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Royal College Peds 2021 > CPS First Nations, Inuit and Metis health committee > Flashcards

CPS First Nations, Inuit and Metis health committee Flashcards

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1
Q

How are scabies transmitted?

A

From person to person by skin-to-skin contact

  • the more parasites on a person, the greater the chance for spread
  • can also spread from clothing and bed linen but scabies do not survive for long once they are off the skin
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2
Q

What is a classic symptom for scabies infection?

-what are the main areas on the body infested by scabies?

A

Extreme pruritis, especially at night

  • main areas: web spaces between fingers, flexor aspect of wrists and elbows, axillae, male genitalia and women’s breasts
  • infants and children can have atypical lesions that are generally distributed but are still usually concentrated on hands, feet, and body folds
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3
Q

How do you make a definitive diagnosis of scabies?

A

Skin scrapings from burrows or other lesions and examine under a low power microscope
-look for mites, feces or eggs

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4
Q

What factors place the Aboriginal population in all countries (both rural and urban) at risk of scabies infections? (8)

A
  1. Crowded housing, shared beds and crowded schools/day cares
  2. Failure to recognize infestation
  3. Limited access to medical care
  4. High peds population
  5. Faulty application of treatment regimens
  6. Failure to treat close contacts
  7. Failure to eradicate scabies from clothing and bed linen
  8. Lack of running water
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5
Q

What is the treatment of scabies?

A
  1. 5% permethrin cream (needs to be 5%!!!! Cannot use the 1% used for treating head lice)
    - apply to skin and wash off after 8-14 hrs (8 for 6 yo)
    - repeat application 1-2 weeks later if live mites are still seen
    - one dose is curative usually
    - take a bath or shower, dry off, then apply to entire body ESPECIALLY to skin folds, fingernails, toenails, behind the ears and groin, face and scalp
    - contraindicated in infants < 2 mo and pregnant/lactating women (although its been done and found to be safe)
  2. Patient and all contacts must be treated at the same time REGARDLESS of whether they have symptoms
  3. Clothes and bed linen should be washed in HOT water
  4. If water is not available, put all linen and clothing into plastic bags and store it x 7 days
  5. Children can go back to day care or school the day after treatment is complete
    * *Itching may still occur even after the mites are dead due to a reaction to material still in the skin
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6
Q

What are possible medications used for treating scabies?

-in infants < 2 mo and pregnant/lactating women?

A
  1. Permethrin (1st line, preferred)
    - do not use in infants < 2 mo and pregnant/lactating women
  2. Lindane cream
  3. Precipitated sulphur in petroleum jelly (can be used safely in very young infants and pregnant/lactating women) = apply on 3 consecutive days, leave on x 24 hr, then wash off
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7
Q

What is the incubation period of scabies?

A

3 weeks…so if you come into contact with scabies, you may not start showing symptoms until then!

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8
Q

What is the evidence on Ivermectin for treatment of scabies?

A

Needs only single oral dose but only acts at certain stages of the life cycle of the parasite (whereas permethrin acts at all stages)
-so far, it is not licensed in Canada and is not recommended currently over permethrin

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9
Q

What is the most common complication of scabies infection?

A

Secondary bacterial skin infection

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10
Q

What are the 3 categories of inhalants in inhalant abuse?

A
  1. halogenated hydrocarbons (ie. hairsprays, varnish, cooking sprays, etc.) (moon gas, poor man’s pot, hippie crack, whiteout)
  2. nitrous oxide (whipping cream aerosols, balloon tanks) (ie. whippets, shoot the breeze)
  3. volatile alkyl nitrites (angina medications, room odourizers, etc.) (ie. poppers, thrust, climax)
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11
Q

The majority of inhalant related deaths are caused by which inhalants?

A
  1. gasoline
  2. air fresheners
  3. propane/butane
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12
Q

What are the effects of inhaling volatile alkyl nitrites (ie. poppers, climax, thrust)?

A

Vasodilatory effects = hypotension and syncope, sensations of warmth and flushing, sphincter relaxation and penile engorgement in young men for anal sex

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13
Q

What is the leading cause of death among inhalant abusers?

-mechanism of death?

