CPS Mix

Question 1

All of the following are benefits of breastfeeding except:

a) Enhanced cognitive development
b) Reduced risk of malignancies in mother and child
c) Increased fertility in mother
d) Reduced risk of type 1 and 2 diabetes
e) Reduced risk of infant bacteremia

Answer 1

C

Question 2

All of the following are true regarding the composition of breast milk
except:
a) Milk for a preterm infant is lower in carbohydrates but higher in
calories
b) Colostrum is particularly rich in IgA
c) Hind milk has 50 % higher fat content than fore milk
d) Breastmilk provides 60/40 casein-to-whey ratio

Answer 2

D

• breast milk is “WHEY” better, so higher ratio of Whey compared to Casein

Question 3

Who should have soy formula?

Answer 3

Soy based formula should only be used for infants with galactosemia or for
cultural/religious reasons (CPS statement Feb, 2019)

Question 4

When to introduce cow’s milk?

Answer 4

Delay introduction of cow’s milk until 9-12 months (max of 750 mls
per day = 25 ounces) – should be homogenized

Question 5

During a routine visit with a patient who has Asthma and a peanut
allergy the mother tells you that she is pregnant with her second
child. She is concerned her newborn child will also develop food
allergies. Despite a love of Pad Thai she is avoiding eating peanuts
and wonders what else she can do. What advice would you give her?

Answer 5

Do not restrict maternal diet either during pregnancy or while
breastfeeding as there is no evidence that avoiding eggs, milk or
peanuts will prevent allergy
• Evidence for restricting maternal diet is contradictory

Question 6

When to introduce allergenic foods?

Answer 6

• For high risk infants, common allergic foods should be introduced
around 6 months and not before 4 months of age (4-6 month
theoretical window)
• No or low risk infants should not have complimentary foods
introduced before 6 months
• Introduce allergenic foods one at a time but there does not need to
be much delay between each new food
• Do not delay introduction of any specific solid food
• Allergenic foods need to be offered a few times a week to maintain
tolerance

Question 7

Do pacifiers increase the risk of OM?

Answer 7

• Up to 50 % of pacifiers contain microorganisms but they are not the bugs that
typically cause OM
• Several studies have shown that pacifiers are a risk factor for OM
• Recommend restricting pacifier use but use at bedtime or naptime, but not all the time

Question 8

Do pacifiers affect dentition?

Answer 8

May have negative effect on dental arch or occlusion issues when there is
prolonged use
• Canadian Dental Association still promotes pacifiers over finger sucking

Question 9

Do pacifiers prevent SIDS?

Answer 9

• Association exits between pacifier use and protection from SIDS
• Etiology is not well understood
• Based on current evidence cannot recommend pacifiers to prevent SIDS but
should not discourage them either

Question 10

Pacifiers - should they be used in preterm infants?

Answer 10

• Non-nutritive sucking in the preterm infant has been shown to have many
positive outcomes including comfort, state regulation and opportunity to
better develop oromotor skills
• Recent systematic review showed decreased hospital stay

Question 11

All of the following are protective from childhood obesity except:

a) Adequate sleep
b) Regular family meals
c) ‘Grazing’ throughout the day
d) Siblings
e) Parental limit setting and supervision

Answer 11

C

Question 12

Risks of screen time on development

Answer 12

• Heavy early screen use is associated with language delays
• ? Attentional difficulties (need very high exposure)
• Background TV negatively affects language use and acquisition, attention and
cognitive development in kids < 5years AND decreases parent-child interaction and
distracts from play
• E books are inferior to paper books
• Prolonged TV viewing negatively impacts executive function

Question 13

How much screen time should <2 year olds have and 2-5 year olds?

