Community Peds Flashcards
The incidence of plagiocephaly is highest at:
a) 6 weeks
b) 4 months
c) 12 months
d) 24 months
c
List 4 factors that increase the risk of positional plagiocephaly:
Male sex, firstborn, limited range of neck motion at birth (congenital torticollis), supine sleeping position at birth and 6 weeks, only bottle feeding, tummy time less than 3 times per day, lower activity level with slower achievement of milestones
The side of occipital flatness correlates strongly to:
a) Congenital torticollis on the ipsilateral side
b) Lambdoid craniosynostosis of the contralateral side
c) Coronal craniosynostosis of the ipsilateral side
d) The side that the head faces when in supine sleep position
d
For mild to moderate positional plagiocephaly in the first 4 months of life, which of the following is the most effective therapy:
a) Parental counselling on positioning
b) Parental counselling on positioning and physiotherapy program
c) Moulding therapy
d) Surgical repair
b
List 3 differential diagnosis for positional plagiocephaly
Lambdoid craniosynostosis, congenital torticollis, positional torticollis, coronal craniosynostosis (forehead flattening only though), cervical spine abnormalities
The vast majority of positional plagiocephaly resolves by:
a) 4 months
b) 6 months
c) 12 months
d) 24 months
d
List 3 side effects to moulding (helmet) therapy for treatment of positional plagiocephaly
Contact dermatitis, pressure sores, local skin irritation
For severe positional plagiocephaly, which of the following is the most effective therapy:
a) Parental counselling on positioning
b) Parental counselling on positioning and physiotherapy program
c) Moulding therapy
d) Surgical repair
c
List 2 recommendations for preventing plagiocephaly
Alternating positioning of supine sleep (head of bed, foot of bed), tummy time for 10-15 minutes 3 x per day,
Which of the following statements regarding plagiocephaly are true:
a) Surgical correction is only required for confirmed cases of craniosynostosis
b) Moulding (helmet) therapy is first line therapy for mild to moderate plagiocephaly
c) Head circumference monitoring is not indicated in patients with plagiocephaly due to its inaccuracy
d) Skull X-rays are helpful in confirming a diagnosis of positional plagiocephaly
a
In positional plagiocephaly, which of the following is not typical:
a) Ipsilateral anterior displacement of the ear
b) Ipsilateral frontal bossing of the forehead
c) Paralellogram shaped-head
d) Ipsilateral posterior displacement of the ear
d
List 3 limitations to rectal thermometry
Rectal temps slow to change in relation to changing core temps, stay elevated after core temps decrease, affected by depth of measurement, affected by stool, risk of rectal perforation, risk of spreading infectious contaminants from stool
What factors can influence oral thermometry reading?
Recent food/drink ingestion, mouth breathing, young age (poorer compliance), unconscious/uncooperative patients
List factors that contribute to the variability of ear-based temperature measurements.
Ear canal’s structure, probe design, probe positioning
List, in order or accuracy, the methods of thermometry
- Rectal
- Tympanic
- Oral
- Axillary
What is the normal range for rectal temperature?
36.6 to 38.0
What is the normal range for tympanic membrane thermometry?
35.8 to 38.0
What is the normal range of oral thermometry?
35.5 to 37.5
What is he normal range for Axillary thermometry?
34.7 to 37.3
What are the negative outcomes of inadequately treating constipation?
Significant abdo pain, appetite suppression, fecal incontinence, lowered self-esteem, social isolation, family disruption
Define constipation
Infrequent, difficult, painful or incomplete evacuation of hard stools
What are the Rome III Diagnostic Criteria for Functional Constipation
Occurring > 1 time per week, > 2 months
In patient 4yo (developmentally)
Two or more of:
1. 2 or less BM per week
2. Minimum 1 fecal incontinence per week
3. Retentive posturing or volition all stool retention
4. Painful or hard BM
5. Presence of large fecal mass in rectum
6. history of large diameter BMs that may obstruct the toilet
List different management strategies for functional constipation
Education Behavioural modification Daily maintenance of stool softened Dietary modification Fecal disimpaction
List the negative outcomes of inadequately treated constipation
Significant abdominal pain Appetite Suppression Fecal incontinence Lowered self-esteem Social isolation Family disruption
Define constipation
Infrequent, difficult, painful or incomplete evacuation of hard stools
List the Rome III Criteria for Functional Constipation
Two or more of the following occurring at least once per week for at least two months in a child who is developmentally 4 years old
- Two or fewer defecations in the toilet per week
- At least one episode of fecal incontinence per week
- History of retentive posturing or excessive volitional stool retention
- History of painful or hard bowel movements
- Presence of large decal mass in rectum
- History of large diameter stools that may obstruct the toilet
Describe what points you would highlight in educating parents about functional constipation
- Normal physiology of defecation
- Pathophysiology of stool retention and constipation
- Realizing soiling is not willful or defiant behaviours
- Encourage positive messaging from the parents
- Acknowledge the long-term treatment plan, encourage patience and realistic goals for improvement
- Education around misconceptions of stool softeners
What are the misconceptions of stool softeners that are actually false?