A

“Sudden sniffing death syndrome” = cardiac arrhythmia caused by:

  1. disrupted myocardial electrical propagation caused by the inhalant which is worsened by hypoxia
  2. inhalants also sensitize the heart ao adrenaline so when a user is startled during inhalation (such as being caught), a burst of adrenaline can cause them to have cardiac arrest
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14
Q

What are long term effects of chronic abuse of inhalants? (6)

A
  1. Irreversible neurological effects: damage of myeline and neuronal membranes by lipophilic chemicals
    - cortical atrophy, brainstem dysfunction with irritability, tremor, ataxia, nystagmus, slurred speech, deafness
  2. Cardiomyopathy
  3. Distal renal tubular acidosis
  4. Hepatitis
  5. Bone marrow toxicity (from hydrocarbons)
  6. Pulmonary toxicity (emphysema, wheezing)
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15
Q

What is the CRAFFT screening tool?

A

Screens for abuse of alcohol and drugs

  • C (car): Have you ever ridden ina car by someone including yourself who was high or drunk?
  • R (relax): do you ever use alcohol or drugs to relax, feel better about yourself or fit in?
  • A (alone): do you ever use alcohol or drugs while you are by yourself or alone?
  • F (forget): do you ever forget things you did while using alcohol or drugs?
  • F (family): do your family members or friends ever tell you you should cut down on your drinking or drug use?
  • T (trouble): have you ever gotten into trouble while you were using alcohol or drugs?

**2 or more yes answers indicates potential substance abuse problem

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16
Q

What is the rate of smoking among first nations people in Canada compared to the general Canadian population?

A

First nations: 59% compared to general Canadian population of 20% (3x higher)
-in 15-17 yo First nations teens, rate is again 3x higher (more common in girls than boys)

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17
Q

What are the main complications of smoking? (4)

A
  1. Myocardial & vascular disease
  2. Chronic lung disease (COPD, lung cancer)
  3. Development of T2DM with faster progression of complications in diabetics who smoke
  4. Increased risk of fires
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18
Q

What are the complications of postnatal exposure to second hand smoke? (5)

A
  1. Increased LRTI
  2. Increased acute otitis media
  3. Increased asthma
  4. decreased lung growth
  5. increased risk of SIDS
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19
Q

What are the complications of perinatal exposure to smoking during pregnancy? (6)

A
  1. Increased number of perinatal deaths
  2. Increased preterm deliveries
  3. Placental insufficiency
  4. Congenital abnormalities
  5. Increased risk of learning disabilities/ADHD
  6. Increased risk of nicotine dependence in adolescence for child
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20
Q

In what age group is the highest prevalence of tobacco use?

A

Youth 15-24 yo

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21
Q

What are the current anti-smoking strategies put in place by provinces? (6)

A
  1. Smoke free public and workplaces
  2. Health warnings on tobacco products
  3. Hiding tobacco products at stores (shower curtain law)
  4. Banning tobacco advertising and displays
  5. Taxing tobacco at high level to deter regular smoking among adolescents
  6. Efforts to standardize legal age limits and penalties for selling to minors
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22
Q

What are the 5 steps to quitting smoking?

A
  1. Get ready
  2. Get support
  3. Learn new skills and behaviours
  4. Get medication and use it correctly
  5. Be prepared for relapse or difficult situations
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23
Q

What are the 5 As in the role of the health care professional in smoking control?

A
  1. Ask about tobacco use
  2. Advise urge to quit
  3. Assess willingness to attempt quitting
  4. Assist counselling and pharmacological therapy (nicotine patch or bupropion)
  5. Arrange follow up
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24
Q

What is the main difference between community acquired MRSA vs. healthcare associated MRSA?

A

CA-MRSA:

  1. generally more suspectible to antimicrobials (with exception of beta lactams)
  2. Can produce cytotoxins capable of inducing tissue necrosis
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25
Q

What are the common risk factors for community acquired MRSA? (7)

A
  1. Overcrowding
  2. Frequent skin to skin contact between people
  3. Participation in activities that result in abraded or compromised skin surfaces
  4. Sharing of potentially contaminated personal items
  5. Challenges in maintaining personal clealiness and hygiene (ie. due to water shortages or lack of clean water)
  6. Limited access to health care
  7. Exposure to antibiotics
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26
Q

What is the medical management of infected scratches/furuncles/impetigo with MRSA?
-what about abscesses secondary to MRSA?

