CPS Community pediatrics

Question 1

What is the Rome III diagnostic criteria for functional constipation?

Answer 1

Criteria must be fulfilled at least once per week for at least 2 months before diagnosis can be made:
2 or more of following in a child of at least 4 yo with insufficient criteria for diagnosis of IBS:
1. 2 or few defectations in the toilet per week
2. At least one episode of fecal incontinence per week
3. History of retentive posturing or excessive volitional stool retention
4. History of painful or hard bowel movements
5. Presence of a large fecal mass in the rectum
6. History of large diameter stools that may obstruct the toilet

Question 2

When are the two periods of time when the developing child is most prone to functional constipation?

Answer 2

1. Toilet training

2. Start of school

Question 3

What is a “fleet enema”?

• recommended for what age group?
• what are side effects? (3)

Answer 3

Sodium biphosphate and sodium phosphate

• recommended for children > 2 years only
• side effects:
  1. mechanical trauma to rectal wall
  2. abdo distention or vomiting
  3. hyperphosphatemia, hypocalcemia

Question 4

What is the potential side effect of use of mineral oil for constipation?
-in which group is mineral oil contraindicated?

Answer 4

Lipid pneumonia if aspirated

-contraindicated in infants because of this reason

Question 5

What is distinguishing feature and benefit of Peg 3350 over other laxatives?

Answer 5

Does not cause electrolyte imbalance (only absorbed in trace amounts from the GI tract)

Question 6

What is the dose of PEG for disimpaction and maintenance?

Answer 6

Disimpaction: 1.5 g/kg/day div BID x 3 d
Maintenance: 0.4-1 g/kg/day (start high and then decrease as necessary)

Question 7

What is a common reason for lack of response to stool softening therapy with PEG?

Answer 7

Inadequate dosing! Start high and then decrease as necessary

Question 8

What is the evidence for docusate in pediatric constipation?

Answer 8

No evidence that docusate is effective!

Question 9

What behavioural modification recommendations can be made to parents for treatment of constipation? (3)

Answer 9

1. Routine scheduled toilet sitting x 3-10 min once or twice a day
2. Footstool to help increase intraabdominal pressure
3. No punishment for not stooling during toileting time; yes praise and reward for stooling and toilet sitting

Question 10

What is the recommended fibre intake for all children?

-what is the evidence for fibre supplementation in children with constipation?

Answer 10

0. 5 g/kg/day to max of 35 g/day

- no evidence to support fibre supplementation

Question 11

What is the next step if a child is unresponsive to adequate medical and behavioural management for constipation?

Answer 11

Consider time-limited trial of a cow’s milk free diet = CMPI has been associated with chronic constipation

Question 12

What is considered “normal” for stooling patterns in infants?

Answer 12

Remember that normal breastfed newborns may stool with each feeding or may not stool at all for 7-10 d

Question 13

How long should children with constipation be treated for with stool softener therapy?

Answer 13

At least 6 months

-should have regular BMs without difficulty before considering a trial of weaning maintenance therapy

Question 14

What is the definition of fever or unknown origin?

Answer 14

Fever > 14 days with no etiology found after routine tests

Question 15

What are the limitations of a rectal temperature? (5)

Answer 15

1. Can be slow to change in relation to changing core temp
2. Accuracy depends on depth of measurement
3. May be inaccurate if there is decreased local blood flow or stool presence
4. Risk for rectal perforation (1 in 2 million)o
5. Can spread infection

Question 16

What is the AAP recommendation on route of temp measurement as screen for fever in neonates? And why?

Answer 16

Ax temp due to risk of rectal perforation with rectal temps (even though risk is super low)
-only used as a SCREEN since it has low sensitivity and specificity in detecting fever

Question 17

What are the limitations of PO temp? (2)

Answer 17

1. Easily influenced by recent ingestion of food or drink and mouth breathing
2. Relies on mouth being sealed and tongue being pressed down which is hard for young children or unconscious/uncooperative patients

Question 18

What is the science behind tympanic thermometers?

Answer 18

Measure thermal radiation emitted from TM and ear canal (infrared radiation emission detectors)

• amount of thermal radiation emitted is in proportion to membrane’s temperature and blood supply to this is very similar in temp and location to the blood bathing the hypothalamus which is the body’s thermoregulatory centre
• not affected by crying, otitis media or earwax

Question 19

According to the CPS statement on temperature measurement, what are the normal temperature ranges for:

• rectal
• ear
• oral
• axillary

Answer 19

Rectal: 36.6-38
Ear: 35.8 - 38
Oral: 35.5 - 37.5
Ax 34.7 - 37.3

Question 20

What are the limitations to tympanic temperature?

Answer 20

1. Influenced by ear canal’s structure, meatus size and probe positioning (need an adequate seal to protect from ambient temperatures); especially difficult in young children

Question 21

What is the recommendation for temporal artery thermometry?

Answer 21

May be a useful tool for screening children at low risk in ER but cannot yet be recommended for home use or hospital use when definitive measurements are needed

Question 22

Overall, what is the recommendation on use of infrared tympanic thermometers?

Answer 22

Accurate, easy and safe to use and so it is an appropriate way to measure temps especially in older children
-children < 2 yo should still have temp taken rectally until a better tympanic temp probe is designed

Question 23

What is the recommended temperature measurement techniques for the following age groups:

• birth to 2 yrs
• 5 yo

Answer 23

• birth to 2 yr: ax as screen rectal as definitive
• 2-5 yo: ax or tympanic as screen, rectal as definitive
• 5 yo: ax, tympanic (or temporal artery if in hospital) as screen, oral as definitive

Question 24

What is the difference between bedsharing and cosleeping?

Answer 24

• Bedsharing: baby shares same sleeping surface with another person
• Co-sleeping: baby is within arm’s reach of another person but not on the same sleeping surface

Question 25

Before 18 months, how fast do children’s feet grow?

-what about toddlers?

Answer 25

• <18 mo: Half a shoe size q2months

- toddlers: half a shoe size q3months

Question 26

When does longitudinal arch development occur in children?

-what is flexible flatfoot?

Answer 26

Longitudinal arch development occurs before the age of 6

• all children < 18 mo have flat feet because of a fat pad under the foot
• flexible flatfoot: common in children < 6 yo (developmental variation and normal!!!) and does NOT need treatment (ie. corrective shoes, inserts, etc.) if asymptomatic!

Question 27

What 3 characteristics of children lead to higher incidence of flatfoot?

Answer 27

1. Greater laxity of ligaments
2. Obesity
3. Shoe wearing in early childhood

Question 28

What is the treatment and prognosis of intoeing, torsions, knock knees and bowlegs?
-when should you consider referral to orthopedic surgeon?

Answer 28

Treatment: NOTHING. Orthotics are NOT beneficial in management of these things! Majority of torsional deformities resolve spontaneously by adulthood and rarely cause functional problems

• refer to ortho if persists beyond age ~8 and if it causes functional impairment
• corrective shoes or other interventions are NOT necessary if asymptomatic

Question 29

A mom brings in her 6 month old baby and asks you “Does she need shoes?” What do you answer?

Answer 29

NO! Infants do not need shoes until they are walking

-they are necessary for protection and that’s pretty much it.

Question 30

What questions should you ask when helping parents choose internet sites for high-quality health information? (4)

Answer 30

1. Is the host of the health info web site engaged in a conflict of interest?
2. Is the info peer reviewed?
3. Is the info up to date?
4. Is the info presented based on proper evidence?

Question 31

What type of hearing loss is the most common in neonates?

Answer 31

Sensorineural

• genetic cause is found in 50%
• of these, 70% have nonsyndromic deafness related to cochlear hair cell dysfunction (errors in production of protein connexin 26)

Question 32

What is the hearing threshold for normal hearing in decibels?

• mild hearing impairment?
• moderate?
• severe?
• profound?

Answer 32

Normal: 0-20 dB
Mild: 20-40 
Moderate: 40-60
Severe: 60-80
Profound: > 80

Question 33

What are risk factors for neonatal sensorineural hearing loss? (5)
-in what percentage of neonates with hearing loss can a risk factor be identified?

Answer 33

1. Family history of permanent hearing loss
2. Craniofacial abnormalities including those involving the inner ear
3. Congenital infections (bacterial meningitis, TORCH)
4. Physical findings consistent with an underlying syndrome associated with hearing loss
5. NICU stay > 2 days OR any of the following regardless of duration of stay:
   - ecmo
   - mechanical ventilation
   - ototoxic drug use
   - hyperbilirubinemia requiring exchange transfusion

***Only about 50% of neonates found to have sensorineural hearing loss had an identifiable risk factor. The other 50% had no risk factors at all; this is why universal screening is so important!

Question 34

What is the average age of diagnosis of hearing loss in unscreened children?
-what about screened children?

