Community Pediatrics Flashcards
Updating since 18/04/2024
1
Q
EPI BULLETS
A
- ~ 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
2
Q
Define Insomnia
A
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
3
Q
Define Primary Nocturnal Enuresis
A
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.
4
Q
What are the CPS’ concerns with poor literacy ?
A
- 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
5
Q
What is your approach to your first evaluation of a child in foster care?
A
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.
6
Q
What are the three criteria to declare housing unacceptable?
What criteria need to be met to be considered for Core Housing?
A
- 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
7
Q
Define positional plagiocephaly
A
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
8
Q
Which conditions require DVT prophylaxis for air travel ?
A
- Thrombophilia disorders
- Active malignancy
- Major surgery within 6 weeks
- Previous thrombotic embolism
Patient will be managed with ASA or LMWH as per hematology
9
Q
Describe the process for managing a feeding tube with air travel
A
- 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
10
Q
Give 3 characteristics of proper potty training regimen
A
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)
11
Q
What is the “Reach Out and Read” method proposed by the AAP (and accepted by the CPS) ?
A
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.
12
Q
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?
A
< 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.
13
Q
Define the following sleep terms:
- Sleep Latency
- Sleep duration
- Waking Events
A
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.
14
Q
List 3 behavioural interventions to optimize pain/distress with procedures
A
- 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
15
Q
What is the FiO2 in an aircraft whilst it is in flight
A
About 15 % FiO2
16
Q
EPI BULLETS
A
- 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.
17
Q
What is the management for “Nursing Strikes”, in the context of babies breastfeeding ?
A
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.)
18
Q
At what age is the typical child physiologically capable of potty training?
A
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).
19
Q
What are the general iron and cobalamin needs for a vegetarian relative to a typical diet ?
A
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.
20
Q
What are the decibel thresholds for defining normal vs. mild, moderate, severe and profound hearing loss ?
A
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
21
Q
What are the risk factors for congenital/neonatal hearing loss ?
A
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)
22
Q
How does one assess if a shoe is properly fitting a child?
A
- 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.
23
Q
EPI BULLETS
A
- 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
24
Q
What is the best evidence based advice for introduction of allergens for infants ?
A
- 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.
25
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.
26
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.
27
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
28
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.
29
What is your management escalation for lice ?
1. **Topical insecticides** *(permethrin 1%, pyrethrin)*
2. Assess **safety of alternative** methods *(NO Resultz for \< 4 y.o. or dimeticone for \< 2 y.o.)*
3. Assure **hygiene** measures in home are taken
4. **Consider Septra** for refractory cases
30
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)*
31
List _2 negative_ aspects of Immediate Release Stimulants and 2 **positive** aspects of Extender Release Simulatants, as treatments
## Footnote
*(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
32
What are the principles of safe sleep to encourage for your patients?
With ALL episodes of sleep (including daytime naps)
1. **NO CO**-sleeping
2. **PRONE** sleeping
3. **BORING BEDS** *(firm mattress, taught blankets no toys)*
4. **ROOMING** in, but not co-sleeping
5. **NO SMOKE**-ing within the family/household
6. **BREAST FEEDING**; doesn't have to be exclusive
*Safe sleep has decreased the incidence of SIDS by ~ 50 %*
33
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
## Footnote
*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.*
34
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
35
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
## Footnote
IR = immediate release, XR = extended release, Rx = prescribed
36
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.
## Footnote
\*\*\* ASQ-3 is a developmental screening tool used in the US
37
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.
38
What is the management for a child with a febrile UTI ?
## Footnote
*(as per the CPS)*
You are suspecting a urinary tract infection
1. **Discuss** the importance of obtaining the ideal urine sample, and the options for collection **with the family**.
2. Obtain a **urinalysis** and **culture** sample
3. If the patient is **STABLE**, there is **_no_** need for **blood cultures** to be drawn.
4. Select antibiotics if urinalysis/exam is consistent with suspicion for urinary tract infection;
1. \< 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.
2. \> 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.)*
5. All **febrile** UTIs in a **\< 2 year old** get anatomy **ultrasounds**.
39
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 surfac**e 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 **keep**ing **to yourself** within the craft rather than taking excessive precautions.
40
What is your Management Plan for Functional Constipation ?
## Footnote
*(I'll provide the CPS' sequence as their statement)*
1. **Educate** both the family and patient on pathophysiology, dieetary/activity changes, treatment benefits/safety and course of disease)
2. Emphasize **NO negative** **reinforcement**
3. **Oral PEG-3350** at "clean out" doses for age/size
4. If PO not tolerated, admit for NG clean-out
5. Maintenance **PEG-3350 daily**
6. If refractory to **6 months** of therapy, consider other dx
7. CPS says **NO** to **probiotics** for this indication
8. CPS says **NO** to **manual disimpaction** of children
## Footnote
*We need to treat the constipation acutely AND implement dietary changes to avoid Behavioural Constipation.*
41
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\*
## Footnote
*\*Not joining sports, avoiding gym class, not hanging with friends, needing a ride to school, not visiting friends with triggers in the home*
42
What is the ideal controlled asthma treatment regimen ?
## Footnote
*(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
43
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.
44
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**
## Footnote
*Sick cell patients ALL require oxygen for flights above 7,600 feet. So a flight test isn't needed, this is standard of care.*
45
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.
