CPS Statements

Question 1

Special considerations for the health supervision of children and youth in foster care

Answer 1

• Screen for chronic medical conditions, mental health conditions, behavioural problems + school problems
  
  • +/- Vision, hearing, dental, psychoed
• Consider (not routine): CBC, ferritin, lead, hep B+C, HIV, bHCG, STIs
• Need to see more frequently
• Advocate for permanency planning

Question 2

A bite in the playroom: Managing human bites in child care settings

• How do you clean the wound?
• Hep B considerations
• When do you give ABx ppx?

Answer 2

• Children cannot be excluded from day care b/c of HBV, HCV, or HIV infection
• Clean wound
  
  • If skin not broken: soap + water, cold compress, soothe
  • If skin broken: don’t squeeze if bleeding, soap + water, mild antiseptic
• Hep B: very low risk of transmission > HCV > HIV
  
  • If unknown HBV status of biter + bitten -> vaccinate both
  • If unknown HBV status of one, non-immune status of other -> vaccinate non-immune child (or both)
  • If one is HBV carrier, other is non/incompletely immune
    
    • HBIG + vaccinate the non-immune
    • F/U to complete vaccine series and in 6mo for HBV serology
• Review + update tetanus
• ABx ppx if
  
  1. Moderate to severe tissue damage
  2. Deep puncture wounds
  3. Bites to face, hand, foot, or genital area that are more than simple superficial abrasions

Question 3

A case-based update of PALS: The 2010 paediatric basic and advanced life-support guidelines

A. Asystolic cardiac arrest

B. VFib

C. Wide complex tachycardia

D. Septic shock

Answer 3

A. Asystolic cardiac arrest

• C-A-B
• 30:2 single rescuer
• 15:2 two-rescuer CPR if infant/child
• If advanced airway: 100bpm to 10 breaths/min
• Effective CPR: push hard, push fast, allow recoil, minimize interruptions, avoid excessive ventilation
• If art line in place, can use to monitor CPR effectiveness
• Capnography can be used to confirm ETT placement and monitor CPR quality + ROSC

B. VFib

• If unresponsive and apneic/gasping, start CPR (no look, listen, feel)
• LImit pulse check to 10s
• Infants manual defibrillaotr > AED with pediatric dose attenuator (up to 8yo or 25kg) > standard adult AED without dose attenuator
• Use amiodarone or lidocaine for shock-refractory VF or pulseless VT
• Consider standard dose epi as vasopressor during cardiac arrest
• Consider ECPR (CPR + ECOM) if known cardiac Dx with in-hospital arrest
• Post-ROSC
  
  • Target SpO2 94-99%
  • Maintain SBP >5%tile for age
  • If comatose post-ROSC, consider therapeutic hypothermia (T32-34 x2d + T36.5-37.5x3d) OR continuous normothermia x5d
  • EEG in first 7d post cardiac arrest (pronosticate neuro outcome)
  • No sz ppx, but treat clinical sz

C. Wide complex tachycardia

• QRS > 0.09s (each small box = 0.04s)
• Can be ventricular or supraventricular in origin
• Give adenosine in stable pts with regular, monomorphic QRS to distinguish VT vs SVC
  
  • DO NOT give if known WPW
• Resusc doses based on actual body wt (not ideal body wt)

D. Septic shock

• Rapid bolus 20mL/kg crystalloid as initial choice
• Don’t use etomidate routinely b/c adrenal suppression
• Consider cuffed tubes to decrease risk of aspiration + reintubation
• Cuffed tube
  
  • If <1yo: use 3.0mm internal diameter tube
  • If 1-2yo: use 3.5mmID
  • If >2yo: ID = 3.5 + (age/4)
• Uncuffed = cuffed + 0.5mm
• No point of cricoid pressure

Question 4

A harmonized immunization schedule for Canada: A call to action

Answer 4

• Safer + less costly
  
  • Better prices for bulk purchases
  • More cost-effective translation into different languages
  • Simiplied educational info for HCP + parents
  • Introduce vaccines in coordinated fashion
• Harmonized core schedule would not preclude prov/terr from enhancing its program for a vaccine not yet universally recommended by National Advisory Committee on Immunization (NACI)

Question 5

Acute management of croup in the emergency department

• What 5 signs reflect croup severity?
• What are 3 red flags for more serious conditions?
• What are 3 therapies I can give?
• What has no evidence? (3)
• When can I D/C?
• When do I admit?
• When do I consult ENT?

Answer 5

• Croup severity: 1) CNS hypoxia, 2) barky cough, 3) stridor, 4) indrawing, 5) cyanosis
• Red flags: 1) toxic, 2) drooling, 3) dysphagia
• Therapies
  
  1. Dex 0.6mg/kg/dose PO/IM for all. Improve within 2-3H, persists for 24-48H. Fewer admissions + return visits
  2. Neb epi: for mod-severe croup. Can reduce intubation. Need to monitor for 2-3H post
  3. Heliox: for severe croup. Avoid intubation. Not routine
• No role for 1) humidified air, 2) ABx, 3) ventolin
• Discharge home
  
  • Immediately w/o observation if mild Sx
  • If mod-severe, then observe 2-4H until mild Sx
• Admission
  
  • Ward if steroids >=4H ago + still has mod resp distress, stridor at rest, indrawing. No agitation or lethargy.
  • ICU if recurrent severe episodes of agitation/lethargy, severe resp distress not responsive to Tx
• ENT consult
  
  • Now to assess a/w persistently severe despite Tx
  • Outpt if multiple croup episodes or outside age range (3mo-6yo)

Question 6

Acute Otitis Externa

• What are 10 RFs for AOE?
• What is malignant otitis externa? How does it present?In what population? What do I do?
• How do I counsel about preventing AOE?

Answer 6

• 10 RFs
  
  1. >2yo
  2. Swimming
  3. Chronic otorrhea
  4. Trauma
  5. FB in ear
  6. Hearing aid
  7. Tight head scarves
  8. Certain dermatological conditions
  9. Immunocompromised
  10. Ear piercing
• Malignant otitis externa
  
  • Invasive infection into cartilage + bone of canal + external ear
  • Facial nerve palsy + pain
  • Immunodeficient + insulin-dependent diabetes
  • CT/MRI to confirm Dx, aggresive debridement, systemic ABx for p aeru + staph
• Prevention
  
  • Avoid moisture (soft ear plugs)
  • Avoid trauma (no cotton swabs)

Question 7

Addressing vaccine hesitancy in immunization programs, clinics and practices

• What are the 5 recommendations for HCPs?

Answer 7

1. Detect and address vaccine hesitant subgroups
   
   • Different reasons for different groups
2. Educate all HCPs with consistent and accurate information about vaccine safety and benefits
   
   • Best practices; the specific and serious risks of vaccine-preventable diseases; possible vaccine SEs; Canada’s adverse event surveillance systems; the importance of clear language, ‘framing’ (i.e.,presumptive versus participatory approaches) and motivational interviewing techniques; and pain mitigation strategies
3. Use evidence-based strategies to increase vaccine uptake
   
   • make vaccine services more convenient + accessible
   • remind parents by text/email/mail
   • minimize immunization pain
   • Consider mandates +/ incentives for immunizations
4. Educate children, youth + adults on importance of immunization for health
5. Work collaboratively across provincial/territorial jurisdictions and with the federal government, NGOs, community leaders and health services
   
   • Only Christian Science specifically does not support immunization and even this is not rigid

Question 8

ADHD in children and youth

Part 1—Etiology, diagnosis, and comorbidity

• How common is ADHD?
• What is the etiology of ADHD? (3)
• What are the 6 predictors for persistence into adol/adult?

Answer 8

• Common MH disorders: 1) depression, 2) anxiety, 3) ADHD
• Etiology: 1) genetics (most important), 2) neuro, 3) envo
• Predictors for persistence:
  
  1. combined inattention/hyperactivity
  2. increased Sx severity,
  3. comorbid MDD or other mood disorder
  4. high comorbidity (>3 additional DSM d/o)
  5. parental anxiety
  6. parental antisocial personality d/o

Question 9

ADHD in children and youth

Part 1—Etiology, diagnosis, and comorbidity

• How do we diagnose ADHD?
• What conditions are commonly misdiagnosed as ADHD? (8)
• What conditions are comorbidities? (8)

Answer 9

• ADHD Dx
  
  • DSM5 - multiple settings + lead to impairment in everyday activities
  • Only Conner’s Comprehensive Behaviour Rating scale + ADHD Rating Scales IV have been validated in pre-schoolers
  • No routine labs, genetic tests, EEG, or neuroimaging
  • Don’t order psychological, neuropsychological, or SLP assessments
  • Don’t use psychological tests (TEACH, CPT) or measures of executive fxn to Dx ADHD +/ monitor Sx + functional improvement
• DDx (decreasing frequency). Also the comorbidities
  
  1. Learning d/o - most common comorbid condition
  2. Sleep d/o
  3. ODD
  4. Anxiety d/o
  5. ID
  6. Language d/o, mood d/o, tic d/o, conduct d/o
  7. ASD
  8. DCD

Question 10

ADHD in children and youth

Part 2—Treatment

• What non-pharmacological interventions have evidence?
• When do I start medications?
• Stimulants
  
  • What are the benefits for stimulants? (3)
  • What are the classes?
  • What formulation should I start?
  • When do I see a response?
  • What do I need to do before starting?
  • What are the SE? (9)
  • What are causes for poor adherence? (3)
• Non-stimulants
  
  • When are these indicated? (3)
  • Which ones are there? (3)
  • What is their benefit?
  • What do I need to do before starting?
  • What are the SE? (9) Specific for each drug?
• What medications should I start if substance use disorder?

Answer 10

• Non-pharm
  
  • Start psychoeducation plan first, then add non-pharm + pharm as needed
  1. Parents: Parent based training - 1st choice for preschoolers
  2. School: Classroom management, daily report card
  3. Child: Organizational skills training, Behavioural peer interventions, Physical exercise
• Pharm Indications:
  
  • Behaviours + social interactions impaired by impulsivity/hyperactivity
  • Learning or academic performance impaired by inattention
• Recommendations
  
  • Before starting, set goals + target outcomes focused on Sx reduction + improved functioning to guide Tx plan
  • Use standardized checklists to monitor Tx response. Need >=2 settings + direct input from school.
• 1st line: Stimulants
  
  • Benefits
    
    • Improved QoL + academic achievement
    • Fewer morbidity + mortality related to motor vehicle injuries
    • Lower anxiety + depression
  • Methylphenidate vs dextroamphetamine classes
    
    • Both have short, medium, + extended release formulation
    • Start in either. Try a different drug in same class before swtiching to the other
  • First line: extended release
    
    • Better adherence b/c once-daily
    • Less likely diverted for recreational use
    • Last 6-13H
  • Immediate release if cannot tol ER (e.g. preschooler) or short-term attention + behavioural goals
  • Should see response in 2-4wks. Titrate Q1-2wks to lowest effective dose, then Q1mo to monitor.
    
    • May need to increase dose initially b/c “upregulation” of liver enzymes that catabolize stimulants -> tachyphylaxis
  • Determine baseline SE Sx before starting
  • No need for routine preTx ECG. Do thorough H+P to screen risk
  • SE
    
    1. Increase HR + BP
    2. Appetite suppression - most common
    3. Sleep
    4. Moodiness
    5. Irritability
    6. Tics (not increased vs untreated, not a contraindication)
    7. Vasculopathic Sx (Raynaud’s)
    8. Psychosis (rare)
    9. PRiapism (rare0
  • Reasons for poor adherence: 1) SE, 2) older age, 3) learning, mood or behavioural comorbidity
• 2nd line: Non-stimulants
  
  • Used wehn stimulants are 1) contraindicated, 2) ineffective, 3) not tolerated
  • Atomoxetine (Straterra) + guanfacine chlorohydrate XR (Intunivr) approved for 6-17yo with ADHD. Adjunct or monotherapy.
    
    • Intuniv if ADHD + comorbid ODD
  • Clonidine not currently approved by Health Canada for ADHD
  • Benefit: Lower potential for abuse vs stimulants
  • Monitor BP at start and regularly
  • Do not need baseline liver function tests unless Sx
  • SE
    
    1. GI Sx (abdo pain, decreased appetite)
    2. Somnolence
    3. H/A
    4. Moodiness
    5. Irritability
    6. SI (rare)
    7. Hepatic disorder (rare)
    8. Raynaud phenomenon
    9. Dose-dependent prolongation of QTc
    • Straterra (norepi reuptake inhibitor): increase BP + HR
    • Intuniv: sedation, somnolence, fatigue. Orthostatic hypotension, bradycardia, syncopal episodes
    • Clonidine: sedation, dizziness, hypotension. (all more than Intuniv)
  • Counsel about risk of rebound HTN (even HTN encephalopathy) if stop guanfacine or clonidine abruptly
• SUD
  
  • Non-stimulant or ER stimulant for lower risk of abuse + diversion

Question 11

ADHD in children and youth

Part 3—Assessment and treatment with comorbid ASD, ID, or prematurity

Answer 11

• ADHD + ASD
  
  • 50% with ADHD have ASD and vice versa
  • More severe behavioural problems that either d/o alone
  • Comorbid psych disorders more prevalent
  • Genetic syndromes: fragile X, tuberous sclerosis, 22q11 deletion, Williams syndrome
  • 1st line for meds: psychostimlants
    
    • More likely to be non-responders + have SE
    • Most common SE: irritability with emotional outbursts
  • Guanacine significantly reduced Sx
  • No role of antipsychotics for ADHD
• ADHD + ID
  
  • ADHD is most common comorbidity with ID
  • Psychological tests cannot Dx ADHD, but can evaluate ID
  • More severe ADHD Sx, harder to Tx
  • Higher rates of agitation/aggressive behaviours + conduct problems
  • 50% of ID assoc’d with chormosomal, metabolic, or neuro conditions
  • 1st line: psychostimulants
  • 2nd line: nonstimulants
  • If functionally disabling behaviours are not responsive to behavioural + ADHD med Tx: consider neuroleptics (Risperidone) cautiously
• ADHD + Prematurity
  
