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CPS Statements > CPS Statements 2019 > Flashcards

CPS Statements 2019 Flashcards

1
Q

5 risk factors for IDA in <2 years?

A 
HAEM Problem:
High milk intake
Anemic mother
Early cord clamping
Male
Premature
Also: BW<2500g, Low socioeconomic status, infants born to moms with obesity, exclusive BF x 6 months, prolonged bottle use, chronic infection, lead exposure, low intake of Fe-rich foods
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2
Q

What is NOT associated with IDA?

a) Indigenous status
b) Lower motor function
c) chronic disease
d) macrosomia

A

Macrosomia

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3
Q

At what point do infants who are breastfed become Fe def?

A

6 months (so, at this time: introduce Fe-rich foods)

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4
Q

Cow’s milk daily limit for 9-12 mos?

A

750 ml/day

once 12 mos, lowers to 500 ml/day

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5
Q

Exclusively breastfed infants get how much Fe per day?

A

0.05-0.07 mg/kg/day
Formula fed would be 1-2 mg/kg/day
PREM formula fed would be 2-3 mg/kg/day

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6
Q

a) Write Rx for toddler with IDA secondary to poor intake (assume weight of 10 kg) b) When do you follow up? c) What two tests at follow up?

A

a) Elemental Iron 6 mg/kg/day= 60 mg/kg/day= 20 mg PO TID, to take with orange juice x 30 days; Repeat x 2
b) 3 months
c) CBC, ferritin

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7
Q

2 differences with AAP and ESPHAGAN guidelines?

A

AAP: If mostly BF, automatic Fe supplementation at age 4-6 mos
ESPHAGAN: No cow’s milk until 12 mos (same limit though of 500 cc at this time)

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8
Q

How much iron should formula contain?

A

6.5-13 mg/L Fe

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9
Q

Should infants 4-6 mos automatically receive Fe supp?

A

Not according to CPS

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10
Q

Infants with BW 2-2.5 kg: Supplement how much iron? for how long?

A

1-2 mg/kg/day x 6 months

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11
Q

Infants with BW <2 kg: Supplement how much iron? For how long?

A

2-3 mg/kg/day x 1 year

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12
Q

SAQ: Give the definition of
hypoglycemia in the first
week of life (2 points)

A

<2.6 within first 72 hours;

<3.3 after first 72 hours

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13
Q

Give 5 signs/sx of

hypoglycemia in newborn

A
  • Tremors /jitteriness
  • Cyanotic episodes
  • Convulsions
  • Apneic spells
  • high-pitched/weak cry
  • Lethargy
  • Poor feeding
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14
Q

SAQ: Give 5 risk factors for

hypoglycemia

A 
Mnemonic:Sugar SLIP
SGA
Steroids (antenatal)
LGA
IUGR
Prematurity

Also:
Asphyxia (perinatal)
Diabetic Mother
Labetalol (Maternal)

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15
Q

MCQ: Babies with hyperinsulinism may need target glucose of?

  1. 6
  2. 8
  3. 2
  4. 3
A

3.3

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16
Q

Who does not need to be tested for hypoglycemia

A

Term, not-at risk or symptomatic infants

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17
Q

SAQ: Well at-risk baby has glucose <2.6 at 2 hours of life. Do what? (3 points)

A

Give 40% dextrose gel and breastfeed OR feed 5 ml/kg and breastfeed
Check glucose 30 min post-feed

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18
Q

SAQ: At-risk baby has glucose at least 2.6 at first check at 2 hours of life. Do what? (2)

A

Feed ad lib

Check glucose again before next feed

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19
Q

At second check (if tolerated feeds), do what if glucose <1.8? (3)

A

Initiate D10W infusion at hourly requirements
If sx, give D10W bolus 2 ml/kg over 15 min
Check BG after 30 minutes

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20
Q

In addition to scenario with baby having glucose <1.8 at second check post birth, what other scenarios would warrant plan described below?

Initiate D10W infusion at hourly requirements
If sx, give D10W bolus 2 ml/kg over 15 min
Check BG after 30 minutes

A

Unwell infant/Symptomatic infant

Infant who should not be fed

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21
Q

After starting IV glucose, what’s the target range for infants <72 hours of age?

A

2.6-5.0

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22
Q

After starting IV glucose, what’s the target range for infants at least 72 hours?

A

3.3-5.0

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23
Q

If after 30 minutes of infusion, BG is still too low, do what?

A

Increase D10W infusion by 1 ml/kg/h every 30 min; repeat glucose every 30 min until within target range

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24
Q

2 things you should calculate during glucose infusion?

A
  • Lowest GIR at which BG is within target range

- D%W concentration at which BG is within target range

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25
Q

How do you calculate GIR?

A

[% dextrose concentration x infusion rate (cc/kg/h)] divided by 6

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26
Q

Check lytes how often during dextrose infusion?

A

q8-12h

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27
Q

GIR at which you should consider central access and level 3 care?

A

> 8-10 mg/kg/min

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28
Q

GIR at which you should consider medication?

A

> 10-12 mg/kg/min

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29
Q

After 72 h, GIR in which further investigation required?

A

> 10-12

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30
Q

For infants who are tolerating feeds, at second glucose check, do what if glucose 1.8-2.5? (3 points)

A

For infants who are tolerating feeds, at second glucose check, do what if glucose 1.8-2.5? (3 points)

  • Give 40% dextrose gel 0.5 ml/kg AND feed 5 ml/kg and breastfeed
  • OR feed 8 ml/kg and breastfeed
  • check glucose 30 min post-feed
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31
Q

For infant tolerating feeds, if at second glucose check glucose is at least 2.6, do what?

A

Once 2 consecutive samples at least 2.6, continue monitoring pre-feed or every 3-6 hours

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32
Q

If after 2 feeds, glucose less than 2.6, do what?

A

Go into infusion pathway (treat as if symptomatic)

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33
Q

For babies undergoing infusions, do what for readings at least 2.6? (3)

A
  • monitor q3 hours
  • when glucose at least 2.6, introduce enteral feeds as tolerated and wean IV stepwise (TEXT says wean after BG stable x 12 hours)
  • Continue pre-feed glucose monitoring until on full enteral feeds and 2 consecutive samples within normal range
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34
Q

At what time should first glucose screening happen?

A

2 hours of life (or immediately if baby unwell)

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35
Q

If BG at least 2.6 for 12 hours, for whom can you discontinue screen? (2)

A

LGA, IDM

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36
Q

If BG at least 2.6 for 24 hours, for whom can you discontinue screen? (2)

A

SGA, Prem

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37
Q

Indication for critical sample?

