How many g of Na is recommended per day?
Age 1-4: 1500
Age 5+: 2300
Name 4 health risks of climate change
Heat and cold related morbidity and mortality
Natural hazards and extreme weather events
Increasing air pollution
Contaminated water sources
Infection risks associated with insects, ticks, and rodents
Stratospheric ozone depletion (worse up North with thinner ozone layer)
Why are children at higher risk of climate related health effects?
They have longer life time exposure and metabolize more per kilo
What children are at higher risk for climate related health risks?
What health concerns occurs occur in natural health hazards and weather events?
Injury and death Displaced from home Overcrowding Mental health impacts Food or water shortage Interruption to health care and education
What health complications occur due to ozone layer depletion?
Increased UV exposure
More skin cancer and cataracts and immune system compromise
How can pediatricians prevent climate change health complications?
Advocate for government to act against climate change
Volunteer on disaster planning committees
Recommending trainee climate change teaching
Role model environmental sustainability
5 ways to approach vaccine hesitancy in the community
Detect and address vaccine hesitant group
Educate health care providers on immunization best practices
Evidence based strategies to improve uptake
Educate children, youth, and adults on importance of immunization
Name 4 EBM strategies to increase vaccine uptake
Target underimmunized groups Make vaccine services convenient and accessible Engage community leaders (religious etc) Remind patients by text, mail, etc. Ensure uniformity across Canada Minimize pain Mandates or incentivized vaccines Build trust in immunization program
How to approach vaccine hesitancy in your clinic?
Don’t discharge anti vaccer from clinic
Presumptive approach and motivational interviewing
Effective clear language to explain vaccines
Manage immunization pain
Reinforce importance in community protection
Do you need neuropsych or psychology assessment to diagnose ADHD?
Only if complex ADHD with comorbidities or hard to diagnose
How should you manage suspecting ADHD in toddlers?
Parents should go to parenting class to teach them developmentally appropriate expectations of toddlers
Risk factors for ADHD (4)
Family history Epilepsy Hypoxic ischemic brain injury Traumatic brain injury In utero alcohol or tobacco exposure Low birth weight Intellectual disability Autism Prematurity (inattentive type only) Environmental toxins Central auditory processing d/o Fragile X Turner syndrome 22q11 Tuberous sclerosis NF1
Adverse outcomes of ADHD (4)
Poor education outcomes Poor relationships More MVA More accidental injuries More substance abuse
Do stimulants worsen tics?
Sometimes better and sometimes worse and sometimes no change. Don’t stop meds just change dose.
Ways to help diagnose ADHD (4)
Mutliple clinic visits
Evaluate for comorbid d/o
Review report cards
Neurological and dysmorphology physical exam
Full history including prenatal
Ask about attachment, temperament, regulation
What makes ADHD more likely to persist into adulthood? (3)
More than 3 DSM d/o
Parental antisocial personality disorder
Intellectual disorder (also decreased med response especially when IQ under 50)
DSM V Criteria (5)
- Symptoms are severe and persistent since under 12 years old and for more than 6 mo
- Symptoms impair daily functioning in some way
- Need to have a reason for why there is discrepancy in symptoms in different settings
- Specify type ( inattentive, hyperactive, or both)
- Severity defined by degree of impairment
What are inattentive ADHD symptoms? (5)
Lack of detail focus Easily distracted Lose objects Forgetful Difficulty organizing tasks Cannot follow instructions Difficulty keeping attention Hard time listening
What are hyperactive ADHD symptoms? (5)
Leaves seat often Blurts out answers Fidgeting Running around or restless Lour or noisy Always on the go Excessive talking Cannot wait their turn Acting without thinking
What is first line med in youth with ADHD (after non pharmacological therapy)
MPH or dexamphetamine extended release
What is the condition that can develop if guanficine or clonidine are stopped quickly?