  • 50% of extrem prem or ELBW have developmentl d/o
  • Cognitive impairment is most common disability
  • “Preterm behavioural phenotype”: inattention, internalizing d/o (anxiety, depression, withdrawal, somatic complaints), socail difficulties
  • Follow same protocols as for term b/c not studied for prems specifically
• Recommendations
  
  • ASD, ID + prem have increased risk of ADHD + greater impairment
  • F/U programs to monitor developmental, cognitive + emotinal outcomes at least until school entry, preferably until children are integrated + adapted into school with stable academic performance
  • Dx requires multidisciplinary approach
  • Psychostimulant is first line med as part of comprehensive Tx program
  • SE of ADHD meds more common in ASD + ID
  • Positive role for regular physical activity mitigating ADHD Sx

Question 12

Extended release meds for children with ADHD

Answer 12

• Recommend XR as first line - preferred by both families + physicians
• H/e ADHD disproportionately diagnosed in children from low SES, so XR meds may not be affordable
• XR are not necessarily more efficacious (how well a Tx works under tightly controlled study conditions) than IR but is more effective (how well a Tx works in the real world)
• Benefits of XR:
  
  • better adherence
  • less likely to switch if started
  • lower risk of ER visit for injury
  • fewer and shorter hospitalization for injury
  • don’t have to take at school (less stigma, less issues with school storing + administering controlled drugs)
  • Less misuse/diversion potential than immediate release

Question 13

Adolescent Pregnancy

• What is the trend of teen pregnancies?
• What is the rate of abortion?
• What is a major cause of pregnancy complicaitons in teens?
• What do I need to screen for?
• What to counsel about options?
• How to prevent teen pregnancies (3)
• Which high risk teens are at high risk of pregnancy + need contraception counselling? (7)

Answer 13

• Rates of teen decreasing in last decade
  
  • Highest in 18-19yo
  • 50% end in induced abortion
• Poor prenatal care is major cause of pregnancy complications (early detection is challenging)
• Important to screen for: 1) current supports, 2) explore options, 3) physical + emotional health, 4) substance use, 5) housing, 6) school
• Maternal mortality from pregnancy + its complications is much higher in this age group thn mortality from surgical abortion
• If want to continue the pregnancy, refer to maternity homes + support groups
• Continue school to improve maternal+child outcome + reduce depression
• To prevent teen pregnancies: 1) ensure good F/U, 2) mulitple options for contraceptives, 3) life-skills training
• Counsel high risk teens about contraception
  
  1. Previous pregnancies
  2. Siblings who got pregnant as teens
  3. Early puberty
  4. Social difficulties
  5. School abseenteeism
  6. Substance use
  7. Living in group home/detention centre

Question 14

Adolescent sexual orientation

• What are gay + lesbian teens at higher risk of? (6)
• What are the infectious risks of unprotected anal intercourse? (5)
• What work up for gay men? (5)

Answer 14

• Higher risk
  
  1. Assault b/c of orientation
  2. Smoking
  3. Substance use
  4. Attempting suicide
  5. STIs
  6. More likely to have sex, more sexual partners
• Do not disclose information about orientation to parents without teen’s consent, even in cases of suicidal ideation
• Unprotected anal intercourse
  
  • 1) HIV, 2) HPV, 3) Hep A 3) B 4) C, 5) parasites
• Work up for gay men
  
  • 1) chlamydia, 2) gonorrhea, 3) anal cytology, 4) HIV, 5) stool studies
• Counsel about HPV vaccine for all

Question 15

Advance care planning for pediatric patients

Answer 15

• Discussions should occur early + regularly throughout the course of Tx, ideally before crises arise
• Review + revise decisions on a regular basis
• Clarify wishes regarding emergency + life-sustaining therapies including CPR. Document
• Palliative care options should be integrated into discussions of Tx goals where appropriate

Question 16

Air travel and children’s health issues

• What airborne illnesses can be transmitted? (5)
• What is the best method of protection?
• What should MD provide?
• What 7 types of pts should be evaluated for potential hypoxemia before air travel?
• What 3 pediatric cardiovascular diseases are contraindicated to commercial airline flight?
• VTE
• Sickle cell
• AOM
• Food allergies
• T1DM
• Sz
• Air sickness
• Behavioural effects
• Jet lag
• Medical mechanical devices
• Orthopedic cases
• Physician assistance

Answer 16

• Transmissible airborne illnesses
  
  1. TB
  2. Measles
  3. Influenza
  4. Severe ARDS
  5. Meningococcal disease
• Low risk of transmission, similar to bus/train
• Best way to prevent is handwashing
• MDs should write medical letter explaining medical status +/- need for medical equipment, supplies + meds
• Evaluate for potential hypoxemia
  
  1. Suspected hypoxemia
  2. On supplemental O2
  3. Known or suspected hypercapnia
  4. Known chronic obstructive disease or restrictive disease (CF)
  5. Recent exaceration of CLD
  6. Previous difficulty during air travel
  7. Other chronic conditions that may be exacerbated by hypoxemia
  • ABG, PFTs, Hypoxia altitude stimulation test (breat mixutre of 85% N2 + 15% O2, if PaO2 <55 then may need O2)
• Contraindicated CVD
  
  1. Uncontrolled HTN
  2. Uncontrolled SVT
  3. Eisenmenger’s syndrome
• VTE
  
  • No evidence of risk in helathy children on prolonged fligh
  • Consider thrombosis consult + LMWH/ASA for 1) prev VTE, 2) thrombophilia, 3) malignancy, 4) major surgery w/in 6wks
• Sickle cell
  
  • Increased risk for crisis during flight. May need O2
• AOM
  
  • If adequately treated for AOM, can fly 2wks from Dx. Can give topical nasal decongestant before takeoff + landing.
  • If must fly within 48H of Dx, give appropriate analgesia
• Food allergies
  
  • Encourage parents to tell crew + airline, carry Epipen + antihistamines on flight
• T1DM
  
  • day shorted by >2H, may need to decrease intermed or long-acting insulin
  • day lengthed by 2H, may neeed to increase insulin
• Sz
  
  • Can fly if Sz controlled by meds
• Air sickness
  
  • Antiemetics PRN
• Behavioural effects
  
  • Parents explain steps in advance, mindfulness, don’t give sedation for behavioural control
• Jet lag
  
  • No benefit of melatonin
• Medical mechnical devices
  
  • Cap all feeding + infusion tubes. Watch for gas expansion introducing air into body
• Orthopedic casts
  
  • Bivalve plaster or fiberglass casts. Analgesia + elevate limb
• Physician volunteers protected from liability by “Good Samaritan”

Question 17

Ankle sprains in the paediatric athlete

• What is the mechanism?
• Which is the most common ligament involved?
• What are 3 findings on PEx?
• What 2 DDx to r/o?
• When do I get an Xray?
• What to do for Mgmt?
• What to do for rehab?
• When to return to play?

Answer 17

• Mechanism is inversion of plantar flexed foot
• ATFL is most commonly injured ankle ligament > CFL + PTFL
• PEx: 1) anterolateral swelling +/ bruising, 2) tenderness over ligaments, 3) difficulty bearing wt
• R/o fractures (proximal fibula, base of 5th metatarsal, Salter-Harris)
• R/o inerruption of syndesmotic ligameter (btwn fib+tib) = “high ankle sprain”
• Ottawa ankle rules in >10yo
  
  • ​Ankle Xrays if:
    
    • Pain in malleolar area AND >=1
    • Bone tenderness in posterior edge 6cm from tip of medial malleolus
    • Bone tenderness in posterior edge 6cm from tip of lateral malleolus
    • Refusal to weight bear at time of injury and in ED
  • Foot Xrays if:
    
    • Pain in midfoot area AND >=1
    • Bone tenderness at base of 5th metatarsal
    • Bone tenderness at navicular
    • Refusal to weight bear at time of injury and in ED
• PRICE
  
  • Protection - don’t immobilize. Functional bracing iwth early mobilization is better.
  • Rest
  • Ice: 15min 1-3X/d in first 36H of injury
  • Compression
  • Elevation
  • NSAIDs
• Rehab
  
  • Exercises to maintain ROM (esp dorsiflexion), strenghthen + increase flexibility
  • Proprioceptive rehab
  • Bracing for extra support (better than taping)
• Return to play
  
  • Begin when pain resolved and ROM, strength + proprioception normalized. Step-wise return to play. Continue PT until full return.
  • Use ankel brace to protect from further injury in first 3-6mo of return.

Question 18

Ankyloglossia and breastfeeding

• What is it?
• What to do conservatively?
• What to do surgically?
• What is important to r/o?

Answer 18

• Ankyloglossia = tongue tie = abnormally short lingual frenulum
• Congenital anomaly. Usually in isolation
• Conservative: paretnal education, lactation support, reassurance
• Frenotomy: controversial for improving feeding. Risk of post-op scarring requiring repeat
• R/O other oral anomalies via thorough exam + observe breastfeeding

Question 19

Anti-fungal agents for common outpatient paediatric infections

1. Mucocutaneous candidiasis
   
   • ​Oropharyngeal candidiasis
   • Candida diaper dermatitis
2. Tinea versicolor
3. Seborrheic dermatiits
4. Tinea capitis
5. Tinea corporis
6. Tinea pedis

• Oral antifungals (4)
• Drug interactions

Answer 19

1. Mucocutaneous candidiasis
   
   • Candida albicans colonization can occur from first week of life
   • Oropharyngeal candidiasis
     
     • Can start at 7d of life. 5-10% incidence.
     • Nystatin 200,000 units QID. Give after feeds. Cure 50% in 1wk, 80% in 2wks
     • If chronic thrush: topical clotrimazole troches
     • If doesn’t respond to topical (esp if immunocompromised): PO 2nd gen imidazoles (fluconazole + itraconazole)
   • Candida diaper dermatitis
     
     • Common at 2-4mo of age
     • Change diapers frequently, leave diapers off
     • Ointment/creams/powders of nystatin, miconazole, clotrimazole. Treat 2X/d for 7-14d
2. Pityriasis/Tinea versicolor
   
   • Malassezia. Hypo/hyperpig lesions with scale on trunk. Occurs in adol when sebaceous glands active.
   • Topical ketoconzaole, selenium sulfide, clotrimazole
   • Shampoo preparations to affected area for 15-30min QHS for 1-2wks, then Q1mo x3mo to prevent recurrence
3. Seborrheic dermatitis + pityriasis capitis (cradle cap)
   
   • Malassezia furfur
   • MIld soap applications
   • If severe: shampoos with selenium sulfide or an azole
4. Tinea capitis
   
   • most common superficial dermatophyte infection in peds
   • Microsporum canis, Trichophyton tonsurans
   • PO ketoconazole, fluconazole, itraconazole, terbinafine
5. Tinea corporis = ringworm
   
   • Trichophyton + microsporum species
   • Transmitted by direct contact
   • Topical cotrimazole, ketoconazole, miconazole, or terbinafine. 1-2X/d x 14-21d. Don’t mix with C/S
6. Tinea pedis = athletes foot
   
   • Topical antifungal +/- drying agent (Burow’s solution; if macerated or vesicular)
   • PO antifungal if involving toenails
   • Fluconazole, itraconazole, terbinafine
   • Prevent with good foot hygiene

• Oral antifungals
  
  • Fluconazole: hydrophilic, present in bodily fluids. Candida, many dermatophytes + mycoses. Not helpful for superficial
  • Itraconazole: keratin + lipophilic, excreted in sebum. Candida, dermatophytes, M furfur, some molds.
  • Ketoconazole
  • Terbinafine: keratin + lipophilic, dermatocytes + some moulds. No drug interactions b/c not metabolized through CYP450. SE: GI, skin, loss of taste.
• Drug interactions
  
  • Azoles are metabolized by CYP450 (3A). Inhibit elimination of antiarrhythmics, cortisol, cyclosporin, estradiol, tacrolimus.

Question 20

Antifungal agents for the treatment of systemic fungal infections in children

Answer 20

• Amphotericin B
  
  • Broad-spectrum antifungal
  • Lipid based products available - ampho B lipid complex, liposomal ampho B
    
    • Less nephrotoxic
    • Use if refractory/intolerant to ampho B deoxycholate.
  • SE: nephrotoxicity, infusion-related events (fever, chills, rigors)
• Triazoles
  
  • Fluconazole: PO/IV
    
    • Excellent bioavailability
    • Tx candida + cryptococcal infections
    • No role for Aspergillus or other moulds
    • PPx for allogenic HSCT recepients
    • SE: hepatotoxicity (rare but serious), drug interactions (CYP450 inducer)
  • Itraconazole: PO/IV
    
    • <5yo have lower plasma concentrations than older
    • PPx for candida + aspergillus (HSCT + lung transplant)
    • Step-down therapy for severe Aspergillus
    • SE: GI intolerance (abdo pain, V/D), elevated liver enzymes, drug interactions (CYP450 inhibitor)
  • Voriconazole: PO/IV
    
    • Avoid IV if mod/severe renal failure b/c potential toxic effects
    • Tx invasive aspergillosis (preferred Tx)
    • Can Tx systemic Candida (fluconazole first line)
    • SE: skin rash, photophobia, blurred vision, photosensitivity, elevated liver enzymes + bili. All generally reversible.
• Echinocandins
  
  • Glucan syntehsis inhibitors interfere with cell wall
    
    • Caspofungin: IV only (dose per m2)
      
      • Tx invasive candidiasis + aspergillosis (esp invasive pulmonary aspergillosis)
      • Empiric Tx febrile nutropenic pt with impaired renal function
    • Micafungin: same indication as caspo. Fungal ppx in HSCT
  • Antimetabolites
    
    • Flucytosine: PO
      
      • Used in combo with ampho B for CNS Candida or cryptococcal infxns
      • SE: GI intolerance, BM suppression. May have rash, hepatotoxicity, H/A, confusion, hallucination, sedation, euphoria
• Combination antifungal therapy
  
  • Cryptococcal meningitis
  • Incomplete reponse to initial therapy (esp if toxicity impedes optimal dose)
  • Empiric therapy of severe disease presumed due to organisms with distinct fungal suscpetibility profiles (i.e. different drugs for each pathogen)
  • Initial therapy for invasive pulmonary aspergillosis

Question 21

Antimicrobial stewardship in daily practice: Managing an important resource

Answer 21

1. Use clinical judgment
   
   • Accurate diagnosis
   • Investigate judiciously (CXR to confirm PNA)
2. Treat infection, not contamination/colonization
   
   • Use appropriate samples when indicated
     
     • No bag urines
     • Throat Cx only when Sx suggestive of disease
     • Surface swabs often reflect colonization
3. Document rationale for ABx use
4. Document suspected drug reaction as much as possible
   
   • Rash vs anaphylaxis
5. Know your local antibiogram
6. Select narrowest spectrum of ABx needed
   
   • Optimize dosing
   • Optimize duration
   • If strep pneumo or GAS -> beta-lactam (penicillin) NOT azithro/clarithro
     
     • Only do throat culture if no cold Sx
     • No F/U swabs on if completed therapy for GAS pharyngitis
   • If staph aureus -> clox or keflex
   • If MRSA -> drainage alone +/ septra PO or vanco IV
   • If CAP -> empiric amox PO TID or amp IV.
     