A

BG<2.8 at 72 hours or more of life

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38
Q

Before discharge, neonate should be able to maintain BG >3.3 for how long?

A

5-6 hours

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39
Q

Prior to 72 hours of life, BG cut-off for further investigation?

A

2.6 (2.8 after 72 hours)

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40
Q

If feeding does not work, what’s your IV dextrose order?

A

IV D10W at TFI 80 ml/kg/day

GIR= 5.5 mg/kg/min

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41
Q

How do you prescribe dextrose bolus (controversial as per text)?

A

D10W at 2 ml/kg IV

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42
Q

3 meds for hypoglycemia

A 
HGOD
Hydocortisone
Glucagon
Octreotide
Diazoxide
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43
Q

Max dextrose concentration for PIV?

A

20%

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44
Q

Max TFI during transitional period?

A

100 ml/kg/day

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45
Q

Rx for dextrose gel

A

40% dextrose gel 0.5 ml/kg intrabuccal; give concurrently with enteral feeds

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46
Q

“40% dextrose gel 0.5 ml/kg intrabuccal” is equivalent to what?

A

IV bolus of D10 2 cc/kg

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47
Q

2 ways to prescribe glucagon?

A

0.1-0.3 mg/kg IV bolus

10-30 ug/kg/hr IV infusion

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48
Q

2 pros of dextrose gel?

A

Decrease NICU admission rate
Decrease treatment failure
Decrease supplemental formula

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49
Q

2 cons of dextrose gel

A

No improvement in developmental outcome

Similar neurosensory impairment long-term

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50
Q

10 items on critical sample?

A 
"AB2C2
FG2
IL"
Cortisol
Beta-hydroxybutrate
FFA
Glucose (plasma)
Insulin
Bicarbonate
Acyl-carnitine profile
Carnitine
Lactate
GH
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51
Q

In healthy newborns, BG can be as low as ___ transiently

A

1.8

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52
Q

Enteral supplementation appropriate for whom?

A

No sx

BG 1.8-2.5 (recheck 30 min later)

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53
Q 
All birthing centres should use BG measurement methods that are reliable within what range? 
0.5-2.5
1-3
1.5-3.5
2-5
A

1-3

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54
Q

3 categories of pain control?

A

Physical, Psychiatric, Pharmaceutical

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55
Q

Give 3 examples of physical pain control?

A

Breastfeeding, sucrose, non-nutritive sucking, Insert IV at same time as BW, grouping labs, avoiding daily labs, less painful approach

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56
Q

Give 3 egs of psychiatric pain control?

A

Preparation (if >4 yrs)
Distraction
Deep Breathing
Hypnosis

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57
Q

Give 3 egs of pharm pain control?

A

EMLA= lidocraine prilocaine 5%
Maxilene= liposomal lidocaine 4%
Ametop= amethocaine 4%/tetracaine
Pain Ease= Vapocoolant spray

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58
Q

Arrange the following in order of onset (Fastest-> Slowest):

Maxilene, EMLA, Ametop, Pain Ease

A

Pain Ease= immediate
Maxilene, Ametop= 30 min
EMLA= 60 min

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59
Q

Arrange the following in order of max application time (longest to shortest):
Ametop, EMLA, Maxilene, Pain Ease

A

EMLA 4 hours
Maxilene 2h
Ametop 1 hour
Pain Ease 10 sec

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60
Q

Arrange the following in order of duration of efficacy after removal (longest to shortest)

A

Ametop 4 hours
Maxilene
EMLA 1-2 h
Pain Ease 45-60 s

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61
Q

Advantage of EMLA?

A

No cross-sensitivity with Ametop

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62
Q

Advantage of maxilene?

A

rapid action
occlusion not required
No cross-sensitivity with Ametop

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63
Q

Advantages of ametop?

A

Rapid action

Superior to EMLA

No cross-sensitivity with lidocaine

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64
Q

Avantage of pain ease?

A

immediate

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65
Q

Side effects of EMLA? (3)

A

vasoconstriction
methemoglobinemia (increased if <1 yo)
hypersensitivity (rare)

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66
Q

Side effect of maxilene?

A

methemoglobinemia (rare)

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67
Q

Side effect of ametop?

A

Hypersensitivity

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68
Q

Side effects of pain ease? (2)

A

Burning sensation

Frostbite

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69
Q

Which analgesia topicals cannot be applied to open wound/mucosa/eyes?

A

emla, maxilene, ametop

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70
Q

Which topical analgesic would be contraindicated in pt with PABA= paraaminobenzoic acid or sulfonamide allergy?

A

ametop

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71
Q

which topical analgesic is contraindicated for patient with heart block?

A

maxilene, emla

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72
Q

which topical analgesic is contraindicated for patient with severe hepatic d/o?

A

maxilene, emla

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73
Q

which topical analgesic is CONTRAINDICATED for methemoglobinemia?

A

emla

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74
Q

which topical analgesic is CONTRAINDICATED for g6pd?

A

emla

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75
Q

which topical analgesic is contraindicated for <3 yrs?

A

pain ease

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76
Q

Give 2 procedures for which positioning and BF/sucrose is not helpful?

A

Laceration Repair

X-ray for fracture, dislocation

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77
Q

Which analgesic can go in eyes but not mucosa/open wound?

A

pain ease

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78
Q

Positioning to control pain is NOT helpful for what?

A

urine collection

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79
Q

pharmaceutical analgesic for lac repair?

A

LET +/- infiltrative anesthetic with bicarb, small needle

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80
Q

Mod-severe pain control for fracture?

A

IN fentanyl

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81
Q

Less painful way to get urine: catheter or SPA?

A

catheterization

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82
Q

Mild sedation agent that can be easily combined with EMLA?

A

nitrous oxide (in cooperative children)

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83
Q

2 symptom domains of ASD?

A

1) social communication impairments, and 2) restricted, repetitive patterns of behaviours and interests.

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84
Q

ASD can be reliably diagnosed by age ___

A

2 yrs

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85
Q

mean age of dx for ASD?

A

4-5 yrs

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86
Q

2 strong RFs for ASD

A

male sex; positive fam hx

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87
Q

Recurrence risk for siblings of children with ASD?

A

7-19%

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88
Q

rate of ASD in general population?

