CPS Flashcards
1
Q
How do you improve participation levels in children neuromotor disorders?
A
Addressing mismatches in multiple environments compared with functional
abilities (motor, communication, social emotional
skills)
“Mental health problems in children with neuromotor disabilities”
2
Q
Which SSRI has most data supporting its use in children with depression?
A
Fluoxetine
“Use of selective serotonin reuptake inhibitor
medications for the treatment of child and
adolescent mental illness.”
3
Q
Which SSRI should not be used in long QT?
A
Citalopram
“Use of selective serotonin reuptake inhibitor
medications for the treatment of child and
adolescent mental illness.”
4
Q
For patients with cardiac disease who need to be started on ADHD meds, what tests should you do?
A
History and physical to identify those at risk of sudden cardiac death
No routine ECG or referral to cardiology unless indicated by hx/px
If CHD, PCP can start meds, but discuss with cardiologist re: further tests
“Cardiac risk assessment before the use of stimulant
medications in children and youth”
5
Q
List 3 pros and 1 con of long acting ADHD medications
A
Pros:
Better adherence
Reduced stigma (ex. not taking pill at school)
Less misuse and diversion (ex. selling them to others)
Less injuries and shorter hospital stays
Con:
Expensive
6
Q
List 3 ways physicians can promote literacy
A
- Inquire at regular health care visits about use, access to books
- Anticipatory guidance for literacy development
- Encourage to look at books daily
- Encourage library
- Literacy-rich waiting room
7
Q
List 3 principles of effective discipline
A
Discourage physical punishment
Consistent rules, consistent consequences
Must be developmentally apporiate
Perceived as fair by the child
Close in time to behaviour needing change
Self-enhancing: The goal is to help the child regulate behavior effectively, not “punish”
“Catch the child being good” and heap on the
positive reinforcement
8
Q
Children with lice infestations typically carry how many mature head lice?
A
<20 (usually <10)
“Head lice infestations: A clinical update, 2016”
9
Q
How is the diagnosis of head lice made?
A
Detection of live lice
NOT nits (indicates past infection)
Use fine toothed lice comb
“Head lice infestations: A clinical update, 2016”
10
Q
Is there any role for environmental decontamination in lice infestation?
A
NO
At most, wash items in prolonged contact with head in hot water, dryer x 15 mins
OR store in plastic bag for 2 weeks
“Head lice infestations: A clinical update, 2016”
11
Q
How many times should topical head lice insecticide be applied?
A
Two applications 7-10 days apart
“Head lice infestations: A clinical update, 2016”
12
Q
Name 2 first line treatments for head lice
A
- Pyrethrins (R&C shampoo and conditioner) >=2 months of age
- 1% Permethrin (Nix) >=2 months of age
“Head lice infestations: A clinical update, 2016”
13
Q
Name 2 treatments you can use if patients fail first line treatment for head lice
A
- Isopropyl myristate/ST-cyclome-thicone solution (Resultz) >4 years
- Dimeticone solution (NYDA) >2 years
“Head lice infestations: A clinical update, 2016”
14
Q
List 3 reasons patients can fail topical head lice insecticide
A
Wrong diagnosis
Reinfestation
Resistance
“Head lice infestations: A clinical update, 2016”
15
Q
What is the preferred IV fluid for hospitalized children >1 month?
A
D5W.0.9% NaCl
Unless Na 145-154-D5W.0.45% NaC
Ringers lactate is not appropriate
16
Q
How do you calculate maintenance fluids under 10 kg?
A
TFI 100 ml/kg/day
17
Q
Compression to ventilation ratio for single rescuer CPR and two rescuer CPR?
A
30: 2 for single-rescuer CPR
15: 2 for two-rescuer CPR
18
Q
In intubated patient, what is the compression/ventilation ratio?
A
CPR at 100 compressions/min
Ventilation 8-10 breaths/min
19
Q
List 4 characteristics of effective CPR
A
Optimal depth (1/3 AP diameter)
Rate 100 compressions/min
Allow full recoil
Minimize interruptions (10s for pulse check, 5 seconds pause for compressor switch)
20
Q
How much shock to deliver in manual defibrillation
A
Initial shock of 2 J/kg to 4 J/kg, subsequent at least 4 J/kg (max 10 J/kg)
21
Q
What is the recommended method of defibrillation for infants?
A
Manual defibrillation
If not available, can use AED with a paediatric dose attenuator (up to 25 kg or 8 yo)
22
Q
Target SO2 post cardiac arrest
A
94-99%
23
Q
What is the definition of a wide complex tachycardia?
A
QRS > 90ms
24
Q
Formula for appopriate size of uncuffed ETT
A
<1 year: 3.0
1-2 years: 3.5
>2 years: 3.5 + (age/4)
25
Why should etomidate not be used in patients with septic shock?
Increased risk of adrenal suppresion and mortality
26
When should adenosine not be given?
WPW with wide complex tachycardia
27
List 2 common causes of hyponatremia in hospitalized children
1. Hypotonic fluids
| 2. ADH secretion
28
What is the most common trigger for anaphyalxis?
In order:
1. Food***
2. Hymenoptera (bee/wasp) stings
3. Medications
29
What foods commonly trigger anaphylaxis?
Peanuts, tree nuts, fish, milk, eggs and shellfish (eg, shrimp, lobster, crab, scallops and oysters)
30
Clinical criteria for diagnosing anaphylaxis
1. Acute onset of an illness (minutes to several hours) with involvement of the skin, mucosal tissue or both and at least 1 of the following:
a. Respiratory compromise (eg, dyspnea, wheeze-bronchospasm, stridor, reduced PEF or hypoxemia)
b. Reduced BP or associated symptoms of end-organ dysfunction (eg, hypotonia [collapse], syncope or incontinence)
2. Two or more of the following that occur rapidly after exposure to a likely allergen for that patient (minutes to several hours):
a. Involvement of the skin-mucosal tissue (eg, generalized hives, itch-flush or swollen lips-tongue-uvula)
b. Respiratory compromise (eg, dyspnea, wheeze-bronchospasm, stridor, reduced PEF or hypoxemia)
c. Reduced BP or associated symptoms of end-organ dysfunction (eg, hypotonia [collapse], syncope or incontinence)
d. Persistent gastrointestinal symptoms (eg, crampy abdominal pain or vomiting)
3. Reduced BP after exposure to a known allergen for that patient (minutes to hours)
a. Infants and children: low systolic BP (age specific) or greater than 30% decrease in systolic BP*
31
What forms of self-injectable epinephrine are available in Canada?
0. 15 mg (EpiPen Jr)
| 0. 3 mg (EpiPen)
32
Below what weight should patients be given Epipen Jr?
Patients weighing 10 kg to 25 kg
33
Where should IM epinephrine be administered?
Anterolateral thigh
34
What is the primary indication for H1 and H2 antihistamines in anaphylaxis?
Treat cutaneous manifestations
H1+H2 together more effective
H1=cetirizine (preferred), benadryl
H2=ranitidine
35
In a patient on betablockers who presents in anaphylactic shock, what medication should be given?
Glucagon
36
In a patient with persistent hypotension despite repeated IM epinephrine for anaphylaxis, what is the next step?
IV epinephrine infusion
37
When do biphasic reactions occur in anaphylaxis and how long should patient be observed in ED?
