • improper restraint can contribute to injury
  • ideal is car seat in their own chair
  • should not use front infant carriers or slings
173
Q

What are the rules around physicians volunteering to help on an aircraft?

A

-covered by the good samaritan act and are protected from liability

174
Q

What percentage of children have reading delays?

A

5-15%

-most kids who have not mastered reading by the end of grade 3 will never catch up

175
Q

What are some direct effects of low literacy on health?

A
  • incorrect use of medications
  • failure to comply with medical directives
  • errors in administration of infant formula
  • safety risks in the community, workplace and home
176
Q

Why is reading from birth and early on important for children?

A
  • synapses are stimulated by frequent use during the early years
  • those that are seldom used are eliminated (pruning)
  • book sharing, literacy, language are important for the foundation for later reading ability
177
Q

What is dialogic reading?

A

-when parent uses questions to encourage the child to participate beyond being a passive listener

178
Q

What should be done by physicians to promote literacy?

A
  • address it at visits
  • ask about family literacy, book sharing, access to books, routines
  • anticipatory guidance about literacy development
  • have good literacy materials in your waiting room
  • books to be given out at well-child visits
179
Q

At what age to kids reach for pictures? turn pages (several at a time)? Point at pictures with one finger? turn pages one at a time? Hold book without help?

A

reach for pictures - 6-12 month
turn pages (several at a time) - 12-18 mo
Point at pictures with one finger - 12-18 mo
turn pages one at a time - 18-36 mo
Hold book without help - 3 yrs and up

180
Q

What is transracial adoption?

A

-children that are adopted by parents from a race different than their own

181
Q

When looking at adoption and race what factors should you consider?

A

-better/preferred to place kids with a family of the same race or ethnic background but if that is not possible then transracial adoption is preferred to foster care

182
Q

What are the steps in childhood development related to racial identity?

A
  • become aware of racial differences by age 3 yrs
  • become aware of labels and emotional responses associated with various racial groups btwn 3-7 yrs
  • race permanence at 7 yrs
  • teens are searching for their identity and physical differences in appearance compared to parents are more prominent
183
Q

What are risk factors that negatively affect a child’s outcome in transracial adoption?

A
  • older age at the time of adoption
  • history of abuse or neglect
  • institutionalization
  • health problems
184
Q

What are key components that physicians play related to caring for transracially adopted kids and families?

A
  • need accept and their physical appearance, birth heritage and heritage of upbringing
  • emphasize that a kid’s cultural heritage is important
  • help them develop pride in their racial identity
  • anticipatory guidance and skills for dealing with racism
  • multicultural family planning and events
  • acknowledge that the family is visibly different from others
  • celebrate diversity
  • recognize that other children in the family may experience bullying due to having a transraially adopted sibling
  • be aware of subtle stereotypes in the media
  • have families be in contact with other families who have transracially adopted kids
185
Q

What are the basic principles of homeopathy?

A
  • ‘laws of similars’ or ‘like cures like’ - substance can cure in a a patient the same set of symptoms it can induce in a healthy person
  • choose the remedy based on symptoms and when given in a very dilute form it should alleviate these symptoms
186
Q

Are homeopathic products regulated?

A

Yes. As of 2004 homeopathic products get a drug identification number from Canadian Natural Health Products Directorate (a branch of Health Canada)

187
Q

What are the risks of taking homeopathic remedies?

A
  • if properly prepared tend to have few side effects b/c are so dilute
  • quality of information on them is lacking, few studies showing a beneficial effect
  • undiluted concentrations can be harmful
  • worry of negative attitude toward vaccines by some homeopaths
  • delay in seeking conventional care due to awaiting homeopathy results
188
Q

What is the definition of SIDS?

A
  • sudden death of an infant under one year of age which remains unexplained after thorough case investigation including doing an autopsy
  • generally agreed that the death takes place during sleep
189
Q

What is bedsharing?

What is co-sleeping?

A

bed-sharing -baby shares the same sleeping surface with another person
-co-sleeping - infant is within arm’s reach of his/her mother but on on the same sleeping surface (share a room but not a bed)

190
Q

What are some of the arguments made in favour of bedsharing?