Answer 34

24 months when there is an expressive language deficit

• mild and moderate hearing losses aren’t usually detected until school age
• In screened children, average age of diagnosis is 3 months of age with intervention by 6 mo

Question 35

What are the components of a successful screening test?

Answer 35

1. Test is reliable and accurate
2. Test can lead to earlier diagnosis
3. Little adverse effects of test
4. Earlier detection has available and effective intervention
5. Good long term outcome from earlier intervention

Question 36

What are the two screening tests for hearing loss?

-main similarities and differences?

Answer 36

• **Both tests should be performed in infants > 24 hrs old and > 34 wks CGA
• noninvasive

1. Otoacoustic emission (OAE)
   - identifies conductive and cochlear hearing loss from level of external ear to the level of the outer hair cells in the cochlea
   - sound stimulus is sent to the auditory system via ear specific probes and then echoes returning from the outer hair cells of the cochlea are measured
2. Automated auditory brainstem response (AABR)
   - identifes conductive, cochlear AND NEURAL hearing loss from the external ear to the level of the brainstem including assessment of 8th nerve function
   - records brainstem electrical activity in response to sounds presented to the infant via earphones

Question 37

In a newborn with no risk factors for hearing loss, what is the indicated screening test for hearing loss?

• in a child with risk factors for sensorineural hearing loss?
• in a child who fails the 1st screening test?

Answer 37

2 step screen for infants with no risk factors: use OAE –> if fails –> move onto AABR
-in child with risk factors for sensorineural hearing loss: start with AABR

Question 38

What are cochlear implants?

• what are current recommendations for their use?
• what are children with cochlear implants at increased risk for getting?

Answer 38

Electronic devices surgically placed in the cochlea to provide stimulation to the auditory nerve = has been shown to be highly effective in hearing and language development

• current recommendations: bilateral implantation for children who quality between 8-12 months ofa ge coupled with speech language therapy
• increased risk of meningitis

Question 39

What is the false positive rate for hearing screening tests?

Answer 39

2-4%

Question 40

What is the management of a child with confirmed hearing loss on screening and diagnostic testing?

Answer 40

1. Full hx and pe to rule out associated comorbidities or syndromes
2. Consult ENT, ophtho, and genetics
   - need to confirm vision assessment to maximize sensory input
3. CONSIDER neuroimaging studies, renal and cardiac evaluation based on findings

Question 41

What is ankyloglossia?

• what is the association with lactation problems, speech disorders or other oral motor disorders?
• is there a way to classify or diagnose ankyloglossia?

Answer 41

Abnormally short lingual frenulum = may result in varying degrees of decreased tongue mobility

• inconsistent association with problems!!!
• there is no universally accepted definition or criteria for diagnosing ankyloglossia!

Question 42

What is the recommended management for ankyloglossia?

-indication for frenotomy?

Answer 42

Conservative! = no intervention required usually beyond parental education and reassurance

• most babies with ankyloglossia don’t have significant consequences and most are able to breastfeed successfully
• indication for frenotomy: when complete fusion of the tongue is found (complete ankyloglossia)

Question 43

What are the complications of frenotomy?

Answer 43

1. Bleeding
2. Infection
3. Injury to Wharton’s duct
4. Postoperative scarring resulting in worsened limitation of tongue movement

Question 44

What is the mechanism of maintaining the circadian rhythm of the sleep-wake cycle?

Answer 44

Secretion of melatonin by the pineal gland in response to darkness

Question 45

What are the two most common type of sleep disorders in the pediatric age group?

Answer 45

1. Delayed sleep phase type
   - initiation of sleep significantly later than the desired bedtime
   - sleep latency (time it takes between laying down to sleep and onset of sleep) takes longer than normal 30 minutes
2. Behavioural insomnia of childhood
   - sleep onset association type (caregivers need to do certain things before the child goes or returns to sleep at night)
   - limit setting type (child stalls or refuses to go to bed or return to bed and the caregiver demonstrates unsuccessful limit-setting behaviours)

Question 46

What are common medical conditions that can result in insomnia? (3)

Answer 46

1. Sleep apnea
2. Anxiety
3. Depression

Question 47

What are components of good sleep hygiene? (8)

Answer 47

1. Consistent routine = stable bedtime and morning wake time
2. Age-appropriate number of hours in bed
3. Dark and quiet sleep space
4. Avoiding hunger and eating prior to bedtime
5. Relaxation techniques before bed
6. Avoid caffeine, alcohol and nicotine
7. Avoid tv, computers, video games
8. Encourage reading prior to bedtime

Question 48

In what age group can melatonin be used for treatment of insomnia?

Answer 48

Greater than 2 years old (no evidence to support use in children < 2 yo)

Question 49

What is the 1st line treatment for delayed sleep phase type insomnia?

• what about sleep-onset association type?
• what is the 2nd line treatment?

Answer 49

***For both, SLEEP HYGIENE INTERVENTION IS 1st LINE!
If this fails: then consider pharmacological therapy
-Delayed sleep phase type: potential for melatonin to advance onset of sleep is high!
-typical dose: 2.5-3 mg in children and 5-10 mg in adolescents 30-60 mins prior to desired bedtime
-sleep-onset association type: supported by RCT showing improved sleep onset and sleep duration
-same dose as above

Question 50

What special populations might melatonin be effective in? (4)

Answer 50

1. ADHD
2. ASD
3. Intractable epilepsy
4. Neurodevelopmental disabilities

Question 51

What are the clinical features of plagiocephaly?

-what is the expected course of positional plagiocephaly?

Answer 51

1. Unilateral flattening of the occiput
2. Ipsilateral anterior shifting of the ear
   - expected course: incidence starts at 6 wks, increases to max at 4 months, then slowly decreases over 2 years with resolution of most cases

Question 52

What are the risk factors for positional plagiocephaly? (7)

Answer 52

1. Male sex
2. First born
3. Limited passive neck rotation at birth (congenital torticollis)
4. Supine sleeping position
5. Exclusive bottle feeding
6. Tummy time < 3 times per day
7. Lower activity level with slower achievement of milestones
8. Positional preference of sleeping with the head to same side

Question 53

What condition is on the differential for positional plagiocephaly?
-how can you differentiate on exam between the two?

Answer 53

Craniosynostosis = lambdoid suture involvement is the only craniosynostosis that causes occipital flattening and is very infrqeuent
-will generally feel ridging of the affected suture with posterior displacement of the ear (as opposed to anterior displacement with PP)

Question 54

How do you diagnose positional plagiocephaly?

Answer 54

Clinical diagnosis = only get skull xrays if there is clinical suspicion of craniosynostosis or worsening of head shape at an age when PP would be expected to improve

Question 55

What are the ways to prevent plagiocephaly? (2)

Answer 55

1. Sleep placement: positioning the baby with his/her head to the foot or to the head of the bed on alternating days encouraging the baby to lie on the side of the head that allows them to look into the room
2. Tummy time = awake time spent in prone position for at least TID x 10-15 minutes
   - this also aids in progress of developmental milestones that require prone position

Question 56

What is the treatment for positional plagiocephaly?

• what about helmet therapy?
• side effects of helmet therapy?
• what is the maximum age to consider helmet therapy?

Answer 56

Overall, for children < 4 months of age with mild-moderate assymmetry: physiotherapy program combining positioning with exercises where needed (congenital torticollis, positional preference or developmental stimulation) is superior to parental counselling for preventive measures without PT support

• **Helmet therapy: EXPENSIVE with lots of side effects thus is NOT recommended
• have to wear 23 hrs/day, associated with contact dermatitis, pressure sores and local skin irritation
• can consider in children in severe asymmetry regardless of age
• maximum age to try helmet therapy is 8 months
• ***these recommendations are not supported by evidence!

Question 57

What 3 conditions should be ruled out in children with plagiocephaly?

Answer 57

1. Craniosynostosis
2. Congenital torticollis
3. Cervical spine abnormalities

Question 58

What is a macrobiotic diet?

Answer 58

Not necessarily vegetarian but is based largely on grains, legumes and vegetables, may contain some animal products

Question 59

What is the recommended protein intake for vegetarian children compared with nonvegetarians?
-what are major plant food sources of protein?

Answer 59

Due to lower digestability of plant proteins, need to increase protein intake for vegetarian children:

• < 2 yo: increase by 35%
• 2-6 yo: increase by 30%
• > 6 yo: increase by 20%
• **Major plant food sources of protein:
• legumes (beans and lentils), cereals, nuts and seeds, nut butters
• each has different qualities and essential amino acids thus need a mixture of these to have good nutrition

Question 60

What is the most common nutritional deficiency in children?

Answer 60

Iron deficiency

Question 61

What is the recommended iron intake for vegetarian vs. non vegetarian children?
-sources of iron in plant foods?