1-72 hours, but most occur within 4-6 hours
| Should be observed 4-6 hours
38
5 things to do on discharge of patient with anaphylaxis from ED
1. Epipen prescription
2. Counseling on how and when to use Epipen
3. Keep Epipen with patient at all times (at school and with the parent or child)
4. Ideally, two doses should be available for administration at each location (eg, two EpiPen autoinjectors)
5. 3 day course of oral H1 and H2 antihistamines (cetirizine and ranitidine) and oral corticosteroids
6. Advise getting Medic-Alert bracelet
39
List 4 groups at risk for severe disease
- Prems <35 weeks GA
- Age < 3 months at presentation
- Hemodynamically significant cardiopulmonary disease
- Immunodeficiency
40
List 6 indications for admission for bronchiolitis
- Severe resp distress (indrawing, grunting, RR >70)
- Supplemental O2 required to keep saturations >90%
- Dehydration or history of poor fluid intake
- Cyanosis or history of apnea
- At risk for severe disease
- Family unable to cope
41
How long does it take for ondansetron to take effect?
Reaches peak plasma concentrations in 1-2 hours
42
One side effect of ondansetron
Mild diarrhea up to 48 hours after administration of drug
43
List 3 benefits of oral ondasetron therapy in patients with gastroenteritis
1. Reduced vomiting
2. Less IV fluids
3. Reduced hospitalization
44
In what age group should you consider single dose oral ondansetron for management of gastroenteritis
6 months to 12 years
WITH:
-Mild to moderate dehydration
-Failed oral rehydration therapy
45
How long after administering oral ondansetron should ORT begin?
15-30 mins
46
Recommended doses of oral ondestron
8 kg to 15 kg = 2 mg
15 kg to 30 kg = 4 mg
> 30 kg = 6-8 mg
47
List 3 options for pre-hospital management of seizures. Which one is the best?
1. Buccal midazolam-BEST
2. Intranasal midazolam-BEST
Others:
3. Buccal or rectal lorazepam
4. Rectal diazepam
48
If patient received benzodiazepine prehospital, what is the next step in management of persistent seizure?
Can give one more dose of IV benzo before moving to second line
49
If no IV access, what are 3 options for 2nd line treatments for status epilepticus?
IM fosphenytoin
IO phenytoin
PR paraldehydge
50
List 3 side effects of fosphenytoin
- Cardiac arrhythmias
- Bradycardia
- Hypotension
51
Why is fosphenytoin generally more effective than phenobarbitol?
- Fosphenytoin less likely to cause resp depression
| - Phb is less effective if seizure refractory to benzos
52
List 2 indications to use phenobarbitol before phenytoin in status epilepticus management
Neonates
| Patient on phenytoin maintenance
53
When should midazolam infusion be considered in the status epilepticus algorithm?
Within 20-30 mins of starting seizure algorithm
Rationale: If seizure lasts >1 hour, unlikely to terminate with 2nd line meds
54
List 3 options for pharmacotherapy in refractory status epilepticus
1) Midazolam continuous infusion
2) Barbiturates (thiopental, pentobarbital)
- If starting, discontinue midazolam and phenobarbital, continue phenytoin
55
```
What is the minimum age for licensed use for each of the following inhaled corticosteroids?
Beclomethasone
Budesonide
Fluticasone
Cicelsonide
Mometasone
```
```
Beclomethasone > 5 years
Budesonide >6 years (except by nebulizer)
Fluticasone >12 months
Cicelsonide >6 years
Mometasone >12 years
```
56
For ORT, what is the optimal glucose/Na ratio for absorption?
1:1
57
What is the ideal osmolarity of ORT?
200-250 mOsm/L
| Includes pedialyte, enfalyte, cera, gastrolyte, revised WHO formula
58
List the features of mild dehdyration (<5%)
Slightly decreased urine output
Slightly increased thirst
Slightly dry mucous membrane
Slightly elevated heart rate
59
List the features of moderate dehydration (5-10%)
```
Decreased urine output
Moderately increased thirst
Dry mucous membrane
Elevated heart rate
Decreased skin turgor***
Sunken eyes***
Sunken anterior fontanelle***
```
60
List the features of severe dehydration (>10%)
```
Markedly decreased or absent urine output
Greatly increased thirst
Very dry mucous membrane
Greatly elevated heart rate
Decreased skin turgor
Very sunken eyes
Very sunken anterior fontanelles
Lethargy, Coma***
Cold extremities, Hypotension***
```
61
Recommended rehydration for gastroenteritis with mild dehydration (<5%)
ORS 50 ml/kg over 4 hours
Replace ongoing losses with ORS
Age appropriate diet after rehydration
62
Recommended rehydration for gastroenteritis with moderate dehydration (5-10%)
ORS 100 ml/kg over 4 hours
Replace ongoing losses with ORS
Age appropriate diet after rehydration
63
Recommended rehydration for gastroenteritis with severe dehydration (>10%)
IV bolus 20-40 ml/kg
Start ORS when stable
Replace ongoing losses with ORS
Age appropriate diet after rehydration
64
How should infants <2 years travel on a plane?
SHOULD occupy own seat IN A CAR SEAT
65
What should be done for children with recent fracture < 48H and plaster/fiberglass cast who are flying?
Cast should be bivalved
| Trapped gas beneath a cast may expand during a flight
66
List 3 interventions for "air sickness"
1. Gravol
2. Cool air to face
3. Selecting a seat away from rear of cabin
4. Looking at horizon
67
When should children with AOM fly?
2 weeks after treatment
If the diagnosis is made within 48 hours and flight cannot be cancelled then give analgesia
68
List 3 interventions to prevent otalgia in children at risk (recurrent otitis media, adenoidal hypertrophy) while flying
1. Yawning
2. Chewing
3. Valsava
4. Topical nasal decongestant 30 mins before take off and landing
69
What recommendation would you make for a patient with HbSS who is flying?
O2 should be available
O2 should be given routinely regardless of symptoms on flights >2135 m (7600 ft) – especially splenomegaly or high blood viscosity
70
List 3 medical conditions that are contraindications to commercial airline flight
Uncontrolled hypertension
Uncontrolled supraventricular tachycardia
Eisenmenger’s syndrome
71
Which patients are recommended for evaluation of potential hypoxemia before air travel?
Patients with known or suspected hypoxemia
Patients with known or suspected hypercapnia (may suggest lower pulmonary reserve)
Patients with known chronic obstructive lung disease or restrictive lung disease
Patients who already use supplemental oxygen
Patients with a history of previous difficulty during air travel
Patients with recent exacerbation of chronic lung disease
Patients with other chronic conditions that may be exacerbated by hypoxemia
72
List 2 indications for frenotomy in newborns with ankyloglossia
- Complete fusion of the tongue
| - Significant breastfeeding problems
73
List 3 complications of frenotomy for ankyloglossia
Bleeding
Infection
Injury to Wharton's duct
Limitation to tongue movement secondary to postop scarring
74
What is one serious complication of chiropractic manipulation in children?
Vertebrobasilar occlusion
75
List 4 indications for a genital exam in a prepubertal child
Periodic health exam to check external genitalia
Assessing for endocrine disorders
Suspected child abuse
Parental request
76
What is the optimal position for girls for the genital exam?
Can sit on the parent’s or caregiver’s lap in the supine frog-legged position
77
What is the optimal position for boys for the genital exam?
Lateral decubitus position
78
For older school children and adolescents, who should be present during genital exam?
Physician + nurse/parent
79
When should children start wearing shoes?
When they start walking
80
Under what age if flexible flat foot common?
<6 years
Additionally, nearly all children <18 months have flat feet!
Improves with age!
81
Are orthotics recommended for the treatment of flexible flatfoot, intoeing, or mild torsional deformities ?
Nope, nope, nope
Unless symptomatic
Arch development in walking children <6 y.o. is not enhanced by shoes, inserts, or heel-cups
82
List 3 barrier to health care for children with foster care
- Inadequate medical records
- Inconsistent care due to temporary placements
- Difficult access to services
83
List 5 health challenges are more common in children in foster care?