Answer 13

Screen time for children younger than 2 years is not recommended
• Children 2-5 years should have regular screen time limited to less
than 1 hour per day
• Ensure sedentary screen time is not a routine part of child care for
children < 5 years
• Maintain daily ‘screen free’ parts of the day
• Avoid screens 1 hour before bed

Question 14

Definition of Obesity

Answer 14

Birth to 2 years (WFL) overweight >97, obese >99.9
2-5 years (BMI) overweight >97, obese >99.9
5-19 years (BMI) overweight >85, obese >97, severe obesity >99.9

Question 15

Safest place for babies to sleep?

Answer 15

The safest place for babies to sleep in their first year of life is in their
own crib, and in the parents room for the first 6 months
Reduces risk of SIDS: sleeping on back, room sharing
Increases risk of SIDS: smoking, bedsharing (especially with other caregivers), soft pillows and bedding, sleeping with infant on couch

Question 16

A 2 month of term infant is not sleeping through the night. You tell the
exhausted parents that most (70-80%) infants sleep through the night
(uninterrupted sleep for 6-8 hours) by:
a) 2 months
b) 4-6 months
c) 7-9 months
d) 12 months

Answer 16

7-9 months

Question 17

How much sleep should children get?

Answer 17

Amount of sleep children need changes with maturation
• Healthy FT infant – 16-18 hours/day
• 6 months – 14 – 15 hours/day
• 1 year – 13-14 hours/day
• 2-3 years – 12-13 hours/day
• 5-6 years – 10-11 hours/day
• 9 years – 9 hours/day
• Teenagers – 9 hours/day
• Many infants can sleep at least 5 hours through the night by 3-4
months
• Brief arousals are a normal part of the sleep cycle

Question 18

What medications should be used to assist with sleep in children?

Answer 18

Melatonin (CPS Statement, 2018)
• Produced by the pineal gland and regulates circadian rhythms
• Only medication shown to be safe and effective in children
• Assists with sleep onset (not maintenance)
• Studies have shown positive effects for children with both ADHD and Autism
• Adverse effects are mild and self limited

Question 19

When to start sleep training?

Answer 19

• Literature supports behavioural treatment for bedtime problems and
night-waking in infants, toddlers and preschoolers
• Wait until 6 months to start sleep training

Teach families strategies that encourage self soothing
• Consistent, calming sleep routines (bath, book, bed)
• Put babies in crib drowsy but awake
• No bottle in bed
• Wait a few minutes to see if they will settle themselves after waking
• Avoid overstimulation during nighttime feeds or diaper changes

Question 20

How common is positional plagiocephaly?

Answer 20

• Seen in approximately 16 % of infants at 6 weeks, 19.7% at 4 months
and then decreases to 6.8 % by 12 months and 3.3 % by 24 months
(CPS)
• Increased incidence secondary to recommendation that babies
should sleep on their backs
• Occurs when infant spends increased time in the supine position or
preferentially rests head on one side, causing the occiput or one side
to become flat
• Look for craniosynostosis and torticollis

Question 21

Treatment/advice for plagiocephaly

Answer 21

• Recommend ‘tummy time’ for 10-15 min 3 x a day
• Treat torticollis with physiotherapy if present
• Moulding therapy (helmets) may be considered for severe asymmetry
• Helps rate of improvement but not final outcome
• Insufficient evidence to recommend in mild-moderate asymmetry
• Craniosynostosis needs further investigation and consideration of
surgical treatment

Question 22

Normal infants hit their peak of crying time at 6 weeks of age. How
many hours per day of crying is considered developmentally normal at
this age?
a) 30 minutes
b) 1 hours
c) 3 hours
d) 4 ½ hours

Answer 22

3 hours

Median daily crying times:
2 week infant is 1 ¾ hours
Peaks at 2 ¾ hours at 6 – 8 weeks
Less than 1 hour by 12 weeks

Question 23

Infantile colic - any treatment needed?