     • If not effective, consider complications of PNA or other Dx before changing ABx
     • Macrolide only if evidence for Mycoplasma or Chlamydia penumonia
     • CXR has high SN. Do before ABx
   • Skin + soft tissue usually S aureus or GAS -> keflex
7. Promote vaccinations to reduce likelihood of disease

Question 22

Assessment of cardiorespiratory stability using the infant car seat challenge before discharge in preterm infants (<37 weeks’ gestational age)

Answer 22

• CPS does not recommend routine ICSC (infant car seat challenge test) before discharge for preterm infants
  
  • Transferability of information from controlled testing environment is questionable
• PSG is gold standard for assessing resp stability in infants at risk of adverse events
  
  • superior to clinical observation + cardiac/sat monitoring for detecting cardioresp events
• Counsel parents about safe car seat use. They should demo appropriate technique + practice before D/C
• Do not leave infants of any GA in car seats when not being transported. Assoc’d with infant deaths from asphyxiation

Question 23

Autistic spectrum disorder: No causal relationship with vaccines

Answer 23

• MMR
  
  • 1998 study claimed vaccine admin leads to a form of ASD based on claims from 8 parents
  • 10/13 authors have now retracted their interpretation
  • Many studies have refuted the claim
• Thiomersal
  
  • Contains ethyl mercury. Has been used as an additive to biological therapies + vaccines b/c of its effect in preventing bacterial contamination
  • NO causal relationship between thimerosal-containing vaccines and autism
  • Canadian MMR vaccine (unlike US) NEVER contained mecury to begin with
  • Rates of autism have continued to increase despite removal of thimerosal from vaccines

Question 24

Azithromycin use in paediatrics: A practical overview

• What is the mechanism of macrolides?
• What coverage does azithromycin have?
• What about pneumoccoal resistance?
• When should azithro be used? (2)

Answer 24

• Macrolides inhibit bacterial protein synthesis by binding 50S subunit of ribosomes + blocking protein translocation
• Azithro is worse for G pos (strep pneumo), better against G neg (H influ, moraxella) - unlike erythro
• Pneumococcal resistance to macrolides is more common than to penicillin. Pen resistant strains are almost always macrolide-resistant
• Don’t use azithro for acute pharyngitis, AOM, or CAP in otherwise healthy children EXCEPT

1. 2nd line for life-threatening beta-lactam allergy to treat acute pharyngitis caused by macrolide-sensitive GAS
2. Consider for treating PNA caused by atypical bacteria
   
   • School-aged child
   • Subacute onset
   • Prominent cough
   • Minimal leukocytosis
   • Non-lobar infiltrate

Question 25

Banning children and youth under the age of 18 years from commercial tanning facilities

• What types of cancers?
• What acute SE?
• What is the vit D benefit?
• What are the recommendations for 1) gov’t, 2) industry, 3) HCPs

Answer 25

• WHO added tanning beds to Class 1 “physical carcinogens”
• Skin cancers related to UVR
  
  • Cutaneous malignant melanoma
    
    • accounts for most Canadian skin cancer deaths
    • Increased risk with having ever tanned indoors
  • Squamous cell carcinomas - increased risk w chronic/total UVR
  • Basal cell carcinomas - increased risk w early life UVR
• Acute SE: erythema + sunburn (most common), more serious burn, infections, skin dryness, pruritus, nausea, photodrug rxns, disease induction + exacerbations
• UVR is not a reliable source of vit D (risk of DNA damage)
• Indoor tanning assoc’d with 1) more “extreme” risk taking, poorer self-esteem, 3) unhealthy lifestyle choices, 4) parental use. NOT assoc’d with SES or knowledge of risks
• No enforceable limits to amount of artificial UVR exposure available year-roung to public
• Recommendations
  
  • <18yo should be prhibited by law from using commercial indoor tanning facilities
  • All unsupervised commercial tanning bed operations + use of coin-operated machines should be banned
  • Gov’t should enact tanning industry regulation + ensure enforcement
  • Tanning industry should be required to acknowledge product is carcinogenic and advise public there is no health benefit
  • Impose tax on all commercial tanning bed operations
  • HCPs should screen for use of artificial tanning activities + provide anticipatory guidance to discourage this

Question 26

Baseball and Softball

• How to prevent overuse injuries in pitchers? (6)
• What safety equipment to use? (6)
• What medical things to be aware of?

Answer 26

• Encourage participation b/c relatively safe sports
• Prevent overuse injuries in pitchers:
  
  1. Age guidelines regarding the # of pitches thrown daily
  2. Rest requirements between pitching assignments (3 mo/yr)
  3. Season + yearly total pitch limits
  4. Should not also be catcher
  5. Adequate core strength + scapular muscle strength
  6. Proper instruction + training
• Use proper safety equipment
  
  1. hitters: batting helmets w face protection
  2. catchers: helmets, masks with throat guards, chest protectors, shin guards
  3. all male players: hard plastic athletic cup
  4. all players: rubber-spiked soles
  5. pitchers + infielders: consider head + face protection
  6. Functionally one-eyed atheletes (<20/50 best corrected), prev eye surgery, or prev severe eye injury: eye protection at all times (face shields or polycarbonate sports goggles)
• Commotio cordis is not effectively prevented by chest barrier protection
• Coaches must be prepared to activate emergency response + have AED ideally all within 3min if player has medical emergency
• Adults need to be aware of cause, prevention, recognition + response to concussion
• Postpone games when weather conditions are extreme

Question 27

Bicycle helmet use in Canada: The need for legislation to reduce the risk of head injury

Answer 27

• Bike injuries = 5% of all deaths due to unintentional injury in <15yo Canadians
  
  • Head injuries 20-40% of totally bicycling injuries in ED
• Helmets reduce risk of head injuries while cycling (severe brain + facial
• Legislation increases use of helmets in youth -> reduce risk of bicycle-related head injury
• Recommendations
  
  • All jurisdictions in Canada should legislate + enforce bike helmet use for all ages
  • Concurrently implement bike lanes + community safety programs
  • MDs counsel families about importance of bike helmets
  • Sales tax exemptions or rebates + federal tax credits to make purchase of bike helmet

Question 28

Bodychecking in youth ice hockey

Answer 28

• Eliminate bodychecking from all levels of recreational/non-elite competitive hockey
• Delay until 13-14yo in elite male competitive hockey
• Implement Hockey Canada’s 4 stage skill dvlpt program for body checking for all leagues (1) body positioning, 2) angling, 3) stick checking, 4) body contact)
• Parents + caregivers should learn injury prevention + risk reduction strategies (incl’g concussion prevention, recognition, management)

Question 29

Boxing participation by children and adolescents

Answer 29

• Most common injuries are to head, face + neck due to deliberate blows
• Most common injuries: #1 Concussion, #2 open wounds/lacerations/cuts/fractures
• Acute subdural hematoma is most common cause of death
• Strongly discourage boxing among pts. Encourage alternative sports
• If still choose to participate, boxing organizations should ensure appropriate medical care (medical coverage at events, pre-participation medical exams, regular neurocognitive + ophthalmologic screening exams)

Question 30

Bronchiolitis: Recommendations for diagnosis, monitoring and management of children one to 24 months of age

• What are the recommendations for investigations?
• What are indications to admit?
• What therapies are a) recommended, b) equivocal, c) no evidence
• When can I discharge home?
• How do we prevent? (3)

Answer 30

• What are the recommendations for investigations?
  
  • Generally not indicated
  • CXR only if severity or course suggests alternate Dx
  • NP swab only for cohorting pts
  • CBC not helpful
  • Gas only if concerned about potential resp failure
  • Bact Cx not recommended routinely (low risk SBI, highest in <2mo for UTI)
• What are indications to admit?
  
  1. Resp status
     
     • Signs of severe resp distress
     • Need O2 to maintain SpO2 >90%
  2. Hydration
  3. Risk for progression to severe disease
     
     • Cyanosis, Hx of apnea
     • Groups at higher risk for severe disease
       
       1. <35wk GA
       2. <3mo old at presentation
       3. Hemodynamically significant cardiopulm disease
       4. Immunodeficiency
  4. Family’s ability to cope
• What therapies are recommended
  
  • Recommended
    
    • O2 to keep SpO2 >90%
    • Hydration
  • Equivocal
    
    • Nasal suctioning
    • Epi nebs
    • 3% NS
    • Combined epi + dex
  • Not recommended
    
    • Salbutamol
    • Corticosteroids
    • Abx
    • Antivirals
    • Chest PT
    • Cool mist therapies or therapy with saline aerosol
• When can I discharge home?
  
  • No or mild resp distress
  • Maintain SpO2 >90% w/o O2 OR stable for home o2 therapy
  • Maintaining hydration - adequate oral feeding
  • Education provided (recognize + respond to signs of deterioration) + appropriate F/U arranged
• How do we prevent RSV?
  
  1. Hand hygiene
  2. Breastfeeding
  3. Avoidance of cigarette smoke

Question 31

Canada’s eight-component vaccine safety system: A primer for health care workers

Answer 31

1. Evidence-based pre-license review + approval process
2. Regulations for manufacturers
3. Evidence-based vaccine use recommendations
4. Immunization competencies training for HCPs
5. Pharmacovigilance for adverse events following immunization (AEFI)
6. AEFI causality assessment
7. Safety + efficacy signal detection
8. Canadian Immunization Research Network special immunization clinics

Question 32

Cardiac risk assessment before starting stimulants

Answer 32

• Risk of sudden death in children with ADHD on medication is similar to the general population
• Thorough Hx + PEx for everyone
• No need for ECG if no red flags
• Known benign murmur shouldn’t preclude from starting stimulants
• Referral to cardio prior to starting medications
  
  • SOB, exercise intolerance, sz/fainting with exercise/startle/fright, palpitations with activity
  • Known cardiac Hx (WPW, long QT, cardiomyopathy, transplant, pHTN)
  • New possibly pathologic murmur, HTN, sternotomy incision
  • FHx of sudden death or arrhythmia
• If known cardiac conditions, start meds should still be decision of ADHD specialist, but cardiology input recommdned

Question 33

Care of adolescents with chronic conditions

Answer 33

Developmental issues

1. Independence + assertiveness
   
   • Encourage pt to develop the highest level of independence based on a realistic and objective evaluation of abilities and limitations
   • Encourage parents to strike balance between parental supervision and increased control of care by the adolescent
   • Help parents recognize and accept safe forms of self-expression (adolescents often achieve autonomy by engaging in behaviours that parents may perceive as dangerous)
2. Peer relationsihps
   
   • Questions about relationships + advise on any problems to ensure they develop + maintain friendships
3. School + work
   
   • Help parents have realistic academic expectations for their adolescent with a chronic condition
   • Help teachers understand the adol’s condition
   • Facilitate integration of the adol into the school program
4. Physical appearance
   
   • Anticipate + address early the isuses of delayed puberty + physical appearance in a manner appropriate to the teen’s developmental age
5. Sexuality
   
   • Ask questions on sexuality, sexual orientation, sexual activities, and physical + sexual abuse
   • Provide information on pregnancy, STIs, types of contraception allowed by the adolescent’s condition, fertility
6. Death + dying
   
   • Address issues of death + dying whenever appropriate
   • Address pain control in chronic conditions like sickle cell anemia, JIA, neuromuscular conditions. Do not underestimate pain, treat appropriately

The practical approach to care

• Age limits + office practice
• Networking
  
  • Know about + facilitate access to community organizations that can provide support to adolescents + their families
  • Foster broader community responsibility for the chronically ill + be community educators + advocates
• Educating adolescents about their disease, so they can be involved in decision-making regarding Tx or referral
• Hospital-based care must be adolescent-friendly and support the developmental issues involved
• Transition + transfer of care
  
  • Start discussions about transition at 10-12yo. Flexibly decide when to transfer to adult facilities based on developmental age
  • Ensure transition is continuous, comprehensive + coordinated to minimize disability + promote appropriate use of health care services
• Know province-specific legal regulations including around consent, confidentiality + competency

Question 34

Caring for children and youth from Canadian military families: Special considerations

Answer 34

• Frequent moves, prolonged separation, anxiety regarding injury or death fo loved ones
• Military spouses only receive public health care (no special support from military
• overall, children of military parents seek medical care LESS frequently than other kids for other acute care issues, raising the concern of access to care
• parental deployment is associated with increased children’s medical visits for behavioural issues, mental health issues, developmental delay, maltreatment, with increased use of anti- anxiety and anti-depressant meds
• adolescent military dependants have more visits for suicide attempts and injury
• MD needs to anticipate + counsel on the above issues. Ensure good F/U + care transition

Question 35

Causes and prevention of low back pain in young athletes

Answer 35

Question 36

Child and youth injury prevention: A public health approach

Answer 36

• Injuries are the leading cause of child + youth death + disability
  
  • Leading cause of death in Aboriginal children + youth
  • ~60:40 M:F
• MVC is the leading cause of injury-related deaths in Canada
  
  • Leading causal factors: 1) driving speed, 2) impaired driving, 3) lack of occupant restraint
  • Car seat reduce risk of death by 70% for infants and by 50% for 1-4yo, if used correctly
  • Booster seats reduce risk by 60% more than seat belts alone
• Strategies that combine efforts (education, engineering, envo changes, enforcement/legislation) are the most successful
• Health professionals and all levels of government must work together to reduce the burden of child and youth injury in Canada by investing in a pan-Canadian injury prevention (IP) strategy that includes leadership, policy coordination, research, surveillance, public education and social marketing.