A

Infected scratches/furuncles/impetigo:

  1. Wet warm compresses
  2. Washing with warm soap and water
  3. Consider topical antibiotics depending on local sensitivity patterns or for more severe infections, use oral antibiotics

Abscesses:
1. Incision and drainage +/- antibiotics

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27
Q

True or false: decreasing microbial carriage by decolonization reduces the recurrence of community-acquired MRSA
-what are methods of decolonization?

A

FALSE!

  • methods of decolonization: nasal mupirocin, antiseptic baths with dilute bleach baths or chlorhexidine, oral rifampin
  • overtime, CA-MRSA in some communities has shown resistance to mupirocin and there is concern that using rifampin could increase drug-resistant TB in high risk communities
  • studies re: bleach baths’ effectiveness and safety are on the way
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28
Q

What is ONE vaccine that can help prevent severe MRSA infections?

A

Seasonal influenza vaccine!! Encourage this for all children since in MRSA-endemic communities, there is a risk for severe MRSA pneumonia following an influenza infection

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29
Q

What recommendations can you make to patients and families about how to manage MRSA skin and soft tissue infections to prevent spread?

A
  1. Keep wounds covered with clean, dry bandages. If you can’t cover, then exclude from contact sports or child care until wound drainage stops or wounds are healed
  2. Dispose of used dressings in a plastic-lined garbage container with sealed lid immediately after they are removed
  3. Hand hygiene before and after changing dressings
  4. Bathe regularly and change clothes and bedding often
  5. Avoid sharing personal items like towels, bedding, clothing and bar soap
  6. Seek medical attention if fever or other signs of illnes develop or if a lesion doesn’t improve within 48 hrs of starting treatment
  7. Regular cleaning of contact surfaces in the home with household cleaner or detergent
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30
Q

True or false:
When a patient has been diagnosed with CA-MRSA, we should test everyone else in the household to determine carriage rate.

A

FALSE! This is not helpful.

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31
Q

What is the leading cause of death in Canadian indigenous children and youth?
-what about leading cause of death in Canadian children in general?

A

Unintentional injuries = occurs at rates 3-4x national average
-leading cause of death in canadian children: still unintentional injuries!

32
Q

What are the two most common causes of death due to injury in children < 10 yo? What about adolescents?

A

Children < 10 yo:

  1. Fires
  2. MVCs

Adolescents:

  1. MVCs
  2. Drownings
33
Q

What are potential long term consequences of severe injuries?

A
  1. Disability
  2. Interference with education
  3. Interference with growth and development
  4. Impact on future employability
  5. Increased risk of depression and substance abuse
34
Q

Why is there a disproportionate risk of injury among Indigenous children compared to non-indigenous children?

A
  1. Lower incomes, less education and higher unemployment
  2. More likely to live in unsafe, substandard housing
  3. More likely to have minimal access to health care personnel and resources (including post discharge rehab care)
  4. Historical inequities, cultural alienation and loss of connectedness with the environment have contributed to depression, alcohol and substance abuse and risk taking behaviours and inadequate parenting skills for some
  5. Lack of culturally appropriate or targeted injury prevention programs (CPR training, swimming lessons, etc.)
35
Q

What type of mechanism causes the most injuries and deaths in First Nations children and youth?
-what are contributing factors to this higher risk in indigenous populations?

A

MVCs
-increased risk since communities are isolated, health care facilities are harder to get to, road conditions are poor, more use of ATVs and snow mobiles, underuse of seatbelts, inadequate enforcement of restraint laws, lack of helmet use, substance abuse

36
Q

What are factors contributing to a higher risk of death from fire in indigenous communities? (5)

A
  1. Higher proportion of smokers at home
  2. Wood-framed, substandard housing
  3. Underuse of working smoke detectors
  4. Longer travel times for fire rescue personnel and equipment
  5. Shortage of trained firefighters
37
Q

What are the 6 Es of successful injury prevention?

A
  1. Education: identify community champions to disseminate safety messages, use anticipatory guidance about seat belts/helmets/personal flotation devices, develop IP programs like first aid/swimming lessons/fire prevention, etc.
  2. Empowerment: incorporate indigenous culture, language and beliefs into IP planning
  3. Enabling: provide easier access and affordability to IP education and devices through community purchasing
  4. Engineering: design safer products and environments (well lit roads, etc.)
  5. Enforcement
  6. Employment
38
Q

Use the six E’s of injury prevention to teach about MVCs.