A

1.5%= 1/66

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89
Q

The Dx criteria for ASD has 7 features according to the CPS statement, including the 2 symptomatic domains of
1) social communication impairments, and 2) restricted, repetitive patterns of behaviours and interests. In addition to these components, give 5 other features of ASD dx?

A
  • Signs or symptoms must be present during early development but they may not be fully evident until later
  • Symptoms interfere with everyday functioning
  • Symptoms are not better explained by intellectual disability or global developmental delay
  • ASD may occur with or without medical, genetic, neurodevelopmental, mental or behavioural disorders, or an intellectual or language impairment
  • Level of severity for each of the two domains may be used to refine diagnosis: Level 1: Requiring support; Level 2: Requiring substantial support; Level 3: Requiring very substantial support. These levels may be difficult to determine at the initial time of diagnosis with very young children.
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90
Q

Give 5 risk factors for ASD

A

SOCIAL Miss:

  • Specific genetic syndrome
  • Older parents (at least 35)
  • Close spacing of pregnancies (<12 mos)
  • In utero exposure to traffic-related air pollution
  • ASD in family
  • Low BW
  • Male

Others: extreme prem, in utero exposure to pesticide, valproate; maternal obesity, diabetes, htn

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91
Q

Give 3 warning signs for ASD in patient age 6-12 mos

A
  • Reduced smiling directed at others
  • Limited or no eye contact
  • Limited recipriocal sharing of sounds, facial expression
  • Diminished babbing, gestures
  • Limited response to name when called
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92
Q

Give 2 warning signs for ASD in age 9-12 mos

A
  • emerging repetitive behaviours (eg: spinning or lining up objects)
  • unusual play (eg intense visual or tactile exploration of toys)
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93
Q

give 3 warning signs of ASD in age 12-18 mos

A

No single words
Absence of compensatory gestures (such as pointing)
Lack of pretend play
Limited joint attention (initiating, responding, sharing of interests)

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94
Q

Give 1 warning sign of ASD in age 15-24 mos

A

Diminished, atypical, or no spontaneous or meaningful two-word phrases

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95
Q

Give 2 warning signs for ASD irrespective of patient age

A

Parental and other caregiver concerns about the possibility of ASD

Developmental regression (loss of skills): reduced frequency or loss of social behaviours (e.g., directing eye gaze to others) and communication (words and gestures) relative to earlier age

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96
Q

Give 5 ASD screening tools

A 
PLACE, SIMA, SR
Parental qs:
ASQ-3
CDI
ECSA
PEDS
Looksee Checklist
Parent/teacher qs
M-CHAT R/F
ITC
SRS-2 Preschool
Autism Spectrum Rating Scales

Interactive:
STAT
RITA-T

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97
Q

Which ASD screening tool takes the least amount of time?

A

ECSA: 1-5 min

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98
Q

Which ASD screening tools can be used as young as 1 month of age?

A

ASQ-3

Nippising

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99
Q

Which ASD questionnaire can be used up to age 15 y?

A

Autism Spectrum Rating Scales

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100
Q

Does CPS recommend routine ASD screening?

A

Not at this time (not unless identified as being at increased risk for ASD)

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101
Q

3 interventions while awaiting referral for ASD dx

A

SLP
OT
Preschool program
Also audiology, vision testing

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102
Q

5 things to include in ASD referral

A
  • Parental or health care professional reports of signs or symptoms of ASD, developmental delays or concerns, missed developmental milestones, abnormal behaviours, plus any general development or ASD screening results
  • Clinical observations of signs or symptoms of ASD
  • Antenatal and perinatal histories
  • Developmental milestones achieved
  • Any specific risk factors for ASD
  • Relevant medical history and investigations
  • Information from previous assessments
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103
Q

5 things to do to prepare for first time office visit with child suspected of ASD

A

-Consider scheduling a telephone call with a parent in advance of the first visit, to discuss the child’s:
Medical and developmental history, with related family factors
Strengths and challenges
Sensory sensitivities that might influence behaviour within the office environment; and
Strategies to optimize compliance during the clinical visit.
-Consider inviting both patient and parent for a ‘practice visit’ to familiarize the child with the care setting.
-Consider scheduling the child for the first (or last) appointment of the day, when there are fewer people in the waiting room, to minimize wait time.
-Schedule a longer appointment than for a typically developing child.
-Advise parent(s) to bring a couple of favourite toys or foods to offer as a distraction or reward, if needed.
-Consider re-arranging the examination room to accommodate sensory sensitivities (i.e., quiet, with dim lights).

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104
Q

3 approaches to diagnosing ASD?

A

1) Sole pediatric care practitioner using DSM 5
2) Shared care model: clinician + another HCP
3) Team-based approach with multi-D team (sometimes need this for accessing specialized services)

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105
Q

What should the first PCP consider for ASD dx?

A
  • Dev, med, fam, social hx
  • Info from school, child care, community
  • Audiology, vision assessment
  • Direct clinical observation
  • +/-ASD dx tool
  • DSM 5 dx criteria
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106
Q

If peds PCP can confirm ASD dx, next steps? (4)

A
  • Discuss results (with written report)
  • refer for individualized interventions adn community based services
  • Conduct or refer for other assessments as needed
  • Provide fam support services
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107
Q

If peds PCP can’t confirm ASD (dx uncertain), do what next? (4)

A
  • Obtain a second opinion from other ASD specialists
  • Acquire additional info from diff community settings
  • Discuss results (written report)
  • refer for individualized interventions and community-based services if not already done
  • provide fam support
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108
Q

Recommended interval between ASD dx referral and assessment?

A

3-6 mos

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109
Q

3 key objectives of ASD assessment?

A

1-provide categorical dx of ASD
2-explore ddx/co-morbidities
3-determine overall level of adaptive functional and personal interests

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110
Q

8 major elements of ASD dx assessment

A
  • records review
  • interviewing parents, fam members, other caregivers
  • assessment for core features of asd
  • comprehensive phys exam and additional investigations
  • consider ddx and comorbitidies
  • establish the dx
  • communicate the dx findings
  • comprehensive assessment for intervention planning
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111
Q

can findings from an ASD dx assessment tool be used alone to dx ASD?

A

No; they must complement the dx process

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112
Q

Which ASD dx tool is most sensitive

A

ADOS (also same specificity as CARS and ADI-R)

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113
Q

GIve 2 ASD dx tools based on interacting with child

A

ADOS-2, CARS-2

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114
Q

Give 2 ASD dx tools based on not interacting with child

A

ADI-R; SRS-2

also: DISCO, 3di

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115
Q

Which ASD dx tools can be used under age 2?