- They make the bowel contract or spasm
- They are significantly absorbed from the gut
- They are not safe for long-term use.
List the options for decal disimpaction
- PEG 3350 orally - 3 day clean out
- Daily enemas for 6 days
- High dose mineral oil
- NG lavage with PEG solution
List medications used for maintenance therapy of functional constipation.
- Lactulose
- Milk of Magnesia
- PEG 3350
- PEG solution
- Mineral oil
- Senna
- Bisacodyl
- Docusate sodium
- Glycerin suppositories
- Phophate enemas
List the benefits of PEG 3350 in treating functional constipation
- Tasteless
- Odourless
- Easily dissolves in liquid
- Only absorbed in trace amounts from the GI tract
- No risk of electrolyte imbalances
- Effects start within a week of treatment
List the adverse effects of PEG 3350
- Bloating
- Abdominal pain
- Flatulence
- Loose stools
What guidance should parents be given with regards to the management of functional constipation using a stool softener?
- Adjust the dose to the response (increase until stool soft, decrease if liquid)
- Warning that leakage or soiling may occur initially
- Provide “emergency plan” of how to adjust therapy if signs of impaction develop
List the behavioural modifications recommended for functional constipation
- Dedicated time for defecating (twice a day, 3-10 minutes, after meals)
- No negative reinforcement for lack of defecation
- Positive reinforcement for stool and for sitting on toilet
- Provide stool for child’s feet to sit on
- Keep a stool diary
- Regular physical activity
List ways a parent could modify their child’s diet to help manage functional constipation
- Balanced diet including finer
- Prune, Pear, Apple juices (carbohydrates in these juices)
- Adequate fiber intake (0.5g/kg/day)
- Adequate fluid intake
- Consider trial of cow’s milk-free diet, especially in patients with atopy
- Consider decreasing excessive milk intake
List recommended treatments for constipation in infants
- Lactulose
- Glycerin suppositories
- PEG 3350 0.8g/kg/day
What is contraindicated in the treatment of constipation in infants?
Mineral oil (can be aspirated)
What is the incidence of permanent hearing loss?
1-3/1000 live births
Other than genetic causes of hearing loss in infants, what other causes exist of sensorineural hearing loss?
- ototoxic meds
- hyperbilirubinemia
- congenital infections (ie CMV)
Why is universal newborn hearing screening beneficial?
- earlier diagnosis
- earlier treatment
- improved expressive and receptive language scores
- improved language, social adjustment and behaviour scores
What decibel threshold defines normal hearing?
0-20dB
List the risk factors associated with neonatal sensorineural hearing loss
- Family history of SN hearing loss
- Craniofacial abnormalities
- Congenital infections
- Signs of underlying syndrome associated with hearing loss
- NICU > 2 days or use of ECMO, assisted ventilation, ototoxic drugs, exchange transfusion for hyperbilirubinemia
What’s the difference between the OAE and the AABR screening tests for hearing loss?
- OAE is cheaper and faster to conduct. It measures the sound echoes generated by the cochlear hairs in response to auditory stimulus. It will detect abnormalities in hearing pathway from external ear to cochlea.
- AABR is more expensive and takes a bit longer to conduct. It measures the brainstem electrical activity in response to auditory sounds presented using earphones. It is able to detect abnormalities in the hearing pathway from external ear to brainstem (can detect auditory neuropathy - rare)
What intervention strategies exist for hearing loss?
- hearing aids
- cochlear implants
- bone-anchored hearing aids
- brainstem-implanted auditory devices
- surgery
- sound amplification devices
What are the limitations of universal newborn hearing screening?
- less severe congenital hearing loss may be missed
- progressive or late-onset hearing loss may be missed
- auditory neuropathy may be missed if only using OAE as initial screening modality
What medical conditions are children with hearing loss at increased risk for?
- meningitis
- complicated AOMs
What are some of the consequences of poor visual acuity?
- adverse effects on educational development
- adverse effects on social development
- limitations to career choices
When are visual assessments recommended?
From birth and at all routine health supervisory visits and when concerns arise.
What is amblyopia?
Reduced vision in the absence of ocular disease, which occurs when the brain does not recognize the input from the eye.
What are two causes of amblyopia in children?
- strabismus
- difference in refractive error
List the normal visual development landmarks.
- Birth to 4 weeks: face follow
- 3 months: visual following
- 42 months: visual acuity measurable with appropriate chart
At what age should ocular alignment be established?
6 months
List the devastating effects of oral pain on children
- lost sleep
- poor growth
- behavioural problems
- poor learning
- impact on communication
- impact on socialization
- impact on self-esteem
- decreased school attendance
Define early childhood caries
The presence of one or more decayed, missing (due to caries) or filled tooth surfaces in any primary tooth in a preschool aged child
What are the ways in which Canadians pay for dental care?