Question 37

Children and natural health products: What a clinician should know

• What 3 factors increase the likelihood of drug herb interactions

Answer 37

• What 3 factors increase the likelihood of drug herb interactions
  
  1. Pts with serious, chronic or recurrent illness are the most likely to use NHP and also most likely to be on prescription meds.
  2. Most pt use NHP to complement their health care, not replace
  3. Research confirms that a substantial proportion of Canadians who use NHPs use more than one simultaneously

Question 38

Chiropractic care for children: Controversies and issues

Answer 38

• Routinely ask families about complementary and alternative therapies or products
  
  • If going to chiropractor: ask about neck manipulations or forceful thrusts, herbal or homeopathic preparations
  • Ask for which conditions, how frequent are the visits, motivation, their percieved benefit of Tx
• Spine + MSK, colic, enuresis, asthma, recurrent otitis media, cancer, and illness prevention
  
  • Spinal manipulation: no evidence in peds
  • Mild to moderate asthma: no benefit of spinal manip
  • Colic: collaborative RCT showed chiropractic manipulation no more effective than placebo
• Of concern is the possibility that chiropractors may attempt to treat acute paediatric conditions, leading to a delay in appropriate medical therapy or the refusal of families to seek conventional treatment
• Canadian chiropractic association accepts vaccination as a cost-effective and clinically efficient public health preventive procedure for certain viral and microbial diseases
• Parents may at times request radiographic examinations that are suggested by their chiropractor. Parents should be made aware that there is a lack of substantiated evidence for the theory of subluxated vertebrae as the causality for illness in children, and x-rays taken for this purpose expose the child to unnecessary radiation

Question 39

Clostridium difficile in pediatric populations

• What is the case definition of CDI?
• When should I consider C diff colitis?

Answer 39

• What is the case definition of CDI?
  
  • Presence of symptoms (usually watery diarrhea b/c toxins cause intestinal cell water secretion)
    
    • Note: children can be asymptomatic
  • AND stool test positive for C diff toxins OR colonoscopic findings demonstrating pseudomembranous colitis
    
    • Note: C diff disease only firmly diagnosed once toxin(s) is identified
    • Only test diarrheal stools
    • 2 step test
      
      1. Confirmatory: Toxin EIA OR (preferably) cytotoxin assay
      2. Initial screening: EIA for GDH (glutamate dehydrogenase, present in almost all strains of C diff)
• When should I consider C diff colitis?
  
  • Any pt with Abx w/in previous 12 wk AND signs of bloody diarrhea +/- systemic toxicity, fever, abdo pain
  • Immunocompromised pts with Abx or chemo w/in previous 12wks AND any diarrheal illness (watery or bloody)
  • NOT in previously healthy <1yo
• How do I treat C diff? (see image)
  
  • Tx does not eradicate C diff or toxin from stool
  • Clinical relapse rate 15-35%, does not mean drug resistance
• How do I prevent CDI?
  
  1. Meticulous hand hygiene: alcohol based products do not kill spores
  2. Environmental source control: chlorine-containing agents
  3. Contact precautions: until 48h with no diarrhea
  4. Private rooms or cohorting: isolate solely based on Sx b/c stools often remain toxin-positive despite cure; do not retest stools once Sx resolve
  5. Antimicrobial stewardship!
  6. Probiotics may be beneficial in prevention, need more data

Question 40

Community acquired MRSA in Indigenous people

• What are 8 RFs for CA-MRSA?
• Which 7 populations have increased rates of CA-MRSA?

Answer 40

• What are 8 RFs for CA-MRSA?
  
  1. Overcrowding (10X more frequent in First Nations living on reserve)
  2. Frequent skin to skin contact
  3. Activities that lead to compromised skin surfaces
  4. Sharing potentially contaminated personal items + surfaces
  5. Challenges to personal cleanliness + hygiene
  6. Limited access to health care
  7. Lower socio-economic classes
  8. Exposure to ABx
• Which 7 populations have increased rates of CA-MRSA?
  
  1. Indigenous populations
  2. Athletes
  3. Daycare attendees
  4. Military recruits
  5. IVDU
  6. MSM
  7. Prisoners
• How can we prevent MRSA?
  
  • Increase public awareness of antimicrobial resistance in the general public + HCPS
  • Monitor resistance (Cx drainage). Develop MRSA Tx guidelines based on local sensitivity patterns
  • Improve hygiene: hand hygiene, bath regularly, avoid sharing personal items, household cleaner on contact surface
  • Wound care: keep wounds covered with clean, dry bandages. If cannot, then exclude from contact sports or child care
  • Encourage seasonal flu vaccine for risk of severe MRSA pneumonia after influenza
  • Contact public health if recurrent infxn (>=3 in same indvl w/in 6mo) or suspected outbreak in closed population (day care)

Question 41

Ethical approach to genital examination in children

Answer 41

• Pap or screening for STI should only be done in sexually active youth
• Examine boys in lateral decubitus, and girls in frog leg position, may do so while sitting in the lap of a caregiver/chaperone

Question 42

Congenital syphilis: No longer just of historical interest

Answer 42

• What are the risks of vertical transmission
  
  • 70-100% if maternal untreated primary or secondary syphilis during pregnancy
    
    • Infection can occur from 9wk GA to contact with active genital lesion at the time of delivery
  • 40% if early latent syphilis (at risk of reactivaion)
  • <10% if late latent syphilis
• When should mothers be screened?
  
  • Routine first prenatal visit
  • If high risk, at 28-32wk GA + delivery (similar times as Rhogam)
  • If very high risk (e.g. sex trade worker in area with syphilis outbrek) then Q1mo
  • If not done antenatally, then don’t D/C newborn without result
  • If hydropic or stillbirth newborn of unknown cause, screen mother for syphilis
• How to screen
  
  • Initial screen: RPR or EIA
    
    • EIA has higher SN + SP
    • RPR needed for staging infection, follow response to Tx + diagnosing reinfection (must do if EIA pos)
  • Confirm by treponemal test (INNO-LIA, FTA-ABS, TP-PA, MHP-TP)
    
    • Fairly high SP
    • Can also occur with nonveneral treponemal diseases
    • Usually remains reactive for life (unless Tx very early)
  • If mother has non reactive RPR during pregnancy + reactive treponemal test with no Hx of Tx + no evidence of early primary syphilis, then she should be treated for late latent syphilis and assume some risk of vertical transmission
• Congential syphilis features
  
  • Early (first 8wks)
    
    • CNS: Neurosyphilis
    • HEENT: Rhinitis +/ snuffles, chorioretinitis
    • MSK: Osteocondritis or perichondritis, pseudoparalysis
    • Derm: Necrotizing funisitis (“barbershop pole”, rare but pathognomonic), Diffuse maculopapular rash +/ desquamation, vesciular, bullous, papulosquamous or mucosal lesions
    • Heme: Coomb’s neg hemolytic anemia, thrombocytopenia, LND, HSM
  • Late (after 2yo)
    
    • Eyes: intersitial keratitis
    • MSK: frontal bossing, poorly developed maxillas, saddle nose, Hutchinson’s teeth, Mulberry molars, winged scapula, sabre shins, Clutton’s joints (painless knee effusions)
    • CNS: SNHL (CN8 deafness)
    • • How to treat
  • Crystalline benzathine Pen G IV x10d (NOT benzyl)
• How to monitor Tx
  
  • Adeq therapy: expect RPR titre drop by 4X in 6mo (e.g. 1:32 to 1:8 dilution)
    
    • Secondary syphilis: drop 8X at 6mo, 16X at 12mo
    • Early latent syphilis: drop 4X at 12mo
  • If no congenital syphilis: infant RPR titres will decline by 3mo and be nonreactive by 6mo. Passive Ab theroretically clear by 12-18mo
  • If congenital syphilis + adeq Tx: sustained RFR titres drop by >=4X and lose treponemal AB by 18mo
  • If CSF initially abN, repeat CSF Q6mo until normal. Retreat if CSF abN persist
• Test for cure
  
  • Repeat RPR (if initial RPR reactive). If infectious case then 1,3,6,12mo. If latent case then 12, 24mo.

Question 43

Contraceptive care for Canadian youth

Answer 43

• By 17yo, >50% of Canadian youth are sexually active
• Confidential sexual + reproductive health care for youth. In QB, must be >=14yo
• 1st lier: LARCs - copper IUD, hormone-releasing IUS
  
  • 1st line in teens. Nulliparous. Sig decrease rates of preg. Use bridging method until inserted.
• 2nd tier: hormonal contraceptives
  
  • Daily: COC + POP
    
    • COC 30-35mcg EE. 28d (21 active, 7 placebo). Extended use (active pills >=2 cycles, then 4-7 placebo). SE resolve after 2-3 cycles.
  • Weekly: transdermal patch - less effective if >90kg
  • Monthly: vaginal ring
  • Q3mo: DMPA - decrease BMD (vit D, wt bearing exercise, avoid caffine/alcohol/smoking), increase wt (2.5kg in first yr, 3.6kg in 2y, more like if overwt)
• 3rd tier: use at time of intercourse - condoms, diaphragm, sponge, spermicide, withdrawal, fertility awareness
• Use tier 1/2 + 3 OR two tier 3s together (multiple failure rates for total failure rates). Discuss proper use.
• Always use condoms to decrease STIs
• Quick start method. Medical Hx, BP + baseline wt. No pelvic exam. Offer screen STIs (do at time of IUD). Start in first 7d after LMP. Or preg test, start if neg, repeat test 21d later. Backup condoms for min 7d. Give year-long Rx.
• EC as backup, not primary method
• SE of hormonal contraceptives: decr BMD. VTE risk ↑2-3X and stroke risk ↑1.5-2X but low baseline risk in 15-19yo, so low absolute risk. PO + transdermal don’t affect wt gain.

Question 44

Counselling and management for anticipated extremely preterm birth

Answer 44

• U/S is most accurate (other than IVF). First TM crown-rump length most accuate for dating within 3-8d.
• Antenatal corticosteroids (ANCS) to 22+0 to 25+6 wk GA at risk of birth when early intensive care is an option and risk of extremely preterm birth is high
  
  • Max period of efficacy is reached within 7d of last dose
• Canadian Neonatal Network provides up to date data on survival rates
• Stat sig decrease of 6% in risk of mod-to-severe NDD with each increasing wk of GA. Cognitive impairment > CP > vision + hearing
• ELBW/VLBW rate their QOL similar to full term
• Parents rate their QOL lower than term parents, but variable
• Prognostic factors: GA, BW (100g increments), singleton (vs multiple), ANCS, female, birth in tertiary perinatal centre. ICH, PVL, ROP, BPD, sepsis.
• Discuss multiple times, re-evaluate, team approach
• If palliative, then provide comfort measures (warmth), bereavement care, options to create memories (footprints, handprints, photos)

Question 45

Cross-cultural communications: tools for working with families and children

Answer 45

LEARN model

• Listen: Pt’s understanding of their health condition, its causes and potential treatments. Elicit expectations.
• Explain: convey own perceptions
• Acknowledge: be respectful in discussing areas of agreement and differences
• Recommend: develop + propose Tx plan
• Negotiate: reach agreement on Tx plan
• Use trained interpretor

Question 46

Decision-making around gastrostomy tube feeding in children wtih neurologic impairment: engaging effectively with families

Answer 46

• When to start discussions: mention potential benefits of Gtube feeds early. Poor oral intake + wt gain despite calorie boosting of oral feeds, recurrent aspiration or prolonged feeding times, GERD, insufficient oral intake, dysmotility dspite meds. If anticipate need G-tube feed >3mo
• G-tube insertions: 1) IR (U/S or fluoroscopy), GI (endoscopic), gen surg (open/lap)
• Types of G-tubes: 1) “button” sits flush with skin, 2) tube with long external portion
• Benefits of G-tube feeds: improve wt + nutrition, decrease need for hospitalizations + ABx for chest infxns, decrease feeding times, increase ease of medication, improve caregiver QOL
• Risks of G-tube feeds
  
  • Short-term (insertion procedure): peritonitis (2%), bleeding, infection, abdo organ perf, anesthesia-related problems, (rarely) periop death
  • Long-term: 1) tube malfunction - blockage, dislodgement, breakage; 2) stoma issues - infxns, bleeding, irritation
• Steps for G-tube decisions
  
  • Build decision-making partnership with family, include chid if capable
  • Allow adequate time for repeated discussion + for families to “work through” their decision
  • Clarify goals of G-tube feeding
  • Be clear about risks + benefits, but frame the intervention in positive terms
  • Elicit family values + preferences
  • Be sensitive to family context: culture, decision-making styles, financial resources, caregiving support at home
  • Provide concrete examples of how G-tube or PO feeds can impact child + family life
  • Engage extended family members in discussions (when parents wish)
  • Help parents meet + share experiences with other families who faced this decision
  • Decision to not start G-tube feeds may be appropriate. Ensure f/u to reassess

Question 47

Determining goal weight for children with anorexia nervosa

Answer 47

• Plot ht, wt, BMI on pediatric growth chart
• Consider genetic growth potential, activity level, ethnicity, age at menarche (or when menses stopped)
• Consider weight at return of menstruation. Need at least 2kg more for normal function
• If nutritional restriction has stunted growth, obtain BA. If there is still growth potential, get back to wt which matches pre-morbid growth percentile to encourage growth in ht
• If don’t have previous info, focus on normalizing diet + habits with close monitoring of vitals, labs, menses return, and disappearnce of ED behaviours
• Reassess TGW Q3-6mo
• Don’t lower TGW even if child gets upset

Question 48

Diagnosis and management of acute osteoarticular infections in children

Answer 48

• Hematogenous osteomyelitis 1-13/100,000
• Osteomyelitis = inflammation of bone + bone marrow d/t infection with microbial pathogen
• Acute osteomyelitis (AO): Sx <4wks. Any bone. most common is metaphysis of long tubular bones (femur, tibia, humerus)
• Chronic osteomyelitis: Sx >4wks. Presence of avascular bone (sequestrum) alone or surrounded by new bone (involucrum) (Brodies’ abscess)
• Acute septic arthritis (SA): can occur concurrently with AO, esp if <2yo
• AO + SA should be considered in all children with pain in jt/bone +/ pseudoparalysis