Answer 61

Vegetarians require 1.8x the iron intake of nonvegetarians because of different bioavailability
-sources of iron: iron-fortified cereals, grain products, dried beans and peas, supplementation

Question 62

Is zinc supplementation recommended for vegetarian children?

Answer 62

No since zinc deficiency is quite rare

-just recommend including zinc rich foods such as legumes, nuts, fermented soy products

Question 63

In vegetarian children, which subgroup is most likely to be calcium deficient?
-calcium rich foods?

Answer 63

Strictly vegan children are at highest risk for calcium deficiency

• calcium rich foods: bok choy, chinese cabbage, kale, collards, cereals, juices, soy products
• strictly vegan children/adolescents require additional supplementation to ensure recommended intakes

Question 64

Is calcium content of breast milk affected by a vegan diet in the mother?

Answer 64

No it does not :)
-however, after weaning of breastfeeding, should ensure baby gets adequate intake of calcium fortified foods such as fortified soy products, cereals, juices, leafy vegetables

Question 65

What fat/fatty acids are deficient in a vegan diet?

-what are the recommendations in making sure they get enough?

Answer 65

Deficiency in long-chain omega-3-fatty acids (DHA and EPA) = found in fish, seafood and eggs

• vegans thus don’t get this unless they eat sea vegetables or algae
• recommendations: need adequate sources of the precursor linolenic acid (flaxseed, canola oils, walnuts and soy products) which are then converted into EPA and DHA
• can also get microsupplements of microalgae

Question 66

What vitamin deficiency is often seen in vegans and can have serious neurological consequences?
-recommendations for intake?

Answer 66

1. Vitamin B12: only found in animal products (meat, eggs. etc)
   - recommendations: need supplementation or fortified foods for all strict vegan infants/children/adolescents
   - at least 3 servings of food rich in vitamin B12 in daily diet = fortified soy/nut beverages, cereals OR 5-10 mcg per day
   - keep in mind that vegetarian diets are usually high in folic acid intake and can therefore mask vit B12 deficiency anemia but children will still have neurological deficits from the vit B12 that can go undetected until too late

Question 67

What are recommendations for vitamin D intake?

• children < 1 yo?
• children < 2 yo living above northern lattitude of 55 degrees, dark skin, or avoiding sunlight? Timing?
• children > 1 yo

Answer 67

• Children < 1 yo: 400 U vit D OD
• Children < 2 yo living above northern lattitude of 55 degrees/dark skin/avoiding sunlight: 800 IU Vit D in winter months from October to April
• children > 1 yo otherwise: 200 U vit D OD (sunlight exposure x 20-30 minutes three times per week)

Question 68

What is the recommended maximum fibre intake?

-why do we set a max?

Answer 68

0. 5 g/kg/d
   - set a max so that calories aren’t diluted and there is no interference with absorption of minerals and essential nutrients

Question 69

How do the birth weights of infants of vegetarian mothers compare with those of nonvegetarians?
-what 2 vitamin deficiencies are of concern for infants of breastfeeding vegan mothers?

Answer 69

They are comparable!

• vitamin deficiencies:
  1. Vit B12
  2. Vit D
• require adequate sources of both through fortified foods or supplementation during pregnancy and lactation

Question 70

What is the recommended intake of vitamin D for all pregnant/lactating mothers during the winter months?

Answer 70

2000 U vit D OD

Question 71

What is the likelihood that a lacto-ovo-vegetarian diet will meet nutrient needs for a growing child?
-what about strict vegan diet?

Answer 71

Lacto-ovo-vegetarian diets are adequate to meet all nutrient needs!
-strict vegan diet CAN meet the nutrient needs as long as there is intake of calorie-dense foods to provide for adequate growth so should monitor very closely

Question 72

What are the specific recommendations for strictly vegan children in terms of: (don’t need specific numbers, just increase/decrease/keep same)

• protein intake
• iron intake
• zinc intake for breastfed infants of vegan moms
• zinc intake for strict vegans
• calcium intake
• fatty acid intake
• vitamin B12 intake

Answer 72

• protein requirements: need to increase to account for lower digestibility of plant protein
• iron needs: need to increase iron fortified foods or supplementation
• zinc intake for breastfeeding babies of vegan moms: need fortified foods after 7 months of age
• zinc intake for strict vegans: need 50% more daily zinc
• calcium intake: need to increase
• fatty acid: need to take linolenic acid foods (flaxseed, canola oil, walnuts)
• vitamin B12: need to have 5-10 mcg per day

Question 73

What are the 5 key domains of a child’s early development?

Answer 73

1. Physical
2. Social
3. Emotional
4. Language/cognitive
5. Communication skills

Question 74

What is an EDI? :)

Answer 74

Early development instrument: population-based survey that kindergarten teachers fill out across the country to measure child development across the country

Question 75

What criteria need to be met before a diagnosis of primary nocturnal enuresis can be made? (3)

Answer 75

1. Bladder control has never been attained
2. Child must be > 5 yo
3. Regular bed-wetting (more than twice per week)

***Remember that this is a variation in the development of normal bladder control and may be associated with deep sleep patterns

Question 76

What percentage of 5 yo children still have bedwetting?

• 8 yo?
• 15 yo?

Answer 76

5 yo: 10-15%

• 8 yo: 6-8%
• 15 yo: 1-2%

Question 77

Where is the gene for enuresis?

Answer 77

Chromosome 13q

Question 78

Should you order a urinalysis in a child with primary nocturnal enuresis with normal history and physical exam?

Answer 78

NO! Low pretest probability of a true positive result on UA with potential of getting a false positive result!
-thus only order if history or physical suggests to do so

Question 79

How does an alarm device work in the management of nocturnal enuresis?

• what does success of the alarm depend on?
• in what age group is the alarm system most effective?

Answer 79

Teaches the child to respond to a full bladder when asleep

• goes off when the child starts to void and teaches the child to wake up to the alarm and then transfer the waking to the sensation of a full bladder
• worn on the body and runs on miniature batteries, sensitive to a few drops of urine
• success depends on the motivation of the child and parent to be awakened
• most effective in 7-8 yo

Question 80

How long should the alarm device be trialed for nocturnal enuresis?

• how long does it take to see an improvement?
• when can you stop the alarm system if it is successful?
• what is the “overlearning” method?

Answer 80

Need to trial the alarm system for 3-4 months as it may take up to 1-2 months to start seeing an improvement

• initially, will see decrease in UO as opposed to totally dry night
• can stop when there has been 14 consecutive dry nights
• some people recommend “overlearning” which is when you reach 14 consecutive dry nights, then the child drinks extra fluid (2 glasses of water) before bed and do this until the patient has achieved 7 dry nights in a row, then can stop the alarm

Question 81

What is the actual cure rate of primary nocturnal enuresis using alarm devices based on systematic overviews?

Answer 81

Just under 50% but this is still better than nothing so CPS recommends using it!

Question 82

What are potential side effects of DDAVP for treatment of nocturnal enuresis?

Answer 82

1. Headache
2. Abdo pain

• *For intranasal prep:
  1. Congestion
  2. Epistaxis

Question 83

You have prescribed DDAVP to a child with nocturnal enuresis. Mom asks you when he should avoid consuming fluids in relation to when he takes the medication. What is your advice?

Answer 83

No fluids for one hour before and 8 hours after taking desmopressin

Question 84

What are the options for treating primary nocturnal enuresis? (4)

Answer 84

1. Alarm system
2. DDAVP (short-term)
3. Imipramine
4. Behavioural therapy

Question 85

What is the evidence for use of imipramine in nocturnal enuresis?
-dose?

Answer 85

Should only be used as 3rd line (after alarm system and DDAVP) given the possibility of accidental or deliverate overdose
Mode of action is unclear but has immediate antienuretic response
-recommended dose is 25 mg for children 6-12 yo and 50 mg for > 12 yo
-give 1-2 hr before bedtime x 2 wk trial before adjusting dose. Can increase gradually to max of 50 mg
-pretty effective, similar to DDAVP but relapse rate is high after stopping, similar to DDAVP

Question 86

What are possible side effects of imipramine as treatment for primary nocturnal enuresis?

Answer 86

Personality changes, disturbed sleep patterns, headaches, changes in appetite, cardiac arrhythmias, seizures in overdose situations

**overall, remember that it’s a TCA!!!!

Question 87

What is the evidence for behavioural therapy (ie. reward systems) for nocturnal enuresis?

Answer 87

They’re shitty! Don’t do it! How can you convince a child that bedwetting is nothing to be ashamed of if you give them a gold star for not doing it?
-decreases self-esteem, increases family conflict and emotional problems

Question 88

A mom presents with her 7 yo son who has primary nocturnal enuresis. She is very distressed about this and constantly brings up the fact that all the other kids his age have learnt how to not wet the bed. What is your advice?