```
Underimmunization
Injuries
Dental neglect
LD
DD
Substance abuse related birth defects
Physical disabilities
ADHD
```
84
What 4 questions should pediatricians advice parents to think about when gathering health information from the internet?
Is host of website engaged in conflict of interest ?
Is the info presented on the website peer reviewed?
Is the information up to date?
Is the information presented based on proper evidence?
85
What are the AAP recommended child:staff ratios in child care centers?
3: 1 child:adult ratio for children <24 months
4: 1 for children 24-30 months
5: 1 for 31 months to 36 months
7: 1 for >36 months
86
List 3 ways to reduce childcare associated injuries
- Injury-reporting procedures and forms should be available in all child care centres
- All staff should be trained in basic first aid and CPR
- Adequate staff-child supervision
- Routine safety audits should be conducted
- Play equipment should comply with Canadian standards association recommendations
- Children should only use equipment designed for their age group
87
List 3 ways to prevent infections in daycare
Immunizations
Caregivers should get influenza vaccine
Hand hygiene
Ready access to sinks, hand sanitizers
88
List 3 principles of homeopathy
1) Like cures like
2) The higher the dilution is, the more potent the medicine
3) Choose remedies based on symptoms, not disease
89
What is the only condition for which there is evidence for homeopathy?
Diarrhea-RCT an metanalalysis showed decrease in stool frequency and duration
90
How does hyperglycemia in T1DM impact on school performance?
Associated with slowing of cognitive performance on tests
Increased errors
Slower responses on basic mathematical and verbal tasks
91
List 3 barriers to safe and effective management of hypoglycemia in T1DM in schools
- Incomplete training of school personnel
- Unscheduled activity and inactivity
- Altered meal or snack times; --Lack of rapid access to a glucose meter, treatment supplies.
92
When should a child first see the dentist?
CDA recommends 1st visit within 6 months-1yr of first tooth
Every child has a dental home by ONE YEAR
93
What physical exam finding is suggestive of positional plagiocephaly?
Unilateral flattening of the occiput, with ipsilateral anterior*** shifting of the ear
94
What is the natural history of positional plagiocephaly?
Starts at 6 weeks, peaks at 4 months and decreases over 2 years
95
List 5 risk factors for positional plagiocephaly
- Male sex
- First born
- Limited passive neck rotation at birth (congenital torticollis)
- Supine sleeping position at birth and 6 weeks
- Only bottle feeding
- Awake tummy time < 3 times per day
- Decreased activity level with decreased achievement of milestones
- Sleeping with the head to the same side and positional preference when sleeping
96
What 3 things must you rule out in a patient with positional plagiocephaly?
Craniosynostosis
Congenital torticollis
C-spine abn’s
97
What type of craniosynostosis can mimic positional plagiocephaly?
Lamdoid suture synostosis
- Causes occipital flattening
- Difference=posterior displacement of ear
98
List 2 interventions to prevent positional plagiocephaly
Tummy time x 10-15 mins 3 times per day
Alternate positions in crib (alternating with head to foot or head of bed on alternating nights)
Position baby to encourage lying on both sides
99
What is the recommended treatment of mild/moderate positional plagiocephaly?
Physiotherapy + positioning
100
What is the recommended treatment of severe positional plagiocephaly?
Helmet therapy <8 months
101
List 3 components of a safe sleep environment
On back
In crib
No soft bedding/pillows/blanket
In parents room x first 6 months
102
What should we recommend to parents re: using pacifiers?
- Controversial and decision to use pacifier should be left to parents
- Infants with chronic or recurrent otitis media should be restricted in their use of a pacifier
-Counsel on benefits and risks:
Benefits:
-May be protective against SIDS
Risks:
- Early weaning (studies inconclusive)
- Increased risk of AOM (related to frequency and length of use)
- Dental problems such as caries, malocclusion, gingival recesseion (only if prolonged to >5 years of age, sweeteners added)
103
Recommendations for temperature measurement techniques in the following age groups:
Birth to 2 years
2-5 years
>5 years
Birth to 2 years
1. Rectal (definitive)
2. Axillary (screening low risk children)
2-5 years
1. Rectal (definitive)
2. Axillary, Tympanic
>5 years
1. Oral (definitive)
2. Axillary, Tympanic
104
When do children become aware of racial difference?
3 years of age
105
When do children understand racial permanence?
7 years of age
106
What type of hearing loss is most common in newborns?
SNHL
107
What is the most common cause on non-syndromic SNHL?
70% of SNHL is non-syndromic
Most often related to cochlear hair cell dysfunction-mutation in connexin 26
108
What % of newborns with hearing loss have a risk factor?
50%
109
List 4 risk factors for neonatal SNHL
1. Family history of permanent hearing loss
2. Craniofacial abnormalities including those involving the external ear
3. Congenital infections including bacterial meningitis, cytomegalovirus, toxoplasmosis, rubella, herpes and syphilis
4. Physical findings consistent with an underlying syndrome associated with hearing loss
5. Neonatal intensive care unit stay >2 days OR with any of the following regardless of the duration of stay:
• ECMO
• Assisted ventilation
• Ototoxic drug use
• Hyperbilirubinemia requiring exchange transfusion
110
When do unscreened children with hearing loss typically present?
24 months
vs.
3 months or younger in screened populations
111
What is the difference between OAE and AABR?
OAE-identifies conductive and cochlear hearing loss from the level of the external ear to the level of the outer hair cells in the cochlea
AABR-does the above, but ALSO can diagnose auditory neuropathy because it evaluates the auditory pathway from the external ear to the level of the brainstem
112
When do you use OAE vs AABR for newborn hearing screening?
1. AABR first-babies with RFs or in NICU
| 2. OAE, then AABR if fails-everyone else
113
What are possible interventions for hearing loss detected on newborn screening?
1. Hearing aids
2. Cochlear implants (implant at 8-12 months of age)
3. Surgery for some conductive disorders
114
Infants with fever >39°C for >48 h without another source are highly likely to have a UTI. True or false?
True
115
Under what age should urine cultures be taken in FWS?
<3 y.o.
Older children should be able to report symptoms
116
Above what age is UTI in males less common?
>3 years
117
How many CFU/mL are indicative of a urinary tract infection for the following urine colleciton methods:
i) MSU
ii) In and out cath
iii) Suprapubic aspiration
i) MSU ≥10^5
ii) In and out cath ≥5×10^4
iii) Suprapubic aspiration Any growth
118
When is it ok to give po antibiotics for UTI?
>3 months
| 2-3 months-debatable, some would say start with IV
119
List 4 signs of a complicated UTI. What should you do about it?
- Hemodynamically unstable
- High creatinine
- Bladder or abdominal mass
- Poor urine flow
- Not improving within 24h or fever is not trending downward within 48h of appropriate antibiotics
Evaluate by getting U/S to r/o obstruction or abscess and give IV antibiotics
120
If child with UTI is better by time susceptibilities return and they indicate resistance to the antibiotic chosen, what should you do?
Repeat urine culture
| Change Ab only if positive
121
Under what age should you order renal U/S for first UTI?
<2 years
U/S reliably detects hydronephrosis, which usually occurs with high grade (IV or V) VUR
122
When should you order VCUG in child with UTI?
1. Renal US is suggestive of renal abnormalities or obstruction, or high-grade VUR
2. Second UTI in child < 2 years
123
What strategy can be used to reduce GI side effects of SSRIs?
Take with food
| Absorption is unaffected by ingestion of food
124
Which SSRI has the least withdrawal symptoms?