A
  • promotes infant arousal which may be protective against SIDS
  • breastfeed more often and for longer than if in their own bed
191
Q

What are risk factors for SIDS?

A
  • sleeping prone
  • exposure to tobacco during or after pregnancy (including passive exposure to smoke)
  • soft surface
  • pillow use
  • bedsharing with someone other than the parents
  • sofa sharing
  • bedsharing when the parent has consumed alcohol or has extreme fatigue
192
Q

What are the recommendations for sleeping for infants?

A
  • sleep in their own crib for the first year of life and to sleep in their parents’ room for the first 6 months
  • use a sleeper to avoid needing blankets/covers, consider only a thin blanket
  • do not use car seats or infant carriers as replacement for cribs b/c risk that harness straps can cause obstruction
  • makeshift beds are dangerous
193
Q

What are key components of effective discipline?

A
  • consistency
  • trust
  • respect
  • fair
  • developmentally appropriate
  • goal to foster acceptable and appropriate behaviour and raise emotionally mature adults
194
Q

What type of discipline should be used for infants (birth to 12 months)?

A
  • they need a schedule for feeding, sleeping, play
  • do not overstimulate them
  • develop tolerance to frustration and ability to self-soothe
  • no time outs, or consequences
195
Q

What type of discipline should be used for early toddlers (1-2 yrs)?

A
  • remove the child or object with a firm no or very brief verbal explanation (“no-hot”)
  • redirect
  • parent should stay with the child (b/c susceptible to fear of abandonment)
  • verbal explanations not reliable
196
Q

What type of discipline should be used for late toddlers (2-3 yrs)?

A
  • susceptible to temper tantrums

- after a tantrum, give simple verbal explanation, redirect child to activity away from scene of tantrum

197
Q

What type of discipline should be used for preschoolers and kindergarten-age kids (3-5 yrs)?

A
  • consistency
  • time-outs (one minute for every year of age)
  • lectures do not work well
  • using logical consequences (e.g. if break the toys then they don’t get new toys)
198
Q

What type of discipline should be used for school-age kids (6-12 yrs)?

A
  • praise and approval used liberally
  • withdrawal or delay of privileges
  • consequences
  • time-out
199
Q

What type of discipline should be used for adolescents?

A
  • contracting with the teen
  • consequences
  • accountability (eg. if break something then need to help pay for it)
200
Q

What are guidelines around setting rules for kids?

A
  • catch kid being good
  • avoid nagging or making threats without consequences
  • apply rules consistently
  • prioritize rules with safety coming first
  • pick your battles (don’t focus on things that are not important eg. swinging legs under table)
  • follow through with consequences
  • reinforce the correction is against the behaviour not against the child
201
Q

When can you start using time out and how do you do it?

A
  • start age 2 yrs
  • must be done unemotionally and consistently
  • one minute for every year of age (max 5 mins)
  • pick the right location away from tv or distractions
  • explain which behaviour is linked to the time-out
  • when the kid is in time-out they should be ignored
  • parent should be the time-keeper
  • after time out is done do not discuss it but move on to new activity
202
Q

What is reasoning or away-from-the-moment discipline? At what age can it be used?

A
  • dealing with the difficult behaviour not in the heat of the moment but in advance or away from the actual misbehaviour
  • use after age 3 or 4 yrs
203
Q

What are the guidelines around spanking?

A
  • associated with negative child outcomes
  • should not be used ever
  • may need to restrain a child to prevent them from harming themselves but that is different than spanking
  • if parents are getting angry they themselves should take a time out
204
Q

What is the relationship between pacifier use and breastfeeding?

A
  • pacifier use may be an identifiable factor in early weaning from the breast
  • exact cause and effect remains elusive
  • pacifier use may be a marker of breastfeeding difficulties
205
Q

Should we be recommending pacifier use to parents?

A

-evidence is controversial so should be a parental choide

206
Q

What are arguments in favour of pacifier use?

A
  • protective against SIDS (pathophysiology of this is unclear)
  • effective and noninvasive adjunct to minimize pain during painful procedures
  • non-nutritive sucking is part of routine development of the preterm infant and can help organize promoter development
207
Q

What are arguments against the use of pacifiers?