A
  1. Education: avoid alcohol while driving, use seat belts
  2. Empowerment: community plan for safety education and promotion for alcohol reduction and use of seat belts
  3. Enabling: car pooling, designated drivers, affordable child restraints
  4. Engineering: improved road and lighting conditions, separation of pediatrian and motor vehicles, restraining livestock
  5. Enforcement: max speed limits, child restraints, alcohlol usage
  6. Employment: local enforcement and education, first response team
39
Q

What medical conditions has vitamin D deficiency been linked to? (9)

A
  1. Osteoporosis
  2. Asthma
  3. Rheumatoid arthritis
  4. MS
  5. Inflammatory bowel disease
  6. Diabetes
  7. Disturbed muscle function
  8. TB resistance
  9. Specific types of cancers
40
Q

What is the pathway of vitamin D metabolism?

A

Vitamin D3 is produced in the skin of animals from exposure to ultraviolet rays (and vitamin D2 is from plants)

  • this is then first metabolized in the liver by 25-hydroxylation to 25(OH)D2 and D3 = inactive but stable forms (THIS is what we measure in the lab to define vitamin D status)
  • then the 25(OH)D2 and D3 undergo 1-hydroxylation in the kidney to 1,25(OH)2D2 and D3 = active but unstable forms
41
Q

What is the definition of OPTIMAL plasma 25(OH)D levels?

A

Optimal = level at which PTH production and calcium reabsorprtion from bone are minimized and intestinal calcium absorption is stabilized
-optimal range is anywhere from 30 ng/mL to 90 ng/mL (or 75-150 nmol/L)

42
Q

What level of 25(OH)D is considered potentially toxic?

A

> 200 ng/mL = associated with hypercalcemia and calcium deposition in tissues
-> 500 ng/mL is considered for sure toxic

43
Q

What factors influence the amount of exposure to sunlight?

A
  1. Skin pigmentation
  2. Latitude
  3. Clothing choices
  4. Use of sunscreen
44
Q

Fill in the blank: as your BMI increases, your plasma 25(OH)D _____.

A

Decreases!

  • plasma 25(OH)D varies inversely with BMI
  • thus overweight and obese children are at higher risk for vitamin D deficiency and may need higher intake
45
Q

When do maternal vitamin D stores get depleted in pregnancy?

A

3rd trimester: this is when rapid development of the fetus increases incorporation of calcium into the skeleton

46
Q

Maternal deficiency in vitamin D can be associated with what issues in the newborn? (4)

A
  1. Hypocalcemia
  2. Rickets
  3. SGA
  4. Dental malformations
    * **the fetus and the newborn are entirely dependent on the mother for their supply of vitamin D
    * **Thus, moms need enough vitamin D to meet their own needs and their infant’s needs
47
Q

What is the recommended vitamin D intake for breastfeeding, healthy term infants?
-what about babies from northern Native communities during the winter months?

A
  • 400 IU daily for breastfed, healthy term infants
  • 800 IU daily for infants in northern latitudes (ie. north of the 55th parallel aka north of Edmonton) during the winter months (Oct to April)
48
Q

What level of vitamin D supplementation in the mother during pregnancy is effective in assuring adequate vitamin D in breast milk for newborns?

A

Start with 2000 IU/d but can go up to 4000 IU/d as needed

-can periodically check 25(OH)D and calcium levels

49
Q

What is the vitamin D requirement in adults?

A

Some say anyway from 200 IU/d up to 4000 IU/day. Different studies say different things but needs increase as you get older

50
Q

What is thought to be the tolerable upper intake level for Vitamin D in infants < 1 yo?

A

1000 IU/day - try not to exceed this

51
Q

What is the recommended daily vitamin D intake for premature babies?

A

200 IU/kg/day to max of 400 IU/day

52
Q

How much sun exposure should infants and children get to take advantage of vitamin D production in skin but minimize skin damage?

A

< 15 min/day

53
Q

What are known risk factors for type 2 diabetes?

A
  1. Genetic markers ie. family history
  2. Maternal gestional diabetes
  3. Obesity
  4. Physical inactivity
54
Q

What are the components of metabolic syndrome? (6)

A
  1. Acanthosis nigricans
  2. PCOS
  3. Hypertension
  4. Dyslipidemia
  5. Steatohepatitis
  6. Insulin resistance
55
Q

What are the criteria for screening for type 2 diabetes?