- Third party insurance
- Private dental insurance
- Paying directly out-of-pocket
- Government-subsidized programs
What are the factors that contribute to ECC?
- dietary factors (high carb intake)
- bacteria (S. mutans)
- host factors (type of enamel etc.)
List risk groups for ECC
- working poor
- aboriginal children
- immigrant children
- children with special needs
When should a child first go to the dentist?
- within 6 months of development of their first tooth or by their first birthday
A pregnant mother with a history of peanut allergy and eczema is worried about her infant developing allergies. What recommendations do you provide her?
- Do not restrict maternal diet during pregnancy or lactation
- Encourage exclusive breastfeeding for first 6mo of life
- If unable to breastfeed, choose a hydrolyzed cow’s milk-based formula
- Do not delay introduction of any specific solid food beyond six months of age, later introduction of high risk foods may increase risk of developing food allergies
- Recommend regular ingestion of newly introduced foods in order to maintain tolerance
How does delaying introduction of solid foods at six months put infant at risk?
- Increased risk for iron deficiency anemia
- Risk for other macronutrient deficiencies
What are some reasons commonly given for planned weaning from the breast?
- painful feedings/mastitis
- returning to work
- new pregnancy
- wanting a partner/alternate caregiver to give feedings
- eruption of baby’s first teeth
List 4 steps to managing a nursing strike
- Make feeding time special and quiet, minimize distractions
- Increase amount of cuddling and soothing of baby
- Offer breast when infant is very sleepy or just waking up
- Offer breast frequently using different nursing positions, alternating sides, nursing in different rooms
A mother who has had to abruptly wean her baby from breastfeeding due to medical reasons is experiencing discomfort. What recommendations do you give her?
- Take analgesics
- Express just enough milk that make breasts feel comfortable
- Cold gel packs
- Breast massage
- Avoid binding of breasts = can lead to mastitis, more discomfort
In a febrile child >3yo, what symptoms would encourage you to do a urinalysis and culture?
- dysuria, urinary frequency, hematuria, abdo pain, back pain, daytime incontinence
List the predictie rule for ruling out UTI in girls
If no more than one of following present
- 39C
- fever for >2 days
- absence of another source of infection
List the common causative agents of UTIs
- E. coli
- Klebsiella
- Enterobacter
- Citrobacter
- Serratia
- Staph saprophyticus
In an infant >3 months with UTI/pyelo, what is the recommended delivery of antibiotics
- po (2-3mo can start with either po or IV… not great evidence)
- po empiric = cefixime
- IV empiric = gentamicin +/- ampicillin (Some may choose cefotax/ceftriaxone)
What is the duration of therapy for cystitis?
- 2-4 days of po antibiotics
List features that would be concerning for complicated UTI
- Hemodynamic instability
- elevated Cr
- bladder or abdo mass
- poor urine flow
- no improvement clinically within 24h of antibiotics
- fever not trending downward within 48h of antibiotics
In a patient
- Renal/bladder U/S during or within 2 weeks of acute illness
- Detects hydronephrosis (occurs with Grade IV/V VUR)
When is it indicated to perform a VCUG in a patient
- second episode UTI
- RBUS is suggestive of selected renal abnormalities, obstruction or high-grade VUR (hydronephrosis present)
What are the drawbacks to performing VCUG
- expense
- exposure to radiation
- risk of causing UTI
- discomfort to child
What is the recommended duration of antibiotic therapy in an infant/child with a febrile UTI
7-10 days
When should antibiotic prophylaxis be prescribed in a patient with UTI
- evidence of high grade (IV or V) VUR
- significant urological anomaly
In cases where antibiotic prophylaxis is recommended for UTI, what is the recommended duration?
- 3-6mo, then reassess
What are the antibiotics of choice for UTI prophylaxis
- trimethoprim/sulfamethoxazole
- nitrofurantoin
- Traditionally 1/4-1/3 of traditional dosing
List complications of frenotomy (tongue tie snipping)
- postoperative scarring may limit tongue movement
- bleeding
- infection
- injury to Wharton’s duct
A new mother is having breastfeeding difficulties with her infant and the lactation consultant recommended a tongue-tie release. The mother wants to know your opinion. What do you tell her?
- Most newborns with ankyloglossia are still able to breastfeed successfully
- There is no absolute relationship between ankyloglossia and breastfeeding difficulties
- Risks include: postoperative scarring that may limit tongue movement, bleeding, infection, injury to Wharton’s duct
What are the recommended child-to-adult ratios for childcare settings?
36 months: 7:1
List recommendations of the Canadian Child Care Federation’s national statement on quality child care
- respect for child
- collaboration with families
- quality indoor and outdoor physical and learning environments
- learning program
- supported workforce
- effective infrastructure that includes a vision of an early learning and child care system
- adequate wages and parent fees
- skilled and knowledgeable child care practitioners with some formal postsecondary training in early learning and child care (i.e. training in ECE)