Answer 23

Definition of colic (Rome III criteria):
• Paroxysm of irritability, fussiness or crying that starts and stops without
obvious cause. Episodes last for at least 3 hours per day, at least 3 days per week for at least
one week
• No failure to thrive
• Etiology is unknown
• There is little evidence that dietary modification makes a difference
and it should not be encouraged
• For babies with severe colic and suspected cow’s milk protein allergy
a short (2 week) trial of hypoallergenic diet may be considered
• For breastfed infants with colic may consider eliminating cow’s milk
from maternal diet but must monitor closely and reintroduce milk to
mother if no change in 2 weeks
• Avoid soy formula
• No evidence to support use of
lactase or probiotics

Question 24

Which of the following statements regarding oral health are true?
a) The first teeth to erupt are usually the lower central incisors at 5-
8 months
b) The last primary teeth to erupt are the upper canines at 16-20
months
c) Dental extraction of caries is a rare procedure in children
d) 20 % of Canadian kids 6-11 years have had a cavity
e) The most common causative organisms for dental caries is
Streptococcus viridans

Answer 24

A - first teeth are central incisors at 5-8 mo

• In the US it is the most common chronic disease of childhood ( 5 x more common than Asthma in children 5-17 yrs.)
• Canadian studies show 57 % of Canadian children 6-11 years have had a cavity with an average of 2.5 teeth affected by decay
• The definition of Early Childhood Caries (ECC) is the presence of one or more decayed, missing (due to caries) or filled tooth in any primary tooth in a preschool aged child
• In urban areas, 6-8 % have ECC but in Indigenous communities it exceeds 90%
• 32 % of Canadians have no dental coverage (50 % of which fall into the
lower income bracket)

Question 25

What is the most effective way to prevent dental caries?

Answer 25

• Inhibits plaque by killing/inhibiting bacteria
• Inhibits demineralization by making teeth more resistant to acid
• Enhances remineralization
• Risk is fluorosis which results from impaired biosynthesis of dental
matrix causing mottling and pitting
• Recommend:
• Fluoride should be added to municipal water supplies if natural fluoride is less
than 0.3 ppm (stay under 0.7 ppm)
• Consider supplementation with fluoride if not added to water in children > 6
months if they do not have teeth brushed
• > 3 years brush teeth 2 x per day with a pea sized portion of tooth paste
CPS 2019

Question 26

When should kids start seeing a dentist?

Answer 26

The Canadian Dental Association recommends the assessment of infants, by a dentist, within 6 months of the eruption of the first tooth or by one year of age

Question 27

What are normal visual developmental landmarks?

Answer 27

• Normal visual development landmarks:
• Birth to 4 weeks – Fix on face
• 3 months – Visual following
• 42 months of age – visual acuity is measurable

Question 28

The following is true of Universal Newborn Hearing Screen
recommended for all Canadians
a) AABRs are the primary, initial screen that makes up universal
screening
b) Mild congenital hearing loss can be missed in most programs
c) In unscreened children, hearing loss is identified as a speech
delay at an average of 36 months of age
d) Admission to the NICU for 24 hours is a risk factor for neonatal
sensorineural hearing loss

Answer 28

Answer: mild congenital hearing loss can be missed in most programs

OAE (otoacoustic emission) is the first screen usually
If fail OAE, then go on to ABR (automated auditory brainstem response)

Less severe congenital hearing loss is not detected
• Progressive or late onset hearing impairment will be missed (e.g. CMV
infection)
• Need to remain attentive to issues with hearing and language and
repeat testing if needed

Question 29

What is the incidence of daytime continence in toddlers?

a) 75 % by 25 months
b) 25 % by 30 months
c) 75 % by 30 months
d) 60 % by 36 months
e) 98 % by 36 months

Answer 29

E - 98% are toilet trained by 36 months

Timing:
• Generally 24-48 months, slightly earlier in girls
• 3-6 months to attain full control
• Don’t necessarily attain control of bowel and bladder at same time
Readiness:
• Physiologic readiness comes before psychologic readiness
• By 18 months they have mature sphincter control and myelination of extrapyramidal tract
• Physically need to walk to potty, sit with stability, remain dry for several hours, have appropriate language skills, have a desire independence and respond to positive reinforcement

Question 30

When is nocturnal enuresis considered secondary?