A

ADOS-2 (12 mos-adult); DISCO (any age)

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116
Q

Which ASD dx tool takes the shortest time? The longest?

A

Shortest: SRS2 (15-20 min); longest ADI-R adn DISCO (up to 3 hours)

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117
Q

Give 5 elements of phys exam for ASD

A
  • ht and wt
  • HC
  • Skin exam for signs of NF1, TS (eg using wood’s lamp)
  • neuro exam
  • cong anomalies and dysmorphic features (large and prominent ears)
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118
Q

2 investigations should be done for all kids undergoing ASD assesment?

A

hearing and vision assessment (with referral to audiology and ophtho/optometry)

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119
Q

Give 5 tests to order for ASD if needed

A 
EEG
MRI
metabolic testing 
chrom microarray
blood lead levels
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120
Q

Give 4 neurodev d/o’s that are in ddx for ASD

A 
ADHD
GDD/ID
Language or learning d/o
social communic d/o
stereotypic movement d/o
tourette's d/o or tic d/o
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121
Q

Give 4 mental/behav d/os in ddx for ASD

A 
anxiety d/os
CD
Selective mutism
OCD
ODD
Also:
depresive d/o's
disruptive mood dyreg d/o
Reactive attachment d/o
Schizophrenia
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122
Q

Give 2 genetic conditions in ddx for ASD

A

Fragile X sydrome
Rett Syndrome
Other genetic variants (16p11)

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123
Q

Give 4 neuro/other med conditions in ddx for ASD

A 
CP
Epilepsy
Mitochondrial d/os
Neonatal encephalopathy
Landau-Kleffner syndrome
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124
Q

ASD is diagnosed __ x more frequently in boys

A

4

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125
Q

3 groups likely to have a later dx for ASD?

A

girls, minorities, children living in rural areas

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126
Q

7 approaches to post-dx ASD management?

A
  • Test for associated med conditions
  • assess/managed co-morbidities
  • other therapies that address ASD_associated functioning
  • Behav/dev interventions
  • manage challenging behaviours
  • CAM approaches
  • Family and other support interventions
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127
Q

what types of etiological testing done for ASD associated med conditions?

A

-phys and neuro exam
-hearing assessment
-vision assessment
-dental assessment
genetic testing if indicated
metab testing if indicated

128
Q

4 co-morbid conditions with ASD that require require reg assessment

A 
GI conditions
nutrition
sleep 
anxiety/depr/other mood issues
ADHD
129
Q

therapies/assessments for ASD-associated functional challenges

A 
SLP
Psycho-educational assessmnet
OT
PT
individualized education supports
130
Q

Behvavioural interventions are based on what approach?

A

applied behavioural analysis (ABA)

131
Q

Give 4 positive features of an effective behavioural intervention program for ASD

A
  • trained/experiences therapists/teachers
  • teachers/therapists supervised by professioals with ++ ASD experience
  • parent are actively involved
  • child’s progress monitored and adjustments made accoridngly

also: use evidence-based protocols
interventions support ongoing child development

132
Q

give 5 things that can increase risk of challneging behaviours in ASD

A
  • communication defs
  • bullying
  • dev changes like puberty
  • physical environemnets
  • changes in daily routines

also: coexisting medical and mental health problems

133
Q

give 3 management strategies for challenging behaviours in ASD

A
  • parenting programs/classes
  • ongoing med tx for co-occurring phs disorder, tx for mental health issue
  • counsel families on interventions regarding phys environment
  • use alternative communication systems for minimally verbal children
134
Q

for challenging behaviours in ASD, meds are __ line

A

second

135
Q

2 meds for ASD pts iwth anxeity

A

fluoextine, sertraline

136
Q

meds for ASD pts with ADHD

A

First-line treatment is with methylphenidate or another stimulant medication. Atomoxetine and alpha-2 adrenergic receptor agonists (e.g., clonidine or long-acting guanfacine) are appropriate alternatives, when combined with parent training in ADHD behavioural management

137
Q

type of medication for ASD pt with depression

A

SSRI

138
Q

sleep med for ASD pt?

A

melatonin

139
Q

strategy if parent of asd pt wants to try complementary /alternative med?

A
  • should not replace conventional asd tx
  • try one tx at a time
  • closely monitor and record outcomes
140
Q

alternative ASD therapies consider to be RISKY and ineffective:

A

hyperbaric o2
chelation
secretin
certain herbal products

141
Q

safe but unproven asd tx

A

vitamin B6, c, d, mg, omega 3 fatty acid, gluten free diet, casein free diet, massage therapy, music therpay, horseback riding, pet therapy, yoga, reiki

142
Q

give 3 online ASD resources

A

autism speaks
autism canada
autism junction

143
Q

8 population who should be vaccinated for flu

A
  • kids 6 mos-59 mos
  • kids over 6 mos with cancer (eg)
  • indigineous people
  • chronic care facility residents
  • pregnant adolescents an women
  • adults>65
  • household contact of person with diabetes (for eg)
  • members of a household expecting birth of a newborn
  • people who provide essential community services
144
Q

why vacc for flu yearly?

A

strain changes

145
Q

what type of vaccine should be used for flu

A

quadrivalent; inactivate influenza vaccine IM or IN live attenuated vaccine…for 2019-2020 season, LAIV in short supply and not available

146
Q

if quadrivalent inactivated influenza vaccine (IIV4) not available, can use what?

A

IIV3 or IIV-Adj (IIV-Adj is ONLY for kids <2 yrs though!)

147
Q

WHEN should you give the flu shot?

A

as soon as avaialble, ideally BEFORE flu season…but can be offered until end of flu season.

148
Q

who cannot receive flu shot?

A
  • hx of anapylaxiss to previous flu shot or to any of the components of the vaccine (except egg)
  • onset of GBS within 6 weeks of flu vaccine without other known cause
149
Q

who cannot get LAIV?

A
  • severe asthma= current active wheezing or currently on oral or high dose inhaled glucocorticosteroids, or medically attended wheezing within the previous 7 days
  • pregnancy
  • chronic ASA therapy
150
Q

dose of flu shot?

A

IIV: 0.5 ml IM
IIV3-Adj: 0.25 ml IM
LAIV4: 0.2 ml = 0.1 ml intranasally in each nostril

151
Q

how do you administer flu shot to patient receiving it for the FIRST time?