A
  • may be identifiable factor in early weaning from the breast
  • may be a risk factor in the development of otitis media (greater risk factor with prolonged and more frequent use)
  • prolonged use may cause malocclusion (dental)
  • are a famine and can be colonized with microorganisms but their ability to cause clinically significant infection is questionable
208
Q

What are the Canadian Dental Association’s recommendations about pacifier use?

A
  • pacifiers over thumb sucking b/c easier for parents to control the sucking habit
  • stop it before permanent teeth erupt
  • use a clean, unsweetened pacifier
209
Q

What are some health canada guidelines around pacifiers in terms of how they are made?

A
  • much have a collapsible or hinged handle
  • any loop of cord or other material attached to it should not be more than 14 inches in circumference
  • made of latex or silicone
210
Q

What advice should you give parents of kids with chronic or recurrent otitis media about pacifiers?

A
  • restrict the use of pacifiers b/c can cause disequilibrium btwn nasopharynx and middler ear pressure and change the eustachian tube potency
  • the more prolonged and frequent use of a pacifier the higher it is as a risk factor contributing to otitis media
211
Q

What is the central tenet of chiropractic practice?

A

-diseases are often caused by subluxations of the vertebrae which lead to an interruption of nervous impulses and that correction of these subluxations allows the body to heal itself

212
Q

What are the conservative and liberal ways of practicing as a chiropractor?

A
  • conservative - narrow scope of practice restricted to treating MSK conditions
  • liberal - not limited to MSK practices but extends beyond (e.g. colic, asthma etc), occasionally immunizations etc
213
Q

What is the evidence for chiropractic manipulations?

A
  • no evidence to support its use in asthma
  • insufficient evidence for its use in low back pain
  • may have some short term relief in subacute or chronic neck pain
  • no good studies done in children
214
Q

What is the Canadian Chiropractic Association’s position vaccinations?

A

-accepts vaccination as a cost-effective and clinically efficient public health preventive procedure for certain viral and microbial diseases, as demonstrated by the scientific community

215
Q

What are risks of chiropractic manipulation?

A
  • short term - mild pain, discomfort, slight headache, fatigue
  • are reports of major neurological complications
  • 1/4 of traumatic cervical artery dissections in ppl under 45 years are associated with neck manipulations (can cause stroke)
  • one case report of vertebrobasilar occlusion after manipulation
216
Q

How should you a approach a parent whose chiropractor asks you to order an X-ray for them?

A

-explain there is a lack of substantiated evidence for the theory of sublimated vertebrae as the causality for illness in kids so would be unnecessary exposure to radiation

217
Q

What is an essential question to ask in a kid who is presenting with stroke?

A

-any recent neck manipulation by a chiropractor?

218
Q

What are important questions to ask families about chiropractors?

A
  • do they have one
  • any alternative or complementary therapies
  • any neck manipulations or forceful thrusts
  • frequency of visits
  • advice given
  • motivation for seeking the chiropractor
219
Q

When do most kids achieve bowel and bladder control?

A

-age 24-48 months

220
Q

What is the average time from initiation of toilet learning to attainment of independent toileting?

A

3-6 months

attainment of bladder control does not always coincide with bowel control and same with night vs daytime continence

221
Q

What are the 7 signs a child’s toilet learning readiness?

A

1) able to walk to potty chair/adapted seat
2) stable while sitting on potty
3) able to remain dry for several hours
4) receptive language skills allow for kid to follow simple commands
5) expressive language skills allow kid to communicate need to use potty with words or reproducible gestures
6) desire to please based on positive relationship with caregivers
7) desire for independence, and control of bladder and bowel function

222
Q

What approach is used for toilet training and when should it start?

A
  • child-oriented approach

- do not start at a stressful time in the kid’s life (e.g. after birth of a new sibling)

223
Q

How should parents approach toilet training using the child oriented approach? What are the practical steps to take?