Fluoxetine (long half life-96 hours!)
125
How often should you monitor a patient when starting SSRI?
What to monitor:
- Depressive symptoms at baseline and after treatment
- Assess for side effects, SI, medication adherence
Frequency of visits:
- Weekly for the first 4 weeks following initiation of SSRI medication
- Every two weeks for the next four weeks
- At 12 weeks
- Then as clinically indicated
126
Which SSRI has most evidence in teens?
Fluoxetine
127
How long should SSRIs be continued?
6-12 months
128
List 4 side effects of SSRIs
```
Mild:
GI symptoms
Sleep changes
Restlessness
Headaches
Appetite changes
Sexual dysfunction
```
Rare severe s/e’s:
- Coagulopathy
- SIADH
- Serotonin syndrome/toxicity →Mental status changes, myoclonus, ataxia, diaphoresis, fever and autonomic dysregulation
- QT-interval prolongation and Arrhythmia → dose dependent risk with citalopram dosages >40 mg/day
129
What are the 3 most significant factors that impact a child’s well-being during separation/divorce?
1. Quality of parenting (including effective discipline)
2. Quality of parent-child interaction
3. Degree, frequency, intensity and duration of hostile conflict
130
Following a divorce, kids whose parents have joint-custody are better adjusted. True or false?
True
131
What is beneficial for children under 5 years old dealing with divorce?
Do better with routines and frequent access to both parents to develop memory of the other in their absence
132
How do 4-5 year olds respond to divorce?
Often blame themselves for a separation and become ‘clingy’,
133
How do school aged children react to divorce?
Prone to loyalty conflicts and may take sides
134
List 10 steps to successful breastfeeding as per the Baby Friendly Initiative
1: . Have a written breastfeeding policy that is routinely communicated to all health care providers and volunteers.
2. Ensure all health care providers have the knowledge and skills necessary to implement the breastfeeding policy.
3. Inform pregnant women and their families about the importance and process of breastfeeding.
4. Place babies in uninterrupted skin-to-skin contact with their mothers immediately following birth for at least an hour or until completion of the first feeding or as long as the mother wishes: Encourage mothers to recognize when their babies are ready to feed, offering help as needed.
5. Assist mothers to breastfeed and maintain lactation should they face challenges including separation from their infants.
6. Support mothers to exclusively breastfeed for the first six months, unless supplements are medically indicated.
7. Facilitate 24-hour rooming-in for all mother-infant dyads: mothers and infants remain together.
8. Encourage baby-led or cue-based breastfeeding. Encourage sustained breastfeeding beyond six months with appropriate introduction of complementary foods.
9. Support mothers to feed and care for their breastfeeding babies without the use of artificial teats or pacifiers (dummies or soothers).
10, Provide a seamless transition among the services provided by the hospital, community health services and peer support programs. Apply principles of primary health care and population health to support the continuum of care, and implement strategies that affect the broad determinations that will improve breastfeeding outcomes.
135
What is the Baby Friendly Initiative?
A WHO initiative to protect, promote and support breastfeeding
In order to receive the Baby-Friendly designation, hospitals must:
- Adhere to 10 Steps of Successful Breastfeeding for at least 80% of all women and babies it cares for
- Comply with WHO code provisions that ensure ethical marketing of breast-milk substitutes by industry
136
Can ancephalic newborns be used as organ donors?
No
Because of difficulties surrounding the establishment of brain death and the lack of evidence to date supporting successful organ transplantation
137
If you are planning to do research in pediatric populations, what two regulations must you abide by?
1) Tri-Council Policy statement
- Analyzes risk involved to research subjects, and steps taken to minimize risk
2) Institutional REB review
138
List 3 roles of an institutional REB
1) Uphold TCPS
2) Ensure respect for human dignity (free/informed consent, confidentiality, justice, inclusiveness, respect for vulnerable persons (including children)
3) Ensure well designed study
4) Ensure equipose between treatment options in RCTs
139
List 3 ethical principles involved in medical education in pediatrics
1. Maleficence
- Do no harm, but trainees need opportunity to learn to be clinically competent
2. Distributive justice
- Limits should be placed on number of times child is expected to volunteer for exams
3. Informed consent
- If child too young to consent, need their assent
4. Confidentiality
- Need to ensure child's identity is not disclosed, but may not be possible if rare condition
140
What kind of consent is needed for the following situations in medical education?
- Involvement of trainee in clinical care
- Trainee performing a procedure
- Education sessions and clinical teaching rounds
- Clinical skills teaching
- Patient participation in OSCEs
1. Involvement of trainee in clinical care
- Trainee's role and supervisory context should be explained
- Parents have right to request trainee not be involved in their care
2. Trainee performing a procedure
- Supervisor should obtain consent from parents
- Trainees need to inform parent and be honest
3. Education sessions and clinical teaching rounds
- Consent not needed
- BUT information should be shared with family after
- Verbal consent for photographs
- Written consent for case reports
4. Clinical skills teaching
- Parents consent and child's assent needed
5. Patient participation in OSCEs
- Parents consent and child's assent needed
- Should be compensated if other SPs are
141
In what situations is it ethical to do genetic testing in children?
1. Timely medical benefit to the child
- I.e. genetic testing to confirm a diagnosis in a symptomatic child to allow medical monitoring, prophylaxis or treatment
2. For genetic conditions that will not present until adulthood (predictive testing), testing should be deferred until the child is competent to decide whether they want the information
3. For carrier status for conditions that will be important only in reproductive decision making, testing should be discouraged until the child is able to participate fully in the decision
142
List 3 ways physicians can preserve privacy online
- Use high privacy settings and understand this does not completely protect
- Avoid online friendships with patients
- Keep business and personal websites separate
143
List 2 ways of protecting patient confidentiality and privacy on social media
- Not posting identifiable patient information online
| - Not accessing a patient’s blog without their permission
144
List 3 hallmarks of informed consent
1) Appropriate information: information necessary to make decision
o Disease, likely course, treatment options, option of no treatment, benefits + risks for each, likely outcomes, etc
2) Decision-making capacity: ability to receive, understand + communicate information, appreciate effects of treatment, alternatives, or non-treatment
3) Voluntariness: no manipulation/coercion, can always change their mind
145
What is a mature minor
Capable” minors, i.e. understand their health condition, understand Rx options and their risks + benefits
146
In what situations is a physician not obligated to provide life-sustaining care to a patient?
- Irreversible progression to imminent death
- Treatment is clearly ineffective/harmful
- Life is severely shortened regardless of Rx
- Limitation/withdrawal will allow greater palliative/comfort care
- Patient will face intolerable suffering/distress that cannot be prevented/alleviated
147
If there is disagreement between parents and HCP regarding a child's medical care, what should be done?
1. Parental decision accepted, unless not in child's best interest
2. If concern re: child's best interest, MD must provide referral to second uninvolved medical consultant and SHOULD seek assistance of ethics consultant
3. If not resolved with above, child protection service may need to be involved
148
In what cases is withholding or withdrawing artificial nutrition and hydration (ANH) both legally and ethically permissible?
1. Child who permanently lacks awareness and ability to interact with environment
- e.g. persistent vegetative state, anancephaly
2. ANH only prolongs and add morbidity to the process of dying
- e.g. terminal illness in final stages of dying, infants born with CHD incompatible with survival beyond few months with transplant as only therapeutic option, infants with renal agenesis, infants with severe GI malformation/destruction with total intestinal failure whose parents have opted for palliative care rather than intestinal transplant
149
Nationally, palliative care is accepted as the usual approach when an infant is born less than ____ weeks GA
21 weeks GA
150
Above what gestational age should antenatal corticosteroids be offered?