A

If <9 yrs of age, admin 2 doses at least 4 weeks apart

152
Q

T or F: canada is the only high income country with universal healthcare not including Rx drugs

A

True

153
Q

give 2 issues with compounding drugs= manipulating adult drug for peds

A
  • can reduce bioavailability
  • can reduce stability
  • can reduce potency
  • can vary from one pharm to another–> inconsistent composition
154
Q

way to fix issues re: compoudning?

A

should approve commercial formulations of pediatric drugs

155
Q

T or F: 50% of pediatrics meds are off-label

A

F; 80%

156
Q

Give 3 recommndations for health canada re: peds drugs

A
  • should have universal comprehensive drug coverage for children and youth
  • federal govn’t should have list of approved pediatric drugs for which all children in canada should have access
  • Health Canada should modernize process for drug approvals and ensure appropriate pediatric labeling for all meds marketed in canada
  • federal govn’t should support pediatric drug trials, cost-effectiveness researach in pediatrics, adn development of commericial pediatric drug formulations
157
Q

2 problems due to increased temp (climate)?

A
  • increased flooding
  • worse wildfires
  • hunting more dangerous
158
Q

3 reasons why kids are disproportionally affected by climate change?

A
  • risk exposure over longer life
  • rapid growth and development
  • metabolize more water, air, food per kg than adults
159
Q

Give 4 climate issues and disease-related consequences

A
  • increased air pollution: worsens asthma
  • ozone depletion: increased risk of melanoma
  • extreme weather: increased homelessness and food shortages
  • contaminated water: risk of Salmonella typhi
160
Q

issues with health canada drug approval

A
  • regulatory norms based on adult data

- HC doesn’t require manufacturers to submit peds data

161
Q

3 issues with off-label drug use in kids?

A

can –> tx failure
prescribing errors
adverse events

162
Q

give 3 issues with compounding meds

A
  • uncertain stability
  • uncertain bioavailability
  • uncertain potency
  • decreased adherence due to poor taste
163
Q

role of Special Access Program?

A

facilitate access to essential medications not marketed in Canada

164
Q

Issue with pricing/reimbursement for drugs in Canada?

A 
No public reimbursement entity is required to consider the unique attributes of
paediatric patients (all based on adult norms)
165
Q

CPS’s goals for Bill C-17?

A
  • require manufacturers to provide additional info, perform new studies and change monographs when significant safety risks are identified…including for off-label uses
  • authorize the import, manufacture, or prep of a product for children when a specific/urgent therapeutic need is identified
166
Q

3 recommendations for HC/Canada’s Minister of Health regarding pediatric medication

A
  • Establish a permanent Expert Paediaric Advisory Board (to advise on regulatory, reimbursement, research activities)
  • Invest in peds drug research
  • Fund development of a national online resource re: prescribing

others:

  • promote development of child-friendly formations
  • solicit and review pediatric-specfic drug data
167
Q

5 ways that physicians can help engage and support families (and give an example)

A

-ASK questions (has anything stressful happened to you or your child since your last visit?)
· Build on each family’s relational strengths (inquire about protective parenting factors, eg: healthy routines)
· Counsel with family-centred guidance (remind parents that parents need regular social and emotional support)
· Develop plans for changing behaviours related to sleep or discipline as needed (eg: for toddlers and up: bedtime routine should be in child’s room and not include screens)
· Educate about positive parenting strategies (eg: no physical punishment)

168
Q

5 key principles for supporting parents

A

MDRRR

  • help them building loving Relationships with children
  • accept that there are Reasons for all behaviours
  • help Mitigate impact of early adverse childhood experiences
  • recognize and respect Differences
  • be aware and informed of Resources for parents
169
Q

Relationship between Adverse Childhood experiences (stressful or traumatic events in childhood) and health risk behaviours and later disease?

A

Early toxic stress puts children at risk for physical, mental, and behavioural problems; absence of mitigating factors compounds such effects…but caring adults can buffer stress and help build resilience!

170
Q

crying = normal for what age?

A

2 weeks- 4 months (peaks at 6-8 weeks)

171
Q

should wait til what age before considering sleep intervention strategies?

A

6 mos (when normal circadian rhythm has developed)

172
Q

first line strategy for sleep issues in kids?

A

parental education!!

173
Q

REDIRECT acronym for behaviours?

A 
Reduce words
Embrace emotions
Describe (without lecturing)
Involve the child in discipline
Reframe a "no" into a "yes" with conditions
Emphasize the positive
Creatively approach a disciplinary situation
Teach
174
Q

should not consider time-out until what age

A

3 yrs

175
Q

Do what for serious misbehaviours?

A

parent management training

176
Q

blood lead level of concern? –> what type of sx?

A

5 mcg/dL; neurological

177
Q

most common sources of lead exposure? (3)

A
  • food and water
  • household dust and soil
  • mouthing products that contain lead
178
Q

4 risk factors for lead poisoning?

A

-sibling with history of lead poisining
-PICA
-immigrated from country where population lead levels higher than those in canada
-lived in a house built before 1960
..also think of infants born to moms with exposure or lack divalent minerals during pregnancy also well as kids with ASD and those living in poverty

179
Q

3 sx associated with lead exposure?

A
  • asymptomatic
  • cognitive delay
  • inattention
  • hyperactvity
  • hearing impairment
  • poor balance
  • speech delay
180
Q

6 tests to order for lead poisoning?

A

Mnemonic- Cognitive Concerns? Advise Poke For Lead

Lead level (venous)
CBC
ferritin
calcium
protein
albumin
181
Q

gold standard for recent lead expsoure?

A

blood lead level

182
Q

does a low BLL rule out lead as contributing factor to sx?

A

No (could have had higher level earlier)

183
Q

at what age does BLL peak?

A

2-3 yrs

184
Q

10 qs to ask for lead expsoure?

A
  • House build before 1960?
  • Building where child spends time in poor state of repair?
  • exposure to candles?
  • expsoure to costume jewelry?
  • diet include wild game shot with lead bullet?
  • family uses food containers made or pewter or ceramic?
  • history of pottery glazing?
  • history of demolition/renovations?
  • sibling with lead exposure?
  • previously lived in country with higher population lead levels?
185
Q

tx for lead toxicity?