A
  • decide on the vocabulary use
  • ensure potty chair and position are easily accessible
  • if using a regular toilet have a foot stool
  • encourage kid to tell parents when need to use toilet and praise them for this
  • avoid punishment

1) have child sit fully dressed on potty, then sit on potty after a dirty diaper has been removed
- start to lead kid to potty several times a day and encourage them to sit without wearing a diaper
- develop a routine of sitting on the potty at specific times (in the am, after meals, etc)
- praise the kid when interested in setting on the potty, do not use material rewards
- once kid has used potty successfully for one week or more can try training pants or cotton underwear

224
Q

What if a kid refuses to comply with toilet training?

A
  • take a break for 1-3 months and then try again

- if over age 4 yrs and still no success consult peds or a developmental paediatrician

225
Q

What is the definition of fever of unknown origin?

A

-fever lasting more than 14 days with no aetiology found after routine tests

226
Q

What are the pros and cons of rectal temperature measurements?

A
  • risk of rectal perforation
  • capacity to spread contaminants if not properly cleaned
  • temps slow to change in relation to changing core temps
  • affected by the depth of insertion
227
Q

What are the pros and cons of axillary temps?

A
  • easy to measure
  • inaccurate estimate of core temp
  • can be used as a screening test for fever in neonates
228
Q

What are the pros and cons of oral temperature measurements?

A
  • sublinguial site is easily accessible
  • tempearture easily affected by recent food ingestion, mouth breathing
  • need to keep mouth closed with tongue depressed for 3-4 mins so need cooperation from kids
229
Q

What are the pros and cons of tympanic temperatures?

A
  • TM’s blood supply very similar to hypothalamus so ideal location for core temp estimation (crying, otitis media and wax do not change reading significantly)
  • dependent on the infrared probe’s ability to go deep enough to orient the sensor toward the TM
  • can be affected by skin temperature if not properly positioned
  • still consider rectal temp a better measurement
230
Q

What is the role for temporal artery (forehead) temp measurements?

A

-may be a good tool for screening low risk kids in ED but not recommended for home use

231
Q

What is a normal rectal temperature?

A

36.6 to 38

232
Q

What is a normal TM temperature?

A

35.8 to 38

233
Q

What is a normal oral temperature?

A

35.5 to 37.5

234
Q

What is a normal axillary temp?

A

34.7 to 37.3

235
Q

What is the recommended temperature measurement technique in a child birth to 2 years?

A
  1. Rectal (definitive)

2. axillary (screening low risk kids)

236
Q

What is the recommended temperature measurement technique in a child 2- 5 years?

A
  1. Rectal (definitive)

2. Axillary, tympanic (or temporal artery if in hospital) if screening low risk kids

237
Q

What is the recommended temperature measurement technique in a child > 5yrs?

A
  1. Oral (definitive)

2. Axillary, tympanic (or temporal artery if in hospital) if screening low risk kids

238
Q

What are the appropriate positions in which to examine the genitalia of a prepubescent girl?

A

1) frog-leg position either on examining table or parents lap
2) knee-chest position (child on hands and knees)

239
Q

What are the appropriate positions in which to examine the genitalia of a prepubescent boy?

A

lateral decubitus

240
Q

What should be the approach to genital exams in children?

A
  • perform only when indicated
  • explain why it is necessary
  • if old enough ask for consent
  • always advise the child before touching them
  • never force or restrain the child
  • for younger kids parents should be close to the child
  • older teens should have a parent or nurse present during the exam
241
Q

What percentage of children have sleep difficulties?

A

15-25%

242
Q

What is melatonin and what does it do?

A

-secreted by the pineal gland in response to darkness, is important in maintaining the circadian rhythm of the sleep-wake cycle

243
Q

What are the two most common sleep disorders in childhood?

A

1) delayed sleep phase type

2) behavioural insomnia of childhood

244
Q

What is delayed sleep phase type sleep disorder?

A
  • initiation of sleep much later than the desired bed time

- sleep latency (time btwn lying down and falling asleep) is more than the normal 30 minutes

245
Q

What is behavioural insomnia sleep disorder?