46
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 **stop**ping **melatonin** *(doesn't work with jet lag)*
47
What colonies forming units per litre (CFU/L) are consistent with a urinary tract infection for:
1. Catheterized sample
2. Clean catch sample
3. Suprapubic needle aspiration?
1. Cath Sample : \> 5 x 10^7
2. Clean Catch : \> 1 x 10^8 *(Twice as much)*
3. **Suprapubic** needle: **ANYTHING**
48
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)*
49
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
## Footnote
*\*\*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!*
50
EPI BULLETS
* **5-10 %** of all **preschoolers** have **visual defeciencies**
* Routine screening dropped Amblyopia incidence by 70 % and increased general acuity by + 60 %
51
What is the CPS' management of positional plagiocephaly ?
1. Confirm benign nature of condition *(i.e. not craniosynostosis, syndromic malformation rather than deformation etc.)*
2. Radiographs if abuse suspected or Differential uncertain
3. Educate on Tummy Time *(3+ times per day for 10-15 minutes)*, to continue safe sleep practices and the benign nature of the condition
4. If sutures are closed, surgery is required
5. If sutures are open and 2/2 other pathologies *(e.g. torticollis)*, then physio referral is suggested
6. If really bad (subjective) then consider helmet
52
Is Melatonin safe to use in patients with Autism, for sleep ?
YES
## Footnote
*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.*
53
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)
54
What is the CPS' Management Plan for patients with Nocturnal Enuresis?
1. Reassurance that this is common and benign
2. Inform family to avoid diapers (pull-ups ok), pre-sleep fluids/caffeine, humiliation and behavioural therapies.
3. Offer voiding alarms *($$$)* or parent waking routines
4. Offer Desmopressin (ADH) if child is bothered by sx
5. Offer Imipramine (TCA), however there was no benefit over placebo and the side-effect profile is high.
6. If 8+ y.o. consider a work-up for other (rare) aetiologies
## Footnote
*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.*
55
What 3 issues erodes the integrity of homeopathic literature?
1. **Small** study size
2. Poor study **execution/method** consistency
3. **Data manipulation** and presentation for inaccurate assumption of efficacy
## Footnote
*When the research is performed in a proper, RCT/exposure review there are no benefits found versus placebo.*
56
What urologic anomalies require prophylactic anti-biotics ?
* Vesico-ureteric reflux (VUR) Grades **4 and 5**
* **Significant** urologic **anomalies** as dictated by nephrology and/or urology
## Footnote
*Previous guidelines and practice was to give every patient with reflux prophylactic antibiotics, this is has not been shown to benefit versus the risks associated with chronic antibiotic use.*
57
A patient on prophylactic Abx for a renal anomaly's urine grows a suspected contaminant that is resistant to their ppx.
They are asymptomatic of any urinary tract infection symptoms.
What is your course of action ?
Change prophylaxis to a susceptible anti-biotic
## Footnote
Even if the patient is asymptomatic at this time, they are colonized with a possible source of resistance for other pathogens through plasmid transformation or could develop an infection from this now-contaminant later.
58
What additional context/questions need to be established when evaluating children of Millitary Personnel ?
What phase of deployment is the family in ?
**Pre-deployment**
* If recent relocation; previous medical records? Vaccinations? Adjustment to new school/community?
* What changes does the spouse anticipate in the house/activities once the MP has been deployed?
* How does the Child feel about the deployment?
**Deployment**
* How is the child coping? School, home or friend issues?
* Adjustment disorder screening
* Access to firearms?
* Substances in the home?
**Post-Deployment**
* Screen for abuse/neglect within the home
* How child feels about returning parents
* Changes to the new baseline in the home
Always arrange an appointment prior to deployment to establish routine follow-up throughout deployment and afterwards.
59
Fun Facts about Lice
* For 1st infection, it takes **4-6 weeks to itch**
* Finding a **nit does NOT mean** active **infection**
* Using a **lice comb** increases you chance of proper **diagnosis 4-fold**, and twice as fast!
* **Kids** are **NOT** allowed **to be sent home** from school for lice
60
What are indications for a lipid profile in a child ?
## Footnote
*Lipid or Metabolic Profile typically includes Total Cholesterol, HDL, LDL, Triglycerides, AST, ALT, ALP, glucose and occasionally HbA1C*
* Obesity (\> 10 y.o.)
* Family history or suspected dyslipidemia
* Hypertension
* Diabetes Mellitus (Type 1, 2 and genetic)
## Footnote
* Lipid or Metabolic Profile typically includes Total Cholesterol, HDL, LDL, Triglycerides, AST, ALT, ALP, glucose and occasionally HbA1C*
* A metabolic profile requires 1-2 SST (yellow) tubes and a cell tube (lavender)*
61
TRUE or FALSE
The **following are ok** for the **primary** care physician to do in asthma
* Control with **Leukotriene** inhibitor **instead** of **ICS**
* **Increase ICS** during **acute illness**
* Daily **regular** B-agonist
**FALSE**
## Footnote
* **Leukotrienes are** an **adjunct** therapy to ICS, they help mitigate the allergic component of the asthma and *can decrease* the *dose* of steroid, but **only ICS keeps the inflammation at bay**
* **Increasing ICS** during **illness** is something a **respirologist** will do on case by case basis, this practice is to be stopped.
* Daily **regular B-agonist** is an old practice that is occasionally ordered by respirologists. This practice should **not be routine** for paediatricians.
62
What criteria does the CPS Statement suggest to appraise in a sick child between 3 - 24 months old to not investigate for UTI?
* \< 12 months old
* Fever \> 38 ºC for 2 days
* Fever \> 39 ºC
* Absence of another source (viral ENT/GI/Resp symptoms)
* Caucasian race
If only only one of the above is present, the odds of this presentation being a UTI is \< 1 %:
63
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.*
64
What dental coverage can children have in Ontario?
* **Healthy Smiles**: Basic check-up and procedures, no anaesthesia. \< 20,000 $/year household income only.
