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 3 issues erodes the integrity of homeopathic literature?
- Small study size
- Poor study execution/method consistency
- Data manipulation and presentation for inaccurate assumption of efficacy
When the research is performed in a proper, RCT/exposure review there are no benefits found versus placebo.
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
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.
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
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.
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.
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
What are indications for a lipid profile in a child ?
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)
- 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)*
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
- 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.
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 %:
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 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.
What is the CPS’ Checklist for assessing Potty Training readiness?
The following criteria must be met
- Can walk and sit (stably) on potty
- Can remain dry for several hours
- Can identify when they need/have gone to the bathroom
- Can follow 1-2 step commands
- Has a desire to please
- Has a desire to be independant
- No acute stressors/changes in the home
What makes an infant High Risk for an allergy ?
They have a first degree relative with an IgE mediated allergy
What are positive aspects associated with pacifier use prior to 12 months of age?
- Non-nutritive feeding in NICU babies
- Management of pain/distress in procedures
- Decreased SIDS incidence
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
TRUE or FALSE
Homeopathy (not naturopathy) is completely regulated by the Government of Canada?
FALSE
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.
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.
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
https://cps.ca/en/documents/position/mild-asthma
Until what age is isolated bow legging/knocked knees acceptable?
Until 8 years old
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.
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.
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 no dental coverage
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
- Suspicion for UTI must be high
- Catheterised sample must be taken for Cx/Urinalysis (63 % of bag samples are contaminated)
- If Urinalysis/Microscopy is positive, can treat. If negative, must follow-up culture and symptoms.
- Use appropriate antibiotics for region, age and comorbidities (Amoxicillin, Cefixime, Fluoroquinolones, Septra)
- 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.
What are 3 protective factors for dental health?
- Good feeding/bottle hygiene
- Good Nutritional Status
- Fluoridation of Water
- Routine topical Fluoride treatments
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.
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.
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.
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).
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
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
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
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.
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
EPI BULLETS
- 15 to 25 % of kids have sleep initiation issues
- 67 % of kiddos with Autism have sleep issues
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.
What is the purpose/goals of Foster Care?
- Support parents during a crisis/stressor with plans to re-unify the family
- To facilitate a transition period whilst they await permanent placement, adoption or reach the age of adulthood.
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
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.
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
- 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
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)***
***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 .
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)
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
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
Describe your approach to sleeping disorders in patients
(I’ll list the CPS’ approach summarized)
- Clarify issues of Sleep Initiation vs. Maintenance
- Optimize Sleep Hygiene
- Consider off-label Melatonin trial. DO NOT use < 2 y.o. (Dosing is 0.05 mg/kg Q30-60min PRE-HS)
- If ADHD is present, warn parents that efficacy may wane with time if sleep hygiene isn’t maintained.
- Dependance will develop, so wean when you stop.
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.
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 are the common or typical pathogens that cause urinary tract infections in children?
- Escherichia coli
- Klebsiella pneumoniae
- Serratia marcescens
- Enterobacter spp.
- Citrobacter spp.
- Staphylococcus saprophyticus (adolescents)
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.)
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.
SCD-2
Describe Pharmaco-prophylactics for Sickle Cell Disease
(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 Acute Chest/Vaso-occlusive Syndrome in:
- HbSS
- HbSB0 thalassemia
- HbSC if symptomatic
- NOT Hb trait
List Vaccines Required for Patients with Sickle Cell Disease
Additional Vaccines for Sickle Cell Disease
- Pneumococcal 13 valences
- Pneumococcal polysaccharide
- Meningococcal A, C, W, Y
- Neisseria meningitides Serototype B
- Haemophilus influenzae B (HiB)
- Influenza A/B
- Hepatitis A and B
- Salmonella typhi and malaria when travelling
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
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
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 %
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.
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
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
https://cps.ca/en/documents/position/recognizing-and-responding-to-children-with-suspected-exposure-to-intimate-partner-violence-between-caregivers
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
https://cps.ca/en/documents/position/recognizing-and-responding-to-children-with-suspected-exposure-to-intimate-partner-violence-between-caregivers
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)
https://cps.ca/en/documents/position/recognizing-and-responding-to-children-with-suspected-exposure-to-intimate-partner-violence-between-caregivers
What are the three requirements for effective screening for abnormal growth in the child ?
(as per the CPS)
Screening for Abnormal Growth requires:
- Accurate Serial Measurements (i.e. consistent equipment, methods and alternative techniques that are attributed to the child)
- Accomodating/normalizing for prematurity and parental height/weight
- Using reference data that is applicable to your patient’s population
You can stop correcting for prematurity at 3 y.o.
https://cps.ca/en/documents/position/recognizing-and-addressing-atypical-growth
When addressing a child’s growth, which charts should be plotted ?
Growth Charts that must be plotted with each visit
- Weight as a function of age
- Height as a function of age
- Head Circumference as a function of age
- Head Circumference 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.
https://cps.ca/en/documents/position/recognizing-and-addressing-atypical-growth
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.
https://cps.ca/en/documents/position/sport-related-concussion-and-bodychecking
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
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.
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
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.
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)
https://cps.ca/en/documents/position/outdoor-risky-play
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
https://cps.ca/en/documents/position/outdoor-risky-play
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)
https://cps.ca/en/documents/position/access-to-appropriate-interpretation-is-essential-for-the-health-of-children
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.
https://cps.ca/en/documents/position/medical-neglect
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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
https://cps.ca/en/documents/position/medical-neglect
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
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
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
https://cps.ca/en/documents/position/gene-based-drug-therapy-in-children
Where can you check if there is a pharmacogenomic warning for a certain drug ?
Database from many countries and many databases
https://cps.ca/en/documents/position/gene-based-drug-therapy-in-children
Define “Advanced Care Planning”
Advanced Care Planning
Discussions 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.
https://cps.ca/en/documents/position/advance-care-planning
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
https://cps.ca/en/documents/position/advance-care-planning
How does the CPS categorize the three types of advanced care planning interventions ?
- Prolonging Life (“Do everything you can”)
-
Optimizing ‘good time’
(Quality of life is relative, based on your discussions, identify what you can do to optimize that goal of quality living. ) -
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.
https://cps.ca/en/documents/position/advance-care-planning
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® is a free online resource that can help with these discussions
https://cps.ca/en/documents/position/advance-care-planning
Name the three classes of Benign Vascular Tumours
- Infantile hemangioma
- Congenital hemangioma (characterized by involution)
- Pyogenic granuloma
https://cps.ca/en/documents/position/vascular-anomalies
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)
https://cps.ca/en/documents/position/vascular-anomalies
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
https://cps.ca/en/documents/position/vascular-anomalies
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
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 withremote parents
- Some literacy benefit is seen in >24 months from solo-app time, but falls greatly when contrasted with classical parenting and direction/play
https://cps.ca/en/documents/position/screen-time-and-preschool-children
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
https://cps.ca/en/documents/position/screen-time-and-preschool-children