>=22 weeks GA (updated CPS statement)
151
When is the maximal period of efficacy for ANCS reached?
Within 7 days of the last dose
152
What mode of delivery is recommended for extreme preterms?
Routine C/S not recommended
Parents and obstetrical HCPs should decide jointly on optimal mode of delivery
153
What factors, other than gestational age, affect survival and morbidity of extreme preterms?
Birth weight
Singleton vs. multiple birth
Provision of ANCS
Gender (males disadvantaged)
Birth outside a tertiary perinatal centre
NICU course (IVH, PVL, ROP, BPD, sepsis, days on mechanical vent, nutrition)
Parental SES
154
Above what gestational age is early intensive care usually recommended?
- Infant born at 25 weeks GA, without additional risk factors
- Infant born late in 24th week of gestation (e.g., 24+5), well grown with ANCS given, born in a tertiary care centre
155
For what gestational ages is recommending either palliative or early intensive care appropriate?
- Infant born at 23 to 24 weeks GA, irrespective of most additional risk factors
- Infant born at 25 weeks GA, with risk factors (e.g. signs of fetal anemia and abnormal placental blood flow)
156
What foods are high in folate?
Leafy vegetables
Legumes
Red meat
Offal, such as liver
157
What is the risk of recurrence of NTDs?
2-5%
158
At what gestational age do NTDs usually occur?
Failed closure of the neural tube in the third and fourth weeks of gestation
159
Other than NTDs, what are other congenital anomalies does folate supplementation protect against?
CHDs
Oral clefts
Neurodevelopmental problem
160
How much folate supplementation does Health Canada recommend for women of child bearing age to prevent NTDs? How long should they take it?
0.4 mg po daily for at least 2-3 months before conception and throughout the pregnancy and postpartum periods (for a minimum of 4-6 weeks and as long as breastfeeding continues)
In addition, should eat a diet of folate-rich foods!!!
161
List 3 risk factors for NTDs
```
Previous child with a NTD
Family history of NTDs
Maternal obesity
Maternal Hispanic origin
Use of some anticonvulsants
```
162
In patients with risk factors, including family history of NTDs, what is the recommended daily dose of folate supplementation?
5 mg (start 3 months before and continue to 10-12 weeks post conception)
163
Is fortification of flour with folic acid sufficient to provide enough folate to prevent NTDs in women of childbearing age?
NO
At least 25% of women of child-bearing age do not have folate intake sufficient to optimally protect their offspring from NTDs
Reasons: poor availability of folate in natural foods, easy destruction during cooking, lower general consumption of flower, low SES
164
Is it true that folic acid increases risk of cancer or masks B12 deficiency?
No
| Actually decreases risk of lung cancer
165
What are the four most important physiological competencies required for discharge of preterm infants?
1. Thermoregulation:
- Need to be able to maintain body temp 37C
2. Control of breathing
- Apnea free period (at least 5-7 days)
3. Respiratory stability
- SO2 90-95% or greater in RA
4. Feeding skills and weight gain
- Sustained weight gain
- Successful feeding by breast and/or bottle without major cardiorespiratory compromise
Most achieve these by 34-36 weeks
166
When can preterms be transferred to a cot?
Contentious
| >1600 g is probably reasonable
167
What is the definition of apnea of prematurity?
Cessation of breathing for ≥20 s
OR
10 -20 s if accompanied by bradycardia (heart rate <80 beats/min) or oxygen saturation (SaO2) <80% in infants <37 weeks’ PMA
168
When does apnea of prematurity typically resolve?
Most by 36 weeks’ PMA
BUT very preterm infants show more variability in resolution, and apnea may persist up to 44 weeks’ PMA
169
What is the half life of caffeine?
Approx 100h
Therefore risk of apnea days after discontinuation
170
List 4 problems associated with prolonged NICU stay
- Poorer parent–child relationships
- FTT
- Child abuse, parental grief and feelings of inadequacy
- NICU environment (noisy, bright, no day-night cycling) can affect sgrowth and development
- Nosocomial infections
- Financial challenges
171
What 2 factors predict recurrence rate of apneas in preterms ready for discharge?
Recurrence rates higher for infants <30 wks GA and if last spell occurred at >36 wks
For infants <26 weeks’ GA, 13 days were required for 95% to remain apnea-free
172
Is apnea of prematurity a risk factor for SIDS?
No
173
When would you consider home cardioresp monitoring for a baby discharged from NICU?
Rarely
Consider for unusually prolonged and recurrent apnea, bradycardia and hypoxemia, following discussion with parents about risks and benefits
174
What is an appropriate O2 saturation for preterm infants with BPD?
90-95%
175
List 2 interventions that can rsult in earlier attainment of full oral feeding in the NICU
1. Early introduction and advancement of oral feeds based on the infant’s individualized cues, state and behaviour, rather than a predetermined feeding schedule
2. NNS during NG feeding
176
Supplementation with cup feeds may increase the number of babies discharged home fully breastfeeding. True or false?
True
| BUT also delays discharge by 10 days
177
What things need to be done prior to NICU discharge?
1) Parental education:
1. SIDS prevention
2. Back to sleep and other safe sleep practices
3. CPR training
4. Car seat safety
5. Minimizing infection risks,
6. Counseling on smoking cessation if neded
7. Recognizing signs and symptoms of illness
2) Immunizations
- RSV prophylaxis if needed
3) Screening tests
- NBS
- Hearing test
- ROP screening
- HUS at term
4) Arrange follow up
- Need primary care physician-follow up within 72 hours
- NNFU for high risk prems
5) Offer trial of care-by-parent
178
List the 3 phases of grief and mourning
1. Avoidance or protest
2. Confrontation and disorganization
3. Accommodation or reorganization
179
In a perinatal death, what are 5 things physicians do during the dying process and afterwards to support the family?
- Allow families to spend time with dying baby
- Encourage naming the baby, creating mementos, taking pictures
- Give them privacy
- Anticipatory guidance around what death looks like
- Explain need for autopsy (if needed)
- Ask about religious/cultural practices and offer spiritual support
- Discuss organ donation
- Follow up phone call after funeral
180
List 5 benefits of human breast milk in preterms in NICU
1. Less infections
2. Decreased NEC
3. Decreased colonization by pathogenic organisms
4. Decreased length of stay
5. Improved neurodevelopmental outcomes
*Observational studies
181
What is the risk of disease transmission through human donor milk?
Low
There are no reported cases of disease transmission
Why?
All donors screened for HepB, C, HIV, HTLV
Milk pasteurized and recultured
182
Who should be eligible for donor milk?
Preterms
GI surgery
Malabsorption, feeding intolerance
PID
183
List the differences between donor milk and EBM
In DBM:
- Decreased protein-13% denatured
- Decreased immunoglobulins
- Decreased lactoferrin (binds iron required by bacteria and reduces its growth)
- Reduced lysozyme enzyme (attacks bacterial cell walls)
184
What is the cutoff for severe hyperbilirubinemia?
TSB > 340 micromol/L during first 28 days of life
185
What is the cutoff for critical hyperbilirubinemia?
TSB>425 micromol/L in first 28 days
186
What is acute bilirubin encephalopathy?
Clinical syndrome of lethargy + hypotonia + poor suck → can progress to hypertonia (opisthotonos and retrocollis) with high pitched cry and fever → progress to seizures and coma
187
What is chronic bilirubin encephalopathy?