* **ODSP**: Basic check-up and procedures, yes to anaesthesia and oral surgeries. Must be living with disabled parent.
* **ASDC**: Total coverage. Patient must be severely disabled.
* **CINOT**: Only acute costs, not routinely given *(e.g. tooth knocked out, car accidents, abscesses etc.)* Hospital inpatient services are covered.
65
What is the CPS' Checklist for assessing Potty Training readiness?
The following criteria must be met
1. Can walk and sit (stably) on potty
2. Can remain dry for several hours
3. Can identify when they need/have gone to the bathroom
4. Can follow 1-2 step commands
5. Has a desire to please
6. Has a desire to be independant
7. No acute stressors/changes in the home
66
What makes an infant High Risk for an allergy ?
They have a first degree relative with an IgE mediated allergy
67
What are positive aspects associated with pacifier use prior to 12 months of age?
1. Non-nutritive feeding in NICU babies
2. Management of pain/distress in procedures
3. Decreased SIDS incidence
68
What is the role and mechanism for ADH (*desmopressin*) in management of nocturnal enuresis?
Antidiuretic hormone (ADH) can be given to help treat nocturnal enuresis by **decreasing urine production**, however the cure rate with this modality is rather low. CPS suggests using only for isolated events such as sleepovers or camp.
The patient **cannot take liquids 1 h prior, and 8 h post-treatment** to avoid water toxicity. No cases of water toxicity were reported in a systematic review of 752 patients.
*Normal humans increase ADH naturally while we sleep. In a scandinavian study, ADH levels in children and those with NE had static levels when they slept*
69
TRUE or FALSE
## Footnote
Homeopathy *(not naturopathy)* is completely regulated by the Government of Canada?
FALSE
## Footnote
*Homeopathic products are given drug #'s and the source material is assessed for purity/contaminants like any chemical in Canada. Homeopathic Practitioners then create diluted compounds/solution, which are NOT assessed. The arsenic the homeopath bought was appraised and regulated, but the final diluted product is NOT evaluated by any government entity.*
70
What is **Behavioural Insomnia of Childhood**, and how can it be treated?
Insomnia secondary to developmentally **abnormal practices adopted by the patient/family** that must be met for a child to fall asleep.
**Consistent boundaries** instilled by **parents** regarding bedtime rules and conditions have the best evidence for cutting bad habits.
There will be tantrums.
71
What is the outpatient treatment of uncontrolled asthma that is:
* Very Mild *(Rare intermittent symptoms without need for steroid)*
* Mild *(Symptoms \< 8 days/month)*
* Moderate *(Symptoms ≥2 days/week or \> 8 days/month)*
* Severe *(Admission/Emerge visit on current regimen)*
* Very Mild (Symptoms)
* **Review** exposure history*
* Short acting beta agonist PRN is acceptable
* Mild *(Symptoms \< 8 days/month)*
* ***Review** exposure history*
* ***Low dose ICS** or Leukotriene inhibition*
* Symbicort or SABA **PRN**
* Moderate *(Symptoms ≥2 days/week or \> 8 days/month)*
* ***Review** exposure history*
* ***B-agonist** PRN*
* **Medium** dose **ICS** *or* **Low-medium Symb.** *or* **low ICS + a second controller** medication
* Severe *(Admission/Emerge visit on current regimen)*
* ***Review** exposure history*
* ***Medium** dose **ICS*** (or high if previous on medium)
* ***Refer** to **Asthma Clinic**/**Respirology** depending on your center*
## Footnote
https://cps.ca/en/documents/position/mild-asthma
72
Until what age is isolated bow legging/knocked knees acceptable?
Until 8 years old
## Footnote
If the patient continues to have these patterns, evaluation by **orthopedics** may be **warranted**.
If a kid has **uncorrectable/persistent** bow legging/knocked knees a **metabolic/MSK evaluation** is warranted.
73
Do children need car seats on planes and long range buses?
* Long-range **buses need car seats**
* USA **recommends car seats** for **plane** travel *(evidence is equiv.)*
* Small children can stay in parents arms, but not safe. This is financially more appealing than buying a separate seat for the carseat - so this is common practice.
74
EPI BULLETS
* 57 % of 6-11 year olds have a cavity (2.5 cavities ave)
* **Indigenous** children has **\> 90 % prevalence of tooth decay**
* **~32 %** of Canadian Children have n**o dental coverage**
75
What is the management for a febrile non-verbal child *(defined as \< 3 years old)* without a source of fever?
As per the CPS Guidelines
1. Suspicion for UTI must be high
2. Catheterised sample must be taken for Cx/Urinalysis *(63 % of bag samples are contaminated)*
3. If Urinalysis/Microscopy is **positive**, can **treat**. If _negative_, must _follow-up_ culture and symptoms.
4. Use appropriate antibiotics for region, age and comorbidities *(Amoxicillin, Cefixime, Fluoroquinolones, Septra)*
5. If UTI is recurrent, associated with syndrome or the **febrile child is \< 2 years old**, an **Ultrasound** of the urinary tract must be assessed **non-urgently.**
76
What are **3 protective factors** for dental health?
* Good feeding/**bottle hygiene**
* Good **Nutritional** Status
* **Fluoridation** of Water
* Routine topical **Fluoride** treatments
77
What are sources for **essential** *(ones you can't make yourself)* **fats** missing from Vegetarian/Vegan diets?
The fats of particular mention are:
* Omega-3
* Omega-6
These can be found in Flax seed, canola oils, several seeds/nuts. These should be included in the patient's diet for proper brain development.