Hypertension or hypertensive encephalopathy
Name non pharmacological ADHD therapies (6)
Psychoeducation (educate parents) Shared decision making with family Parental behaviour training Classroom behaviour management Daily report card Behavioural peer interventions Organizational skills training Social skills training Cognitive training Exercise
Benefits of stimulants (3)
Improved academics Better parental reported QOL Less risky behaviour Less MVA Less anxiety and depression later on Better job
Side effects of stimulants and non stimulant ADHD meds? (3 each)
Stimulants: Appetite loss Behaviour changes Poor sleep Raynaud's Priapism Up to 2.5 cm shorter
Side effects of stimulants and non stimulant ADHD meds? (3 each)
Stimulants: Appetite loss Behaviour changes Poor sleep Raynaud's Priapism
How often should you increase a stimulant dose?
Every 1-4 weeks
What are risk factors for poor med compliance I’m ADHD?
What side effect do ASD patients see in stimulants for ADHD?
More stereotyped behaviour and iutbursts
3 risk factors for TB
Foreign born in TB endemic region
BCH vaccine contraindication?
How long after exposure to contact case does primary infection normally develop
Within 1 year
What percent of TB infections are asymptomatic?
Who is at highest risk of early primary TB disease?
Children under 4 years old
What are two triggers for reactivation of TB?
Name 5 disseminated regions for TB
Meningitis Disseminated (hematogenous spread and multi system) Lymphadenitis Osteomyelitis Peritonitis Liver or spleen granuloma
2 radiographic findings of early primary TB
Ground glass opacities
Hilar or mediastinal lymphadenopathy
1 disseminated disease CXR finding
Pleural effusion a
Cavitary lesions (usually upper lung field)
What is gold standard to diagnose primary or reactivated TB?
Cultures with stain, PCR, and sensitivity testing from sputum, gastric aspirate, bronchoscopy
What other infectious disease must you test for in all patients with TB?
What is TST positive size? And what are the causes of false positives or negatives?
Greater than 5 mm if immunocompromised
Greater than 10 mm in others
False positive if there is non TB mycobacterium exposure (1% of those with BCG vaccine will have false positive TST after age 10)
False negative if immunosuppressed or malnourished
In children older than 2 is IGRA or TST more specific?
In children less than 2 is IGRA or TST more sensitive?
Over 2 IGRA more specific
Under 2 TST more sensitive
Causes of false positives or negatives in IGRA
False positives: almost none
False negatives: immunocompromised
Better is children with BCG vaccine because more specific
How long must a culture positive patient with TB isolate for?
Either 2 weeks of therapy if initial sputum smear negative OR
3 negative sputum smear negative
If a child has a positive contact with index case if TB what investigations and treatment should be done?
History and physical
Get index case drug sensitivity
Treat children under 5 with negative TST (under 5 mm) with single drug prophylaxis until negative TST done 8-10 weeks from last contact exposure
Treat children with TST over 5 mm as having latent infection
Don’t treat children over 5 with initial negative TST but repeat TST at 8-10 weeks from last contact exposure
What drugs do you use to treat latent TB?
Rifapebtin or isoniazid
What is first line contraceptive for Canadian youth.
What are 2nd tier and 3rd tier contraceptive options?
2nd: hormonal contraceptives
3rd: barriers, withdrawal, spermicide
4 absolute contraindications to estrogen containing contraceptives?
Migraine with aura Severe liver disease Severe HTN Active breast CA Serious immobility after surgery History of clots
How much greater is the stroke or VTE risk on OCP?
What is the only contraceptive option that causes weight gain?
What do you need on exam before starting OCP?
BP and weight
What is a quick start contraceptive method?
If not first 7 days past LMP get bHCG
Start contraception same day
Repeat bHCG in 21 days
How long post coitus can a copper IUD be inserted for emergency contraception?
Who should get HPV vaccine?
All kids age 9-13 and any older children as catch up
How many doses of HPV vaccine are recommended and how far apart?