A

chelation therapy

186
Q

3 long term consequences of lead expsoure

A

Htn
Renal impairment
Aberrant behaviour
Vascular disease

187
Q

Do what if lead level 5-14 mcg/dl? (7)

A
  • review labs with fam
  • neurodev screen and nutrition assessment
  • take exposure history to ID source
  • contact public health
  • retest in 1-3 months to make sure not climbing; if same or better retest in another 3 mos
  • provide nutritional counselling re: ca and Fe; eg fresh frruit with meals to promote fe absorption; do IDA testing
  • complete full neurodev assessment and follow-up
188
Q

do what if lead level 15-44?

A
  • all same steps as for 5-14
  • repeat in 1-4 weeks
  • consider abdo xray +/- gut decontamination +/- poison control
189
Q

do what if lead level 45+?

A
  • same as for 15-44
  • repeat in 48 hours
  • consider hospitalization for chelation therapy
  • mitigate expsoure at home
190
Q

about what % of babies <33 weeks GA have IVH or PVL?

A

21% (about 1/5)

191
Q

nowadays, cystic or non-cystic PVL becoming more common?

A

non

192
Q

crirtical window of acute preterm injury?

A

first 72 hours

193
Q

in terms of neuroprotection, need to consider what if mother has PPROM?

A

if <33 weeks GA, give mom penicllin + macrolide (or macrolide alone if pen allergy)

194
Q

in terms of neuroprotection consdieratons, 3 reasons for careful evaluation fo baby, blood cx, empiric antibx?

A
  • suspected chorio
  • PPROM
  • preterm labour
  • unexplained onset nonreassuring fetal status
195
Q

give an independent RF for IVH or intraparenchymal hemorrhage

A

ROM >72 hours

196
Q

which mother should get antenatal steroids?

A

GA <35 weeks

should be within 7 days of delivery (ideally greater than 48 hours between last dose and delivery)

197
Q

which moms get mgso4?

A

33 weeks or less GA (if expect to delivery within next 24 hours)

198
Q

benefit of MGSO4?

A

decreases CP risk, composite death

199
Q

only clear indication for C/S?

A

breech

200
Q

recommendation for delayed cord clamping?

A

all infants NOT needing immediate resuscitation: do this for 30-120 sec

201
Q

when would you do umbilical cord milking?

A

only if can’t do delayed cord clamping

202
Q

neg consequences of hypothermia at delivery? (2)

A

impairs resuscitaton; increased risk of acute brain injury; increased risk of death

203
Q

gestational age at which polyethylene bag recommended for newborn?

A

under 32 weeks

204
Q

in addition to polyethylene bag, 4 other things to keep baby warm?

A

thermal mattress
preheated radiant warmer
hat
keep delivery room at 25-26 degrees C

205
Q

2 definitions of low BP in neonate?

A

mean arterial blood pressure less than the infant’s GA or <30 mmHg for two consecutive measurements.

206
Q

why should avoid ionotropes for treating low BP in neonates if possible?

A

associated with brain injury, IVH, death

207
Q

for neonates, avoid giving ionotropes unless what other clinical criteria satsifeid?

A

elevated lactate
prolonged cap refill time
decreased UO
low cardiac output

208
Q

before starting ionotropes should consider what two iatrogenic causes of low BP?

A

lung hyperinflation or dehydration…so first you should conisder CXR adn a slow fluid bolus

209
Q

spont PDA closure in most babies by what DOL?

A

3

210
Q

ppx indomethacin for PDA: give only to whom?

A

extreme prems; in consideration of antenatal steroids, birth site

211
Q

risk of large PDA?

A

brain injury

212
Q

risk of COX inhibitor?

A

renal disease

213
Q

goal PCO2 to avoid PVL adn IVH? which happens at which level?

A

aim between 45-55 mmHg
PVL happens <35
IVH happens >60

214
Q

what type of ventilation should you use in prem babies in first 72 hours of life?

A

volume-targeted

215
Q

describe ideal head positioning for newborn prem in first 3 days of life

A

neutral, midline, Head of bed elevated to 30 degrees

216
Q

give an independent RF for acute brain injury in prem < 33 wks

A

transport…better to transport mom before delivering…if can’t make sure mom receives appropriate mgso4 and steroids at her centre

217
Q

elements of environment that can promote neuroprotection?

A 
skin-to-skin
maternal voice
interaction
light cycling
low noise
early parenteral nutrition
218
Q

give 8 states–> immunocompromised

A
  • within 2 yrs of HSCT or still on immunosuppr drugs
  • s/p solid organ transplant
  • any current or recently treated malig
  • aplastic anemia
  • asplenia
  • HIV with CD4+ count <200 if kids 5y + or 15% in kids <5 yr
  • SCID
  • high dose steroids= 2 mg/kg of BW or at least 20 mg/day of pred or equivalent in kids >10 kg when given for >2 weeks
  • antimetabolites like azathioprine
  • transplant-related drugs like tacrolimus, cyclosporine, MMF, sirolimus
  • chemo
  • biologicals like MABs, etanercept
219
Q

2 things important re: vaccines in immunocomp kids

A
  • no live vaccines

- stay up to date!

220
Q

5 times immuncomp kid should wash hands

A
  • before eating
  • after urinating/defecating
  • after touching plants or soil
  • after collecting/depositing garbage
  • after touching animals

also:
After touching body fluids or excretions or items that may have had contact with human or animal feces (eg: clothing, toilets) & after being in any environment outside the home

221
Q

5 ways to prevent resp tract infections

A
  • avoid sick people
  • avoid crowded places during flu season
  • avoid exposure. to tobacco smoke
  • avoid marijuana
  • notify HCP when household member has flu)

also:
- notify HCP at first signs of resp illness during flu season
- minimize exposure to reno sites
- minimize inhalation of fungal spores from plants and animals

222
Q

waterborne illnesses for which immunocomp people at risk?

A

cryptosporidium, giardia, gram negative bacteria

223
Q

3 ways to avoid waterborne illness in immunocomp people?

A

-avoid hot tubs
-avoid swimming in contaminated water
-avoid well water
also:
-don’t drink tap water if boil water advisory in effect
-if suboptimal sanitation, only drink bottled or boiled water
-avoiding drinking from lakes, ponds
-

224
Q

3 ways to avoid foodborne illness?

A
  • avoid raw meat, eggs, seafood
  • only consume milk, fruits, veg, cheese that have been pasteurized
  • wash produce thoroughly
  • avoid cross-contam while cooking
225
Q

reptiles and frogs associated with what pathogen?

