Community Pediatrics Flashcards
Updating since 18/04/2024
EPI BULLETS
- ~ 30 % of homes in Canada are inadequate
- 1 /7 Canadian Children live in Poverty
- In 2006, 2/3 of Indigenous community water sources were contaminated, in 2011 > 1800 indigenous homes had no electricity or running water
- Nunavut has the highest inadequate housing rate (36.5 %); followed by Ontario and BC because of Toronto/Vancouver’s housing costs.
- From 2005 to 2009, the number of children with inadequate housing increased by 50 %
- Canadabenefits.gc.ca can help families access funds
Define Insomnia
Inadequate volume and quality of sleep with negative impact on daytime functioning. In children this manifests with:
- Depressive symptoms
- Anxious symptoms
- Irritability
- Poor school performance/attention
Define Primary Nocturnal Enuresis
Age innapropriate noctural urinary incontinence (2+ times per week) for > 6 months when the patient has never been dry before.
Secondary nocturnal enuresis is a resurgence of the incontinence, and likely is secondary to an underlying pathology.
What are the CPS’ concerns with poor literacy ?
- Poor adherence/execution of prescriptions
- Poor understanding of own/others’ medical conditions
- Formula/Supplement preparation for children
- Poor follow-through with safety recommendations
- Diminished livelihood potential
What is your approach to your first evaluation of a child in foster care?
All children that enter foster care MUST have a medical evaluation within 24 h of placement.
- Review of medical files available, and submit requests from previous healthcare workers regarding file. This is the duty of Social Worker assigned to the case.
- Review vaccination schedule, supplement accordingly
- Routine History and Physical
- Directly Address hygiene, dental care and previous housing
- HEADSS is a good summary for every age
- Developmental history and assess for previous medications that may have been missed in transfer
- Arrange follow-up ~30 days after placement has occured to screen for adjustment disorders.
The CPS dictates you cover these points in these interviews.
What are the three criteria to declare housing unacceptable?
What criteria need to be met to be considered for Core Housing?
- Shelter cost is > 30 % of household income***
- Overcrowded
- Needs major repairs
***To be considered in need for core housing, this criteria must be met
CPS also considers the following as being unacceptable housing conditions:
- Infestations (bed bugs, rats, cockroaches)
- Air/Water compromise
- Unsafe neighbourhood
- Inaccessible for resident disabilities
- >3 moves in a child’s lifetime
Define positional plagiocephaly
Flattening of the occiput secondary to a post-natal external deforming force, identified as sleeping position. The sutures MUST be open, otherwise the diagnosis shifts to craniosynostosis and other cranial anomalies.
Peaks at 4 months old
Which conditions require DVT prophylaxis for air travel ?
- Thrombophilia disorders
- Active malignancy
- Major surgery within 6 weeks
- Previous thrombotic embolism
Patient will be managed with ASA or LMWH as per hematology
Describe the process for managing a feeding tube with air travel
- Board the plane
- Stop active feed
- Flush with water
- Cap and check for air bubbles
- TAKE OFF ! weeeeeeee
- Uncap and resume feed
- Repeat for descent, when descent is announced
Give 3 characteristics of proper potty training regimen
The CPS suggests the following characteristics:
- Consistent between cargivers
- Vigilance
- Positive reinforcement
- No material rewards
- No shaming
- Facilitate return to diapers if needed
(Should a child become discouraged or start to develop any signs of aversion, a break from training for 3-6 months will slow reintroduction is suggested to avoid behavioural constipation)
What is the “Reach Out and Read” method proposed by the AAP (and accepted by the CPS) ?
The “Reach out and Read” approach is a series of steps to promote literacy in your office. Take the following steps:
- Age/culturally diverse reading materials in waiting room
- Provide parents with an age appropraite book at each visit
- Discuss reading to their children at each visit
The ROR in american studies increased 4-10 times the likelihood of parents engaging pro-literacy practices at home. It also significantly improved standardized testing for the children in question in longtitudinal follow-ups.
If there are NO nitrites, leukocyte esterase activity, microscopic WBCs or microscopic bacteria on a urinalysis/microscopy
What are the chances this situation is a UTI?
< 1 %
The sensitivity of these tests goes up to 99.8 % when all 4 are present, but the specificity is still only 70 %. In any case, this assessment will require a culture.