2 doses 6 months apart
3 doses if immunocompromised or if older than 14
What is the disorder infants can have is HPV is transmitted from mother at time of delivery?
Juvenile onset recurrent respiratory papillomatosis
Which strain of HPV causes cancer? Causes warts commonly?
CA: 16 and 18
Warts: 6 and 11
What are risk factors for HPV (3)
More lifetime sexual partners STIs Sexual abuse Young age of first sexual contact Tobacco or marijuana use Immunosuppression HIV MSM
Is HPV vaccine associated with GBS?
When should you discuss potential G tube insertion with a family?
When neurologic impairment is first diagnosed
Poor oral intake and weight gain
GERD causing poor oral intake
Dysmotility despite medical treatment
Enteral feeding for >3-6 months is anticipated
What are 3 short term risks of G-tube feeding?
Peritonitis Bleeding Infection Anesthesia related problems Abdominal organ puncture Perioperative death
What are 3 long term risks of G-tube feeding?
Blockage Dislodgement Breakage Stoma infection Stoma bleeding Stoma skin irritation
3 categories of concerns to address when counselling around G-tube placement
Child topics: benefits and complications, plan for oral feeding or stimulation, socialization plan
Parent topics: meaning of feeding, logistics (finances, etc.), parent self-care, goals of care
Family topics: potential impact on siblings, anticipated reaction of extended family
Name 4 benefits to having a G-tube
Better nutrition Less hospitilization Less antibiotics Less chest infections Less feeding time Less caregiver feeding concerns Increased QOL for caregiver Ease of medication delivery
2 most common organisms causing osteoarticular infections?
S.aureus K.kingae (common in infants) S.pneumoniae S. pyogenes S. agalactiea Salmonella (in sickle cell patients) H.flu (if not vaccinated)
What is the empiric antibiotic used in osteoarticular infections? What if the child is under 4 or unimmunized?
IV cefazolin IV cefuroxime (because if covers H.flu)
What is the most sensitive and specific noninvasive test for acute osteomyelitis?
MRI with gad (still always need a baseline radiograph)
When can you switch from IV to PO therapy for acute osteomyelitis?
Clinical improvement (mild intermittent pain)
Inflammatory markers have started to normalize (CRP decreased by 50% in last 4 days or <20-30)(ESR is less reliable and decreases slowly)
Reliable oral outpatient follow up
Negative blood culture
Weight bearing or able to move affected limb
What is the most common bony location for osteomyelitis?
Metaphysis of the long bones
What is the typical age range for transient synovitis?
How long after contracting Lyme disease do you expect to see Lyme arthritis develop in infected patient?
What skin finding is associated with CRMO? What time is CRMO pain worse?
Worse at night
Associated with psoriasis and palmoplantar pustulosis
Usually occurs in unusual places (jaw, scapula)
How long after a GI or GU infection do you expect to see reactive arthritis?
2-3 weeks later
What is a Brodie’s abscess?
Necrotic bone surrounded by new bone in region with chronic osteomyelitis for more than 4 weeks
Do you need follow up radiographs after osteomyelitis is treated? What if there is growth plate involvement
No. If growth plate is involved there is need for orthopedic follow up.
When you step down to PO antibiotics in osteomyelitis what do you use if the patient is MRSA positive?
TMP SMX, linezolid, clindamycin
What are two very important tests in S.aureus bacteremia?
MRI bone (looking for osteomyelitis) Echo (S.aureus is sticky and often becomes endocarditis even if seeded elsewhere first)
What is the duration of treatment for osteomyeltis or septic arthritis?
3-4 weeks (as long as CRP norma)
4-6 weeks if hip involved (as long as CRP normal)
Most common age to get ITP?
What percetage of ITP cases self resolve by 6 months?
What are 3 secondary causes of ITP?
Drug induced Lupus Infections Immune deficiencies Malignancy
What are 5 red flags for alternate diagnosis for ITP?