A

salmonella

226
Q

give the associated pathogen: chicks and ducklings

A

salmonella

227
Q

give the associated pathogen: rodents

A

lymphocytic choriomeningitis virus

228
Q

give the associated pathogen: kittens

A

bartonella henselae= cat scratch disease

229
Q

give the associated pathogen: cats

A

toxoplasma gondii

230
Q

give the associated pathogen: puppies, kittens, chicks

A

campylobacter

231
Q

fish tanks

A

mycobacterium marinum

232
Q

3 pieces of advice to avoid illnesses from animals in immunocomp people

A
  • wait to acquire new pet until child less immune suppressed
  • avoid contact with ill animals
  • avoid cleaning cages
also:
avoid strays
have pet see vet asap
wash hands after touching
avoid contact with aquariums
inspect areas with raccoons
233
Q

give the associated pathogen: raccoon

A

Baylisascaris proyonis

234
Q

3 pieces of advice when traveling for immunocomp people

A
  • get travel vaccines
  • proper hand hygiene on planes
  • also can give child “health passport” with their meds, immunization, health info, HCP contact info
235
Q

3 ways to prevent insect bites

A

DEET, protective clothing, netting

236
Q

3 ways to prevent STIs

A

condoms
hep B, HPV vaccine
fewer sex partners
education

237
Q

3 benefits of screen time adn digital media in school aged children

A
  • improve academic performance
  • 1 hr per day: lower depression
  • way to socialize (through games)

also: helps with friendships; can be immersive/informative

238
Q

3 risks of screen time in school-aged kids

A
  • higher screen time–> more depression
  • multitasking–> disrupts reading efficiency
  • inappropriate for age–> negative behaviour

also: can be associated with conduct disorder

239
Q

for teens: recommend how much screen time per day?

A

2-4 hours

240
Q

3 benefits of digital media/screen time in teens

A
  • validating experience
  • improve socialization for socially anxious teens
  • fulfills “need to belong”

also:
- mod screen use–> sense of life satisfaction
- game play: increase attention

241
Q

3 risks of digital media in teens

A
  • excessive use associated with depression
  • decrease family connectedness
  • more likely to take risks online

also:

  • need parental awareness to avoid excessive use/risky behaviours
  • neg content associated with anxiety, depression
  • media multi-taking: lower sustained attn, etc
  • if>50% game play, neg effects of well-being, conduct
242
Q

3 neg health impacts of digital media

A
  • distraction while driving
  • worse sleep quality if screen in bedroom
  • wt gain if snacking while viewing
  • repetitive use injuries
  • eye strain
243
Q

2 health benefits of digital media

A
  • wii boxing–> increase phys activity

- some track your phys activity

244
Q

4 M’s to counsel digital media use (+ egs)?

A

1- Manage screen use: eg learn parental controls
2- meaningful screen use: educational activities
3- model health use: parents should review own habits
4- monitor for problematic use: eg: oppositional behaviour in response to limits of use

245
Q

3 consequences of teen parenting?

A
  • lower lifetime educational achievement
  • lower income
  • increased reliance on social support programs
246
Q

what type of contraception to teens tend to use? failure rate?

A

SARCs. failure rate 6-9 % (vs <1% for LARC)

247
Q

% unintended pregnancies in women <20?

A

> 70%

248
Q

% of teens 15-19 who always use birth control and don’t want to become pregnant?

A

74.2%

249
Q

most important barrier to accessing contraception?

A

cost! CPS supports no-cost contraception for all women of reproductive age!

250
Q

2 ways to increase adherence to contraception?

A
  • PROVIDE rather than prescribe 1 yr of contraception

- start PO/injectable contraception immediately rather than wait for menses

251
Q

4 contraception related recommendations of CPS for Helath Canada

A
  • all contracpetives should be covered for free–> age 25
  • free contraception for community based helathcare services
  • if public-private helathcare model, require insurers cover whole cost –> age 25 and allow for protection of patient’s confidentiality from parents/primary policy holder
  • continue to cover costs –> age 25 even if contraception becomes OTC
252
Q

3 most common clinical prsentations of invasive group A strep?

A
  • necrtoizing fascititis or myositis
  • bacteremia with no septic focus
  • pneumonia
  • TSS
253
Q

2 populations most affected by invasive GAS?

A

kids <5 and elderly

254
Q

main risk factors for invasive GAS in kids (3)?

A

varicella, recent pharyngitis, recent soft tissue trauma, NSAID use

255
Q

True or false: invasive GAS is reportable across Canada

A

True

256
Q

How to confirm case of invasive GAS?

A

Isolation of group A streptococcus (GAS) from a normally sterile site, with or without clinical evidence of severe invasive disease).

257
Q

Critieria for Severe invasive GAS? (6)

A
  • Strep TSS
  • Soft tissue necrosis
  • meningitis
  • pneumonia with isolation of GAS from sterile site such as pleural fluid (NOT including BAL)
  • a combination fo the above
  • any other life-threatning condition –> death
258
Q

critiera for TSS?

A 
-Hypotension (<90 for adults or <5th percentile in kids) and at least 2 of the following:
renal impairment (creatinine at least 2x ULN for age or 2x patient's baseline), coagulopathy (plts 100 or lower or DIC), liver function abnormality (transaminases or total bili at least 2x ULN), ARDS, generalized erythmetous macular rash taht may later desquamate
259
Q

4 examples of non-severe invasive GAS?

A
  • bacteremia
  • cellulitis
  • wound infections
  • soft tissue abscesses
  • lymphadenitis
  • septic arthiritis
  • osteomyelitis
  • no evidence of strep TSS or soft tissue necrosis
260
Q

what’s considered soft tissue necrosis for GAS?

A

Nec Fasc
myositis
gangrene

261
Q

how can you try to differentiate polymicrobial or clostridial nec fasc from that associated with GAS?

A

GAS: more likely associted with gen rash, phayrngitis, conjunctiviits and/or strawbery tongue; polymicrobial or clostridial nec fasc comes more with crepitus

262
Q

tx for TSS?

A

Clox + Clinda +/- Vanco if think MRSA….or for kids and really think GAS: pen + clinda….pen= tx of choice for confrimed GAS

263
Q

for nec fasc not clearly due to GAS, what’s a good empiric regimen?

A
  • pip/tazo + clinda
  • carbapenem in combo with clinda
  • +/- vanco or MRSA
264
Q

true or false: GAS has some resistance to pen

A

false (but some to clinda!)