Define the following sleep terms:
- Sleep Latency
- Sleep duration
- Waking Events
Latency - the delay from when the patient assumes the “in bed” position and when they fall asleep. This is a key measurement for assessing Delayed Sleep Phase disorders. Normally ~ 30 minutes
Duration - sum of time a patient sleeps in the night
Waking Events - number of times a patient awakes in the evening and has to repeat the sequence of falling asleep.
List 3 behavioural interventions to optimize pain/distress with procedures
- Distraction tactics (child life, stickers/murals in rooms, tablets/TV ,sing)
- Deep Breathing with the child
- Explain to the child (> 4 y.o.) the procedure
DO NOT SAY IT WON’T HURT OR IT IS THE LAST POKE
What is the FiO2 in an aircraft whilst it is in flight
About 15 % FiO2
EPI BULLETS
- About 8 % of febrile illnesses are diagnosed as UTI
- Rates are 20.7 % for uncircumcised vs. 2.4 % in circumcised boys < 3 months old, and 7.5 % vs. 0.3 % in respective 6 - 12 month olds.
What is the management for “Nursing Strikes”, in the context of babies breastfeeding ?
Nursing strikes are a new onset refusal to sufficiently feed in the absence of organic disease, for a previously well feeding child. The most common reason is external stimulation/stressors.
CPS suggests:
- Evaluate Mother’s diet and remove possible irritants
- Reflect on stressors within the home
- Optimize the experience of breastfeeding; create a cozy focused on baby space (quiet, warm, attentive etc.)
At what age is the typical child physiologically capable of potty training?
18 months
At this age the child should be physiologically capable of potty training. Expectations prior to this age are unfair, and should be discouraged (although it is not impossible).
What are the general iron and cobalamin needs for a vegetarian relative to a typical diet ?
Iron requirements are 1.8x that of a non-vegetarian This is because the iron consumed is not in an optimal valency, also compounds in veggies called phytates/tannins sequester the iron from absorption
Cobalamin (Vit. B12) 5-10 ug/day split TID is required, This can be accessed through supplements, fortified foods and/or eggs. High folate diets (i.e. vegetarians) can mask a B12 deficiency but still have developmental deficits.
What are the decibel thresholds for defining normal vs. mild, moderate, severe and profound hearing loss ?
The decibel threshold is the minimal amount of sounds needed for function, so quieter (lower) is better.
- Normal : 0 - 20 dB
- Mild: 20 - 40 dB [Missed by newborn screening]
- Mod: 40 - 60 dB
- Severe: 60 - 80 dB
- Profound: > 80 dB
What are the risk factors for congenital/neonatal hearing loss ?
Intrinsic
- Family History of permanent hearing loss
- Craniofacial malformations
- Syndromic dysmorphisms
Acquired
- Congenital/Perinatal Infections
- NICU stay > 2 days (noise damage)
- Large Magnitude of Illness (ECMO, Intubation, Sepsis, Meningitis, acute hyperbilirubinemia encephalopathy, prematurity)
How does one assess if a shoe is properly fitting a child?
- Thumbs width between the tip of the shoe and the child’s big toe
- When the sides are squeezed, a ruffle in the middle of the material is formed
- The child says they are comfortable
Archeological studies dating back 10,000 years have demonstrated that pedal deformations correlate with use of poor shoe quality.
EPI BULLETS
- SIDS accounts for 5 % of all infant deaths and 17.2 % of all post-natal deaths
- Risk Factors for SIDS include:
- Indigenous (Inuit, Metis, First Nations)
- Low birth weight
- Low Socio-economic standing
- Prematurity
What is the best evidence based advice for introduction of allergens for infants ?
- NO benefit (but possible harm) in delayed exposure
- Introduction of appropriate allergens* at 4 months yields good allergic outcomes, without adverse events
- Maternal evasion during pregnancy and breastfeeding does NOT change allergy outcomes.
*By appropriate I mean macerated to a consistency/modality that is developmentally appropriate for a 4 months old to seek out and sample. The child is ready for solids, when they demonstrate interest - refer to feeding development.
Which of the following implications, regarding pacifiers, are evidence based?
- Early breastfeeding weaning
- Increased AOM risk
- Dentition problems
- Poor sleep patterns
- Poor speech development
Early breastfeeding weaning - FALSE
An RCT identified the use of pacifiers as not being associated with early breastfeeding cessation or “nipple confusion”. The association is more strongly seen with psychosocial issues, rather than the pacifier.