Answer 30

• Secondary when it reoccurs after 6 months of continence
Associated with a gene on Chromosome 13q
• Must persist beyond 5 years of age and occur more than twice a week
• More common in boys

Question 31

What is the incidence of nocturnal enuresis?

Answer 31

• Incidence:
• 10-15% of 5 year olds
• 6-8% of 8 year olds
• 1-2 % by 15 years

Question 32

A 5 year old boy has new onset nocturnal enuresis. The best initial
intervention for this child is to:
a) Wake him and take him to the bathroom before the parents go
to bed
b) Punish him in the morning
c) Obtain a urinalysis
d) Use an alarm
e) Write a prescription for DDAVP

Answer 32

Obtain an urinalysis

Question 33

What is the treatment for nocturnal enuresis?

Answer 33

Should only be treated when it poses a “significant problem” for the
child
• Alarm devices
• Aims to teach child to respond to full bladder while asleep by alarming when voiding begins
• Parent and child need to be motivated
• Can take up to 1-2 months to see improvement
Pharmacological therapy
• Desmopressin acetate (DDAVP) – synthetic analogue of ADH
• Dose is 200-600 ug
Do not use in children with issues with fluid regulation and CF
• Recommended for short term use (sleepover)

Question 34

What is the success rate of bed alarms for DDAVP?

Answer 34

• Success rate is just under 50 %

* Costs about $80

Question 35

Benefits of breastfeeding

Answer 35

• Benefits of breastfeeding:

1. Decreases infections in infancy
2. Reduced SIDS
3. Enhanced neurocognitive testing
4. Decreased maternal breast and ovarian cancer
5. Economical

Question 36

Contraindications to breastfeeding

Answer 36

• Contraindications: HIV+, cytotoxic or radioactive treatment in
mother, galactosemia

Question 37

when should fluoride be supplemented?

Answer 37

Supplement fluoride >6mo if:
• Drinking water has <0.3ppm
• The child does not brush their teeth BID
• High risk for caries (family history, community prevalence)
• Supplements should be given as mouthwash, lozenge or drops
• Table of recommended fluoride concentrations for
children

• Fluoride should be added to water supplies if <0.3ppm

Question 38

When should transition to cow’s milk and what is the limit?

Answer 38

cow’s milk >12mo, limited to 750mL/day

Formula until 9-12mo, homogenized milk 12-24mo, no formula >12mo, alternative “milks”
not appropriate alternative to cow’s milk, avoid prolonged bottle feeding and at night

Question 39

Which child’s reaction after ingestion of Pad Thai does NOT suggest anaphylaxis?
Diffuse urticaria and periorbital angioedema
Diffuse urticaria and hypotension
Diffuse urticaria, wheeze and vomiting
Increased WOB and facial urticaria

Answer 39

Diffuse urticaria and periorbital angioedema

Question 40

You are seeing an 8 y/o M with an anaphylactic peanut allergy in your community office. He weighs 30 kg. He ate a cookie offered by another child in the waiting room. During the visit, he develops facial hives, wheezing and respiratory distress. In addition to calling EMS, what dose of Epinephrine would you administer to this child?
0.3 mg of 1 mg/mL concentration
0.03 mg of 1 mg/mL concentration
0.3 mg of 0.1 mg/mL concentration
EpiPen Jr

Answer 40

0.3 mg of 1 mg/mL concentration

Question 41

Which of the following is NOT a mechanistic effect of epinephrine?
Increase peripheral vascular resistance
Bronchodilation
Increase cardiac chronotropy
Decrease cardiac inotropy