A

2 types

1) sleep onset association type - need special conditions in place before the child goes or returns to sleep
2) limit-setting type - child stalls or refuses to go to bed or return to bed and the caregiver demonstrates unsuccessful limit-setting behaviours

246
Q

What are components of good sleep hygiene?

A
  • consistent routine
  • stable bedtime and wakeup time
  • age appropriate number of hours in bed
  • dark, quiet sleep space
  • avoiding hunger but also eating before bedtime
  • relaxation techniques
  • avoiding caffeine, alcohol or nicotine before bed
  • no screens before bed
247
Q

What is the evidence for melatonin use in children?

A
  • using it in kids is considered an off-label use

- no evidence for use of melatonin in kids

248
Q

What types of melatonin are available?

A
  • short-acting and sustained release forms

- is not necessarily bioequivalence among products claiming to contain the same number of milligrams of melatonin

249
Q

What is the typical dose of melatonin?

A
  • 2.5-3 mg in children
  • 5-10mg in teends
  • administer 30 to 60 minutes before bedtime
250
Q

What % of children with autism have sleep difficulties?

A

67%

251
Q

What are the long-term effects of melatonin use?

A
  • unknown, we need more studies

- studies to date have looked only at short-term use

252
Q

What are the effects of untreated constipation?

A
  • abdo pain
  • appetite suppression
  • fecal incontinence with low self-esteem, social isolation, family disruption
253
Q

What is the definition of constipation?

A
  • infrequent, difficult, painful or incomplete evacuation of hard stools
  • functional constipaiton is commonly due to withholding feces in a child who wants to avoid painful defecation
254
Q

What are the Rome III writer for functional constipation?

A

-2 or more of the following in a kid at least age 4 yrs

  1. two or fewer defecations in the toilet per week
  2. at least one episode of fecal incontinence per week
  3. History of retentive posturing or excessive volitional stool retention
  4. history of painful or hard bowel movements
  5. Presence of a large fecal mass in the rectum
  6. history of large diameter stools that may obstruct the toilet
255
Q

What are the two most common periods when functional constipation can become apparent?

A

-with toilet training and during start of school

256
Q

What is the physiology of constipation?

A

-stool enters the normal rectum and urge to defecate occurs when stool reaches the external anal sphincter. If kid voluntarily relaxes the external sphincter then rectum is evacuated. If the kid tightens the external sphincter and gluteal muscles the focal mass is pushed back in the rectal vault and the urge to defecate subsides. With holding leads to stretching of the rectum and lower colon and retention of stool. The longer the stool stays in there the more water is removed and the harder the stool gets, to the point of impaction. Can get overflow soiling.

257
Q

How do you diagnose fecal impaction? Why do we need to recognize this?

A
  • history of overflow stools
  • large hard mass in abdomen or dilated fault filled with stool on rectal exam
  • do NOT need AXR

-if do not recognize and just treat with maintenance then can have worse overflow incontinence

258
Q

What are the recommended methods of fecal disimpaction?

A

1) PEG 3350 1-1.5 g/kg/day for 3 days
2) Mineral oil 15-30 mL per year of age (up to 240 mL daily) (do not use under 1 yr)
3) PEG electrolyte solution 25 mL/kg/h by NG (to max 1000 ml/h) until effluent is clear

Do NOT recommend digital disimpaction.

259
Q

What are the benefits of Peg 3350 for maintenance therapy for constipation?

A

-no electrolytes so no risk of electrolyte imbalance
-tasteless, colourless, odourless
-osmotic laxative
-absorbed only in trace amounts from the GI tract
=effective within first week of treatment

260
Q

What are the most common side effects of Peg 3350?

A

-occasional abdo pain, bloating, loose stools, flatulence

261
Q

What is the recommended maintenance dose for Peg 3350?

A

0.4-1 g/kg/day (do not hesitate to start at doses higher than 1 g/kg/day)

262
Q

What is the order of effectiveness in meds for constipation (sennosides, peg 3350, docusate, milk of magnesia, lactulose)?

A
  • peg 3350 = milk of magnesia > lactulose >sennosides> docusate
263
Q

How long should you treat with Peg 3350?

A

-at least 6 months of 1-2 soft stools per day before consider weaning the maintenance dose

264
Q

What behavioural suggestions can you make to help with functional constipation?