Epidemiology

• Pathogens:
  
  • Most common in prev healthy: staph aureus (older children, usu more severe) + kingella kingae (<4yo, usu milder + more subacute; higher yield when isolated from fluid in culture bottle rather than swab)
  • strep pneumo, strep pyogenes
  • Salmonella in sickle cell. Enterobacteriaceae or fungi in neonates, immunocompromised, or envo exposure.
• Most likely portal of entry: colonization of MM of resp tract or skin
• Consider AO or SA if acute pseudoparalysis or limping, pain, +/- fever. Consider AO if staph aureus bacteremia with no apparent source

DDx of acute focal pain in limb or near bone

• AO: acute limp, pseudoparalysis, reluctance to use affected area. Localized pain to palpation, distal or proximal ends of bones, reduced ROM, +/- swelling/erythema, +/- fluctuance (periosteal abcess). +/- fever
• Transient synovitis of hip: 4-10yo, acute hip pain + limp, low grade fever, CRP <20, nontoxic. Hx of URTI in past 2wks. Self-resolve. NSAIDs.
• # or trauma: trauma event, localized pain to palpation, hematoma or bruising +/- swelling. No fever.
• Lyme arthritis: Lyme edemic area 2-12mo before Sx onset. Monoarthritis +/- Baker’s cyst. Less painful, can wt-bear. CRP <40
• Cellulitis: rapid development over hours of swelling/redness/pain/warmth.
• CRMO: insidious bone pain, worse at night. Metaphysis + epiphysis. Unusual sites (clavicle, jaw, scapula). Low-grade fever, malaise, +/- wt loss. Relapsing course. May have derm (palmoplantar pustulosis, psoriasis). Xray: intense sclerosis with healing.
• Heme malig: systemic Sx. Metaphyseal lucencies + periosteal reactions.
• Bone neoplastic lesion: diaphysis or flat bones. Gradual onset (wks). Pain worse at night. Palpable soft tissue or bony mass.
• JIA
• SLE
• Reactive arthritis: oligo of larger joints, subacute and less severe than SA. 2-3wks after GI/GU infxns. +/- ocular or urinary Sx.
• Post-strep reactive arthritis: acute polyarticular, nonmigratory. 3-14d after strep infxn. Persistent or recurrent. Extra-articular (vasculitis, GN)

Investigations

• WBC generally, not always elevated
• Do CRP at presentation (preferred over ESR). Use to monitor response, normalize before stop ABx
• BCx pre-ABx. Repeat in 48H to ensure clearance.
• Joint aspiration: Dx test for SA. If N/A, US to confirm joint fluid, MRI to determine if inflammatory fluid.
• Xray - classic AO findings: lytic lesions, localized periosteal lifting. Only present 7-21d after onset
• MRI gad - most SN + SP. Earliest finding is BM edema.
• Radionucleotide bone scans - lower SN + SP, but use if MRI N/A
• CT if MRI + bone scan N/A

Tx

• If SA or AO complicated by abscess -> need Ortho
• IV cefazolin 100-150mg/kg/d div Q6-8H
• K kingae is resistant to clox, vanco, clinda
• H influ: broaden to cefuroxime in <4yo who are unimmunized or living in area with high rates of invasive H influ
• MRSA: add vanco
• Change from IV to PO when clinically improved, inflammatory markers improved, compliance + F/U assured. Document nromal CRP.
• Usually 3-4wk ABx for AO or SA. 4-6wk for hip SA.
• Only repeat Xrays if growh plate involved +/ large lytic lesion initially. At end of therapy, shows sclerosis + healing changes, lytic lesion will still be present.
• Need ortho F/U if growth plate or immediately adjacent epiphyseal or metaphyseal region involved

Question 49

Diagnosis and Management of typical, newly diagnosed primary immune thrombocytopenia (ITP) of childhood

Answer 49

• Natural History
  
  • No known cause. Triggered by infection or immune event
  • Self-resolve within 6mo (75%) or 1y
  • Most serious complication: ICH (~0.5%)
  • Epistaxis, menorrhagia, petechial oral mucosa, bruising/petechiae
• Red flags for alternate Dx - need Heme consult
  
  • Hx: constitutional Sx, bone pain, recurrent thrombocytopenia, poor Tx response
  • PEx: unwell, LND, HSM, signs of chronic disease
  • IVx: low Hgb, high MCV, abnormal WBC +/ ANC, abnormal smears
• Mgmt
  
  • Goal: increase plt for hemodynamic stability
  • Observation
    
    • SE + disadv: longer activity restriction, anxiety
    • Cost: outpt mgmt
    • Action: 75% improve w/in 6mo. Takes longer for plt count recovery
  • Glucocorticosteroids
    
    • PO pred 4mg/kg/d (div BID-QID) x 4d w/o taper OR 2mg/kg/d x 1-2wk with taper. Can use dex. Can give IV
    • SE + disadv: mood changes, increased appetite/wt, gastritis (use protectant), HTN (longer course), poor taste
    • Cost: outpt mgmt, inexpensive
    • Action: effective in ~75%. Increase plts, usu w/in 48H
  • IVIG
    
    • 0.8-1g/kg single dose
    • Measure baseline IG levels for <1yo or if suspect immune deficiency
    • SE + disadv: H/A (aseptic meningitis), N/V, fever, rash, hemolysis (rare), need IV + hospital stay
    • Cost: hospital admission, expensive
    • Action: effective in >80%. Increase plts, usu w/in 24H, peak at 2-7d. Use if more rapid plt increase required
  • If don’t respond initially to one Tx, use other Tx
  • 1/3 of those who respond to Tx initially will relapse (plts <20 within 2-6wks)
  • If low plts or bleeding, avoid contact sports + activities with high risk of injuries (esp head)
  • Avoid antiplt meds + CAM (NSAIDs)

Question 50

Dietary exposures and allergy prevention in high-risk infants

Answer 50

• 7% prevalence of food allergy in Canada
• Higher risk of developing allergy if FDR with atopic dermatitis, food allergy, asthma, allergic rhinitis
• Do not restrict maternal diet during pregnancy or lactation
• Breastfeed exclusively for first 6mo of life (total duration of 6mo prob more protective than exclusively breastfeed)
• Choose hydrolyzed cow’s milk-based formula if necessary
  
  • Preventative effect against atopic dermatitis vs intact cow’s milk formula
  • Extensively hydrolyzed likely more effective than partially hydrolyzed whey formula to prevent atopic dermatitis
  • Amino acid formula hasn’t been studied for allergy prevention
  • No role for soy formula
• Do not delay introduction of any specific solid food beyond 6mo (doens’t prevent allergy)
• Need more research on early introduction of specific food to prevent allergy
• Regular ingestion of newly introduced foods is important to maintain tolerance
• Discourage routine skin or specific IgE blood testing before first ingestion d/t high risk of potentially confusing FP

Question 51

Dieting in adolescence

Answer 51

• RFs for dieting + disordered eating: older, girls, overwt, vegetarians, early puberty, low self-esteem, chronic illnesses (diabetes/asthma/epilepsy/ADHD), dieters at home, parental criticism, peer teasing, other high risk behaviours
• Consequences: nutritional deficits (iron, Ca), growth retardaion, secondary amenorrhea (even without major wt loss), osteopenia, electrolyte abN (purging/laxatives)
• For normal and over-wt individuals: encourage eating as per Canada food guide, avoid fads, physical activity, review HEADS

Question 52

Drug research and treatment for children in Canada: a challenge

Answer 52

• Big players: Health Canada, CIHR (Canadian Institutes of Health Research), industry, Canadian academic child health cnetres, National Council on Ethics in Human Research
  
  • Develop national research network for therapeutic needs of infants, children + youth
  • Support educational + training opportunities in drug research in children
  • Define and address evolving ethical challenges both nationally + internationally
• Federal goverment should support areas where optimal therapy is poorly defined and unlikely to be researched by other stakeholders

Question 53

Early childhood caries in Indigenous communities

Answer 53

• ECC = tooth decay in any primary tooth of <6yo
  
  • Most prevalent ped infectious disease
  • Most common chronic disease of children
  • Peds dental surgy is most common outpt surgical procedure
• Causative triad
  
  1. Cariogenic bacteria - strep mutans
  2. diet - fermentable carb
  3. host susceptibility - tooth enamel integrity, oral hygiene
• 6 consequences of ECC
  
  • Pain - difficulty chewing, sleeping, growth restriction
  • Risk of decay in primary + permanent dentition
  • Malalignment + crowding of permanent teeth
  • Speech difficulties
  • Poor self-esteem d/t appearance
  • Procedure(s) under GA - economic burden
• 3 assoc’d conditions: 1. Resp tract infxns + 2. AOM in 1st year of life, 3. obesity in low SES children
• RFs for ECC: poverty! Household crowding, family size, maternal + infant nutrition, health behaviours, parenting practices, parental oral health status, envo tobacco smoke, lack of access to dental care
• Prevention
  
  1. Oral health promotion
  2. Disease prevention
  3. Fluoride
     
     • <3yo: use rice grain size portion, brush by adult
     • 3-6yo: green pea size portion, assisted
     • For Indigenous, start fluoride toothpaste at first tooth eruption
     • Topical fluoride varnish +/- sealants
     • Water fluoridation
• Oral health recommendations for Indigenous communities
  
  1. Clinical care: motivational interviewing + anticipatory guidance starting at prenatal visit
  2. Community-based initiatives: decrease sugar-containing foods
  3. Workforce + access: early access to dental by 12mo
  4. Advocacy: water fluoridation
  5. Research

Question 54

Emergency department use of oral ondansetron for acute gastroenteritis-related vomiting in infants and children

Answer 54

• Ondansetron is selective serotonin 5HT3 receptor antagonist
• 6mo-12yo with gastro and mild to mod dehydration or failed trial of ORT should get single dose ondansetron to reduce vomiting + IVF
• Dose: 2mg for 8-15kg, 4mg for 15-30kg, 6-8mg for >30kg
• Start ORT 15-30min after PO ondans
• PO peak plasma concentration 1-2H

Question 55

Energy and sports drinks in children and adolescents

Answer 55

• Water should be first choice for hydration before, during, and after routine physical activity
• Sports drinks
  
  • Marketed as beverages. Replenish lytes, carbs, prevent dehydration.
  • Contain simple sugars (gluc-fruc/high-fruc corn syrup, sucrose, maltodextrin), may contribute to obesity + dental caries
  • If >8% carbs (8g/100mL), can slow gastric emptying + intestinal absorption during exercise
• Energy drinks
  
  • Energy drinks regulated as “food,” energy shots regulated as “natural health product.” Increase energy +/ alertness
  • Contains caffeine (pure or synthetic; herbal - guarana or yerba mate). Max allowed 180mg/single serving OR 400mg/L
  • Contains a LOT of sugar
  • Don’t mix with alcohol (alcohol intoxication), not recommended for children (more like develop caffeine dependence + toxicity) or preg/bf’g women, cannot advertise to <12yo
• Caffeine
  
  • Max daily intake: 4-6yo 45mg/d, 7-9yo 62.5mg/d, 10-12yo 85mg/d, >=13yo 2.5mg/kg/d
  • SE: increase HR, BP, T, speech rate, motor activity, attentiveness, gastric secretion, diuresis, anxiety (in susceptible), arrhythmias.
  • Withdrawal: H/A, fatigue, decreased energy, decreased alertness, dysmorphic mood, irritability, flu-like Sx, N/V, myalgias

Question 56

Ethical issues in health research in children

Answer 56

• Pediatric health researchers should be aware of their obligations to conduct research according to the TCPS (tri-council policy statement), including need for REB review before conducting human research
• Include children in discussion of consent for research participation. If not possible, then consider assent or dissent
• Be aware of potential conflict of interest (COI) as caregiver and researcher and potential financial or academic incentives
• Publish negative and positive results. Return summary of the results to the community + individaul participants. Offer individaul participants relevant results of adequate reliability and validity
• Lobby to include children in agendas of political, academic and scientific bodies

Question 57

Ethical participation of children and youth in medical education

Answer 57

• Inform parents + children about their rights + expectations when medical education is a component
• Make families aware of care provided by trainees and always under supervision of staff physician, including procedures
• All trainees need to introduce their roles
• If child/family used for teaching clinical skills, need informed consent from child or from caregiver with assent from child. Includes OSCEs and photos/videos.
• Consent usually not required for teaching sessions, but recommended to inform family and ensure privacy + confidentiality
• Need written consent to publish case reports
• For OSCE: be aware of impact that portraying a sick/troubled child has on volunteer child and provide approrpiate limits and counseling. Need to be compensate children without causing undue inducement

Question 58

Exercise and febrile illnesses

Answer 58

• Exercise and immune system
  
  • Increase neut + lympho d/t increase adrenaline -> continued increase neut + low lympho b/c increase cortisol
  • Decrease CD4 (helper T) : CD8 (suppressor T) ratio.
  • Suppressed salivary igA
  • Immunological open window: brief period of immunosuppresion after intense exercise
  • Relationship between amount of exercise adn incidence of infection forms a J curve
• Fever
  
  • Affects body’s ability to regulate body temp and increases insensible fluid losses
  • Increases risk of heat injury (heat stroke + heat exhaustion) + dehydration if exercising in hot climate
• Neck check:
  
  • If Sx only above neck (rhinorrhea, sore throat), then can participate if feel able
  • Infected athelete shoudld attempt exercise at mild ot moderate intensity for 10-15min. If Sx worsen, then stop + rest. If doesn’t worsen, can continue.
• If systemic Sx (fever, tachycardia, myalgias, diarrhea): don’t exercise until Sx resolved for 7-14d b/c risk fo dehydratio, prolonged illness, more serious complications. Gradual return to sports, take 1-2d for every training day missed to build up to preillness levels
• If illness has risk to others, don’t return until fully recovered
• Infectious mono
  
  • Assume splenomegaly unless r/o by U/S. Risk of splenic rupture 0.1-0.5%, usually spont, highest in first 3wks of illness (day 4-21)
  • Exclude from sport for min 3wks from onset of Sx or from time of Dx if onset not clear. Criteria before activity:
    
    • Sx resolved (fever, fatigue, LND, pharyngitis)
    • Normalization of all lab markers
    • Resolved splenomegaly by U/S
    • Resolved any + all complxns (fatigue, a/w obstruction d/t enlarged tonsils + hepatitis)
  • Then return to low-impact, non-contact training at 50% of preillness level. Graded return over 1wk to full sport participation if continue to improve with no Sx relapse.
  • If no U/S, consider delay by 1-2wks to avoid potentially late splenic rupture
• Prevent illness: well-balanced diet, adequate sleep, avoid overtraining + fatigue, allow adequate recovery time after intense exercise, avoid sick people, hand hygiene, don’t share towels/water, reduce life stressors, immunize (MMR, hep A/B, influenza, tetanus)

Question 59

Family-based treatment of children and adolescents with anorexia nervosa: guidelines for the community physician

Answer 59

• FBT is most effective therapy for AN (though may not be best initial approach)
• Parents given responsibility for restoring child’s wt
  
  • Parents in charge of eating + exercise. May need to stop exercise, restart once steady weight-gain
  • Parents may need to take LOA from work, encourage both to take responsibility
  • Can continue school, but have to come home for meals
  • Maintains normal environment of adol while minimizing inpt resources + empowering the family
  • Don’t expect pt to agree to this plan, but try to build rapport with them
  • Consider traditional behavioural strategies (reward good behaviour, consequences for unwanted behaviour)
• Outpt F/U
  
  • Initially freq, up to 1X/wk, aim for consistent wt gain 0.2-0.5kg/wk
  • Dietician support: 3 meals, 2-3 snacks
  • Speak with pts alone, then with parents. Parents should get feedback at every visit
  • If poor response to Tx, consider day hospital or inpt program

Question 60

FASD

Answer 60

• Criteria for diagnosis. Each has scale of 1-4.
  