Increased AOM risk - “true”
Identified with chronic, prolonged, use of a pacifier after the age of 12 months. There are no additional pathogen orginating from the pacifiers themselves.
Dentition problems - “true”
Any dental issues are also associated with prolonged and frequent use of pacifiers after the age of 12 months.
Poor sleep patterns - FALSE
Dependance on pacifiers for proper sleep is not a thing. Having one is a common poor practice seen in Behavioural Insomnia of Childhood where parents inconsistently remove/restrict the pacifier.
Poor speech development - “true”
This has been associated with poor initiation of speech if the pacifier is frequently in place whilst the child is playing. It can be a deterrant to speak properly.
What is the mechanism for melatonin (regarding to sleep)?
When your eyes are exposed to the dark, in the right environment, the pineal gland secretes melatonin to fire up the sleep count-down. This need for dark is where the issue with screen-time (blue light) comes from.
Several studies have shown NO development of psychiatric, metabolic or behavioural issues secondary to melatonin.
What organic, developmental and psychiatric disorders are common in Foster Care Children ?
Organic Disease (typically environmental sourced)
- Bug bites/infestations
- Poorly controlled atopy (20 % asthma, 16 % eczema)
- Dental caries and gum disease
- Neglected vision/hearing deficits
- Trauma from abuse/neglect
- Neglected vaccinations
- Physical disabilities (2 % of foster children)
Developmental Disorders
- Learning disabilities (15 % incidence)
- Developmental Delays (10 % incidence)
- Substance abuse sequelae (e.g. Fetal alcohol, cocaine)
Psychiatric Disorders
- Depression
- Anxiety Disorders (e.g. PTSD, phobias, adjustment d/o)
- Substance abuse disorders
Regarding Breastfeeding, explain Baby-led Weaning
Allows the baby to be exposed to solids at 4-6 months of age, permitting them to eat at their own pace with breastfeeding at the end of the feed.
Typically takes 2-4 years to be completed if no additional restrictions made by the family.
What is your management escalation for lice ?
- Topical insecticides (permethrin 1%, pyrethrin)
- Assess safety of alternative methods (NO Resultz for < 4 y.o. or dimeticone for < 2 y.o.)
- Assure hygiene measures in home are taken
- Consider Septra for refractory cases
EPI BULLETS
- 1 - 3/1000 Live births have a hearing deficit
- 50 % of hearing deficits have an identified genetic component (uConnexin26 is the most common); 76 % of this 50 % are non-syndromic genetic hearing deficits.
- If caught and managed early, their standardised school scoring is 20-40 % higher than their missed peers. (remember newborn screening will miss mild cases)
List 2 negative aspects of Immediate Release Stimulants and 2 positive aspects of Extender Release Simulatants, as treatments
(as endorsed by the CPS)
-
Immediate Release
- Requires a repeated dose at school
- Social stigma with “taking a pill”
- Low compliance
- Associated with misuse/vending
-
Extended Release
- Does not require school-involved with medication
- Better compliance
- Improved durations of treatment
- Associated with fewer hospital presentations for impulsivity related medical concerns
What are the principles of safe sleep to encourage for your patients?
With ALL episodes of sleep (including daytime naps)
- NO CO-sleeping
- PRONE sleeping
- BORING BEDS (firm mattress, taught blankets no toys)
- ROOMING in, but not co-sleeping
- NO SMOKE-ing within the family/household
- BREAST FEEDING; doesn’t have to be exclusive
Safe sleep has decreased the incidence of SIDS by ~ 50 %
What are the protein requirements of a vegetarian/vegan relative to their control for:
- 0 to 2 years old
- 2 to 6 years old
- 6+ years old
- 0 to 2 years old : +35 % more protein -
- 2 to 6 years old : +20-30 % more -
- 6+ years old: +15-20 % more
Vegetarian/Vegan athletes in particular will require 1.2-1.4 g/kg for endurance training, and 1.6-1.7 g/kg for weight training. Remember all adolescent diets/will changes in consumption should be screened for an eating disorder.