  • what are the screening methods?
  • what levels are diagnostic for type 2 DM?
A 
Obtain a blood sugar level (random glucose or fasting blood glucose) in all chidlren who have the following risk factors:
Need all of the following:
1. At risk ethnic group: Aboriginal/asian/hispanic/african american/pacific islander descent
2. BMI > 85th percentile
3. Age 10 or older
-AND-
One of the following:
1. Sedentary lifestyle
2. Mom with gestational diabetes
3. 1st or 2nd degree relative with type 2 DM
4. Acanthosis nigricans
5. Dyslipidemia
6. Hypertension
7. PCOS

***Random glucose > 11.1 or fasting glucose > 7.0 is diagnostic

56
Q

How much physical activity should be incorporated into daily routine for schools/daycares/programs?
-what else can schools do to decrease obesity/type 2 DM?

A

at least 30 minutes of high energy physical activity

  • encourage healthy eating and healthy active living into school curriculum
  • schools should be discouraged from selling candy or other sweets for fundraising purposes
  • cafeterias should provide healthy foods
57
Q

What are diagnostic criteria for FAS? (4)

-what is it called if a patient doesn’t meet all 4 criteria?

A

Require history of prenatal alcohol consumption by mom and the following triad of features:

  1. Poor growth prenatally and postnatally
  2. Characteristic facial features
  3. Neurological abnormalities: ADHD, poor abstract thinking, lack of foresight, inability to make choices, inappropriate behaviour, developmental delay, lack of inhibitions, difficulty with transitions, academic difficulties, excessively friendly even to strangers and lack ability to discriminate between friends/family/strangers
    - if doesn’t meet all 4 criteria: atypical FAS
58
Q

What brain changes can be caused by fetal exposure to alcohol?

A

Microcephaly with cerebral dysgenesis, holoprosencephaly (characteristic of FAS), corpus callosum agenesis, brainstem and cerebellum maldevelopment, many many more
-overall: variability of brain lesions can be seen depending on how much alcohol is ingested, pattern and time of drinking, mom’s genetic ability to metabolize alcohol

59
Q

What facial features are characteristic of FAS?

A
  1. Short palpebral fissues
  2. Hypertelorism
  3. Flattened face
  4. Short nose
  5. Absent or hypoplastic filtrum
  6. Thin upper lip and bowing of the mouth downwards
60
Q

What is the most consistent physical finding in newborns with FAS (apart from characteristic facial appearance which might be difficult to appreciate)?

A

Growth retardation, especially microcephaly!!

-can also be jittery, irritable, hypotonic

61
Q

True or false: Low alcohol consumption levels can cause FAS, just as binge drinking does.

A

FALSE!

  • Some studies show that low alcohol consumption levels are unlikely to cause FAS
  • effects are more likely related to high blood alcohol levels and the number of drinks consumed at a time is more important than the average alcohol consumption
  • ie. less than 5 drinks, less than once per week had no measurable effect
62
Q

What are the definitions are the following:

  • abstainers
  • low-risk drinkers
  • at-risk drinkers
  • problem drinkers
A
  • Abstainers: consume no alcohol
  • low-risk drinkers; consume 1-2 drinks per day, 3x/wk or less. They do not use alcohol while driving/pregnant/breastfeeding
  • at-risk drinkers: consume 7-21 standard drinks per week, consume more than 3-4 standard drinks per occasion, drink in high-risk situations
  • problem drinkers: consume > 21 standard drinks per week and may experience negative consequences from drinking (behavioural/family/medical/mental health/employment/legal issues)
63
Q

What is the T-ACE approach to alcohol risk assessment?

A
  • Tolerance: how much alcohol do you drink before you feel its effects?
  • Annoyed: has anyone annoyed you by saying you should cut down on your drinking?
  • Cut down: have you ever thought you should cut down?
  • Eye opener: have you ever had a drink to get going in the morning?
  • if the tolerance question is answered with 2 or more drinks, the score is 2. A positive response to the other questions gives a score of 1 for each question. A total score of 2 or more indicates an AT RISK drinker
64
Q

What are characteristics of newborns with exposure to alcohol in utero?

A
  1. Poor sleeping
  2. Hypersensitive to touch/light/sound
  3. Irritable
  4. Difficulty establishing routines
  5. Poor feeding
65
Q

What is the 4 digit diagnostic scale for the diagnosis of FAS?