Sequelae of acute encephelopathy = Athetoid CP +/- Seizures, GDD, hearing issues, dental dysplasia
188
List 5 risk factors for severe hyperbilirubinemia
* <38 weeks gestation
* Previously sibling with severe hyperbili
* Bruising
* Cephalohematoma
* Male sex
* Maternal age > 25 y.o
* Asian or Europen background
* Dehydration
* Unclear evidence for risk factors of: visible jaundice <24h and breastfeeding
189
Which neonates should be tested for G6PD?
1. Mediterranean, Middle EasterN, African, South Asian
| 2. Severe hyperbilirubinemia
190
How does hemolysis affect G6PD testing?
Hemolysis can cause FALSE NEGATIVE
191
Should only males be tested for G6PD deficiency?
No
Test both males and females
X-linked, but female heterozygotes can have 50% of cells affected
192
In health term newborns, when does TSB peak?
Day 3-5 of life
193
Is transcutaneous bilirubin measurement accurate?
Acceptable as a screen
More accurate at lower levels
Usually TcB is within 37 – 78 umol/L of serum
Less accurate depending on skin colour and thickness
194
List 3 side effects of phototherapy
Temp instability
Diarrhea
Bronze skin
Interfering with mother-baby time
195
What is intensive phototherapy?
2 phototherapy units
OR
High-intensity fluorescent tubes
Needs to be 10 cm from infant
If approaching exchange, need fibre-optic blanket and remove diaper
196
Who should be given conventional phototherapy?
Can be given for newborns with TSB concentrations 35-50 µmol/L lower than threshold
197
When should IVIg be given for a newborn with hyperbilirubinemia?
Infants who are DAT+ who have predicted severe disease based on antenatal investigation or high risk of needing exchange (based on progression of bili)
198
What kind of hearing screening should patients requiring exchange transfusion receive?
Risk of neurosensory hearing loss therefore hearing screen should include brainstem auditory evoked potentials
199
What is the treatement for acute bilirubin encephalopathy?
Immediate exchange transfusion
200
In the nomogram for interpreting TSB in the CPS statement, what should your management be in the following scenarios:
1) Greater than 37 weeks’ gestation and DAT-negative
- High zone
- High intermediate zone
- Low intermediate zone
- Low zone
2) 35 to 37 6/7 weeks’ gestation or DAT-positive
- High zone
- High intermediate zone
- Low intermediate zone
- Low zone
3) 35 to 37 6/7 weeks’ gestation and DAT-positive
- High zone
- High intermediate zone
- Low intermediate zone
- Low zone
1) Greater than 37 weeks’ gestation and DAT-negative
- High zone: Further testing or treatment required (i.e. meaning either start phototherapy if in range OR re-check bilirubin within 24 hours if below)
- High intermediate zone: Routine care
- Low intermediate zone: Routine care
- Low zone: Routine care
2) 35 to 37 6/7 weeks’ gestation or DAT-positive
- High zone: Further testing or treatment required
- High intermediate zone: Follow up in 24-48 hours
- Low intermediate zone: Routine care
- Low zone: Routine care
3) 35 to 37 6/7 weeks’ gestation and DAT-positive
- High zone: Phototherapy
- High intermediate zone: Further testing or treatment required*
- Low intermediate zone: Further testing or treatment required*
- Low zone: Routine care
201
Which newborns should be given iNO?
Infants >35 weeks GA at birth with hypoxemic respiratory failure and failure to respond to appropriate respiratory management (eg surfactant, HFOV)
Usually started when OI (FiO2/ PaO2) is >20-25 OR if PaO2 remains < 100 mmHg despite 100% O2
202
What is the risk of using iNO in prems?
Increased risk of severe intracranial hemorrhage or PVL in sick prems
203
How do you start and wean iNO?
Start at 20 ppm
Response should be seen within 30 mins
If no response, increase to 40 ppm
Wean after 4-6 hours of stability (FiO2 60-80%, OI <10)
Wean by 50% until 5 ppm every 4-6 hours, then by 1 ppm
Mean duration of use is 48 to 96 hours
204
Why can't you abruptly stop iNO?
Abrupt cessation may be followed by severe hypoxemia (suppresses endogenous NO production)
205
List 2 toxicities of iNO
Methemoglobinemia (keep <2.5%)
NO2 toxicity (not typically seen unless dose >80ppm)
Decreased platelet aggregation
Surfactant dysfunction
206
List 5 benefits of Kangaroo care
1. More mature sleep organization
2. Improved neurodevelopmental outcome oat 6 and 12 months
3. Longer duration of breastfeeding
4. Decreased incidence of nosocomial infection (more so in developing countries)
5. Improved mother-infant attachment
207
In which newborns should Kangaroo care be delayed?
1. <27 weeks’ gestation who require high humidification
2. Abdominal wall and neural tube defects
3. Newly postoperative infants Significant hemodynamic instability
Otherwise can be offered to infants who require ventilatory support, chest tubes, ELBW infants and any GA !
208
List 5 indications for surfactant in a newborn
- Intubated infants with RDS
- If MAS requiring >50% 02
- If sick newborn with pneumonia and OI >15
- Intubated with pulmonary hemorrhage leading to clinical deterioration
- If intubated with RDS before transport
- No recommendation can be made for lung hypoplasia or CDH
209
What type of blood should you order for a newborn transfusion?
If not emergency:
- CMV negative
- Irradiated (identifies passive maternal isohemaglutinnins/Ab which can be present for first 2 mo)
- Order type and screen
- O blood, matched with Rh-type
210
In perinatal hemorrhagic shock, how fast can you give blood?
Blood given rapidly until hemodynamically stable (up to 20 mL over 1 min), then more slowly (up to 10 ml/kg/h) to achieve better Hgb
211
What are the transfusion thresholds for preterms according to PINT study?
Resp support=
FiO2 >25% or need for mechanical increase in airway pressure
Week 1:
Resp support: 115
No resp support: 100
Week 2:
Resp support: 100
No resp support: 85
Week 3:
Resp support: 85
No resp support: 75
212
What are the 3 types of ROP that require treatment (type I ROP)?
Zone I – any stage ROP with plus disease
Zone I – stage 3 ROP without plus disease
Zone II – stage 2 or 3 ROP with plus disease
213
In terms of ROP terminology, what is plus disease?
Increased vascular dilatation and tortuosity of posterior retinal vessels in at least two quadrants of the retina
214
Which preterms should be screened for ROP?
1. ≤306/7 weeks’ GA (regardless of birth weight)
| 2. Infants having a birth weight ≤1250 g
215
When should preterms who meet criteria for ROP screening be screened?
Screen at 31 weeks PMA if GA ≤ 26+6
Screen at 4 weeks CA if GA ≥ 27 wks
216
What are two options for treatment of ROP
Retinal ablation
| Anti-VEGF
217
List 5 complications that late preterms are at increased risk of
1. Hyperbilirubinemia
2. Feeding difficulties and growth
3. Apnea and SIDS
4. Sepsis
5. Hypoglycemia
6. Temperature control
218
When does hyperbilirubinemia peak in late preterms?
Day 7 (as opposed to day 3-5)
219
What does the CPS recommend for monitoring of hyperbilirubinemia in late preterms?
Assess for feeding, weight gain and jaundice repeatedly in the first 10 days of life until consistent weight gain without jaundice has been established
220
What does the CPS recommend regarding safe discharge of late preterms with feeding issues?
- Need to demonstrate 24 hours of successful feeding before discharge
- Limit feeds to 20 mins
- Feeding and prep for feeding should not take >6 hours
- Can fortify in short term
221
What should be done to assess the risk of apnea in a late preterm who is 34 weeks GA?
Consider a period of cardiorespiratory monitoring in a neonatal intensive care unit before transfer to a low-risk nursery
If apneas, continued monitoring in NICU until apnea free x 8 days
222
Is there an increased risk of fetal anomalies with maternal SSRI use?