List 3 Systematic/Environmental interventions to optimize pain/distress with procedures
- Have parents present (MUST)
- Have caregiver hold/immobilize the patient (if possible)
- IVs over heel pricks (are less painful)
- Combine IV placements with blood work
- Re-assess needs for blood work/IV placement
EPI BULLETS
- 1/20 children wordwide have ADHD
- 11 % of adolsecents/young adults sell their Rx stimulants
- 22 % of adolescents misuse their Rx stimulants for recreational highs or hyperfocused states
- ~ 50 % of adolescents admit to not taking their IR stimulant
- IR is more implicated than XR for adverse uses/vending
IR = immediate release, XR = extended release, Rx = prescribed
EPI BULLETS
- Children of Military personnel are 3x more likely to fail ASQ-3 if a parent is actively deployed
- 70 % of Military Spouses/Families will experience “deployment” once, (17 % > 5 times)
- 76 % of Military Families relocate at least once
- < 46 % of Military Spouses are employed
- After deployment, Military personnel have 20-50 % prevalence of PTSD symptoms, 24 % ethanol abuse, 15.7 % depressive symptoms.
*** ASQ-3 is a developmental screening tool used in the US
What is the definition of Sudden Infant Death Syndrome (SIDS)?
Sudden death of an infant without a diagnosis for cause of death after autopsy, clinical history review and environmental review.
What is the management for a child with a febrile UTI ?
(as per the CPS)
You are suspecting a urinary tract infection
- Discuss the importance of obtaining the ideal urine sample, and the options for collection with the family.
- Obtain a urinalysis and culture sample
- If the patient is STABLE, there is no need for blood cultures to be drawn.
- Select antibiotics if urinalysis/exam is consistent with suspicion for urinary tract infection;
- < 3 months old = PO Abx with very close follow-up (or IV Abx if not tolerating PO/Parental concern/Follow-up difficulties.) Total course is 7-10 days.
- > 3 months old, non-toxic, no suspicion for abnormal renal anatomy = PO antibiotics for 7-10 days with follow-up. (If not tolerating PO, can give IV until PO is tolerated.)
- All febrile UTIs in a < 2 year old get anatomy ultrasounds.
What are the infectious risks associated with AirTravel ?
- Air is cycled 3-4 x faster than your home within the cabin, through a pathogen filter. There is also less surface exchange as passengers should remain in their seats.
- Infectious risks include:
- Tuberculosis
- Measles
- Influenza (highly infectious droplets)
- Coronavirus spp.
- CPS Suggests to focus more on maintaining hygiene and keeping to yourself within the craft rather than taking excessive precautions.
What is your Management Plan for Functional Constipation ?
(I’ll provide the CPS’ sequence as their statement)
- Educate both the family and patient on pathophysiology, dieetary/activity changes, treatment benefits/safety and course of disease)
- Emphasize NO negative reinforcement
- Oral PEG-3350 at “clean out” doses for age/size
- If PO not tolerated, admit for NG clean-out
- Maintenance PEG-3350 daily
- If refractory to 6 months of therapy, consider other dx
- CPS says NO to probiotics for this indication
- CPS says NO to manual disimpaction of children
We need to treat the constipation acutely AND implement dietary changes to avoid Behavioural Constipation.
What historical findings are consistent with POOR asthma control ?
- > 2 daytime symptoms per week
- Any nighttime symptoms
- > 2 rescue medication dosings per week
- Functional limiting to avoid symptom exacerbation*
*Not joining sports, avoiding gym class, not hanging with friends, needing a ride to school, not visiting friends with triggers in the home
What is the ideal controlled asthma treatment regimen ?
(Assuming they are steroid dependant)
- Rare B-agonist requirements (< 3 doses per week)
- ICS dosing at 100 - 125 ug (Flovent/Alvseco dosing)
- +/- Leukotriene Inhibitor if it helps keep steroid down
Define Homeopathy vs. Naturopathy
Homeopathy is the practice of taking a substance associated with certain clinical symptoms - diluting them in water or a powder - and administering it for disease management.
Naturopathy, which is the collective use of Complementary and Alternative Medicines (CAM) to treat a patient - includes mineral/vitamin supplementation, intravenous rehydration/mineral repletion, acupuncture, dietary advice etc. Not all naturopaths support/perform homeopathy and not all homeopaths are trained naturopaths.
What conditions require oxygen flight testing, prior to travel ?