  • Maternal alcohol consumption in pregnancy
  • Poor growth (microcephaly)
  • Neurological abnormalities
  • Characteristic facial features (short palpebral fissures, increased intercanthal distance, flattened face, short nose, absent or hypoplastic philtrum, bow shaped mouth, thin upper lip)
  • No bicohemical markers
• Atypical FAS: alcohol exposure with incomplete features
• No safe amount of EtOH established. Binge drinking worse than steady moderate drinking (b/c effects depend on blood alcohol level)
• Newborn
  
  • poor growth, microcephaly, altered tone, hearing + eye abN
  • Poor sleep, irritability, hypersensitivity to light/touch/sounds, difficulty establishing routines, poor feeding
  • Handle gently, cuddle frequently
• Early childhood
  
  • delayed motor + speech, cognitive deficits, difficulties with interpersonal relationships, ADHD, specific LD in language processing, speech + hearing abN
  • Establish strict routine, refer to early childhood intervention program, keep tasks + instructions simple, concentrate on life skills, establish acceptable interpersonal behaviours, teach self worth
• Social: poor judgment, unable to appreciate consequences, excessive familiarity, difficulty setting boundaries (doesn’t improve with age), risk of touble with law, risk of abuse (overt friendliness)
• Intervene early by referring to FAS specialist +/ send for behavioural intervention if strong suspicion
• Advocacy
  
  • Primary prevention: school based programs to change attitudes towards drinking in young people
  • Identify at-risk drinker
    
    • Before pregnancy: T-ACE (tolerance, annoyance, cut down, eye opener) >=2 indicates at risk drinker. Advise to cut down or abstain
    • Discourage breastfeeding if still drinking
  • Global funding to all Canadians regardless of ethnicity, status

Question 61

Fever in the returning child traveller: highlights for health care providers

Answer 61

• DDx
  
  • Malaria (20-30%; onset within 6mo of return)
  • Traveller’s diarrhea (10-20%; onset within 2mo of return)
  • Enteric fever (2-7%; onset within 2mo of return)
  • Dengue (5%, onset within 2wk of return)
• Isolation precautions based on presenting Sx
• History
  
  • Travel outside of Canada in the past 12mo
  • Travel details + disruptions: destinations, dates, timing of Sx onset
  • Setting: rural vs urban, living conditions, altitude, season (rainy or dry)
  • Potential exposures: sick contacts, food consumption + handling/preparation (unpasteurized dairy, meat, seafood), water sources (drinking, swimming, washing), insect bites (mosquitos, ticks), animal exposures or bites, sexual encounters
  • Pre-travel prep: counselling, vaccinations, malaria chemoprophylaxis, PPE (clothing, insect nets, repellant)
  • Medical care: health care contacts + meds while traveling and since return
  • P faciparum malaria: well-appearing child can deteriorate quickly. Can also present as a co-infection with pneumonia or bacteremia.
  • PMHx: unvaccinated, immunocompromised, low weight, poor nutritional status, very young age (<1mo)
• Full PEx: include skin exam
  
  • Absence of localized findings does not r/o serious infxn
• Investigations
  
  • CBC+ diff, lytes, Cr, liver enzymes
  • Malaria smears x3 (over 24-48H) +/- antigen detection testing
  • BCx
  • U/A +/- UCx
  • Consider
    
    • CXR
    • Stool C+S (Yersina, Salmonella, Shigella, E coli O157:H7, Campylobacter)
    • Stool O+P (chronic diarrhea or immunocompromised; cyclospora, cryptosporidium, entamoeba histolyica, giardia)
    • Viral serology: acute serology should be saved in the lab and paired with convalescent serology if diagnosis has not been reached within 10-14d. Dengue (fever 14d of return from South or Southeast Asia, Latin America, Caribbean), Zika, or arbovirus
  • Ensure that travel Hx included on all lab + radiologic reqs
• Management
  
  • If malaria-endemic area, child is unwell, or lab Dx may be delayed then empiric Tx for P falciparum malaria
  • ID consult if critically ill or worsening
  • Supportive Tx: fluids
    *

Question 62

Folate and neural tube defects: the role of supplements and food fortification

Answer 62

• NTDs = failed closure of neural tube: includes anencephaly (cerebral cortex) and spina bifida (spinal cord)
• What are 6 RFs for NTDs
  
  1. Birth of previous child with NTD
  2. FHx of NTD
  3. Maternal obesity
  4. Maternal Hispanic origin
  5. Use of anticonvulsants
  6. (Low SES)
• RDI of folate: 400 mcg
• Natural diet: leafy vegetables
• Food fortification: food + cereal in Canada have 150 mcg/100g based on dietary intake in 1990s. Now decreased flour intake
• PO supplementation:
  
  • Health Canada advises women of child-bearing age to take daily multivitamin with 400mcg of folate + vit B12
  • SOGC recommended high risk women to take 5mg for >=3mo prior to conception and 10-12wks post-conception
• Lack of evidence for concerns with supplementation: folate increases risk of cancer (e.g. colon), folate may mask B12 deficiencies

Question 63

Footwear for children

Answer 63

• Shoes only once start walking. For protection, need to fit snugly, soft, light weight, have cushioned soles. Try first.
• Orthotics are not beneficial for physiological flexible flatfoot, developmental intoeing, mild torsional deformities
• Pes planus
  
  • <18mo: in almost all (fat pad under the foot)
  • <6yo: Flexible pes planus, developmental variant
  • <10yo: small minority
  • Rarely causes gait problems or chornic pain if persists into adulthood
  • Higher rates if earlier shoes, overweight, increased ligament laxity
• Torsional deformities
  
  • Metatarsus adductus: if flexible - passive stretching; if not reducible - splints +/ cast; discourage W sit
  • Tibial torsion: if doesn’t resolve, gait plates to reduce tripping
  • Femoral torsion
  • Genu varum + valgum: should resolve by 8yo
  • Majority spont resolve by adulthood. If persist, rarely cause functional problems
• Refer to Ortho if functional disability or pain

Question 64

Gambling in children + adol

Answer 64

• Gambling behaviour is continuum from social, non-problematic play to pathological gambling
• Pathological gambling
  
  • Impulse control disorder
  • Persistent + maladaptive gambling behaviour that leads to sig deleterious legal, financial, physical + psychosocial consequences
  • Exclude manic episode
  • Most report they started galmbing before/during adol, usualy gamble in their homes
• RFs for developing gambling problem: depression, loss, abuse, life-time drug use, impulsivity, antisocial traits, LD, adolescents, males
• Comorbidities: persoanlity d/o, alcohol abuse, life-timer drug use, mood d/o, conduct d/o, ADHD, depression, anxiety
• No gold standard for Tx
• Physicians + HCPs
  
  • Screen for gambling problems: concern for youth’s emotional health, decline in academic perforamnce, sleep problems, money/possessions at home missing, substance misuse, impaired social relationships, comorbidities
  • Frequency (>1x/wk), gamble more than planned, hide behaviours, depression + suicide risk
  • Advocate for schools to become proactive about gambling
  • Be familiar with local Tx providers + Tx services for problem gambling
• Fed/prov/terr gov’ts
  
  • Manages + regulates all legalized gambling, prohibited to minors (18-19yo)
  • Assess impact of new gambling offerings on youth before implementation (e.g. online gampling)
  • Fund research efforts studying problem gambling in youth

Question 65

Getting it right at 18mo: in support of an enhanced well-baby visit

Answer 65

• 2/3 of developmental vulnerabilities that children present wtih in school are preventable
• When children fall behind, they tend to stay behind
• Standardize the Canadian 18mo visit - use Rourke, Nipissing
• Screen for parental morbidities
• Promote early literacy activities
• Provide info on community resources on child dvlpt
• Refer to community resources as appropriate
• Advocate for dvlpt of early years resources
• Support research on standardization of screening programs

Question 66

Going home: facilitating discharge of the preterm infant (<34wk)

Answer 66

• Medically stable + physiologic maturity
  
  • Temp: T~37C, fully clothed, open cot
  • SpO2 >90-95% on RA
  • Apnea of prematurity: <37wk GA, stop breathing >=20s OR 10-20s if HR<80 or SpO2 <80%. Not a RF for SIDS. Apnea free for 5-7d.
  • Sustained weight gain
  • Feed breast/bottle without major cardioresp compromise. non-nutritive sucking during gavage feeding sig shortens LOS + helps transition to PO.
  • Pre-D/C exam + growth parameters
• Screening
  
  • NBS
  • Hearing screen
  • Vit D + iron
  • Assess for RSV ppx + admin if indicated
  • HUS if indicated
  • ROP screening if indicated
  • Immunizations if indicated
• Education + psychosocial
  
  • Parents able to independently + confidently care for their infant
  • Provide meds, nutritional supplements + any special medical care
  • Recognize SSx of illness + respond appropriately, esp in emergency situations
  • Understand importance of infection control + smoke-free environment
  • Safe sleep + SIDS prevention
  • Infant CPR training
• F/U
  
  • PCP - provide written summary of hospital care
  • HCP w/in 72H
  • Med + surg F/Us
  • ROP screening
  • Neonatal neurodevelopmental F/U
  • F/U hearing, NBS, RSV ppx
  • Community resources + supports

Question 67

Guidelines for detection, management + prevention of hyperbilirubinemia in term + late preterm newborn infants

Answer 67

• Don’t use umbilical cord blood TSB - poor PPV + SP
• Routine umbilical cord blood Hgb or HCT doesn’t help predict severe hyperbilirubinemia
• If mother’s blood not tested, send cord blood for blood group + DAT
• TcB limitations: unreliable after starting phototherapy and with changes in skin colour/thickness
• See GI for the rest

Question 68

Guidelines for genetic testing of healthy children

Answer 68

• In all situations where genetic testing of healthy children is considered, parents should be informed of potential psychological + social risks assoc’d with testing
  
  • May find something that’s incurable or something that we don’t know when or how it will present
  • Risk of discrimination on the basis of genetic status if information available to employers, insurers
  • Must consider best interests of the child. If parents insist and no benefit to child, not obligated to test. Refer to ethics or legal opinion.
• Timeliness of medical benefit to guide genetic testing
  
  • Genetic testing appropriate if it’ll confirm a Dx in a symptomatic child OR child at risk of a genetic condition that will occur in childhood which would allow for adequate medical monitoring, ppx, or Tx
  • Defer testing until child is competent
    
    • If condition presents in adulthood
    • If carrier status for conditions only important for reproductive decision making
  • Children considered for adoption should not be subjected to genetic testing if no timely medical benefit

Question 69

Guiding parents in their search for high-quality health information on the Internet

Answer 69

1. Is the host of the health information website engaged in a conflict of interest?
   
   • Selling products/services, ads
   • About us or Contact us link
   • Request for personal information
2. Is the information presented on the website peer reviewed?
3. Is the information up to date?
4. Is the information presented based on proper evidence?
   