Answer 88

1. Assure mom that this is a normal variation of development and that 6-8% of children his age still have primary nocturnal enuresis.
2. Assure child’s access to the toilet
3. Avoid caffeine-containing foods and excessive fluids before bedtime
4. Have the child empty the bladder at bedtime
5. Preserve the child’s self esteem
6. Include the child in morning cleanup in a nonpunitive manner
7. If this is not distressing for the child, you don’t have to treat!! If it is distressing, then treat.

**Your primary goal should be to minimize the emotional impact on the child

Question 89

What is the most effective therapy for primary nocturnal enuresis?

Answer 89

Conditioning alarm system but only successful in long term in <50% of children

Question 90

What are individuals with ADHD at increased risk of in their future?

Answer 90

1. Reduced quality of life
2. Increased risk for injuries
3. Behaviour problems
4. Difficulty in school (academically and socially)

Question 91

True or false: treatment with stimulant medication in ADHD is associated with a reduced risk of poor social outcomes, such as developing drug or alcohol addiction.

Answer 91

True!

Question 92

What is the difference between the terms “efficacy” and “effectiveness”?

Answer 92

Efficacy: how well a treatment works under tightly controlled study conditions
-effectiveness: how well a treatment works in a natural setting in real-world conditions

Question 93

Why is there very little difference in efficacy between XR and IR preps of stimulant medications but significant differences in effectiveness?

Answer 93

Efficacy during school hours is similar for XR and IR preps of stimulant medication but there is a difference in effectiveness (ie. how well a treatment works in real world setting) because there may be decreased compliance with immediate release meds where you have to take it multiple times a day

• plus, there is a stigma associated with taking these medications at school as well as the disruption to the school routine
• multiple studies showing that children treated with XR meds were less likely to switch, discontinue or have gaps in their treatment compared to children prescribed IR meds

Question 94

True or false: Children with ADHD prescribed XR stimulant medication were more likely to visit an ED and more likely to be hospitalized than those prescribed IR meds.

Answer 94

FALSE!!! These children are LESS likely to have these things happen

Question 95

What should be first line treatment for ADHD?

Answer 95

Extended release stimulant medication (ie. methylphenidate)

• improves adherence
• reduces stigma of having to take the medication at school
• reduces problems schools have in storing and administering controlled drugs
• pharmacokinetic profiles

Question 96

What is the definition of “diversion” of medication?

-what about “misuse”?

Answer 96

Diversion: transfer of medication from one patient from whom it is prescribed to another patient for whom it is not prescribed
-“Misuse” use of nonprescribed medications or the use of prescribed medications at doses, times or in combinations other than for which they were prescribed

Question 97

Which type of stimulant for ADHD treatment is more likely to be misused by recreational drug users?

Answer 97

Immediate release methylphenidate (as compared to XR MPH)

Question 98

Why is the XR stimulant less abused by drug users?

Answer 98

The coating mechanism of XR preps make the active stimulant more difficult to extract and less likely to produce euphoria thus much less likely to be diverted or misused than immediate release preps

Question 99

Fill in the blank: most children in Western countries achieve bladder and bowel control between ____ and ___ months of age.
-what is the average time from the initiation of toilet learning to the attainment of independent toileting?

Answer 99

24-48 months of age

-avg time from initiation of toilet learning to attainment of independent toileting: 3-6 months

Question 100

At which age should toilet learning begin?

Answer 100

There is no specific age at which this should begin!

-based on child’s readiness

Question 101

What two physiological processes are necessary for bowel and bladder control and at what age are they achieved in a child?

Answer 101

1. Reflex sphincter control
2. Myelination of extrapyramidal tracts
   - usually achieve this by 18 months of age

Question 102

What are signs of a child’s toilet learning readiness? (7)

Answer 102

1. Able to walk to the potty chair
2. Stable while sitting on the potty
3. Able to remain dry for several hours
4. Receptive language skills allow the child to follow simple one- and two-step commands
5. Expressive language skills permit the child to communicate the need to use the potty with words or reproducible gestures
6. Desire to please based on positive relationship with caregivers
7. Desire for independence and control of bladder and bowel function

Question 103

When should anticipatory guidance about toilet learning be provided to parents?

Answer 103

At child’s first year visit

• need to emphasize that the age for toilet learning is flexible and that the family needs to be ready to dedicate a lot of time to the process
• should NOT be initiated at a stressful time in the child’s life (ie. after a move or the birth of an ew sibling)

Question 104

What are ways that a parent can facilitate a child’s toilet learning? (7)

Answer 104

1. Decide on the vocabulary to use
2. Ensure the potty chair and position are easily accessible and allow the child to watch his or her parents use the toilet
3. If a regular toilet is used, use a toilet seat adapter and a foot stool
4. Encourage the child to tell a parent when they need to voice. Give praise upon success, even if the child tells the parent after the fact. Learn the child’s behavioural cues when he or she is about to void.
5. Encourage the child with praise. Do not expect immediate results, expect accidents. Avoid punishment or negative reinforcement.
6. Ensure cooperation of all caregivers to provide a consistent approach
7. After repeated successes for one week or more, suggest the use of cotton underwear or training pants. Make this a special moment. Children who experience a series of accidents soon after trying cotton underpants or training pants should be allowed to return to diapers without shame or punishment.

***do not use material rewards

Question 105

What is the process of toilet learning you should recommend to parents?

Answer 105

1. First, encourage the child to sit fully dressed on the potty.
2. Next, encourage the child to sit on the potty after a wet or soiled diaper has been removed and place the soiled diaper in the potty to demonstrate its function
3. At a later date, lead the child to the potty several times a day and encourage them to sit on it for a few minutes without wearing a diaper.
4. Encourage the child to develop a routine of sitting on the potty at specific times during the day (ie. after waking in the morning, after meals, before naps and bedtime)

Question 106

A mother brings her toddler to you and is concerned that her toddler is throwing tantrums every time she tries to get him to use the potty. What do you advise?
-when should a referral to a general pediatrician or developmental pediatrician be required?

Answer 106

If the child is expressing toileting refusal, this means the child is NOT ready!

• take a 1-3 mo break from training to allow trust and cooperation to be reestablished between parent and child.
• If repeated attempts are unsuccessful or if the child is older than 4 years, referral is appropriate to explore aspects of parent-child relationship and to rule out physical/neurodevelopmental abnormalities

Question 107

What is the most effective test for amblyopia?

Answer 107

Determinatin of visual acuity by noninvasive testing

Question 108

True or false: Uncorrected amblyopia is a significant risk factor for total blindness, in the case of injury or disease in the better functioning eye

Answer 108

True!

Question 109

When should visual assessments occur (as per recommendations from AAP and American Academy of Ophthalmology)?

Answer 109

At birth and at all routine health supervisory visits

-visual acuity specifically should be assessed at the preschool stage as well as when there is a visual complaint

Question 110

What is the definition of:

• amblyopia
• refractive error
• strabismus
• pseudostrabismus
• cataract

Answer 110

• Amblyopia: reduced vision in the absence of ocular disease, occurs when the brain does not receive a clear image (ie input) from the retina
• refractive error: inability of the eye to focus the image which is usually correctable with a lens
• strabismus: misalignment of the eye in any direction (constant or intermittent)
• pseudostrabismus: occurs when broad nasal bridge covers the nasal sclera unequally
• cataract: opacification of the crystalline lens

Question 111

When should babies start doing the following:

• face follow
• visual following
• visual acuity measurable

Answer 111

• face following: from birth to 1 mo
• visual following: 3 mo
• visual acuity measurable: 42 months 3.5 years old

Question 112

What is the red reflex?

-cornea light reflection?

Answer 112

Red reflex: reflection of orange red light from the RETINA through the pupil
-cornea light reflection: small focal bright white reflection of light on the cornea which should be symmetrically positioned close to the centre of each cornea

Question 113

What is the cover-uncover test?

Answer 113

Cover one eye at a time while the child fixates on a target

• uncovered eye should NOT move
• covered eye should also not reposition when exposed
• if any movement occurs during this test, providing vision is good and fixation is well maintained, need a referral to ophtho

Question 114

When testing for vision with an eye chart, how far away should the child be from the chart?

Answer 114

3 m, one eye at a time (suspected better eye first)

Question 115

What vision screening should occur for a newborn-3 mo of age? (2)
-what about in a high risk newborn?

Answer 115

1. Complete exam of skin and external eye structures: conjunctiva, cornea, iris and pupils
2. Inspection of red reflex to rule out lenticular opacities or major posterior eye disease
   - failure of visualization or abnormalities of the red reflex = urgent referral to ophthalmologist
   * **High risk newborns (retinopathy of prematurity, family history of hereditary ocular diseases such as congenital glaucoma) should be examined by an ophthalmologist

Question 116

What vision screening should be performed for a child 6-12 mo of age? (4)

Answer 116

1. Complete examination of skin and external eye structures
2. Red reflex
3. Cornea light reflex and cover-uncover test to check for ocular alignment (rule out strabismus)
4. Fixation and following a target should be observed

Question 117

What vision screening should be performed for a child 3-5 years of age?