Unlikely
| MAYBE increased risk of CHDs with high dose paroxetine
223
What is the most concerning risk to newborn with maternal SSRI use?
PPHN-extremely rare
224
How long should babies with maternal SSRI use be observed in hospital?
48 hours
10-30% have SSRI neonatal behavioural syndrome
Usually mild neurobehavioural or respiratory symptoms
Resolves within 2 weeks
225
Does supplemental iron reduce the need for transfusion in very late preterms?
No
226
List 5 ways of minimizing blood loss and need for tranfusion in very premature infants
1. Delayed cord clamping
2. Noninvasive CO2 monitoring
3. Noninvasive bilirubin monitoring devices before phototherapy
4. Point-of-care testing
5. Transfuse 20 ml/kg if the hemodynamic and respiratory status of the patient permits
227
What is neonatal ophthalmia?,
Conjunctivitis within first 4 weeks of life
228
What bacteria most commonly cause neonatal opthalmia?
1. Staphylococcus species, Streptococcus species, Haemophilus species and other Gram- negative bacterial species (30-50%)
2. Chlamydia (2-40%)
3. Gonorrhea (<1%)
gonorrhoeae now accounts for
229
List 3 serious complications of N gonorrhoeae ophthalmia neonatorum
Corneal ulceration
| Perforation of the globe Permanent visual impairment
230
What does the CPS recommend for neonatal ocular prophylaxis?
Erythromycin, the only agent currently available in Canada for prophylaxis, may no longer be useful and, therefore, should not be routinely recommended
Reasons:
- High rates of resistance to N. gonorrhea
- Lack of efficacy against Chlymadyia
- Low prevalence of gonorrohea
BUT there is legislation mandating its use in some provinces (including Ontario)
231
What does the CPS recommend re: screening and treating of women during pregnancy?
- All women should be screen for G+C at first prenatal visit
- If positive, should treated and re-screened after treatment AND third trimester/at delivery
- If no testing during pregnancy, send swabs AT delivery
232
What does the CPS recommend re: managing newborns exposed to N gonorrhoeae?
If asymptomatic- conjunctival cultures, IM/IV CTX x 1 dose
If symptomatic-FSWU
If mom's culture unavailable at time of discharge, counsel on signs of conjunctivitis and contact if positive
233
What does the CPS recommend re: managing newborns exposed to C trachomatis?
If asymptomatic-do nothing, no swabs, monitor for conjunctivitis, pneumonitis
234
Who should be on a neonatal transport team?
One RN working with either another RN, an RT or an EMT/paramedic with expertise in neonatal or paediatric transport
235
What is effective discipline for an infant (0-12 months)?
- Avoid overstimulation
| - Allow them to develop some tolerance to frustration, self-soothing
236
What is effective discipline for an early toddler (1-2 years)?
- Parental tolerance
- Discipline to ensure toddler's safety, limit aggression
- Separate child from situation or object with firm "no" or brief explanation "no
NO TIME OUTS OR VERBAL EXPLANATIONS
237
What is effective discipline for a late toddler (2-3 years)?
- Parent tolerance of outbursts to reasonable extent
- Know the child's patterns of reacting - try to prevent/remove from situations that cause flares
- Provide empathy/soothing, but at same time, continue to supervise, set limits
- When regain control, provide reassurance, provide simple verbal explanation, then redirect
- No verbal prohibitions alone; need simple explanations
238
What is effective discipline for preschool child (3-5 years)?
- Some verbal rules, but still supervise to ensure carries through
- Time outs
- Small consequences can be used if related to, and immediately follow misbehaviour (e.g. draws on wall - loses crayons and helps clean)
- Approval and praise are the most powerful motivators
- Do not use lectures
239
What is effective discipline for school age child (3-5 years)?
- Supervise, provide good behavioural models, set consistent rules
- Allow child to have increased autonomy in small decisions
- Use praise and approval liberally but not excessively; motivators as necessary (toys for hobbies)
- Withdrawal or delay of privileges are acceptable
- Consequences and time-outs are also still acceptable
240
What is effective discipline for adolescent (13-18 years)?
- Parents should remain available - despite being challenging, many do want parent guidance and approval
- Set rules in noncritical way, do not belittle (avoid lectures, predicting catastrophes)
- Ensure that basic rules are followed and logical consequences are set
- Contracting is useful tool
241
Above what age are time outs effective and how long should they be?
> 24mo through to primary school years
of minutes=age in years
242
When is reasoning or away from the moment discussions appropriate in administering discipline?
After 3-4 years
243
List 3 CNS abnormalities in FAS
```
Holoprospencephaly***characteristic
Abnormal corpus callosum
associated
Absent olfactory lobes
Hypoplasia of the hippocampus
Microcephaly
```
244
In infant with colic, what intervention can be tried?
Extensively hydrolyzed protein formulas or maternal elimination diet x 2 week trial
245
List 3 direct and 3 indirect ways low literacy impacts health
Direct
- Incorrect use of medications
- Failure to comply with medical directions
- Errors in administration of infant formula
- Safety risks in the community, the workplace and at home
Indirect
-Higher rates of poverty
-Higher than average rates of occupational injuries
-Higher degrees of stress
-Unhealthy lifestyle practices such as:
•smoking
•poor nutrition
•infrequent physical activity
•lack of seatbelt use or wearing of bicycle helmets
•less prevalence of breastfeeding (where applicable)
•less likely to ever have had a blood pressure check
•less likely to practice breast self-examination and to obtain pap smears
246
What is the impact of maternal depression on an infant?
- Insecure attachment
- Negative affect
- Dysregulated attention and arousal
247
What is the impact of maternal depression on a toddler?
- Poor self-control
- Internalizing and externalizing problems
- Lower cognitive performance
- Less creative play
- Difficulties in social interactions
248
What is the impact of maternal depression on school-age and adolescent children?
- Impaired adaptive functioning
- Conduct disorders
- Affective disorders
- Anxiety disorders
- ADHD
- LD
- Lower IQ
249
List 3 risk factors for behavioural dysfunction in a child with depressed mothers
1. Marital conflict
2. Low SES
3. Decreased maternal education
4. Absence of buffering by father
5. Child with less robust and easy-going temperament
250
List 3 things that pediatricians should do to support children with depressed mothers
- Screen for maternal depression at well baby visits
- Reassure SSRIs safe
- Promote breastfeeding
- Social support and home visiting interventions
- Family therapy for older children
251
What are the two most common sleep disorders in pediatrics?
1. Delayed sleep phase type
(problem of sleep initiation with sleep latency of more than 30 min)
2. Behavioral insomnia of childhood
-Sleep onset association type (caregiver has to help child go or return to sleep)
-Limit setting type (child stalls and caregiver demonstrates unsuccessful limit-setting)
252
List 5 recommendations for good sleep hygiene
- Consistent routine with stable bed and wake up time
- Age-appropriate number of hours in bed
- Dark quiet space
- Avoiding hunger and eating before bed
- Relaxation techniques before bed
- Strict avoidance of TV, computers, encourage reading
- Avoiding nicotine, caffeine, alcohol
253
How many minutes before bed should melatonin be given?
30-60 minutes
254
In which patient populations does melatonin have established efficacy?
1. Delayed sleep phase type
2. Behavioural sleep onset association type
3. ADHD
4. ASD
5. Intractable epilepsy, neurodevelopmental disabilities and Angelman’s
255
List 3 side effects of melatonin
1. Abdominal pain
2. Decreased appetite
3. Feeling cold
4. Dizziness
256
What dose of melatonin is recommended?