   • Less reliable: retrospective, observational (testimonials, case reports/series, cohort studies, case-control studies)
   • More reliable: prospective, experimental

Question 70

Harm reduction: an approach to reducing risky health behaviours in adolescents

Answer 70

• Provide messages that encourage delay in initiation of potentially risky behaviours AND promote risk-reduction strategies if adolescents choose to engage or are already engaging in the behaviour
• Use motivational interviewing (emphasizes self-responsibility in changing or modifying one’s behaviour)

Question 71

Health care standards for youth in custodial facilities

Answer 71

• every facility should have person who oversees the health program and advisory comittee which sets policies and procedures for health care
• all facilities should have 24/7 emergency care plan (medical, behavioural and psych emergencies)
• larger facilities should have a MD, smaller faciliites should consult a MD
• Intake assessment within 72H including medical + psychiatric
  
  • dental exams
  • genital exams where appropriate
  • immunizations
  • sexual + drug counselling
  • smoke free areas and smoing cessation programs
  • nutritional services
• Immediately address acute care and infectious illnesses
• communicate assessment, findings + plan to teen
  
  • same rights to health care, consent, and confidentiality

Question 72

Health implications of children in child care centres

Part A: Canadian trends in child care, behaviour and developmental outcomes

Answer 72

• High-quality child care improves some cognitive and behaviour outcomes (e.g. better vocabulary scores). Need better research
• AAP + American Pulbic helath association recommendation for staff ratios: 3:1 for <2yo, 4:1 for 24-30mo, 5:1 for 31-36mo
  
  • Improtant for preventing injuries
• Child care staff should have training in early child education. Appropriately remunerated to minimize staff turnover
• HCPs, gov’t, NGOs, families work together for afforadable, accessible, high quality child care

Question 73

Health implications of children in child care centres

Part B: Injuries and infections

Answer 73

• All staff trained in basic first aid and CPR.
• All child care centres should have written policy on management of a sick child
  
  • Recognize emergent illness/injury. When to call ambulance. Proper use of antibiotics. Procedures for childcare exclusion.
• Return to child care
  
  • Resp conditions: continue to attend if well enough to participate fully in all activities
  • Strep pharyngitis or bacterial conjunctivitis: 24H of ABx therapy
  • Diarrhea: exclude if stool cannot be contained in a diaper, cannot be controlled by toilet-trained child, or signs of bacterial enteritis (fever, blood/mucous in stool). Contact local public health authority (prov/terr regulations for exlusion vary for different tpes of enteritis)
• All children + staff should be fully immunized
  
  • Annual influenza
  • Updated tetanus, diphtheria, and acellular eprtussis
  • Hep A (endemic areas, local outbreak)
• Routine safety audits on weekly, monthly, seasonal, and yearly basis
• Play equipment and surfacing comply with Canadian Standards Association

Question 74

Health research involving Indigenous people

Answer 74

• TCPS (Tri-counsil policy statement) guidelines 2010 discuss ethical research conduction among aboriginal populations
  
  • Autonomy, beneficence, non-maleficence
  • Welfare + respect for persons takes priority over other research considerations
  • Proper informed consent (translated, written +/ oral)
  • Responsibility of researchers to inform aboriginal study participants of their rights outlined in TCPS
• Communities
  
  • Approach community leaders/as a whole. Consult to determine risk for negative impact (stigmatization, discrimination, loss of control over research outcome), study goals aligned with community goals
  • Consent from leaders does not trump individual consent
• CBPR (Community based pediatric research)
  
  • Research approach that ensures research is conducted by and for aboriginal people
  • Ownership: indigenous group/community has ownership of information the same way that an individua has ownership of personal info
  • Control: indigenous people have right to maintain control of all research aspects that impact them
  • Access: indigenous people must have access to all data concerning them
  • Possession of data: mechanism by whihc ownership can be asserted

Question 75

Healthy active living: physical activity guidelines for children and adolescents

Answer 75

• Children with >2H screen time/d are 2X as likely to be overwt/obese than peers watching >=1 h/d
  
  • Higher risk if TV in bedroom and low SES
• Recreational screen time recommendations
  
  • <2yo: none
  • 2-4yo: <1h/d
  • >4yo: <=2H/d
  • Avoid screens in childrens’ bedrooms
• Physical activity
  
  • Physical activity = any body movement that works muscles using more than resting energy
    
    • free play, structured activities, ADLs
  • Exercise = planned, structured + repetitive PA to condition any part of the body
    
    • Aerobic exercise: mod-to-vig activity which increases HR + sweat production and improves cardio endurance. Reduce wt, visceral/subcut abod fat, and SBP. Improves atherosclerosis, insulin resistance, T2DM, NAFLD, SDB, cardioresp fitness, anxiety/depression.
    • Flexibility: increase m/jt ROM
    • Anaerobic exercise (wt training): improve muscle strength
    • High impact weight bearing exercise: promote bone health
  • Avoid sedentary time while awake to <1H at a time
  • Infants: floor-based play (tummy time, reaching, pushing, pulling, crawling)
  • 1-4yo: structured + unstructured activity (free play) for >=3H/d
  • 5-17yo: >=60min/d of mod-to-vigorous intensity PA
    
    • Vigorous intensity activities at least 3d/wk
    • Muscle + bone strengthening activities at least 3d/wk.
  • Special health care needs (e.g. asthma, diabities, NM diability): benefit from flexibility exercises, strength training (increase neuromuscular learning + muscle/bone strength), wt-bearing PA (improve bone mass acquisition)
  • Identify barrier to physical activity in family routine. Document sources of physical activity. Encourage family routine.
  • Ensure protective equipment (bicycle helmets, personal flotation devices)
• Strategies to improve healthy active living
  
  • Passport to Health program: Every day:
    
    • 0 sugar-sweetened drinks
    • 1H of physical activity
    • 2H of screen time
    • 5 servings of fruit or vegetables
  • Create individual PA prescriptions
• Plot BMI and identify obesity-related co-morbidities at every well-child or adolescent visit
• Advocacy
  
  • Develop + fund strategies to promote PA, especially to Indigenous youth
  • Eliminate TV ads that promote fast food, unhealthy foods, and sedentary behaviour during children’s programming
  • Establish school welness council - local MD representation is encouraged
  • School curriculum teaching students health benefits of regular PA
• • Compulsory, quality, daily PE classes in schools taught by qualified teachers. Protecting recess time and extracurricular PA programs
    
    • Accessible community sport/rec programs
    • Safe rec faciliites, parks, playgroups, bicycle paths, sidewalks + cross walks

Question 76

Home IV therapy: accessibility for Canadian children and youth

Answer 76

• Indications
  
  • Infection is most common indication
    
    • soft tissue, bone + joint infections most common
    • PNA: doesn’t tolerate PO, doesn’t require other supportive care
    • meningitis, endocarditis, sepsis: once stable and not expecting sudden deterioration
    • immunocompromised: if stable, for opportunistic infections (CMV, fungal)
    • neonates: if expertise available
  • Others: parenteral nutrition, clotting factors for hemophilia, chemo, Tx for immunodeficiencies, meds for palliative care + anti-inflammatory mediators
  • Need to be at least as effective + as safe as IV Tx in hospital
• Candidates:
  
  • Consider clinical (IV necessary, doesn’t need hospitalization, stable) + family factors (caregiver ability, willingness, safety)
  • Less ideal: meds admin >3X/d, >1 drug, drug instaility
• Complications
  
  • Mechanical: time of IV insertion (vessel puncture) or later (thrombosis, dislodgement, occlusion, leakage)
  • Infection (less frequent)
  • Complications of administered Tx
• Vascular access devices
  
  • PIV: <1wk in young child, <2wk in older child/adol for drugs that don’t cause phlebitis or soft tissue damage from infiltration
  • Midline catheter: 2-4wks, AC fossa
  • If need Tx for >2wks, use CVC. A = adv, D = disadv
    
    • PICC: wk to mo. A: Doesn’t need GA. D: risk of accidental dislodgement if very young/active
    • Tunneled central line (Broviac, Hickman): mo to yrs. A: multiple lumes or frequent blood tests, better for very active. D: req GA, weekly heparin infusion + dressing change
    • Totally implanted ports: mo to yr, useful for very long-term access, intermittent Tx. A: lowest infxn risk, does not impede activities. D: req GA, risk of skin breakdown over device so not useful for continuous/daily access
  • Infusion pumps: gravity, mechanical, portable electronic pumps (lighter, can be worn throughout the day, insert a medication cassette once a day)
• IV team:
  
  • 1) MD with expertise in home IV, condition treated, and peds care; 2) PCP + referring MD; 3) infusion nurse specialist; 4) rep from community home care service; 5) collab with surgeons/IR/VAT who insert vascular access devices; 6) pharmacist; 7) other appropriate specialists (e.g. home PN - GI + dietician); 8) SW; 9) case manager.
  • Need MD/RN available 24h/d for rapid communication with family.
  • Need to have written protocols for assessment + selection of pts, VAD insertion + care, pt education + monitoring, outcome assessment + documentation
• Pt monitoring
  
  • Seen by MD/RN at least 1X/wk. Can be less frequent once stabilized.
  • Can be monitored by PCP who is in weekly communication with home IV team
  • 1) Clinical + lab evaluation of illness + potential to change to PO. 2) Monitor IV site + VAD function (edema, induration, pain at infusion site, erythema, drainage, thrombosis, extravasation or infection). 3) Compliance. 4) Clin + ab evaluation for adverse drug effects + drug levels.

Question 77

Homeopathy in the pediatric population

Answer 77

• Canadian Natural Health Products Directorate, branch of Health Canada, deals with regulation of homeopathic meds. Drug Identifcation Number
• “Like cures like” - give product that would produce same Sx, but dilute significantly to promote cure
  
  • Higher the dilution, more potent. Lots of variability
• Adverse effects seem to be uncommon b/c so dilute, but may be under-reported
• Quality of clinical trials of homeopathy do not compare favourably with those of conventional medicine
  
  • Benefit of homeopathy: diarrhea (sig decrease in diarrhea freq + duration w homeo vs placebo in well-designed studeis)
  • No difference: otitis media (vs placebo or conventional Tx), adenoid hypertrophy (vs placebo), asthma (vs placebo, both w conventional Tx), cold/flu (vs placebo), warts (vs placebo)
  • Bad studies: allergies (w conventional Tx), chemo-induced stomatitis, post-op agitation, ADHD
• Major concern is reluctance on those who practice homeopathy to support vaccinations
• Delays in seeking conventional medical therapies while trying homeopathic Tx can jeopardize child’s health

Question 78

Housing need in Canada: healthy lives start at home

Answer 78

• Types of housing need (substandard living conditions)
  
  • Inadequate housing: needs major repairs
  • Unsuitable housing (crowded): fails to meet National Occupancy Standard requirements for # of bedrooms for size + make-up of the household
  • Unaffordable housing: >=30% of gross household income spent on shelter costs
  • Unacceptable housing: does not meet at least 1 of the standards fo adequacy, suitability, and affordability
  • Core housing need: unacceptable housing and household would have to spend >=30% of their gross household income to access acceptable housing in their community
• Screening tool: HOME
  
  • Harm: is your home in need of major repairs?
  • Occupancy: how many people live in your home, in how many rooms?
  • Moves: how many times has your child moved? have you used a shelter or informal, temporary housing such as staying with friends or family?
  • Enough/income: do you have enough money for housing, food, and utilities
• Negative outcomes of housing need
  
  • Behaviours: aggressive, emotional problems, poor school performance, repeating grade, suspended/expelled, property offenses
  • Health: worsened asthma, communicable diseases, unintentional injuries, decreased outdoor activity (unsafe neighbourhood), lack of access to medical care
  • Social: food insecurity, lack of access to safe water supply
• Who are disproportionately affected?
  
  • Indigenous, recent immigrants, children with disabilities

Question 79

Human milk banking

Answer 79

• Product
  
  • All donors undergo rigorous screening process (similar to donating blood): Interview (cannot smoke, drink, or be on medications), serological screening (sero neg for Hep B, C, HIV, HTLV) + MD consent
  • Mild batched from up to 4 different mothers
  • Milk collected, stored, pasteurized + cultured in accordance with food prep guidelines set by Canadian Food Inspection Agency
  • Pasteurization
    
    • Inactivates bacterial + viral contaminants like CMV.
    • Bacillus survives, but it’s a rare contaminant of human BM (unlike cows) and can be detected in surveillance Cx pre + post-pasteurization
    • Inactivates beneficial immune cells too (IgA, IgG, IgM, lactoferrin, lysozyme)
    • Carbs, fats, salts, fat-soluble vitamins unchanged
    • 13% of protein content denatured. water-soluble vitamins may degrade (not all studied)
• Indications
  
  • Alternative nutrition source for hospitalized neonates when mother’s milk unavailable/limited
  • Prioritized for compromised preterm infants + selected ill term newborns
  • Need written informed consent from parent/guardian
• Benefits
  
  • Reduces severe infections, NEC, + colonization by pathogenic organisms
  • Cost effective nutritional source for hospitalized neonates
• Risks
  
  • No reported case of disease transmission
  • Allergic reaction - human breast milk is species specific, so risk is not higher than formula feeding
• Human milk bank also should promote breastfeeding + ongoing human milk research
• CPS does not endorse sharing unprocessed human milk

Question 80

CRAFFT Screening Tool

From Inhalant Abuse statement

Answer 80

• C: Have you ever ridden a Car driven by someone (including yourself) who was “high” or had been using alcohol or drugs?
• R: Do you ever use alcohol or drugs to Relax, feel better about yourself, or fit in?
• A: Do you ever use alcohol or drugs while you’re Alone?
• F: Do you ever Forget things that you did while using alcohol or drugs?
• F: Do your Family/Friends ever tell you that you should cut down on your drinking or drug use?
• T: Have you ever gotten in Trouble while you were using alcohol or drugs?
• >=2 “yes” => potential substance abuse problem -> need further assessment

Question 81

Inhaled nitric oxide use in newborns

Answer 81

• Indicaton
  
  • >=35wk GA with hypoxemic resp failure (assoc’d with PPHN) who fail to respond to appropriate resp mgmt
    
    • Resp mgmt: optimize tidal volumes/pressure, surfactant, HFOV +/ Jet ventilation
  • All candidates should ideally have ECHO to r/o cyanotic CHD and assess pulm HTN + cardiac fxn
  • Not candidates: 1) CDH, 2) prems (?increase risk of IVH)
• Mechanism
  
  • NO diffuses into vascular muscle cells -> activates gunaylate cyclase -> increased cyclic GMP -> pulmonary vasodilation -> improved vent/perfusion matching
• Dose
  
  • Start 20ppm. Max 40ppm (higher doses increase risk of toxicity w/o additional benefits)
  • Wean once 4-6H period of improved oxygenation + stability and FiO2 60-80% OR OI <=10
  • Wean by 50% Q4-6H if OI <=10. At 5ppm, decrease by 1ppm Q4H, then D/C at 1ppm as long as FiO2 <60% and PaO2 consistently >50mmHg
  • Mean duration in trials was 48-96H. safe duration unknown.
• Benefits
  
  • Term infants with severe hypoxic resp failure have decreased use of ECMO -> decreases combined outcome of death or need for ECMO
• Risks
  
  • Production of NO2 + metHb
  • Decreased plt aggregation, increased risk of bleeidng, surfactant dysfunction

Question 82

Is the medical use of cannabis a therapeutic option for children?