Answer 41

Decrease cardiac inotropy

Alpha-adrenergic: increase peripheral vascular resistance
Beta-1 adrenergic: increase cardiac chronotropy and inotropy
Beta-2 adrenergic effects: bronchodilation

Question 42

An ex-32 weeker, DOL 6, is on CPAP in the NICU. What is his Hb threshold?

a) 115
b) 100
c) 85
d) 75

Answer 42

A) 115

Question 43

An ex-32 weeker, DOL 16, is on room air in the NICU. What is his Hb threshold?

a. 115
b. 100
c. 85
d. 75

Answer 43

C) 85

Question 44

A 3 week old ex-32 week infant on CPAP in the NICU has a Hb of 80 and an increase in apneic and bradycardic skills. He is hemodynamically stable. It has been decided to give him a top-up transfusion. On discussion with mom, she is Jehovah’s Witness and is firmly against the baby receiving a blood transfusion. What is the best course of action?

a) Urgently administer blood transfusion
b) Consult CAS
c) Respect mom’s decision and have an informed discussion with her regarding the risks and benefits of blood transfusion in the context of her baby’s NICU course, and include a discussion of alternative strategies
d) Administer EPO

Answer 44

c) Respect mom’s decision and have an informed discussion with her regarding the risks and benefits of blood transfusion in the context of her baby’s NICU course, and include a discussion of alternative strategies

(EPO can contain human albumin)

Question 45

An ex-29 weeker has a cord rupture at delivery. He is cool, pale, with thready pulses and poor capillary refill. After stabilizing his ABCs, you elect to urgently administer a blood transfusion. Which blood type do you administer?

a) Group O Rh-positive
b) Group O Rh-negative
c) Cord blood
d) PLA-1 negative platelets

Answer 45

b) Group O Rh-negative

Question 46

Which factor(s) have been found to minimize blood loss and/or the need for transfusion in extremely preterm infants?

a) Delayed cord clamping
b) Cord milking
c) Low Hb transfusion thresholds
d) All of the above
e) A and B
f) A and C
g) None of the above

Answer 46

f) A and C

Question 47

Which factor(s) have been found to minimize blood loss and/or the need for transfusion in extremely preterm infants?

a) Higher transfusion volumes e.g. 20 cc/kg
b) Use of Erythropoietin
c) Supplemental iron
d) All of the above

Answer 47

a) Higher transfusion volumes e.g. 20 cc/kg

Question 48

Which factor(s) have been found to minimize blood loss and/or the need for transfusion in extremely preterm infants?

a) Point-of-care testing
b) Non-invasive monitoring of CO2 and bilirubin
c) Caregiver advocacy
d) All of the above

Answer 48

d) All of the above

Question 49

An ex-30 weeker with a BW of 1490g is admitted to NICU and ventilated for RDS. He is DOL 6 and has been found to have a low Hb. What is his Hb threshold for transfusion?

a. 115 g/L
b. 100 g/L
c. 120 g/L
d. 85 g/L

Answer 49

a. 115 g/L

Question 50

An ex-32 weeker is born with a BW of 1390g. Which form and dose if Vitamin K should he receive at birth?

a) Vit K 0.5 mg IM
b) Vit K 1.0 mg IM
c) Vit K 0.5 mg PO
d) Vit K 2.0 mg PO

Answer 50

A (B is for BW > 1500g; c incorrect; d is the correct PO dosing)

Question 51

Parents of a term, healthy baby decline IM Vit K after the baby is born. Despite counselling on the serious consequences of VKDB, parents continue to decline. What is the next best step in management?

a) Call CAS
b) Administer PO Vit K 1.0 mg
c) Administer PO Vit K 2.0 mg
d) Administer IM Vit K 1.0 mg

Answer 51

c) Administer PO Vit K 2.0 mg

Question 52

Parents of a term, healthy baby decline IM Vit K after the baby is born. Despite counselling on the serious consequences of VKDB, parents continue to decline. What do you advise the parents?