A
  • routine scheduled toilet sitting for 3-10 minutes once or twice a day
  • have a footstool at the toilet so kid can do better valsalva
  • consider using gastrocolic reflex (occurs within 1 hour of eating)
265
Q

What are the recommendations around foods fibre for constipation?

A
  • want 0.5 g/kg/day (max 35 g/day) of fibre
  • low fibre associated with constipation
  • sorbitol found in prune, pear and apple juices can increase water content of stools and frequency
266
Q

What are recommendations around cow’s milk related to constipation?

A
  • consider time-limited trial of cow’s mild free diet if unresponsive to medical and behavioural therapy esp in kids with atopy
  • reduced milk intake in infants if having constipation
267
Q

What is a normal number of stools in a breastfed infant?

A

-can be as little as one stool every 7-10 days

268
Q

What are management recommendations for constipation in infants?

A
  • heightened awareness for red flags
  • mineral oil contraindicated
  • increased intake of fluids
  • reduce excess cow’s milk
  • can use lactulose, glycerin suppositories, Peg 3350
269
Q

What is the youngest age you can use Peg 3350 in?

A

-studies show is effective and safe in kids

270
Q

When should you refer a kid with constipation to GI?

A

-refractory cases or suspicion of organic diseas

271
Q

What tests are part of the work up for functional constipation?

A

none

272
Q

For who can you use mineral oil for constipation and why or why not?

A

-not for kids

273
Q

For who can you use milk of magnesia for constipation and why or why not?

A
  • risk of magnesium poisoning infnats
  • has a side effect in overdose of hyperMg, hypoPO4, and secondary hypocalcemia
  • dose is 1-3 mL/kg/day of 400 mg/5mL available as a liquid
274
Q

What is positional plagiocephaly?

A
  • deformational plagiocephaly
  • cranial asymmetrial in the absence of craniosynostosis due to forces that deform the skull shape in the supine position
275
Q

What are the findings of positional plagiocephaly on exam?

A
  • parallelogram head shape
  • unilateral flattening of the occiput with ipsilateral ANTERIOR shifting of the ear
  • rule out craniosynostosis
  • evaluate for congenital torticollis and cervical spine abnormalities
276
Q

When does positional plagiocephaly start to be noted, when is it at its maximum and by when should you expect it to resolve?

A
  • start to notice at 6 weeks
  • increases to a maximum at 4 months
  • most cases should resolve by 2 years
277
Q

What are risk factors that increase risk of positional plagiocephaly?

A
  • male sex
  • firstborn
  • limited passive neck rotation at birth (congenital torticollis)
  • supine sleeping position at birth and at 6 weeks
  • only bottle feeding
  • tummy time
278
Q

What type of craniosynostosis causing occipital flattening and how would you distinguish this from positional plagiocephaly on exam?

A
  • craniosynostosis of the lambdoid sutures
  • ridging of the affected suture
  • skull will show ipsilateral occipitomastoid bossing with POSTERIOR placement of the ear
279
Q

When should you get a skull X-ray in a kid with positional plagiocephaly?

A
  • when suspect craniosynostosis

- when there is worsening of head shape at an age where positional plagiocephaly would be expected to improve

280
Q

How can positional plagiocephaly be prevented?

A
  • alternate which side of the crib you put the baby’s head at to fall asleep
  • tummy time for 10-15 mins at least 3x/day
281
Q

What are the treatment recommendations for positional plagiocephaly?

A
  • mild to moderate - repositioning therapy and physiotherapy
  • severe - physiotherapy and consider moulding therapy (maximum age at which helmet therapy can be considered is 8 months)
282
Q

How is helmet therapy done for positional plagiocephaly? What are the side effects? Up to what age can it be considered? How well does it work?

A
  • wear a helmet 23 hours a day
  • associated with contact dermatitis, pressure sores, local skin irritation, very expensive
  • can only be considered up to 8 months
  • influences the rate of improvement of asymmetry but not its final outcome
283
Q

When do kids need start wearing shoes?