265
Q

other treatment for TSS or severe GAS (in addition to antibx)

A
  • fluids
  • IVIG (150-500 mg/kg/day x 5-6 days or single dose of 1-2g/kg)
  • surgical debridement
266
Q

4 egs of close contacts for GAS?

A
  • Household contacts who, within the previous 7 days, have spent at least 4 h per day on average or a total of 20 h with the IGAS case
  • non household persons who have shared a bed with the case or had sexual relations with the index case
  • direct contact with mucuoous membranes or secretions of index case (or unprotected direct contact with skin lesion)
  • IVDU who have shared needle
  • contacts in child care settings
  • selected contacts in hospital and long-term care settings
267
Q

advice for close contacts fo IGAS?

A

disclose signs and sx of IGAS to watch out for within 30 days of dx of the index case

268
Q

who gets chemo ppx for IGAS?

A

close contacts of a confrimed case of SEVERE IGAS, who were exposed during the period of 7 days before sx –> 24 hours after initiating antibx

269
Q

start chemo ppx for IGAS wehn?

A

ASAP, preferable within 24 hours of identifying the case *up to 7 days after last contact with index case)

270
Q

what if member of family or home-based daycare gets severe IGAS?

A

give ppx to everyone (BUT NOT THE SAME FOR INSITUTIONAL CHILD CARE CENTERS AND PRESCHOOLS)

271
Q

first line ppx for IGAS?

A

cephelxin, cefadroxil (works for pregnant women too)

272
Q

ppx vs. IGAS for preg woman with beta lactam allergy?

A

clinda

273
Q

other than clinda, other 2nd line for IGAS ppx?

A

clarithryomycin

274
Q

should you culture asymptomatic contacts of cases with IGAS?

A

no

275
Q

T or F: IGAS has decreased over past decade

A

false (increased)

276
Q

T or F: all Vaccine preventable diseases are reportable

A

true

277
Q

red flags for vaccine preventable diseases (3)

A
  • potential expsoure history
  • delayed/incomplete vaccines
  • immigrant or refugee children
278
Q

polio symptoms/sign?

A
  • most no sx

- 1% paralysis (preceded by sore throat, fever, +/- stiff neck)

279
Q

test for polio how?

A

stool sample or throat swab

280
Q

where is polio endemic?

A

afghanistan, pakistan

281
Q

4 signs of measles

A

cough, coryza, MP rash descending, koplik spots, high fever

282
Q

4 complciations of measles?

A

OM, pneumonia, encephalitis, death

283
Q

if newborn has unexplained cataracts need to rule out what?

A

rubella

284
Q

4 signs and sx of rubella?

A 
cataracts
HSM
deafness
microcephaly
ragged/streaky bones on xray
285
Q

signs and sx of diphtehria?

A
  • sore throat,
  • weakness
  • fever
  • rapid progression of neck swelling
286
Q

diptheria toxin can damage which areas?

A

CNS, heart, kidneys

287
Q

name a VPD not related to travel or herd immunity

A

tetanus

288
Q

give VPD where vaccine failure is common

A

mumps

289
Q

mumps prodrome?

A

h/a, myalgia, low grade fever

290
Q

5 complications of mumps?

A

MOPE

  • orchiditis
  • mastitis
  • pancreatitis
  • meningitis
  • encephalitis
291
Q

will tetanus ever be eradicated?

A

no

292
Q

test for measles how?

A

serology, NPS, urine sample

293
Q

test for congenital rubella how?

A

serology, throat swab, NPS, urine

294
Q

give two vaccine preventable diseases that are clinical dx?

A

diptheria, tetanus

295
Q

test for mumps how?

A

urine, serology, NPS

296
Q

rate of HIV transmission for mom receiving antiretroviral therapy?

A

<2 % (otherwise 25%)

297
Q

RFs for transmitting HIV to baby? (3)

A
  • late or no prenatal care
  • IVDU
  • recent illness suggestive fo seroconversion
  • reg unprotected sex with partner known to have HIV
  • dx with STI during pregnancy
298
Q

highest risk of transmitting HIV to baby when? (2)

A
  • during delivery

- BF’ing

299
Q

First test for HIV in pregnant mom?

A

antibody test= enzyme immunoassay

300
Q

if first test for HIV in mom (enzyme immunoassay is positive), then do what next test?

A

Western blot for HIV antibodies (to confirm)

301
Q

When do you use DNA/RNA PCR for HIV testing? (2)

A
  • test infection in newborn

- quantify viral load

302
Q

-what if mother in labor has unknown HIV status?

A

rapid testing! if positive, start intrapartum and postnatal ppx ASAP pending confirmatory test

303
Q

what if mother in labour refuses HIV testing?

A

newborn must undergo rapid HIV antibody testing

304
Q

what if mother refuses own testing for HIV and for baby?

A

call child protective services

305
Q

what if mother or infant has positive HIV test?

A

infant ART ppx should be started immediately, and no later than 72 hours after delivery; delay BF’ing until have negative HIV confirmatory test

306
Q

what if can’t do rapid HIV test on baby?

A

consider starting ART pending results

307
Q

what if mother or newborn tests positive for HIV antibody (identifying exposure)?

A

infant should be tested ASAP for INFECTION by HIV DNA or RNA PCR within 48 hours of birth if possible

308
Q

what if newborn’s HIV PCR is positive?

A

stop ppx adn start antiretroviral treatment (call ID)

309
Q

what if seronegative preg or breastfeeding woman is suspected of having acute HIV?

A

do VIROLOGIC test eg: HIV RNA PCR or antigen test (will become positive before antibody test)

310
Q

2 short term effects of HIV

A

anemia

neutropenia

311
Q

2 long term consequences of HIV

A

decreased growth

worse neurodevelopment

312
Q

for infant in foster care who birth mother’s HIV status not known, do waht?

A

HIV ab testing

313
Q

5 common food allergens in kids?

A 
cow's milk
egg
peanut
tree nuts
fish
shellfish
wheat
soy
314
Q

2 RFs for food allergy

A
  • history of atopy

- first degree relative with atopy

315
Q

introduce common allergic solids when for high risk infants?

A

4-6 mos

316
Q

for infants at low risk for allergy introduce complmentary foods when?

A

6 mos

317
Q

3 tips for introducing foods to infants?

A
  • allergic foods should be introduced one at at ime (no delay needed in btwn)
  • if tolerating common allergic food, offer it a few times a week to maintain tolerance
  • ensure texture and size are age-appropriate to prevent choking

CPS Statements (1 decks)

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