Constitutional symptoms Bone pain Recurrent thrombocytopenia Poor treatment response Lymphadenopathy Hepatomegaly Splenomegaly Signs of chronic disease Low hemoglobin High MCV Abnormal WBC Abnormal smear or morphology on smear
What classifies as mild bleeding in ITP? What are your treatment options in mild ITP?
Criteria: no bleeding, small non-ozzing petechiae on mucosa, mild resolved epistaxis, or bruising
Treatment: Observe (consider steroid or IVIG)
What are 2 recommendations to families just observing with conservative management of ITP?
No physical activity risking injury
What classifies as moderate bleeding in ITP? What are your treatment options in moderate ITP?
Criteria: troublesome epistaxis or menorrhagia, severe skin or mucosal lesions
Treatment: steroid (prednisone 4mg/kg/day divided BID for 4 days and taper or 2 mg/k/day once daily for 1-2 weeks) OR IVIG (1g/kg)
What classifies as severe bleeding in ITP? What are your treatment options in severe ITP?
Criteria: prolonged epistaxis or menorrhagia, melena, ICH, hospital admission required for bleeding
Treatment: methylprednisolone AND IVIG (1g/kg) AND platelet transfusion AND tranexamic acid (25 mg/kg/dose 3-4 times a day)
How do you manage ITP relapse or non-response?
In relapse use the same criteria as before to decide to treat.
In non-response try other (ie. steroid or IVIG) that was not yet trialed
What are disadvantages of using steroids in ITP management?
Mood change Increased weight/appetite Gastritis Hypertension Poor taste limits tolerance
What are disadvantages of using IVIG in ITP management?
Aseptic meningitis Nausea/vomiting Fever Rash Hemolysis Risks of IV placement and hospital admission
How long after giving steroids do platelets normally increase in ITP? How about after steroids?
After steroids it takes 48 h to increase.
After IVIG it takes 24 hours to respond (peak at 2-7 days)
What are the 4 Ms of healthy screen use in school aged children and adolescents?
Manage screen use
- make family media plan
- discourage media multitasking
- be present and engaged for media use
- use parental controls and privacy settings
Meaningful screen use
- prioritize routines and physical activity over screens
- focus on educational, active, or social media use
- developmentally appropriate content
Model healthy screen use
Monitor for signs of problematic screen use
- boredom without screen access
- oppositional behaviour
- interference of screens with school, play, etc.
3 benefits of appropriate screen time use in school aged children
Can improve academics, literacy, etc.
Help develop peer or teacher relationships
Video games with others encourage socialization, identity and cognitive development
Lower depression (with 1 hr day recreational screen time)
More inclusive relationships
3 risks of screen time use in school aged children
Age inappropriate or violent contact can negatively effect development/behaviour
>3 hr TV/day = increased conduct problems
High recreational screen time increases depression
Less quality material available to low income families
Less family or social interactions if high screen time
Multitasking causes worse academics
What is the recommended amount of screen time in adolescents daily?
2-4 hours a day
3 benefits of screen time in adolescents
Improved self concept
Social media is validating and allow “bounce back” from social rejection
Improved psychosocial function and emotions (if 2-4 hr/day)
Improved socialization for physically isolated children or those with less social support
3 risks of screen time in adolescents
Negative content (bullying) can cause anxiety and depression
More depression if over 6 hours/day
Lower scores in school with media multitasking
>50% of free time on games causes worse conduct, well-being, hyperactivity, and peer problems
Too much time can impact family closeness and relationships
3 negative impacts of screen time on the physical health of youth
Can decrease physical activity
TV viewing linked with decreased fruits/veggies and increased weight
Screens in bedrooms worsen sleep hygiene
Texting while driving
Headaches and vision concerns if there is too much screen use
3 positive impacts of screen time on the physical health of youth
Some promote physical activity
Health tracking with weight, diet, etc. can encourage healthy habits
Active video games are positive in short term
How old is a child before they are no longer referred to as having a global developmental delay and instead an intellectual delay?