A

when they start walking

284
Q

What is pes planus and what is its natural evolution? What is the role for orthotics for this?

A
  • flatfeet
  • longitudinal arch development occurs before the age of 6 yrs
  • almost all kids
285
Q

What is metatarsus adductus? What can you do about it? What is the role of orthotics?

A
  • intoeing (very common in infants)
  • passive stretching to help it
  • if cannot stretch the forefoot to neutral then may need splints or casts – refer to oath
  • no role for orthotics
286
Q

What is tibial torsion and what is its natural evolution? What is the role of orthotics?

A
  • tibial torsion can cause appearance of intoning
  • improves with age
  • no role for orthotics
  • refer to ortho if causing functional impairement
287
Q

What is the natural evolution of knock-knees or bowlegs? what is the role of orthotics?

A
  • bowlegs and knock knees are expected variants of lower leg development and tend to resolve usually by age 8 years
  • no role for orthotics
  • refer to ortho if significant functional impairment
288
Q

What are some clues about health information websites that suggest they may not have accurate information?

A
  • for-profit website
  • sponsored website
  • selling things
  • advertisements or pop-ups (suggests the website is for profit and the more hits they get the better they do so sometimes post provocative things)
  • request for personal information
  • not peer reviewed
  • no references or posting of when the data was posted
  • based on improper evidence (e.g. ‘expert’ opinion as opposed to RCTs)
289
Q

Which age group is the fastest growing with regards to Type 1 DM?

A

under 5 years and early school age kids

290
Q

How many times a day are blood glucose checks recommended?

A

4x per day

291
Q

What is the effect of physical activity on glucose?

A

-improves the efficiency of glucose uptake and can cause hypoglycaemia

292
Q

What special precautions need to be taken when a kids with T1DM is physically active?

A
  • should be encouraged to be active
  • food intake and glucose monitoring are even more important around activity
  • parents need to know about scheduled changes in school activity to adjust the insulin dose and meal plan
293
Q

What are the effects of hypoglycaemia on learning in T1DM?

A
  • affects learning negatively.
  • low BG can develop over a few minutes and affect concentration, though processing but can take up to 45 mins for its effects on intellectual functions to resolve
294
Q

What is effect of hyperglycaemia on learning in T1DM?

A

-emerging evidence that it is associated with slowing of cognitive performance on tests

295
Q

What are recommendations to the school about management of hypoglycaemia for kids with T1DM?

A
  • regularly schedule meals and snacks
  • clean area for glucose checks
  • adjusting food intake or insulin doses for increased physical activity
  • supervising young kids in ways to help recognize, treat and prevent hypoglycaemia
  • ready access to their emergency kid
  • accommodations for tests, quizzes, or exams
  • when hypoglycaemia is suspected or confirmed THE STUDENT CANNOT BE LEFT UNATTENDED UNTIL HAS BEEN MANAGED AND RESOLVED
296
Q

True or False. Children with T1DM miss more school than other kids.

A

False (with the exception of for when they have medical appointments).

297
Q

What can be done from an insulin perspective to help overcome some of the barriers to safe diabetes care at school?

A
  • start the kid on 2-3 insulin injections daily to avoid the need for a lunchtime injection
  • make sure school employees know that they will not be liable if they take reasonable steps to assist a student with diabetes in an emergency situation
  • school should be provided with verbal and written information about the child’s diabetes care requirements in the school
298
Q

What should be done in terms of education in schools for T1DM management?

A
  • at least 2 trained school personnel to provide support
  • should be provided with diabetes education and attend annual diabetes updates
  • each child with T1DM should have an individual care plan before the start of the school year
  • designated staff member must supervise students’ meals and snacks to ensure they are eaten on time and adequate time given to eat the snack
  • if ER response time is >20 mins in a child with hypoglycaemia it is recommend that personnel be trained to give glucagon
299
Q

What accommodations should be made for students with T1DM with regards to tests?

A
  • be allowed to keep their diabetes emergency kid at their desk
  • in the event of a hypoglycemic event in the half hour preceding or at any time during an exam, a student should be granted an additional 30-60 minutes as needed to allow for cognitive recovery from hypoglycaemia

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