- Congenital Heart Disease exacerbated by hypoxia
- Restrictive Lung Disease or COPD
- Known or suspected chronic hypoxemia
- Known of suspected chronic hypercarbia
- Previous hypoxic travel issues
Sick cell patients ALL require oxygen for flights above 7,600 feet. So a flight test isn’t needed, this is standard of care.
What are 3 phases, regarding deployment, that have unique risks to the Military Personnel’s (MP) family ?
Pre-Deployment
- Time of relocation, establishment of 2 parent lifestyle
- School changes can exacerbate learning/anxiety/mood disorders.
- Anticipatory distancing and blunting affect in child can occur
Deployment
- Readjustment to single parent lifestyle
- Decreased healthcare access, secondary to feasibility
- Early deployment sees most adjustment disorder symtoms which decline as month progress
- Video interfacing has resulted in better MP outcomes but amplifies anxiety for those at home (tangible danger)
- This period has increased abuse/neglect (+42 %) risk
Post-Deployment
- Readjustment disorders of the MP into family/home; psychiatric disorders**. First 3 months is the worst.
- After an initial excitement, the Child will re-enter adjustment disorder phase coupled with MP’s adjustment.
***Child will be exposed to EtOH (24 %) abuse, depression (15.7 %), PTSD (20-50 %) increased risk of neglect and abuse.
What interventions can safely be used for behavioural issues during travel ?
- Anticipatory preparation (Explain process, prepare pass-times determined by the child “their book”, make it exciting/an event)
- Do NOT condone medications for sleep/sedation
- Consider stopping melatonin (doesn’t work with jet lag)
What colonies forming units per litre (CFU/L) are consistent with a urinary tract infection for:
- Catheterized sample
- Clean catch sample
- Suprapubic needle aspiration?
- Cath Sample : > 5 x 10^7
- Clean Catch : > 1 x 10^8 (Twice as much)
- Suprapubic needle: ANYTHING
What risk factors are associated with early onset of oral disease ?
- Low Birth Weight
- Prematurity
- Iron Deficiency
- Low socioeconomic status
(**specifically Immigrants, Indigenous Peoples, Single Parents, Abuse in Home, Teen Mothers)
How often does one assess shoe sizing for a child from 0-12 months, 1-3 years and 3+ years old?
- 0-12 months : Should not be wearing shoes, as they are not needed until the child starts ambulating.
- 1-3 years : Grow 0.5 size/2 months**
- 3+ years : Grow 1 size/year until puberty
**Ankle boots do not provide more support, nor are they better/worse than normal shoes - but they are harder to take off for a toddler, thus harder to lose!
EPI BULLETS
- 5-10 % of all preschoolers have visual defeciencies
- Routine screening dropped Amblyopia incidence by 70 % and increased general acuity by + 60 %
What is the CPS’ management of positional plagiocephaly ?
- Confirm benign nature of condition (i.e. not craniosynostosis, syndromic malformation rather than deformation etc.)
- Radiographs if abuse suspected or Differential uncertain
- Educate on Tummy Time (3+ times per day for 10-15 minutes), to continue safe sleep practices and the benign nature of the condition
- If sutures are closed, surgery is required
- If sutures are open and 2/2 other pathologies (e.g. torticollis), then physio referral is suggested
- If really bad (subjective) then consider helmet
Is Melatonin safe to use in patients with Autism, for sleep ?
YES
67 % of ASD patients have a sleep disorder. Melatonin was shown to improve Sleep Latency (2.6 to 1.06 h), Sleep Duration (8 - 9.8 h) and Waking Events (0.35 - 0.08/night average). Only 1 % of patients in a massive study had worsened sleep conditions secondary to melatonin, and no adverse reactions beyond abdominal cramping/nausea were noted beyond 1 week of therapy initiation in all studies.
What mineral deficits in vegetarians/vegans are highlighted by the CPS ?
- Zinc (Poor absorption) Phytates mitigate bioavailability requiring supplementation or dietician consultation.
- Iron (Poor absorption) Phytates and Tannins mitigate bioavailability, requiring daily intake to be 1.8x that of non-veggies.
- Calcium (Poor intake) Supplementation should be considered with Vitamin D. Rough greens are high in calcium (e.g. collard greens, cabbages, kale)
What is the CPS’ Management Plan for patients with Nocturnal Enuresis?
- Reassurance that this is common and benign
- Inform family to avoid diapers (pull-ups ok), pre-sleep fluids/caffeine, humiliation and behavioural therapies.