78
What is the most successful management for nocturnal enuresis? (describe the management)
Night voiding alarms are the most efficace modality of curing nocturnal enuresis. The alarm is applied for 3-4 month straight, can stop once the patient has 14 consecutive dry nights. \<50 % cure rate is observed however that study had 0 cure rates in the placebo group, so it's worth while.
79
What are the **Rome-IV Criteria** for constipation?
How many are required to make a diagnosis of functional constipation ?
**2/6 Rome-IV Criteria** occuring **weekly** for **2 months**
* ≤ **2 poops**/week in a toilet *(accidents don't count)*
* **1 fecal** **incontinence**/week
* **Retaining** poops
* **Painful** poops
* Toilet **blocking**
* **Big poops** (fecaliths) in the rectum
*Other pathologies (e.g. Hirschsprung's, CF, abdominal mass, gender dysphoria etc.) have been screened for and deemed unlikely.*
80
Regarding Breastfeeding, explain Mother-led Weaning
Planned **schedule** for when **breastfeeding will cease** because of preference, culture, feasibility or other stressors. If this occurs _before 6 months of age_, refer/provide _breastfeeding support_.
**Abrupt/Emergent** **weaning** because of substance, disease or medical reasons should always be as gradual as possible to minimize stress/withdrawal-like symptoms for the baby.
*(e.g. if a Mother is to start chemo, they should start the wean immediately at the time of this decision).*
81
EPI BULLETS
* **Boys** are more prone to nocturnal enuresis
* Nocturnal enuresis prevalence 10-15 % of 5 year old boys 6-8 % of 8 year old boys 1-2% of 15 year old boys As **age increases**, there is a risk of **secondary psychosocial issues** developing
* A gene on the Chromosome 13's q arm (13q) has been identified with NE, and can explain the familial trend
82
Describe the perfect sleep hygiene
* Assure patient has filling supper (**No bedtime hunger**)
* **Consistent** Sleep and Wake Times
* **Relaxing** activities leading up to bedtime
* No nicotine, drugs, ethanol, caffeine in the evening
* **Dark** Room/**No** **Screens**
* Age appropriate **Sleep Duration**
83
How would you assess for housing issues in your patients?
The CPS suggests the acronym of HOME to assess for housing
* **_H_** arm-ful events that occured in the home
* **_O_** ccupancy within the home
* **_M_** oves in the past few years
* **_E_** nough resources to sustain themselves
84
According to the CPS - Explain the Ophtalmogic assesment for the following age groups:
* NB to 6 Months
* 6 Months to 12 Months
* 3 to 5 years
* 5 to 18 years
* NB to 6 Months
**Family History**, assess the external **anatomy** of the eye/face, **red reflex**, **cranial nerves**.
* 6 Months to 12 Months
Review above; addon **Tracking** and **Corneal alignment**
* 3 to 5 years
Review above; addon **acuity**
* 5 to 18 years
Review above; inquire about any additional visual complaints the older child can better describe.
85
Metatarsus adductus should be referred to orthopedics when?
Metatarsus adductus *(in-toeing)* should see orthopedics when it is **not reducible** on passive manipulation or **affects gait**.
A **physiotherapy referral** should be attached with this evaluation
86
EPI BULLETS
* 15 to 25 % of kids have sleep initiation issues
* 67 % of kiddos with Autism have sleep issues
87
What are the imaging modalities seen with urinary tract infections, what do they show and when are they indicated ?
* **Renal/Urinary Tract Ultrasound** - assesses anatomy for malformations/macroscopic scarring, can on occasion identify reflux depending on the skill of the technician. To be used for febrile UTIs \< 2 years old, recurrent UTI or suspicion for underlying malformation based on H/P.
* **DMSA Scan -** radioisotope scan to assess the kidney for function, acute infection and scarring. Rarely changes management, with significant radiation exposure. A common request by parents, not nephrologists.
* **VCUG** - invasive interventional radiology test assessing the anatomy of the urinary tract's lumen. Gold standard for assessment reflux. Avoided for fear of damaging the urethra causing scarring or introducing infection.
* **Nuclear cystogram** - another assessment of renal function through nuclear medicine. Only ordered by nephrology.
88
What is the purpose/goals of Foster Care?
1. **Support parents** during a crisis/stressor with plans to re-unify the family
2. To **facilitate** a **transition** period whilst they await permanent placement, adoption or reach the age of adulthood.
89
What are the systematic issues associated with Foster Children's medical care?
* Insufficent access to/Incomplete **Medical Records**
* Clarity on role of **consent** from Biologic vs. Foster Parents
* Learning issues associated with **frequent school changing**
* Payment/**Access to healthcare** when cross-provincial transfers are made
90
When should an **asthmatic** be **referred to** asthma **clinic** or a **respirologist**?
* **Persistent disease** despite escalating therapy
* **Complex admission** for asthma exacerbation
* Cardiorespiratory **comorbidities**
* Uncertain **diagnosis**
**\****An allergist referral should be in place if the history is strongly suggestive of allergic triggers to assist in environmental controls.*
91
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.
92
EPI BULLETS
* **42 % of Canadians** do **not** meet the High School passing standard of literacy to function in society
* **~80 % of seniors** are **illiterate** secondary to unuse atrophy
* Students **not supported**/caught up in literacy **by Grade 3** will likely **never catch-up**
93
What 4 populations are at risk for having inadequate housing?
* **Indigenous** peoples
* **Immigrants**
* **Single** Parents *(1/3 of single parent households)*
* Children with **disabilities** *(50 % increased risk)*\*\*\*
## Footnote
*\*\*\*A census review of Parents with disabled children, found they earned \< 88 % the income of the average population 2/2 caregiving time and higher cost of living .*
94
Can a patient with AOM travel on an airplane ?