Answer 117

1. Complete exam of skin and eye structures
2. Red Reflex
3. Fixation and following
4. Cornea light reflex and cover-uncover test to rule out strabismus
5. Visual acuity testing with age-appropriate tool

Question 118

True or false: routine comprehensive professional eye exams of healthy children with no risk factors have a proven benefit in decreasing visual issues

Answer 118

NO! There is NO proven benefit of this!

Question 119

What is the risk of acquiring a respiratory infection while on a flight?

• what percentage of bacteria and viruses is removed by high-efficiency particulate filters in pressurized cabins?
• what are other factors that are protective against airborne spread of illnesses on a flight?

Answer 119

Small risk: since transmission of resp infections is usually by direct contact, the risk is no different than to travellers on a bus or a train

• 99.9% of bacteria and viruses from the cabin air is removed by filters
• other factors: air exchange is higher on a flight (15-20x/hr, compared to 5-12 in homes/offices), air flow occurs from top to bottom and not front to back

Question 120

What is the percentage of oxygen in a typical cabin on a flight?

Answer 120

15%

Question 121

What can help you determine if a child with cystic fibrosis will require supplemental oxygen during a flight?

Answer 121

Preflight spirometry

Question 122

What is the hypoxia altitude simulation test?

-what is a fail?

Answer 122

aka HAST = used for simulating airplane cabin environment by creating a mixture of 85% nitrogen and 15% oxygen

• PaO2 on an art gas < 55 mmHg is a fail and suggests need for supplemental O2 on an aircraft
• unknown how comparable these values are for children though

Question 123

What cardiovascular conditions are CONTRAINDICATIONS to commercial airline filght? (3)

Answer 123

1. Uncontrolled hypertension
2. Uncontrolled SVT
3. Eisenmenger’s syndrome

Question 124

Which patients are recommended for evaluation of potential hypoxemia before air travel? (7)

Answer 124

1. Known or suspected hypoxemia
2. Known or suspected hypercapnea
3. COPD or restrictive lung disease
4. Patients already using supplemental oxygen
5. Hx of previous difficulty during air travel
6. Recent exacerbation of CLD
7. Chronic conditions that may be exacerbated by hypoxemia

Question 125

Which children are at high risk of developing DVT on flights?

Answer 125

1. Thrombophilia
2. Previous thromboembolism
3. Malignancy
4. Major surgery within 6 wks
   - may need prophylaxis with low molecular weight heparin or ASA AFTER consultation with a thrombosis specialist

Question 126

What are the recomendations for flying in people with sickle cell anemia?

Answer 126

Due to reduced oxygen pressure, risk for crisis episode during flight
-medical oxygen should be available for these children during flight if altitudes are > 7600 ft (ESPECIALLY if they have splenomegaly and higher blood viscosity)

Question 127

What is barotrauma in flights?

-how can parents help their children with getting rid of this?

Answer 127

Barotrauma = consequence of the inability to equlibrate the pressure differential (especially during landing or takeoff)

• most people including older children can equilibrate the pressure by yawning, swallowing, chewing or valsalva
• infants and young children: parents should encourage them to drink or chew since they often can’t do these things themselves and may just try

Question 128

What is barotitis media?

• associated factors? (4)
• prevention? (4)

Answer 128

Inflammatory change (acute or chronic) of the middle ear secondary to barotrauma = sudden ear pain, impaired hearing, vertigo and rupture of the tympanic membrane

• associated factors: 1. nasal congestion
  2. previous ear pain
  3. recurrent otitis media
  4. adenoidal hypertrophy

Prevention:

1. Teach kids how to do valsalva in flight
2. Tympanostomy tubes
3. Treat nasal congestion or sinus infection before a flight
4. Topical nasal congestant can help if used at least 30 minutes before takeoff and landing

Question 129

You have diagnosed a child in your clinic for an AOM. They have an upcoming flight in a month. Mom asks you, when is the sooner a child can fly after an AOM?

Answer 129

May fly safely 2 weeks from diagnosis but should be re-evaluated before air travel

• if the diagnosis of AOM is made within 48 hrs of a flight that can’t be postponed, child should be provided with appropriate analgesia
• this is all based on expert opinion only
• can consider using a topical nasal decongestant before takeoff and landing

Question 130

True or false: peanut dust can be distributed through ventilation system on an airplane and can cause an allergic reaction.

Answer 130

True..but at least 25 passengers would have to be eating peanuts at the same time

• most airlines have removed peanuts now as a snack
• counsel all allergic children to have epi pen and antihistamines on the aircraft

Question 131

A child in your practice with type 1 diabetes will be taking a long flight crossing time zones. Mom asks you about adjusting insulin. What do you say?

Answer 131

If travelling east and the day is shortened by more than 2 hrs, need to decrease the amount of intermediate or long acting insulin
-if flying west, and the day is lengthened by more than 2 hours, more units of insulin is needed

Question 132

What are 3 alternatives to antiemetic drugs for air sickness?

Answer 132

1. Directing cool ventilated air to the face
2. Gazing at the horizon
3. Selecting a seat away from the rear of the cabin

Question 133

What are the concerns with using medications such as gravol, chloral hydrate for behavioural control of children onboard an aircraft?
-what are alternatives to help parents prepare their child for travelling?

Answer 133

1. Oversedation = combined with hypoxia in flight could be dangerous
2. paradoxical irritability
   - to prep child for travelling, parents could show their children books about plane travel, explain different steps needed and take practice trips to the airport. Relaxation techniques can work too!

Question 134

True or false: melatonin is recommended for children with jet lag as an effective treatment.

Answer 134

FALSE! Recent meta analysis did not show any benefit for its use in children with secondary sleep disorders or jet lag

Question 135

A mother asks you what she should do with her son’s feeding tube before their flight. What do you recommend?

Answer 135

Due to changes in cabin pressure, can get gas expansion in feeding tubes or urinary catheters which then introduce air into a hollow visuc THUS need to cap these all off during takeoff and landing

Question 136

What are the recommendations for orthopedic casts during a flight?

Answer 136

If fracture was recent (48 hrs ago), plaster or fibre glass cast should be bivalved to prevent pain and circulatory issues
-should also provide children with analgesia and instructions for proper limb elevation

Question 137

What are the recomendations on using a car seat on a flight?

Answer 137

AAP recommends mandatory federal requirement for restraint use for children on an aircraft BUT this is a recommendation so far only

• CPS does say in recommendations that holding an infant or child on a caregiver’s lap is improper restraint and has the potential to contribute to injury on an aircraft, particularly in the event of turbulence
• some kids can still fly in their parents’ laps
• studies have shown that if child safety seats are used, mortality can be decreased

Question 138

What country are most children currently adopted internationally from?

Answer 138

China

Question 139

True or false: the North American Council on adoptable children says that a family of the same racial or ethnic background is both preferable and better able to provide children with the skills and strengths to combate racism.

Answer 139

TRUE!
-they also believe that transracial adoption is preferable to long term foster care however and should be considered when a suitable family of the same race cannot be found

Question 140

When do children become aware of racial differences?

• other milestones in terms of racial identify?
• what about for children who are adopted by parents of a different race?

Answer 140

3 years old = become able to distinguish between skin color and hair texture

• at 3-7 yo: become aware of labels and emotional responses associated with various racial groups and begin to see what it means to be different from another race
• 7 yo: begin to understand racial permanence
• adolescence: exploration of racial and ethnic identity
• adopted children: when they become teens, physical differences between themselves and their parents become more apparent and may create feelings of isolation

Question 141

Which of the following is false according to one study mentioned in CPS statement :P:

a. Forming a positive and unambigous identity was more problematic for black children in white families than for children adopted by same-race families
b. Black children with white parents tended to devalue their black heritage and renounce similarities or allegiances to black people
c. Same-race and transracial adoptees had significantly different self-esteem scores
d. Families whose children attended racially integrated schools or lived in integrated communities tended to have children who felt more positively about themselves as black people.
- what do other studies say about this?

Answer 141

C! Self-esteem scores are SIMILAR!

• other studies hav found that most develppmental problems could be traced to preadoption experiences and that most adoptees adapted reasonably
• multiple studies have shown few recorded differences in behavioural problems, quality of life and self-esteem between intercountry adoptees and other adolescents and young adults
• build just as good relationships with adoptive parents and siblings

Question 142

What factors may negatively affect a child’s outcome if they are adopted into a transracial family? (4)

Answer 142

1. Older age at time of adoption
2. History of abuse or neglect
3. Institutionalization
4. Health problems

Question 143

A white couple is planning to adopt a non-white child. What recommendations can you make as their pediatrician to promote the child’s healthy development?