- Offer voiding alarms ($$$) or parent waking routines
- Offer Desmopressin (ADH) if child is bothered by sx
- Offer Imipramine (TCA), however there was no benefit over placebo and the side-effect profile is high.
- If 8+ y.o. consider a work-up for other (rare) aetiologies
Parent waking schedules is labour intensive, and not much better when compared to void alarms. CPS discourages behavioural change strategies (except having child involved in clean-up) because this is not a behavioural pathology. Even positive reinforcement can be met with negative consequences, when the kid tries but fails to be dry.
What are the two tests offered for hearing loss in newborn/infants
How do they work?
Otoacoustic Emissions (OAE)
This test is done by placing an earpiece and measuring a feedback response from cochlear hairs via the tympanic membrane. This will assess for sensorineural hearing deficits from the TM to the Cochlea.
Automated Auditory Brainstem Response (AABR)
Measures the electric response of the brainstem to an auditory stimulus. This allows assessment of hearing from the TM to CN8 to the brainstem to the auditory tracts in the cortex. Narrows down the pathologic locus.
Attached is a report of a child that was initially evaluated with a normal OAE (Written in Blue Ink), with a follow-up (Red Ink) indentifying severe to profound deficits. This is the standard presentation of these results and should be appreciated for the exam.
What are the definitions of:
Strabismus
Amblyopia
Cataract
how are these picked-up on routine pediatric examinations?
Amblyopia : Cortical loss of vision of an eye from preferential use of the other. Amblyopia is the result of other pathologies and cannot be seen on exam. It is irreversible.
Strabismus : Misalignment of the eye in any direction; may be constant or intermittent. This is identified with the eye cover test, white coreneal reflex symetry (how to rule-in/out pseudostrabismus). Can lead to amblyopia if left untreated.
Cataract : Opacification of the lens secondary to trauma, perinatal infection, intrinsic error of metabolism or specific mutations. They will occlude vision from the eye eventually leading to Amblyopia if not treated. They are identified as an absent Red Reflex (leukocoria) on examination.
EPI BULLETS
- There are 76,000 foster Children in Canada
- 48 % of foster children are indigenous, conversely 6 % of all indigenous children are in foster care.
- 70 % of foster children (vs. 17-22 % of controls) have a lifetime history of emotional dysregulation
- 45-92 % of Foster children have a medical issue
- 82 % of Foster children are labelled as “special needs”
- About 1/3 of Foster Children have a chronic illness
What standardized tool should be used for patients who have suffered any head injury ?
Sport Concussion Assessment Tool - 5th Edithion
(SCAT5)
The SCAT5 include red flags for risk of intracranial bleed or impending herniation. This is an excellent, and simply used, tool that should be distributed to all sports coaches as it objectively assesses the patient immediately after the accident for appropriate following.
Available in the Footnote section free
https://bjsm.bmj.com/content/bjsports/51/11/851.full.pdf
List the CPS steps in addressing Medical Neglect
Addressing Medical Neglect
- Identify the decision maker
- Determine and explicitly state the goal of the healthcare plan
- State and discuss the recommendations
- Consider the potential harm and perceived harm, with an intervention
- Explore and understand the reasons for non-adherence/resistance
- Call DPJ/CAS if the child is still at risk - you legally have to
- Document Document Document
I’ve attached a clip of the complete documentation points you need to include when faced with concerning resistance to a treatment plan. This also acts like a cheat-sheet to remind yourself to follow the above steps
https://cps.ca/en/documents/position/medical-neglect
Describe management of infantile hemangioma
Infantial Hemangioma Management
* Full cardiac exam performed (including BP, pulse)
If abnormal or suspicious cardiac exam, ECG and Echocardiography
* If there are >5 cutaneous hemangiomas present: abdominal US
* * Propanolol 1 mg/kg/day BID
Increased by 0.5 mg/kg/day to a max of 3 mg/kg/day
* Propanolol initiation should be done as an inpatient if:
- There are cardiorespiratory comorbidities
- Infant is < 5 weeks old
- Family has insufficient social supports
* Refer if the hemangioma is on the face or occluding an orifice
* Follow-up and dose adjust Q2-3 months
If there is ulceration, recurrent infection, or poor response after 1 month consider referral to dermatology for lazer treatment
https://cps.ca/en/documents/position/vascular-anomalies