A

Four criteria are assessed, quantified and assigned a rating of 1-4 for each criteria, depending on the degree of abnormality:

  1. Impaired growth
  2. Facial abnormalities
  3. Abnormal brain function
  4. Degree of maternal drinking

4 digit diagnostic code: 1111 (normal) to 4444 (unequivocal FAS) depending on findings in these 4 areas

  • results in 22 code combinations leading to different diagnostic possibilities
  • can have FAS, alcohol exposed; FAS, alcohol exposure unknown; or atypical FAS, alcohol exposed

***Rating for abnormal brain function:
Rating of 4: definite brain dysfunction = defines a situation of static encephalopathy and depends on definite findings of brain damage (microcephaly, abnormalities of brain imaging, persistent neuro findings of prenatal origin, or IQ of 60 or lower)

Rating of 3: probably brain dysfunction = static encephalopathy as well, abnormalities in 3 of 4 areas of brain functioning (cognition, achievement, adaptation, language)

Rating of 2: possible brain dysfunction = neurobehavioural disorder only suggesting possibility of brain damage

Rating of 1 = no brain problems demonstrated

66
Q

What are the consequences of delaying intervention for children with FAS?

A
  1. Risk of abuse (excessively friendly children, irritable babies)
  2. Risk of trouble with the law (lack sense of consequence)
  3. Learning disabilities/school failure/loss of self esteem
  • **If early intervention takes placed, a lot of these can be prevented or at least modified
  • do NOT wait for a definitive diagnosis, start making referrals right away
67
Q

What are the 4 key objectives of early childhood intervention and education in children with FAS?
-what are strategies for dealing with difficult behaviours?

A
  1. Establish and maintain sense of self worth
  2. Establish acceptable interpersonal behaviour
  3. Foster independence
  4. Teach children how to make acceptable decisions

Remember that difficult behaviours might be due to attempts at communication or frustration with transitions/difficulty understanding/etc.

  1. Keep tasks simple
  2. Use concrete examples
  3. Keep instructions simple and give them one at a time
  4. Concentrate on life skills
68
Q

What are methods of primary prevention of FAS?

A
  1. School based educational programs
  2. Early recognition
  3. Treatment of at-risk women
  4. Community-sponsored, culturally centered support programs
  5. Physicians should ask all women about their drinking habits
69
Q

What is the definition of early childhood caries?

-most common causative organism?

A

Presence of tooth decay involving any primary tooth in a child < 6 yo
-organism: streptococcus mutans

70
Q

What is the causative triad for caries?

A
  1. Presence of cariogenic bacteria
  2. Exposure to fermentable carbs in diet
  3. Host susceptibility (integrity of tooth enamel)
71
Q

What is the most prevalent pediatric infectious disease?

A

Early childhood caries

72
Q

What are potential consequences of early childhood caries?

A
  1. Pain = altered chewing, eating, sleeping = potential growth restriction
  2. Early tooth loss = speech difficulties and decreased self esteem
  3. Increased risk of decay in permanent dentition as well with possible malalignment and crowding of permanent teeth
  4. Requires extensive treatment under general anesthesia
73
Q

What is the biggest risk factor for early childhood caries?

-why??

A

Poverty: household crowding, family size, nutrition, health behaviours, parenting practices (ie. prolonged bottle use with juice, sugary snacks, smoking), etc.

74
Q

What are prenatal strategies that can prevent or delay early childhood caries?

A

There is evidence for vertical transmission of cariogenic bacteria!
-should involve pregnant women in oral health screening/dental treatment/education on oral health hygiene, improve nutrition, encourage use of fluoride toothpaste

75
Q

What is the evidence on fluoride supplementation through diet as opposed to water/fluoride varnish/toothpaste?
-what is the evidence on the use of sealants to prevent caries?

A

No evidence to support using this!
-sealants: protect pits and fissures on tooth from caries = evidence that populations at high risk of dental caries should get sealants on both primary and permanent molars

76
Q

At what age should children start going to the dentist?

A

Within 6 months of first tooth eruption OR by 12 months of age

77
Q

True or false: all indigenous children should have access to the evidence-based schedule for fluoride varnish and assessment to determine need for sealant placement on teeth

A

True!!

-fluoride varnish should be provided as part of a regular child health clinic program

Royal College Peds 2021 (55 decks)

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