**_YES_**
22 % of children *(regardless of AOM symptoms/diagnosis)* show evidence of barotitis when examined. This cannot be avoided and has NOT been shown to have long-term consequences.
**Manage** the pain with anticipatory **OTC analgesia**, promote ear dranining practices *(e.g. straw sucking, chewy foods)*
95
List 2 medical interventions to optimize pain/distress with procedures
The following must be combined with Behavioural/Environmental Modalities
* Infants can be **breastfed during**/immediately after a procedure *(if possible coordinate procedures with feeds)*
* **Topical** liposomal **lidocaine** modalities; *(Remember Lidocaine toxicity, particularly in heart block)*
* EMLA: 60 minute onset, lasts 45-60 min, "safest"
* Ametop: 30 minute onset, last 30 minutes
* 50 % **Nitric Oxide**: 50 % Oxygen mixtures
* **Lidocaine-Epinephrine (LET)** for laceration repairs. Can be injected (warm) or soaked prior to cleaning/exploration of wounds. 30 minute onset.
* Intranasal **Midazolam** or **Fentanyl**
96
What medical risks, associated with poor housing, must be considered when evaluating a child?
* Asthma/**Atopic** dermatitis control
* **Bug bites** and secondary infections
* Lead (**Pb**) exposure
* **Aggression** in the home
* **Injuries** from home
* Poor **School** Performance
97
Describe your approach to sleeping disorders in patients
## Footnote
*(I'll list the CPS' approach summarized)*
1. Clarify issues of **Sleep Initiation vs. Maintenance**
2. Optimize Sleep **Hygiene**
3. Consider off-label **Melatonin trial.** DO NOT use \< 2 y.o. *(Dosing is 0.05 mg/kg Q30-60min PRE-HS)*
4. If ADHD is present, warn parents that efficacy may wane with time if sleep hygiene isn't maintained.
5. Dependance will develop, so **wean when you stop.**
98
# Define ankyloglossia, a common variant of normal *(prevalence 10 %)*, and explain the pathologies it is implicated in.
Ankyloglossia *(tongue-tie)* ,is a lingual frenulum that has the appearance of restriction/shortening. It has been implicated in:
* Feeding difficulties
* Speech development issues
Evidence is contraversial; but physiologic studies of feeding tips the management to conservative with **frenulotomy** reserved for feeding issues **refractory to supportive holistic care.** Feeding issues are likely secondary to more common issues with feeding.
99
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**
100
What are the **common** or typical **pathogens** that cause **urinary tract** infections in children?
1. E*scherichia coli*
2. K*lebsiella pneumoniae*
3. S*erratia marcescens*
4. E*nterobacter spp.*
5. C*itrobacter spp.*
6. S*taphylococcus saprophyticus* **(adolescents)**
## Footnote
*These should be known, so when a culture grows something different you consider contamination (if low or delayed growth) OR evidence of another underlying condition (e.g. fistulas, hematogenous spread, trauma of urethra etc.)*
101
How do you adjust a Type-1 Diabetic's insulin for travel to a region with a different timezone ?
**_Forward (+) 2 hours or more_**
* **DECREASE** the long acting insulin
* Encourage vigorous **glucose checks**
**_Backwards (-) 2 hours or more_**
* **INCREASE** the long acting insulin
* Encourage vigorous **glucose checks**
*Travelling involves changes in circadian rhythm, subsequently cortisol goes out of whack. Their active day duration is altered meaning insulin must be modified.*
102
# SCD-2
Describe **Pharmaco-prophylactics** for **S**ickle **C**ell **D**isease
*(Timelines, drug names)*
_Sickle Cell Disease Pharmaco-prophylaxis_
* Antibiotics
* **Penicillin V/K**, Amoxicillin or erythromycin or co-trimoxazoles (**septra**)
* Typically prescribed from **2 months to 5 years old**
* Continued in symptomatic **asplenic patients**
* **Hold if** patient is **cytopenic** in consultation with Hematology
* Hydroxyurea
* Offered at **9 Months** old and started at **15-20 mg/kg/day PO**
* Adjusted by increments of 5 mg/kg/day Q8Weeks as per CBC results
* Prevents **A**cute **C**hest/Vaso-occlusive **S**yndrome in:
* **HbSS**
* **HbSB0** thalassemia
* HbSC *if symptomatic*
* *NOT Hb trait*
103
List **Vaccines** Required for Patients with **Sickle Cell Disease**
_Additional Vaccines for Sickle Cell Disease_
* **Pneumo**coccal **13** valences
* **Pneumo**coccal **polysaccharide**
* **Men**ingococcal **A, C, W, Y**
* **N**eisseria **meningitides** **Serototype B**
* Haemophilus influenzae B **(HiB)**
* In**flu**enza **A/B**
* **Hep**atitis **A and B**
* *Salmonella typhi and malaria when travelling*
104
At what age do you **switch** from corrected age **to** chronological age for ex-prems ?
**3 YEARS CHRONOLOGIC**
*e.g. If born at 23 weeks on January 1st 2020, start using chronologic age on January 1st 2023*
105
EPI BULLETS
**Infants canadian-born at < 28 weeks**
* 20 % had **med technology** at home
* 16 % on home **oxygen**
* **8 % Feeding** assistance *(4 % gav. and 4 % tubes)*
* < 1 % needed NIV, stomas, tracheostomy
* **Rehospitalization** from NICU-discharge to 18 months was **29-60 %**; *primarily due to respiratory issues or surgical needs*
* Neurodevelopmental Injury OR was 2.0 for Complex vs. non-complex premies, and Significant NDI was 2.8
106
EPI BULLETS
**Ex-Prem Med Prescriptions in Canadian Study**
*(**Complex** vs. Non-complex)*
* Inhalatants **32 %** vs. 16 %
* Antibiotics **20 %** vs 14 %
* Anti-reflux **20 %** vs . 4 %
* Diuretics **6 %** vs 1 %
* Anticonvulsants **3 %** vs 1 %
107
What **dietary supplementation** do all pre-term babies need **post-NICU** ?