Answer 143

Tell parents to:

1. Recognize that children’s knowledge and understanding of their cultural history are important
2. Help children develop pride in their racial identity and coping skills to deal with racism
3. Role play ways to deal with racism
4. Encourage opportunities for the child to learn about and participate in their birth culture (ie. celebrate ethnic festivals, take vacations to their birth place, be friends with people from the same ethnic background as the child)
5. Recognize the child’s racial identity rather than denying it or acting as if race doesn’t matter
6. Help same-race siblings develop ways to cope and confront teasing by peers about their transracial sibling

Question 144

Explain the “like cures like” law in homeopathy.

Answer 144

Law of similars or “like cures like” = a substance can “cure” in a patient the same set of symptoms it can induce in a healthy individual

• choose plants/minerals/etc based on the patient’s SYMPTOMS and not the underlying condition (ie. if asthma in a patient causes predominantly MUCUS, then would choose one thing vs. if asthma in a patient causes predominantly COUGH, then would choose another thing)
• then you dilute the shit out of it…the higher the dilution, the more potent the medicine
• this is thought to be because during dilutions, a “memory” of the original substance is imparted to the water molecule….wtf.

Question 145

True or false: there are no published trials analyzing the effects of over the counter pediatric homeopathic preparations.

Answer 145

TRUE!!!!
-this is because there is tremendous variability in the methods of practising homeopathy from one practitioner to another so it’s difficult to conduct, analyze, compare and reproduce

Question 146

Are there safety concerns with properly prepared homeopathic products?

Answer 146

Not really - few side effects because they are so diluted that it’s mostly water.

Question 147

What are the major areas of concern with homeopathic care for children?

Answer 147

1. Homeopaths often do not refer children for conventional care OR parents may delay seeking medical attention while awaiting results from homeopathy
2. Negative attitude towards immunizations disseminated by some homeopathic practitioners

Question 148

What are the factors that need to be in place before effective discpline can occur?

Answer 148

1. Needs to be given by an adult with an affective bond to the child
2. Consistent, close to the behaviour needing change
3. Perceived as “fair” by the child
4. Developmentally and temperamentally appropriate
5. Self-enhancing ultimately leading to self-discipline

Question 149

What questions should you ask parents in a psychosocial interview to inquire about discipline? (4)

Answer 149

1. What are your attitudes towards discipline?
2. Who disciplines and what is the type of discipline used?
3. Discussion of difficulties or problems with discipline
4. What are parental stressors?

Question 150

What are 3 main areas of daily routine life that tend to be problematic in a child’s life, resulting in parents wishing to discipline?

Answer 150

1. Feeding
2. Toilet training
3. Beedtime struggles

Question 151

What is the foundation of effective discipline?

Answer 151

RESPECT!

• child should be able to respect the parent’s authority and rights of others
• inconsistency in applying discipline will not help a child respect their parents and same goes for harsh discipline
• thus need to apply discipline with mutual respect in a firm, fair, reasonable and consistent way

Question 152

True or false: time-outs, spanking or consequences is the best way to discipline an infant.

Answer 152

Uh, of COURSE false!

-discipline with infants should never involve these things!

Question 153

A mother with a 1 year old toddler comes in for disciplinary advice. What principles do you recommend?

Answer 153

1. In early toddler stage, it is normal and necessary for toddlers to experiment with the physical world and to exercise their own will versus that of others
2. THUS, parental tolerance is recommended
3. Discipline should focus on ensuring the toddler’s safety, limiting aggression, preventing destructive behaviour.
4. If child is playing with a dangerous object, remove the child or the object with a firm “NO” or a very brief verbal explanation “NO - HOT”. Redirect to an alternative activity and remain with the child to supervise and make sure behaviour does not recur
5. Early toddlers are very susceptible to fears of abandonment and should not be kept in time out away from the parent. Can separate for a few seconds or minutes within the same room.

Question 154

What are the principles of discipline for a late toddler (2-3 yo)?
-example: toddler throws a tantrum in the store. What do you recommend?

Answer 154

Tend to have temper tantrums when realizing limitations to independence and self-assertion; emphasize to parents that this is not anger or willful defiance

1. Tell caregiver to have empathy in regards to this
2. Set limits and routines
3. Knowing the child’s pattern of reactions means you can prevent the situations from occurring that trigger frustrations
4. Once the temper tantrum stops, then the parent can give simple verbal explanation and reassurance, then direct child to another activity away from the scene of the tantrum
   - tantrum in store: remove the child from the place of misbehaviour. Hold the child gently until the toddler gains control, then give a short verbal instruction or reassurance followed by supervision

Question 155

What are disciplinary strategies for preschoolers and kindergarten age children? (3-5 yo)

Answer 155

1. Time out can be used if child loses control
2. Redirection or small consequences related to and immediately following the misbehaviour is also useful
3. Approval and praise are the most powerful motivators for good behaviuor
4. Lectures do NOT work well!!!

Question 156

What are some ways that parents can use rules and limits to promote effective discipline? Giant list….

Answer 156

1. Reinforce desirable behaviour and praise positive behaviour
2. Avoid nagging and making threats without consequences
3. Apply rules consistently
4. Ignore unimportant and irrelevant behaviour (eg. swinging legs while sitting)
5. Set reasonable and consistent limits with realistic consequences (ie. don’t ground for a month)
6. Prioritize rules: give top priority to safety, then to correcting behaviour that harms people and property, then to behaviour like whining/temper tantrums/interrupting, etc.
7. Know and accept age appropriate behaviour (ie. accidentally spilling a glass of water is normal behaviour and shouldn’t be punished!)

Question 157

What are useful tips for applying consequences in discipline?

Answer 157

1. Apply consequences asap
2. Do not enter into arguments with the child during the correction process
3. Make consequences brief (ie. time out should be one minute per year of the child’s age to a max of 5 minutes)
4. Parents should mean what they say and say it without shouting at the child
5. Follow consequences with love and trust and ensure the child knows the correction is directed against the behaviour and not the person. MODEL FORGIVENESS AND AVOID BRINGING UP PAST MISTAKES

Question 158

Why is time-out so effective as a disciplinary technique for children 2-school age?
-tips on how to give effective time-out? (ie. when should it be introduced? Duration, etc.)

Answer 158

Prevents the child from receiving attention that may inadvertently reinforce inappropriate behaviour

• tips:
  1. Must be used unemotionally and consistently every time the child misbehaves
  2. Introduce time out by 24 months
  3. Pick the right place (ie. time-out place should not have built in rewards)
  3. Time out: 1 minute per year of the child’s age, to max of 5 mins
  4. Prepare the child by briefly helping them connect the behaviour with the time-out: “no hitting”
  5. Parents should avoid using time out for teaching or preaching. When the child is in time out, he should be ignored
  6. Parent is the time keeper
  7. After time out is over, it is over. Create a fresh start by offering a new activity. Do not discuss the unwanted behaviour, just move on.
• ***do NOT instill shame, guilt, loss of trust or sense of abandonment!

Question 159

True or false: Discipline is about changing behaviour, not about punishing children. :)

Answer 159

True!

Question 160

True or false: most children who have not mastered reading by the end of grade 3 will never catch up.

Answer 160

True!

Question 161

What are the direct effects of low literacy on health (4)?

Answer 161

1. Incorrect use of medications
2. Failure to comply with medical directions
3. Errors in administration of infant formula
4. Safety risks in community, workplace and home

Question 162

What are the indirect associations between low literacy and health? (6)

Answer 162

1. Higher rates of poverty
2. Higher than average rates of occupational injuries
3. Higher degrees of stress
4. Unhealthy lifestyle practices: smoking, poor nutrition, infrequent physical activity, lack of seatbelt use or wearing of bike helmets, decreased breastfeeding
5. Limited access to and understanding of health info
6. Inappropriate use of medical services

Question 163

Out of all parent-child activities, what is the best way to expose the child to language?

Answer 163

Reading!!! Especially when dialogic reading occurs (when parent uses questions to encourage the child to participate beyond being a passive listener)
-reading aloud by parents is the SINGLE MOST IMPORTANT activity for building the knowledge required for eventual success in reading

Question 164

What are the 3 components of the reach out and read model for clinic-based literacy intervention?

Answer 164

1. Anticipatory guidance regarding literacy development by pediatricians at each well child visit
2. The provision of a new, developmentally appropriate book at each visit; if possible, provide a library card application and prescription to read a fun book
3. Literacy rich waiting rooms including volunteers who demonstrate book sharing
   - parents receiving this intervention are 4-10x more likely to read frequently to their children with greatest effect among the poorest families (intervention is most beneficial to those who need it the most)

Question 165

What are some questions to ask about family literacy at health care visits?

Answer 165

1. Frequency of book sharing
2. Access to children’s books in the home
3. Use of books in children’s routines
4. Caregivers’ literacy levels

Question 166

What are ways physicians can promote literacy for families?