a) PO vit K is less effective than IM vit K for preventing VKDB
b) It is very important the infant receives all follow-up doses at 2-4 and 6-8 weeks of age
c) Their infant remains at risk for developing late VKDB (potentially ICH) despite use of parenteral form of vit K for PO administration
d) All of the above

Answer 52

d) All of the above

Question 53

There are 3 types of HDNB. Which of the following timing and associations are INCORRECT?

a) Early-onset: 1st 24h of life; maternal AEDs
b) Classic: DOL 2-7; low vit K intake
c) Late-onset: 2-12 weeks, up to 6 months; chronic malabsorption
d) None of the above

Answer 53

d) None of the above

Question 54

It is the start of RSV season. Which of the following patients qualified for RSV prophylaxis?

a) 3 y/o F with cystic fibrosis
b) 8 mos old M ex-29 weeker
c) 5 mos old F, ex-32 weeker, living in Iqaluit
d) B and C

Answer 54

c) 5 mos old F, ex-32 weeker, living in Iqaluit

Question 55

It is the start of RSV season. Which of the following patients qualified for RSV prophylaxis?

a) 8 mos old with CLD on home O2
b) 5 mos old M ex-28 weeker
c) 5 mos old F, ex-35 weeker, living in Iqaluit
d) All of the above

Answer 55

d) All of the above

Question 56

You are seeing an 8 mos old on Lasix for a VSD at the start of RSV season. His mom has to travel a far distance to the RSV clinic and she asks you, how many doses of Pavilizumab should he receive?

a) 1
b) 2 doses, 2 months apart
c) 6-7 doses, 38 days apart
d) 3-5 doses, 38 days apart

Answer 56

d) 3-5 doses, 38 days apart

Question 57

An 8 y/o boy comes to your clinic with his third episode of fever in the last 3 months. As per mom, the fevers last about 2 days. During episodes, he complains of abdominal pain. He has no URTI symptoms. He is well in between episodes. A fever started yesterday and his temperature in clinic is 38.6 C Ax. On your exam, he has an erysipelas-like rash on his foot and pain on passive ROM of his ankle. Mom believes her mother also had fevers in childhood. What is the most likely diagnosis?

a. Septic arthritis
b. Juvenile idiopathic arthritis
c. Familial Mediterranean Fever
d. Periodic Fever, Aphthous Stomatitis, Pharyngitis, Adenitis Syndrome (PFAPA)

Answer 57

c) FMF

Question 58

What is the inheritance pattern of Familial Mediterranean Fever?

a. Autosomal dominant
b. Autosomal recessive
c. X-linked
d. Sporadic

Answer 58

b) Autosomal Recessive

Question 59

What is the best treatment for Familial Mediterranean Fever?

a. Watchful waiting
b. Glucocorticoids
c. Colchicine
d. Cimetidine

Answer 59

c. Colchicine

Question 60

A 3 y/o boy comes to your clinic with her third episode of fever in the last 3 months. As per mom, the fevers last about 4 days. During episodes, he complains of sore throat and occasionally a headache. He is well in between episodes. A fever started yesterday and his temperature in clinic is 38.6 C Ax. On your exam, he has tender cervical lymphadenopathy and oral aphthous ulcers. What is the most likely diagnosis?

a. Recurrent viral pharyngitis
b. Cyclic neutropenia
c. Familial Mediterranean Fever
d. PFAPA

Answer 60

d. PFAPA

Periodic fever, Aphthous stomatitis, pharyngitis, adenitis

Question 61

What is the inheritance pattern of PFAPA?

a. Autosomal dominant
b. Autosomal recessive
c. X-linked
d. Sporadic

Answer 61

d. Sporadic

Question 62

6. What is an appropriate treatment approach for PFAPA?
   a. No treatment, as this is a self-limited condition
   b. Glucocorticoids
   c. Tonsillectomy
   d. A, B or C

Answer 62

d. any of the above