Supplementation for Ex-Prems
* **Elemental Iron 2-3 mg/kg/day**
* **Vitamin D 400-800 IU per day**
*Assuming a TFI of 120-140 mL/kg/day, this can be achieved with exclusive formula feeding. You should review a log of what supplement they are taking, what volumes of it and adjust accordingly.*
108
What is the adolescent diagnostic criteria for **Gender Dysphoria** ?
*(as per the DSM-V)*
_DSM-V Diagnostic Criteria for Adolescent Gender Dysphoria_
**Criteria A - Marked gender (≥6 months) manifested by 2/6:**
- Marked incongruence between one's experienced/expressed gender and their current or anticipated physical characteristics
- A strong *_desire to remove/prevent_* incongruent sexual physical characteristics
- A strong desire **to have** the sexual **characteristics of another gender**
- A strong desire to **be of another gender**
- A strong desire to be **treated as another gender**
- A strong conviction that one has the typical feelings and reactions of the other gender
Criteria B - The condition is associated with clinically significant **distress and functional impairment**
109
What impairments can result, **in the child**, when exposed to **intimate** **partner violence** amongst their caregivers ?
**Child Sequelae of exposure to Intimate Partner Violence**
* Mood, Anxiety and Eating disorders
* **Behavioural** issues *(e.g. school distruption, perpetration bullying)*
* Early onset of **substance use**
* **Missed** routine **health services** *(e.g. immunizations, follow-ups.)*
* Early and Unintended **Pregnancies**
* **Perpetration** or victimization **of violence** as adolescents and onwards
## Footnote
https://cps.ca/en/documents/position/recognizing-and-responding-to-children-with-suspected-exposure-to-intimate-partner-violence-between-caregivers
110
Describe McMasters' VEGA **EAR Model **for addressing intimate **partner violence**
_**VEGA's EAR Model**_
***Environment***
* Provide **confidential spaces** for patients/families to discuss possible violence
* Do not allow children/family members to be **language interpreters**
* Only solicit statements from children when it is **developmentally appropriate**, and have a chaperone present.
***Approach***
* Recognizing personal bias that may impact interactions *(e.g. racial, socioeconomic, personal history of violence)*
* **Be up to date** with data; have evidence-based pre-test probabilities when investigating possible partner violence
* Avoid stigmatizing language*(e.g. victim, abuser, narcissist, bully)*
***Response***
* **Prioritize** the reason for seeing **the patient** *(e.g. ear infection, headache)*
* **Tailor inquiries** into possible abuse to the dynamic with the parent, age of the child, cultural background and means to **confirm the child's safety**.
| We "check ourself" to not be accidentally racist/classists
## Footnote
https://cps.ca/en/documents/position/recognizing-and-responding-to-children-with-suspected-exposure-to-intimate-partner-violence-between-caregivers
111
List 4 **Red Flags** for the presence of **Intimate Partner Violence**
**CPS' Indicators for Intimate Partner Violence**
* Shifting ** behaviour/interests ***(typically withdrawing from actitivites)*
* New onset **substance use** in the child or parent
* **Shared** behavioural and physical **maladies** between parent/child
* Worsening **mental health of the caregiver**
* **Deferring of all decisions/information** disclosure to a caregiver
* **Missing appointments** or management non-compliance
* **Sudden** socioeconomic **stressors** *(e.g. job loss, housing crisis, poverty)*
## Footnote
https://cps.ca/en/documents/position/recognizing-and-responding-to-children-with-suspected-exposure-to-intimate-partner-violence-between-caregivers
112
What are the **three requirements** for effective screening for **abnormal growth** in the child ?
| (as per the CPS)
Screening for Abnormal Growth requires:
1. **Accurate Serial Measurements** *(i.e. consistent equipment, methods and alternative techniques that are attributed to the child)*
2. Accomodating/**normalizing** for **prematurity and parental height**/weight
3. Using reference **data** that is applicable to your **patient's population**
| You can stop correcting for prematurity at 3 y.o.
## Footnote
https://cps.ca/en/documents/position/recognizing-and-addressing-atypical-growth
113
When addressing a child's **growth**, *which charts* should be **plotted** ?
**Growth Charts** that must be plotted with each visit
1. **Weight** as a function of **age**
2. **Height** as a function of **age**
3. **H**ead **C**ircumference as a function of **age**
4. **H**ead **C**ircumference as a function of **height**
*Chart #4 tells us if there is a symetric, overall, shift in growth. While a patient may be consistently gaining weight or height, the ratio plot let's us know if there is percentile crossing. Conversely, if it looks like a child is shifting percentiles on charts #1-3, the ratio chart can be reassuring suggesting that his initial weight velocity may have been catch-up or they are falling into their healthy weight.*
## Footnote
https://cps.ca/en/documents/position/recognizing-and-addressing-atypical-growth
114
What are the **4** Symptom **Domains** that occur with **concussion** ?
***Symptoms associated with Concussion:***
(1) **Physical** *[similar to migraine but with a clear hx of injury]*
* Head ache or **pressure**
* Dizziness and **balance issues** +/- nausea and vomitting
* **Vision** changes *(blurred or light sensitivity)*
* **Sound** sensitivity
(2) **Mental** *[similar to depressive symptoms, but sudden onset]*
* Loss of **energy** and capacity for maintaining **attention**
* Issues with **memory** and complex thought
(3) **Emotional**
* Increased **magnitudes** of emotions **and lability**
* Depressive and **anxious** symptoms
(4) **Sleep** *[longer duration and difficult onset]*
| The above MUST have occured after a known head injury, to be concussive.