Answer 82

• Federally licensed producer can supply pt with up to 30d supply, max wt of 150g of marijuana for medical purposes
• Clinical evidence supporting use of marijuana + other cannabis derivatives in children is very sparse
  
  • Sz: cannabis + derivatives may be effective for refractory epilepsy, not evaluated over long term
  • MS: adult studies show CBD oil can improve Sx
• SE: red eyes, dry mouth, tachycardia, delayed motor skills. Cogntiive impairment, nausea, weakness, psychosis, risk of dependence
• Smoking is unacceptable for children (tars + byproducts assoc’d with carcinogenesis; can’t control or adjust dosage)
• Use of cannabis for medical purposes should be case-by-case basis by cliicians with specific expertise + training.

Question 83

Joint Statment on Safe Sleep: preventing SIDS in Canada

Answer 83

• SIDS = sudden death of an infant <1yo that is unexplained after thorough case investigation, including complete autopsy, examination of death scene, and review of clinical history
  
  • Any age but peaks 2-4mo, fewer SIDS deaths after 6mo
• RFs
  
  1. Male
  2. Prem
  3. Low BW
  4. Low SES
  5. Aboriginal
• Recommendations (*= most important modifiable RFs)
  
  1. Back to sleep*
  2. No maternal smoking during pregnancy.* Prevent exposure after birth
  3. Do not share bed. Sleep in crib, cradle or bassinet
  4. No soft bedding
  5. Share room with parent/caregiver for first 6mo
  6. Breastfeeding
     *

Question 84

Kangaroo care for the preterm infant and family

Answer 84

• Positive benefits and no reported detrimental effects on physiological stability for prem >=26wk GA, including on assisted ventilation
• Benefits
  
  • Enhances breastfeeding, may contribute to improved neurodevelopmental outcome
  • Decreases incidence of nosocomial infection b/c infant more likely colonized with maternal flora rather than flora in nursery (ARO + CONS)
• Need further research for impact on ventilated infants <26wk GA. Look at outcomes of IVH, wt gain, neurodvlpt

Question 85

Managing type .1 diabetes in school: recommendations for policy and practice

Answer 85

• If >=1 students with diabetes, school must ensure at least 2 school personnel are trained to provide support
  
  • Each teacher/supervisor must know how to recognize + treat hypoglycemia
• Schools must provide all studies with clean, convenient + safe area for diabetes self care (BG, insulin) and respect students’ personal preference for privacy + level of autonomy varies
  
  • Designated staff member must supervise students’ meals/snacks and ensure eaten on time and in full. Provide adequate time to eat.
• Individual care plan (ICP) must be developed for each student with T1DM and discussed among parents, school principal and teacher with HCP input PRN. Should occur before start of school. Clearly outline roles + responsibilities of school personnel, parents, + child).
  
  • Accommodations for tests/exams. Must be allowed to keep diabetes emergency kit at desk (BG eter, hypoglycemia Tx, snacks as required). If hypogycemia in 30min before or during exam, student should get 30-60min to allow for congitive recovery from hypoglycemia
  • Exclusions should be minimal and only in accordance with student’s ICP.
  • Attendance-incentive policies + practices should not apply for medical appointments
• Hypoglycemia
  
  • Do not leave student alone, if suspected
  • If severe, call 911
  • Give IM glucagon is ideal, but may not be feasible for all schools. If emergency response time expected to be >20min, then school personnel should be trained to admin glucagon
    *

Question 86

Maternal depression and child development

Answer 86

• 13% of women have postpartum depression
• Impact of parental depression
  
  • Infant: insecure attachment, negative affect, dysregulated attention + arousal
  • Toddlers + preschoolers: poor self-control, internalizing + externalizing problems, difficulties in cognitive functioning + social interactions with parents + peers
  • School-age + adolescents: impaired adaptive functioning + psychopathology (CD, affective d/o, anxiety d/o), ADHD + LD
• RFs that exacerbate: poverty, marital conflict, stressful life events
• Protective factors for resiliency: child’s easy-going temperament, good social cognitive skills, understanding parent’s illness
• Maternal antidepressant medications
  
  • Risks of mother’s depression outweigh low risks of antidepressant meds on fetus or breastfed infant
  • During pregnancy: no increased risk of teratogenicity or fetal anomalies, no significant neurodevelopmetnal adverse effects
  • During breastfeeding: no neuro or dvlptal abnormalities through exposure via breast milk, aim for lowest possible maternal dose that provides compete control of depressive Sx, can “pump and dump” 8-9h after medication. SSRIs (sertraline + fluoxetine) and TCAs are drugs of choice
  • St John’s Wort: data scarce. Herbal remedies not recommended during pregnancy + lactation b/c no safe data and many drug interactions
• Screen for postpartum depression
  
  • How are you feeling about being a new mother?
  • Are you enjoying your baby?
  • Do you find that your baby is easy or difficulty to care for?
  • How are things going in your family?
  • Are you getting enough rest?
  • How is your appetite?
  • During the past month, have you often been bothered by feeling down, depressed, or hopeless?
  • During the past month, have you often been bothered by having little interest or pleasure in doing things?
    *

Question 87

Measuring in support of early childhood development

Answer 87

• Fed + prov/terr gov’ts to measure + monitor dvlptal progress of children in Can to allow for research + analysis
• EDI (Early Development Instrument): completed by kindergarten teachers, reports on physical, social, emotional, lang/cog, + communication skills
• Goal for early (18 mon), transition to school (EDI), and middle childhood (Grade 4 MDI) measures of child developpment
• Government should invest in effective early child development interventions that maximize the health, well-being + education of all Canadian children

Question 88

Medical Assistance in Dying: a Pediatric Perspective

Answer 88

• 2 forms of MAID
  
  • Euthanasia: at pt’s voluntary request, practitioner administers med that causes pt’s death
  • Practitioner-assisted suicide (PAS): at pt’s voluntary request, practitioner prescribes or provides med that pt can self-administer to cause their own death
• MAID eligibility in Canada
  
  1. >=18yo
  2. Grievous and incurable illness
  3. Make volunary MAID request
  4. Capable of decision making
• Assessing minor’s personal capacity to make health decisions rest with pt’s clinical team + parents, in consulation with other designated experts (e.g. bioethicists, psychologists, psychiatrists)
• Physician can choose not to participate in MAID, provided they refer requesting pts or families appropriately

Question 89

Meeting the health care needs of street-involved youth

Answer 89

• “Absolute homeless”: live outside
• “Relative homeless”: have no safe, consistent place to live
• As F/U is uncertain, address most pressing concerns first
  
  • Initial mental health screen, focus on suicide, harm to self or others
  • Determine housing status
  • Ask whether they can purchase meds
  • prioritize screening for STIs
  • Administer vaccines
• Advocate for universal health care coverage

Question 90

Meeting the needs of adolescent parents + their children

Answer 90

• Adol parent <20yo
  
  • High rates of MH issues, substance use, repeat preg, domestic violence
  • Need to screen + Tx MH d/o, contraceptive couselling, STI prevention + Tx, lactation counselling, financial security screening + support
• Children of adol mothers
  
  • Increased risk for prenatal death, prem, LBW, growth + dvlpt issues, SL delay, accidental injury, neglect, substance use, early sexual activity
  • Need to screen for dvlpt, screen for home safety + violence, give mother anticipatory guidance regarding all normal gen peds issues
• “Medical home” model: holistic care for both mother + child
• Offer resources: positive parenting programs, early literacy, SLP, sexuality
• Refer to outreach services incl’g home-based interventions

Question 91

Mental health problems in children with neuromotor disabilities

Answer 91

• Children with neuromotor d/o have more MH Sx
• Difficult assessment d/t: communication problems, atypical presentations of motor disability + neurodvlptal d/o (e.g. ADHD), challenges to obtain clinical hx
• MSK pain:
  
  • CP - physical pain directaly related to severity of functional disability
  • Sources of chronic pain: medical procedures, NM disturbances (sytonia), MSK issues (hip dislocation)
  • Pain assoc’d with isolation, frustration, sadness, anxiety, difficulty concentrating, irritability, lower activity levles
  • CBT
• Medical co-morbidities
  
  • Sz + AEDs can affect cognition, motor + emo/behav fxn
  • Dysphagia -> aspiration + recurrent PNA
  • GERD + constiation -> pain + nutritiona probs
  • Sleep d/o multifactorial
• Motor activity
  
  • internalizing problems -> less engaged, less physical activity -> lower child-reported HRQOL
  • externalizing problems -> lower parent-reported HRQOL but higher child-reported HRQOL
• Communication, cognition + learning
  
  • Spina bifida assoc’d with nonverbal LD, ADHD, executive dysfunction, hydrocephalus
• Family: strategic use of respite care
• School: positive academic + social involvement at school is a protective factor for health. Personalized classroom supports assoc’d with increased participation. Screen for social isolation + bullying.
• Community:

Question 92

Minimizing blood loss + need for transfusions in very prem infants

Answer 92

• Risks of blood draws: pain, sepsis, iatrogenic anemia, need for transfusion
• Risks of pRBC transfusions: acute lung injury, GVHD, increased in-hospital mortality of VLBW infants. NEC is controversial
• Recommend delayed cord clamping (30s to 3min) if not immediate need of resusc
• Do not recommend cord milking routinely
• See PINT study for transfusion thresholds (115, subtract 15)
• Transfuse 20mL/kg if hemodynamic + resp stable

Question 93

Minimizing infection risks after paediatric organ transplants: advice for practitioners

Answer 93

Pre-transplant

• Optimize vacccines before immunosuppression
  
  • DTAP, Hib (regardless of age), PCV 13/23 polysaccharide, N meningitides, rotavirus (if appropriate), inactivated influenza, Hep A+B, MMRV, HPV
  • Inactivated vaccine >=2wks before transplant
  • Live vaccine >=4wks before immunosupression
  • Only live atenuated vaccine not recommended even before transplant is influenza
  • Live vaccines are relatively contraindicated after transplant
  • Household contacts should get age-approp vaccines, incl’g influenza
• Identify infxns in candidate + donor
  
  • Screen serologies: HIV 1+2, HTLV1+2, Hep A + Hep B (vax if non-immune), Hep C, Hep D (if HBsAg pos), CMV IgG (do UCx if pos), EBV HSV, VZV, Toxo, MMR (if vaccinated), Strongyloides (if endemic)
  • TB test, sputum Cx (CF pts or lung transplant candidates), X-Rays as indicated

Post-transplant

• Expectations
  
  • First 6mo: >95% of infxns similar to if non-immunosuppressed undergoing similar surgical procedure. Rest d/t pre-transplant infection exacerbted by surgery/anesth/immunosuppressive therapy OR transmitted by allograft
  • 1-6mo: immunosuppression -> opportunistic infxns
    
    1. viral: CMV, EBV, HHV6, Hep B/C. Can be primary, reactivation of latent, or reinfection with new strain.
    2. Listeria monocytogenes, Aspergillus
  • >6mo:
    
    • If good allograft fxn on maintenance immunosuppresion, same community-acq’d infxns as healthy children
    • If poorer post-transplant outcomes, high risk for recurrent infxns d/t uncorrected mechanical/anatomical probs, and opportunistic infxns (PJP, listeria, cryptococcus, enoformans, Nocardia asteroides)
• Prophylaxis (D = donor, R = recepient)
  
  • Bacterial (post-op wound infxn + sepsis): All recipients. ABx + duration dep on organ/nature of surgery/recipient factors
  • PJP: All recipients. TMP-SMX. 6-12mo. Lifelong if on steroids, CD4 <200/mm3, lung/sm bowel transplants, Hx of prior PJP or chronic CMV
  • HSV: sero pos recipients. Acyclovir x3mo (if not already on gangiciclovir)
  • CMV: risk stratify b.on CMV donor/recipient serostatus. IV gangiclovir (or valgan for low-intermed risk older children) +/- IVIG x ~3mo
  • EBV: high risk pts that are D+R-. No est’d regimen (may decrease immunosuppresion or ganciclovir +/- IVIG), variable duration
  • Candida: high risk pts (e.g. liver, intestinal transplants). Fluconazole or amphotericin B, or nystatin. Up to 4wks.
  • Aspergillus: lung/heart recipients. Voriconazole, itraconazole, ampho B. 4-6mo.
  • Toxoplasma gondii: heart/heart-lung recipients. Pyrimethamine/sulfadiazine for D+R-. TMP-SMX for R+. 6mo.

Evaluation of febrile transplant pt

• If abN exam + defined focus of infection: consider admit. Work up incl’g minimum CBC+diff, BCx.
• If N exam + no focus of infection: admit if clinically unwell. Outpt if pt well and good F/U, can return promptly if worsens, degree of immunosuppression, interval since transplant. Work up incl’g minimum CBC+diff, BCx, UCx.
• Viral infxns can have fever but no focus of infxn (e.g. CMV, adenovirus)
• Be aware of potential interactions between Abx + immunosuppressive drugs

Post-transplant immunizations

• No vaccines in first 6-12mo post-transplant
  
  • Exception: inactivated influenza, at least 1mo post-transplant
• Live vaccines contraindicated
  
  • MMR considered in low risk pts, but not varicella
• Indicated vaccines
  
  • Invasive pneumococcal: PCV 13, then in 8wks the 23-valent polysaccharide. Functional/anatomical asplenia are candidates for long-term penicillin
  • Meningococcal: routine schedule, use men conjugate quadrivalent (rather than polysaccharide quadrivalent) in >24mo old
  • Inactivated polio, Hib, diptheria, tetanus: routine schedule, preferably before transplant. Give Hib regardless of age
  • HPV: safe post-transplant
  • Hep A: if hepatic RFs other than transplant (chronic liver disease, epidemiological). Note: transplant meds may be hepatotoxic
  • Hep B: routine, double the usual dose

Question 94

Screening for disruptive behaviours in pre-schoolers in primary care settings

Answer 94

• Behaviours considered a disorder if all are met:
  
  • Atypical for child’s developmental age
  • Persists for >=6mo
  • Across all settings
  • Impairs function
  • Distressing for child and family
• Standardized screening
  
  • Rourke, ABCDaire, Child behaviour checklist
  • Better at r/o than confirming
• Borderline behaviours:
  
  • Anticipatory guidance
  • Age-appropriate expectations
  • Parental reading materials
• Disruptive behaviour
  
  • First line: Parent behaviour training programs (e.g. Triple P)