Answer 166

1. Address low literacy as a child health problem beginning at birth and continuing through adulthood
2. Inquire about family literacy at each health care visit
3. Include literacy promotion in routine clinical practice: provide developmentally appropriate books, etc.
4. Encourage parents and child care providers to look at books daily with their children beginning at birth! If the caregivers have a low literacy level, singing, storytelling and talking about pictures in their native language should be encouraged
5. Encourage families to get a library card and visit the library regularly
6. Ensure that clinic waiting areas encourage literacy

Question 167

What are examination room techniques for promoting literacy?

Answer 167

1. Bring book early in the exam and do not save for end of visit
2. Hand book to child right away, watch how child handles it, listen for language, and watch parent-child interaction
3. Listen for words elicited by the books and pictures
4. Compliment the parent on the child’s interest in the book, the child’s ability to handle the book and turn pages
5. Inquire about favourite books and use of books in child’s routine
6. Help parents see that their child’s interest in books is related to language development and intelligence
7. Model reading aloud for parents and discuss what you ar doing and why

Question 168

Do pacifiers lead to early weaning off breastfeeding?

Answer 168

Conflicting data: multiple studies however, have shown that maybe pacifier use is a marker of breastfeeding difficulties or reduced motivation to breastfeed rather than a true cause of early weaning
-due to many possible confounders and biases, exact cause and effect nature of pacifier use and early weaning is unknown

Question 169

Do pacifiers increase risk of otitis media?

Answer 169

Yes…it is a risk factor in the development of otitis media but is only ONE of the factors!

• increases risk more with prolonged and more frequent use
• it is NOT because pacifiers carry AOM organisms (usually only carry yeast)

Question 170

Do pacifiers increase risk of dental caries?

-when should pacifier use stop?

Answer 170

Yes but only if prolonged use (> 5 yo) or inappropriate use (sweetened pacifier)

• the longer the use, the stronger the association with openbite and crossbite
• pacifier use should stop before permanent teeth erupt (ie. before 12 months of age)

Question 171

Do pacifiers prevent SIDS?

Answer 171

Currently, there is no recommendation to use pacifiers to reduce the risk of SIDS based on the available evidence BUT there are a few studies that show there may be an association between pacifier use and reduced risk of SIDS
-so overall, evidence is sufficient that pediatricians should be cautious before advising against their use

Question 172

What are the benefits of pacifier use in preterm infants?

Answer 172

Leads to non-nutritive sucking which is associated with:

1. More rapid weight gain
2. Lower incidence of nec
3. Earlier hospital discharge
4. Provides comfort
5. Organizes oromotor development

Question 173

True or false: infants and children with chronic or recurrent otitis media should be restricted in their use of a pacifier.

Answer 173

True.

Question 174

What are 3 barriers to health care for children in foster care?

Answer 174

1. Difficulty accessing services
2. Lack of consistent care or follow up due to temporary placements
3. Lack of or inadequate medical records

Question 175

What are the risk factors for a child to need foster care? (9)

Answer 175

Parent factors:

1. Drug and alcohol addiction
2. Prenatal alcohol or drug use
3. Violence
4. Cognitive or functional impairment of parents with little resources or support
5. Family history of mental health disorders
6. Previous involvement with child welfare system

Child factors:
7. Severe behaviours or complex medical problems

Environment factors:

8. Extreme poverty
9. Homelessness

Question 176

What is Jordan’s principle?

Answer 176

Child-first principle used in Canada to resolve jurisdictional disputes within and between governments regarding payment for services provided to First Nations children

• when a jurisdictional dispute arises between provincial/territorial or federal governments OR between two departments within the same government regarding payment for services of a Status Indian child, the government or ministry/department of first contact must pay for the services without delay and then figure out the dispute later
• this is based on the non-discrimination provisions of the UN convention on the rights of the child that doesn’t allow differential treatment on the basis of race or ethnic origin

Question 177

Who is the legal guardian while a child is in foster care?

Answer 177

Usually the child protection worker
-of course foster and birth parents or group home may also be part of the contact but the child protection worker is the person who will provide consent

Question 178

What are the minimum requirements recommended for the health supervision of children in foster care? (3)

Answer 178

1. Initial medical visit within 24 hrs of placement
2. Comprehensive follow up visit within 30 days of placment
3. Routine screening for development, mental health, dental health, STIs

Question 179

What are common health care issues seen in children in foster care? (8)

Answer 179

1. Poor hygiene
2. Underimmunization
3. Dental neglect
4. Behavioural issues: ADHD, negative peer involvement, aggression, emotional issues
5. Learning disability, developmental delay
6. Substance-abuse related birth defect
7. Chronic medical conditions such as asthma, derm issues, ophtho issues
8. Contraception issues for adolescents

***This is in addition to medical issues that children may already have that increases their risk of being in foster care (ie. hx of developmental delay or physical disability increasing chance of being abused)

Question 180

During an initial assessment of a child in foster care, what screening tests should be considered?

Answer 180

Routine ordering of tests is not recommended BUT consider as needed: CBC, ferritin, lead level, HIV, Hep B and C titres, beta-HCG, cervical or urethral swabs for STIs

Question 181

True or false: children who are either currently or previously in foster care should be monitored more frequently than the general peds population.

Answer 181

True!

Question 182

What is the Greig Health Record?

-how often are preventive health care visits recommended?

Answer 182

For children 6-17 years old: template for periodic health visits
-preventive health care visits are recommended q1-2 yrs

Question 183

True or false: there is evidence to support the exclusion of counselling for breast and testicular self exams as well as screening maneuvers for scoliosis.

Answer 183

TRUE

• screening for scoliosis is still recommended by the american academy of ortho surgeons and AAP but there is little evidence to support this position!
• there is evidence that asymptomatic individuals have a mild clinical course and interventions will not improve back pain or quality of life

Question 184

What 5 physical exam findings are ALWAYS recommended in every periodic health supervision visit? (ie. on the Greig Health Record)

Answer 184

1. Height
2. Weight
3. BMI
4. Blood pressure
5. Visual acuity

Question 185

What is the adult BMI cut off for overweight? What about for obese?

• at what age should you start using BMI instead of weight for age?
• what are the cut-offs are underweight, overweight and obese in children?

Answer 185

BMI cut off for overweight: >25 kg/m2

• obese: > 30 kg/m2
• for children > 10 years old, need to use BMI and not weight for plotting
• in children: we don’t have a BMI number for cutoff, instead use growth percentiles after you plot BMI
• underweight: 97th percentile

Question 186

Is chlamydia screening in sexually active adolescent females recommended?
-what about gonorrhea?

Answer 186

CDC recommends screening adolescent females annually

-gonorrhea: only screen in communities with a high prevalence of gonorrhea

Question 187

What is the leading cause of absenteeism from school and work for adolescent females?

Answer 187

Dysmenorrhea!

Question 188

What is the main nutritional problem in adolescent girls worldwide?

Answer 188

Anemia

-especially in women with heavy menses

Question 189

True or false: the WHO recommends supplements (ie. vitamins) for all children.

Answer 189

FALSE! WHO recommends supplements for specific nutrient deficiencies but suggests that using food sources is important for making corrections for dietary deficiencies!

Question 190

What is the rate of CAM use in healthy children?

-what about children with chronic, recurrent or intractable conditions?

Answer 190

• healthy children: 20-40%

- chronic, recurrent or intractable conditions: >50%

Question 191

What is the upper limit recommended for occupational noise exposure?
-rock concerts and personal music players can reach an intensity of what?

Answer 191

• Recommended for occupational noise exposure: 85 dB

- rock concerts/music players: 110-120 dB

Question 192

How much sleep do adolescents require?

Answer 192

9-9.5 hrs of sleep per night

Question 193

At what age should children be using booster seats?

Answer 193

Good evidence for use of booster seats for children ages 5-7

-in Canada, there is a lot of variation in booster seat legislation though

Question 194

What is the MINIMUM age of operation of ATVs and snowmobiles recommended by CPS and AAP?

Answer 194

16 years old

-children should also not ride as passengers due to risk of serious head/brain/pelvic/spinal cord injuries

Question 195

What are the two most important preventive strategies for drowning/near drowning?
-when can swimming skills be learned most efficiently?

Answer 195

1. Active supervision
2. Pool fencing
   - swimming skills learned most efficiently at 5 yo

Question 196

A workweek of ____ hours or more is associated with emotional distress in adolescents. Fill in the blank.

Answer 196

20 hours

Question 197

What is the only routine lab investigation recommended to be completed during a periodic health visit?
-when should lipid and plasma glucose screening occur?

Answer 197

Rubella titre for adolescent females

• other tests are based on index of suspicion on hx/pe
• lipid and plasma glucose screening: should be performed on overweight or obese children over the age of 10

Question 198

What is the most sensitive and specific measurement for iron deficiency?