Dose: 2.5-3mg kids, 5-10mg teens
Short acting for sleep initiation
Long acting for sleep maintenance
257
Average growth (weight and height gain) in the following age groups:
1st year of life
2nd year of life
From age 2-5
1st year = gains 7kg and 21cm
2nd year = gain 2.3kg and 12cm
From 2-5 = gain 1-2kg, 6-8cm/year
258
List 5 pieces of advice you can give to parents of picky eaters
1. Reassure parents that a decrease in appetite is normal for children 2-5 years of age
2. Explain that parents responsible for which foods children are offered, the child is responsible for how much to eat
a. Parents should choose nutritious food of appropriate texture and taste for the child’s age, and provide structured meals and snacks
b. Parents need to be flexible and allow food preferences, within reason
3. Start with small portions (one tablespoon of each food per year of the child’s age) and to serve according to the child’s appetite
4. Snacks mid-way between meals. Should not be offered if the timing or quantity of snacking will interfere with the child’s appetite for the next meal
5. Children should NOT be allowed to graze or to drink an excessive amount of milk or juice
6. Remind parents that eating should be an enjoyable activity. No bribes, threats or punishments.
7. Limit time at table to 20 min. When mealtime is over, all food should be removed, and only be offered again at next planned meal or snack
8. Highlight that to stimulate appetite, children need exercise and play. However, they are less likely to eat well when they are tired or overstimulated.
9. A 10-15 min notice before any meal helps children to prepare, settle down before eating
10. Avoid distractions such as toys, books or TV at the table
11. Parents should only insist on table manners that age and stage appropriate.
12. Eating with the family provides the toddler with a pleasurable social experience and the opportunity to learn by imitation.
13. Appetite stimulants such as cyproheptadine are generally not indicated for isolated food refusal and should never be considered solely to alleviate parental anxiety.
14. Vitamin or mineral supplements can be used if the quality of the diet is questionable. When a child is growing well there is no role for nutritional supplements, such as special formulas for toddlers and children.
259
When do moist children achieve bladder and bowel control?
2-4 years
260
What is the average time between initiation and mastery of toilet training?
3-6 months
261
List 5 signs of readiness to toilet train
-Physiologic readiness: usually reflex spinchter control by 18 months
- Psychological/developmental readiness:
- Able to walk to potty
- Stable when sitting on potty
- Able to remain dry for several hours
- Able to follow simple 1 or 2 step commands
- Child can communicate need
- Desire to please caregiver
- Desire for independence
262
What should you recommend if a child is expressing toileting refusal?
Take a 1 to 3 month break from training
263
What does the CPS recommend regarding bodychecking in hockey?
- Eliminate bodychecking from all levels of organized rec./non-elite competitive male ice hockey
- Delay bodychecking in elite male competitive leagues until 13-14 years of age (bantam level)
264
What does the CPS recommend regarding participation of children in boxing?
Oppose boxing as a sport for any child or adolescent
265
What is the most common injury and most common cause of death in boxing?
Most common injury= death
Most common cause of death=subdural hematoma
266
What are the 3 leading causes of injury related death?
MVA
Drowning
Threats to breathing
267
What are the 3 principles of injury prevention
1. Education
2. Enforcement/legislation
3. Engingeering
268
List 4 risk factors for injuries in youth
Aboriginal
Rural setting
Male
SES
269
List 3 things you can counsel families on preventing choking
1. Avoid the following foods in children < 4 years of age
- Hard candies
- Cough drops
- Gum
- Gummy candies
- Chewable vitaminn
- Peanuts
- Sunflower seed
- Fish with bones
- Snacks on toothpicks or skewers
2. The following foods require special preparation for children < 4 years of age
- Grapes – slice lengthwise
- Hot dogs, sausages – slice lengthwise
- Raw carrots, apples – chop, grate
3. Use labels on toys and child products to identify choking hazards
4. Safe sleeping environment (e.g. for cribs ensure firm, tight-fitting mattress and no soft bedding)
5. Eliminate loose or dangling cords by cutting them short and by anchoring any remaining
6. Avoid clothing with drawstrings at the neck or waist
7. Avoid magnetic toys.
8. Do not use latex balloons
270
What does the CPS recommend regarding children's use of ATVs?
- Children and youth younger than 16 years of age should not operate an ATV
- ATV drivers should:
1) wear helmet, eye protection, protective clothing
2) Not operate ATV when impaired
3) Complete an approved training course
271
What is the most common cause of injuries on playgrounds?
Falls
272
What is the most common type of playground injury?
Fractures, usually upper arm
273
Playground deaths are most commonly caused by...
Strangulation
274
3 strategies advocated by the Canadian Standards Association to reduce playground injuries
1. Reducing the maximum fall height of equipment
2. Reducing the risk of falling from equipment
3. Improving protective surfacing under and around play equipment
275
List 3 risk factors for injury in skiing and snowboarding
- Snowboarding > Skiing
- Male sex
- Lack of experience
- Younger age
- Poor equipment/ poorly adjusted bindings
- Rented or borrowed equipment
- Poor facility design – e.g. location of trees, lifts, frequency of grooming/powder
276
List 3 preventive strategies to reduce injuries in snowboarding
- Helmets
- Wrist Guards
- Ensure proper fit and adjustment of equipment, particularly bindings
- Taking formal lessons
- Ski area safety programs → the Alpine Responsibility Code
- Avoid drugs/alcohol
- Appropriate supervision
277
What does CPS recommend regarding the operation of snowbiles in children/adolescents?
- Children younger than 16 years of age should not operate snowmobiles
- Children younger than six years of age do not have the strength or stamina to be transported safely as passengers on snowmobiles
- Recommend graduated licensing process for youth >16
278
Below what age should children not participate in organized sport?
Children don’t have sufficient combinations of fundamental skills for participation in organized sport until age 6
279
What are the two best strategies for preventing drowning?
Constant adult supervision (arms-length if near water, held by adult if in water)
Four-sided pool fencing with self closing, latching gate
Not effective:
Pool alarms
Swimming lessons in children <4 years
PFDs-still need supervision
280
What does the CPS recommend regarding trampolines in the home?
Trampolines should not be used for recreational purposes at home (including cottages and temporary summer residences) by children or adolescents.
281
What are common and serious trampoline injuries?
Common-Fractures (mainly upper extremity)
Serious (rare)-c-spine, knee ligamental, popliteal artery thrombosis, ulnar nerve injury, vertebral artery dissection
282
With respect to car seats, what are the 3 most common errors?
Seat not tightly secured to vehicles (moves > 2.5cm/1inch in any direction)
Harness not snug (more than 1 finger width between harness strap and child)
Chest clip not at armpit level
283
Who can use Stage I car seats (rear facing)?
Until child weighs at least 10 kg (22lbs) AND is at least 1 year of age and able to walk
284
Who can use Stage II car seats (forward facing)?
Use for children 10-22kg (22-48 lbs) and up to 122 cm (48 inches)
285
Who can use Stage III car seats (booster seats)?
- For children who exceed weight/height limitations of forward facing car seat
- 18-36 kg
286
When can children use seatbelts without carseat (Stage 4)?
May be used for children > 36kg (80lbs), >145 cm AND at least 8 years of age AND who properly fit adult restraint in vehicle
287
When can children sit in the front seat?
>13 years
| But rear seat ALWAYS preferred
288
Can you place rear-facing systems in front seat of a vehicle with an airbag?
NO!
289
Which vascular access device requires the most ongoing care?
Tunneled central line!
| Requires ongoing catheter site care, weekly heparin infusion and dressing changes
290
What two lines can be inserted for home IV needed for months to years?
1. Port
| 2. Tunneled central line