## Footnote
https://cps.ca/en/documents/position/sport-related-concussion-and-bodychecking
115
What **standardized tool** should be used for patients who have suffered any **head injury** ?
**S**port **C**oncussion **A**ssessment **T**ool - 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
## Footnote
https://bjsm.bmj.com/content/bjsports/51/11/851.full.pdf
116
What is the **complete management** for a **head injury**, that eventually is a suspected **concussion** ?
| Tell me the long-term management as well as the acute.
**Management of Head Injury - *Concussion***
(1) **ABCs** with initial GCS scale
(2) **Confirm** history and **mechanism of fall**. *Assess for red flags of possible syncope, seizure predisposition, intracranial anomalies or bleeding d/o.*
(3) **Treat** acute **symptoms** *(nausea, vomitting, headache)* conservatively
(4) **Brain rest protocol** *(as per your institution)*
(5) **Follow-up at 4 weeks** - *if symptoms are not improving refer to Concussion Clinic services +/- neuropsychiatric testing for developmental deficits.*
117
What are **risk factors** for prolonged **post-concussive syndrome** ?
***Risk Factors for Prolonged Post-Concussive Syndrome***
* Severe initial **symptom burden** *(e.g. n/v, cognition, headache)*
* **Female** sex
* Presence of persistent **ocular dysfunction**
* Concomitant **cervical injury** or intracranial process
* **Psychosocial** stressors
* Pre-injury **post-concussive syndrome** *(i.e. back to play too early)*
* Pre-existing medical issues
- Mental health disorders *(e.g. anxiety, ADHD, depression, ED)*
- Developmental disorder *(e.g. IQ, learning, specific sphere delay)*
- Neurologic disorder
118
What are evidence based **policy interventions** to prevent head injuries ?
***Evidence Based Policies for Head Injury Prevention***
* Prohibition of **body checking**
* **Helmet** mandates
* Mandatory restricted **'Return to Play' protocols** focused on post-concussion management
* **Mouthguard** mandates***
*The CPS says the evidence is mixed regarding mouthguard in relation to concussion. I read the papers cited and it's a solid report despite a relatively smaller n. That being said, the reduction in oro-dental injury alone is enough reason to enforce these as there is NO NEGATIVE impact of using them.*
119
Define **"Risky Play"**, as per the CPS
*"Risky play is defined by thrilling and exciting forms of free play that involve uncertainty of outcome and a possibility of physical injury"*
**Risky situations** are when there is a challenge that **prompts the child to gauge** whether they can/cannot do it, and how to troubleshoot. *(e.g. the difficulty of THAT tree for climbing, for THIS child)*
**VERSUS**
*Hazardous situations* are when situation is *beyond the capacity of a child* to recognize (or manage) possible harm to self or others, and needs to be intervened by the parents *(e.g. the tree appears to be safe, but there is actually a rotten branch that could crumble under their weight. The child has never been shown this kind of issue before)*
## Footnote
https://cps.ca/en/documents/position/outdoor-risky-play
120
# TRUE OR FALSE
Risky play is
* **Ignoring** evidence-based and mandated **safety measures** *(e.g., the use of helmets, car seats, life jackets, stair safety gates)*
* **Leaving children unsupervised** in potentially hazardous situations *(e.g., street play in traffic areas)*
* **Pushing children to take risks** beyond their own comfort level.
**FALSE**
***Teaching** children to know basic safety, how to adopt it and being **available to consult uncertainty** is how to promote healthy risky play. Help them recognize their limits, and make plans for when/how they can push them*
## Footnote
https://cps.ca/en/documents/position/outdoor-risky-play
121
EPI BULLETS
* **6.2 %** of Canadians **don't speak** solely **french or english** at home
* Our only study on medical interpretation showed 67 % of interpreters used in medical settings are professionally trained, with 13 % being **friends/family members (WHICH IS A NONO)**
## Footnote
https://cps.ca/en/documents/position/access-to-appropriate-interpretation-is-essential-for-the-health-of-children
122
Define medical neglect
| CPS' Definition
**Medical neglect**
*"[...] medical neglect can be viewed as not having their health needs met, regardless of the reason(s)"*
This is the raw crux of it, but as with all things **you have to consider the parents' perspective** and reasoning behind the apparent neglect. If the neglect is because of access, it's not really neglect by the parent, but rather a failure of the system.
## Footnote
https://cps.ca/en/documents/position/medical-neglect
123
# ```
```
Give an example where **health care providers** are the cause of **medical neglect**
**Health Care Provider's faults leading the neglect**
* **Not considering** full range of options for diagnosis or management
* **Not being aware** of alternative options for management/investigation
* **Not appreciating** factors that influence family's decision making
## Footnote
https://cps.ca/en/documents/position/medical-neglect
124
List the CPS steps in addressing **Medical Neglect**
**Addressing Medical Neglect**
1. Identify the **decision maker**
2. Determine and explicitly **state the goal** of the healthcare plan
3. State **and discuss** the recommendations
4. **Consider** the potential harm and **perceived harm**, with an intervention
5. **Explore** and understand the reasons for non-adherence/resistance
6. Call DPJ/CAS if the child is still at risk - *you legally have to*
8. ***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*
## Footnote
https://cps.ca/en/documents/position/medical-neglect
125
What is a **non-laboratory screening tool** to help identify possible patient-specific **(genetic) reactions to drugs** ?