Answer 198

Ferritin!!!! (NOT hemoglobin)

Question 199

What is the most common form of therapy provided by chiropractors?
-evidence of effectiveness?

Answer 199

Spinal manipulation

• systematic review of RCTs showed insufficient evidence to prove that spinal manipulation is useful for treating acute or chronic low back pain
• no studies have been published on chiropractic treatment of back pain in peds population

Question 200

What is the most worrisome complication resulting from chiropractic cervical manipulation?

Answer 200

Vertebrobasilar accidents (stroke) from cervical artery dissection leading to ischemia

Question 201

What are two concerning complications from chiropractic use in children?

Answer 201

1. Complications such as vertebrobasilar accidents from neck manipulation
2. OF GREATER CONCERN THOUGH: chiropractors may attempt to treat acute pediatric conditions, leading to a delay in appropriate medical therapy or the refusal of families to seek conventional treatment

Question 202

What is the position of the American Chiropractic association on vaccination? What about the Canadian Chiropractic association?

Answer 202

Americans: think vaccinations have risks and therefore supports conscience clause in compulsory vaccination laws
-Canadians: accepts vaccination as a cost effective and clinically efficient public health preventive procedure

Question 203

What are the recommended ratios for child to caregiver ratios based on the following age groups:

• children < 24 mo
• 24-30 mo
• 31-36 mo
• > 36 mo

Answer 203

Children < 24 mo: 3:1

• 24-30 mo: 4:1
• 31-36 mo: 5:1
• > 36 mo: 7:1
• these ratios are thought to promote more child to caregiver interactions to facilitate development

Question 204

What does a cochrane collaboration review conclude about the behaviour and developmental outcomes of children in child care centers?

Answer 204

Found a positive effect on IQ, school achievement, behaviour, decreased criminal behaviour, lowered teenage pregnancy rate
-interpret these results with caution since the RCTs included may have had confounding factors such as parental training and low ratios between children:caregivers that are not realistic in real life

Question 205

True or false: the quality of daycare is a better predictor of behaviour outcome than age of starting daycare or percentage of time spent in daycare

Answer 205

True!

Question 206

What are the recommendations on what qualifications child care staff should have in order to work at a child care centre?

Answer 206

Should have some training in early childhood education in order to improve child care quality

Question 207

True or false: children who spend more time in nonparental child care have a reduced risk of unintentional injury.

Answer 207

True! This might be because these places provide more supervision and/or safer play equipment

Question 208

What are the two categories of child care injuries? (ex of each)

Answer 208

1. Child factors: falls, collisions, pinching, biting, pushing, hitting, etc. (way way more common cause of childcare injuries)
2. Environmental factors: wet floors, sharp objects, objects on floor, equipment or furniture (less common cause)
   * *this suggests that while safe equipment and design are helpful, appropriate supervision of child is more critical

Question 209

True or false: An injury reporting procedure and form should be available in all child care centres and all staff should be trained in basic first aid and CPR

Answer 209

True!

Question 210

Which immunizations should child caregivers have?

Answer 210

1. Annual flu vaccine

2. Ensure tetatnus, diphtheria and pertussis are current

Question 211

Daycare exclusion: when should the following children be allowed to return to daycare?

• respiratory infection
• GAS pharyngitis
• Bacterial conjunctivitis
• diarrhea

Answer 211

Respiratory infection: when well enough to participate in all activities

• GAS pharyngitis and bacterial conjuncitivits: after 24 hrs of antibiotic therapy
• diarrhea: once their stool can be contained in a diaper, controlled in a toilet trained child and if there are NO signs of bacterial enteritis (fever/blood/mucus in stool)

Question 212

What guideline should be used as a point of safety reference for child care centers?

Answer 212

Well Beings book!!! = offers guidelines on how to conduct safety audits on a weekly, monthly, seasonal and yearly basis

Question 213

What should occur at an enhanced 18 month primary care visit?

Answer 213

1. A physician-prompt health supervision guide with evidence-informed suggestions (such as the Rourke Baby record)
2. Developmental screening tool (Nipissing District Developmental screen, Ages and Stages Questionnaire are good examples) to stimulate discussion with parents about their child’s development
3. Screen for parental morbidities (mental health problems, abuse, substance misuse, physical illness)
4. Promotion of early literacy activities for every family
5. Provide families with info about community based early childhood development resources (ie. parenting programs, libraries, community centres, etc.)

Question 214

What are the 4 ways that Canadians pay for dental care?

Answer 214

1. Third-party insurance (employment-related dental coverage2. Private dental insurance3. Out of pocket4. Government subsidized programs (eg. First nations non-insured health benefits or veterans’ affairs)

Question 215

What dental services do most publicly delivered pediatric dental programs in Canada include?

Answer 215

Only emergency or basic treatment for recipients of financial assistance or for children in low-income families. The comprehensiveness of these programs differs significantly among provinces and terriroties in terms of types of services covered, age restrictions and limits on the frequency of dental visits

Question 216

What are the recommendations for flouride varnish for decreasing dental caries?-What about fluoride mouth rinse?

Answer 216

Biannual varnish application should be completed for high risk populations such as First Nations children-fluoride mouth rinses should be used regularly as they have been shown to reduce tooth decay regardless of other fluoride sources**Overall: the CPS and Canadian Dental Association support fluoride supplementation through water supply and topical application/mouth rinses

Question 217

What is the most common causal organism for dental caries?-modes of transmission?-window of infectivity?

Answer 217

Streptococcus mutans-vertical transmission: from caregiver to infant-horizonal transmission: from kid to kid in daycare for example-window of infectivity: early infancy

Question 218

Which populations have the highest burden of dental disease? (4)

Answer 218

1. Low income families2. Aboriginal children3. New immigrants4. Children with special health care needs**These marginalized populations often have limited or no access to oral health care

Question 219

Why are “the working poor” more vulnerable to receiving poor support for dental care?

Answer 219

Their employment status renders them ineligible for dental care under publicly funded programs while the jobs they hold seldom offer employment-related health insurance

Question 220

When should children have their first dental assessment?

Answer 220

Canadian Dental Association: dental assessment should occur for infants within 6 months of their first tooth appearing and no later than one year of age-important for examination, risk assessment and anticipatory guidance for parents to prevent dental disease

Question 221

Is there any benefit to delaying the introduction of any specific solid food (including peanuts, eggs, fish) beyond six months of age to prevent development of food allergies?

Answer 221

NO! No evidence of benefit! Some studies suggest that delay may actually increase food allergyWhether there is any benefit of introducing the solid food BEFORE six months of age in prevention of allergies is still up for debate - major randomized controlled trials are in progress right now to figure this out!

Question 222

What defines an infant as “high risk” for developing a food allergy?

Answer 222

Infants with 1st degree relative (parent or sibling) with atopy:1. Eczema2. Allergic rhinitis3. Asthma4. Food allergy

Question 223

Is there any evidence in maternal dietary restrictions during pregnancy to decrease risk of atopy in infants?-What about maternal diet restriction while breastfeeding?

Answer 223

NO! Recent Cochrane review found little evidence that avoiding milk, egg, or other potential allergens during pregnancy reduced the risk of atopic eczema or asthma in infants-Breastfeeding: No evidence that it prevents allergic conditions (except maybe eczema but study quality was poor)**Also risks of maternal undernutrition and potential harm to infant from avoiding these foods is significant!

Question 224

How long should exclusive breastfeeding ideally occur for?-What about for infants at high-risk of developing food allergies?

Answer 224

At least until 6 months of age-For infants at high-risk of developing food allergies, some studies have suggested that introducing foods early at 4 months of age while continuing breastfeeding may decrease atopy-Total duration of breastfeeding (at least six months) may be more important than exclusive breastfeeding for six months

Question 225

Is there any evidence on which formulas may decrease risk of infant allergies?-Does soy formula have a role in allergy prevention?

Answer 225

No conclusive evidence - studies aren’t great, some are sponsored by formula companies-However, there is consensus that soy formulas do NOT have a role in allergy prevention!-If you have to choose, consider a hydrolyzed cow’s milk based formula (limited evidence that it might protect against eczema compared with intact cow’s milk formula)

Question 226

In an infant at high risk of developing allergies, should routine skin or specific IgE blood testing before first ingestion be performed?

Answer 226

No! This is because of high risk of potentially confusing false-positive results

Question 227

What is the recommended method of discipline for older children?

Answer 227

1. Withdrawal of privileges or reward positive behaviour
2. Model good behaviour
3. Discipline should be fair and consistent

Question 228

What is the expected growth in weight and height for a baby in their first year?
-what about 2nd year?

Answer 228

8-10 kg in one year
20 cm in one year

In their 2nd year:
2-4 kg
10 cm