**Family History**
Ask about medication 'allergies' in the parents
Adverse events **during** surgery / child delivery / chemotherapy / hospitalisations
126
Give 3 examples of drugs that have known significant **genetic pharmacokinetic issues** that could result in harm
**Known Gene-sensitive Drugs**
* **Tacrolimus** *(CYP3A5 deactivates faster - **underdose**)*
* **Codeine** *(CYP2D6 and UGT1A1 cause hyperactivation - **overdose**)*
* Fluoxetine (40 % of patients don't respond - suspected issues)
* **Carbamazepine** *(HLA-B15:02,HLA-A31:01 - **sev. autoimm. rxn**)*
* **LABA** *(ADRB2 - **poor asthma control**)*
* **Warfarin** *(CYP2C9 & VKORC1 - **dosing variation**)*
* Chemotherapeutics - *the common side-effect profiles have been linked to several genetic predisposition which may shift protocols in the future.*
**---------------------**
* Aminoglycosides *(mitochon. genes with ototoxicity pre-disposition)*
* Rifampin & Isoniazid *(NAT2 - hepatotoxicity)*
* Sulfonamides* (HLA variants associated with SJS/TEN)*
* Clavulin *(HLA vairants associated with hepatotoxicity)*
| These statements are based on really good chart reviews
## Footnote
https://cps.ca/en/documents/position/gene-based-drug-therapy-in-children
127
Where can you check if there is a **pharmacogenomic warning** for a certain drug ?
[PharmGKB](http://www.pharmgkb.org/)
| Database from many countries and many databases
## Footnote
https://cps.ca/en/documents/position/gene-based-drug-therapy-in-children
128
Define "Advanced Care Planning"
**Advanced Care Planning**
Discussion**s** with care givers regarding the **expectations** of function, limits of means/access and subsequently **goals of care** regarding a patient. This discussion **should be revisited** as the patient grows, develops *(or doesn't)* and the nature of their disease evolves.
## Footnote
https://cps.ca/en/documents/position/advance-care-planning
129
What are the three **steps** for a proper **advance care** planning discussion ?
**Advanced Care Discussions**
1. **Ensure understanding** of clinical status, prognosis, needs and means for management
2. Identify **what matters most** to the family and patient, find a common ground based on their ideals, culture and personal needs that develops into a goal.
3. Recommend a **treatment to meet those goals**
## Footnote
https://cps.ca/en/documents/position/advance-care-planning
130
How does the CPS categorize the three types of **advanced care planning interventions** ?
1. **Prolonging** Life *("Do everything you can")*
2. **Optimizing** 'good time'
*(Quality of life is relative, based on your discussions, identify what you can do to optimize that goal of quality living. )*
3. **Comfort** Care
*(Shifting care strategies, and goals, to prevent prolonging states of pain/discomfort. This does not always mean a morphine drip!)*
*Involvement of Palliative Care early on is super helpful with these discussions. Remember to frame your referral as goal-oriented care, not withdrawal/end of life.*
## Footnote
https://cps.ca/en/documents/position/advance-care-planning
131
EPI BULLETS
* An adolescent study revealed that **> 90 % of patients** wanted to know **if their condition was likely terminal**, and to be involved with Advanced Care planning.
* 36 % of parents studied revealed the detailed poor prognostic factors of their child's health to be distressing, but "very" or "extremely" helpful.
* [Five Wishes®](http://www.fivewishes.org/) is a free online resource that can help with these discussions
## Footnote
https://cps.ca/en/documents/position/advance-care-planning
132
Name the three classes of **Benign** Vascular Tumours
1. Infantile hemangioma
2. Congenital hemangioma *(characterized by involution)*
3. Pyogenic granuloma
## Footnote
https://cps.ca/en/documents/position/vascular-anomalies
133
What is the natural **progression** of an **Infantile Hemangioma**, and indication for *intervention* ?
**Infantile Hemangioma**
* Proliferates rapidly from birth **until 5-12 months**
* **Plateaus** from **12-18 months** of age
* Involutes over several years *(90 % will stop involuting by 4 years old)*
***Management*** is indicated when anticipated loss of function can occur:
- **Airway** compromise
- **Hand** compromise *(especially the back of the hand)*
- **Occular**/perioccular involvement
- Lips and **nose tips**
- **Auditory** canal
- Risk of facial dysfigurement
- Persistent ulceration *(usually get lasered)*
## Footnote
https://cps.ca/en/documents/position/vascular-anomalies
134
EPI BULLETS
* **50 % of untreated hemangiomas** leave behind cosmetic and fibrofatty lesions
* 90 % will stop involuting by **4 years old**
* 15 % of Infantile hemangiomas will ulcerate
## Footnote
https://cps.ca/en/documents/position/vascular-anomalies
135
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*
## Footnote
https://cps.ca/en/documents/position/vascular-anomalies
136
SCREEN TIME FACTS
* Children **under 2 years** can watch and be attentive to screens and immitate behaviours, but **do not learn or develop from it**.
* **Dialogic screentime** has similar benefits to traditional book sharing, and **should be encouraged with*remote parents***
* Some literacy benefit is seen in >24 months from solo-app time, but falls greatly when contrasted with classical parenting and direction/play
## Footnote
https://cps.ca/en/documents/position/screen-time-and-preschool-children
137
What is the CPS' **4 Ms of Screentime** ?
Optimizing Screentime
* **Minimize** screentime as a whole
* **Mitigate** the exposure to low-quality TV
* be **Mindful** of screens within the home and routine
* **Model** good behaviours with your screens
## Footnote
https://cps.ca/en/documents/position/screen-time-and-preschool-children