GDD diagnostic criteria
Significant delay (at least 2 SDS below mean) in at least 2 of the following:
- gross or fine motor
ID diagnostic criteria (3)
Meet all 3 of the following:
- defects in intellectual functions (planning, problem solving, academic learning)
- defects in adaptive functions (not able to be independent or socially responsible)
- onset of both of the above during developmental period
Categories and causes of intellectual disability or GDD. (4 categories (1 example of each))
Prenatal intrinsic - genetic, metabolic, CNS malformation Prenatal extrinsic - toxin, infections Perinatal - asphyxia, prematurity, neonatal complications Postnatal - neglect, infection, trauma
What two exams should all patients with intellectual and GDD receive in their initial work up? (2)
EEG (if suspected seizures)
What should you do for 1st investigations if a child has ID or GDD with unknown cause? (4)
Fragile X testing
Tier 1 investigations
Brain MRI is abnormal neuro exam or micro/macrocephaly
MECP2 in girls (moderate to severe symptoms)
What are the Tier 1 metabolic investigations for ID/GDD NYD? (7)
CBC, glucose, gas, BUN/Cr, lytes, AST/ALT, TSH, CK, ammonia, lactate, amino acids, acytlcarnitine, carnitine, homocysteine, copper, ceruloplasmin, biotinidase, ferritin (when diet restriction of PICA), vitamin B12 (when diet restriction of PICA), lead level (when risk factors), urine organic acids, urine creatine metabolites, urine purines/pyrimidines, urine GAGs
If there is no cause of IDD or GD on first tier testing what are your next steps? (2)
Genetics/metabolics referral (for tier 2 work up and gene panels)
Brain MRI (if not done)
When should you do autism screnning?
Regular well child or health visits, with thorough assessment at 18 months
Earlier if: sibling with ASD, health care provider or parental or caregiver concern
What are the DSM V diagnostic criteria for autism?
Symptoms in two domains
1) Social communication impairment
2) Restricted, repetitive pattern of behaviour/interests
3) Signs and symptoms present early in development
4) Interferes with everyday life
5) Symptoms not better explained by intellectual disability or GDD
4 examples of symptoms of social communication impairment in the DSM V autism diagnosis
1) Difficulty initiating or responding to social interactions
2) Reduced spontaneous sharing of interests
3) Reduced eye contact
4) Less gestures
5) Reduced facial expressiveness
6) Use someone’s hand to get an object
7) Less interest in peers
8) Not engaging in imaginative play
4 examples of symptoms of repetitive and restrictive behaviours/interests in the DSM V autism diagnosis
1) Repeated words or phrases
2) Repetitive activity with objects
3) Repetitive body movements
4) Transient stiff posturing
5) Wearing same clothes/eating same foods
6) Distress with routine change
7) Restricted interests
8) Hypo or hypersensitive
Risk factors of ASD (3)
Male Family history Sibling with ASD Certain genetic syndromes Parents over 35 Maternal obesity, diabetes, or HTN In utero valproate, pesticide, or traffic pollution exposure Maternal rubella Pregnancy less than 12 month apart Low birth weight Extreme prematurity
Common red flags for ASD at age 6-12 months (3)
Reduced smiling Limited eye contact Limited reciprocal sound or facial expression sharing Diminished babbling or gesturing Limited response to name
Common red flags for ASD at age 9-12 months (1)
Common red flags for ASD at age 12-18 months (2)
No single words
Lack of pretend play
Limited joint attention
Common red flags for ASD at age 15-24 months (1)
No two word phrases
Name two developmental screening tests that assess for general development and two for ASD specifically (4)
Generic: ASQ-3, Child Development Inventory, Nipissing District Developmental Screen, Brief Early Childhood Screening Assessment, Parents’ Evaluation of Developmental Status, Rourke Baby Record
ASD Specific: M-CHAT, Infant Toddler Checklist, Social Responsiveness Scale, Autism Spectrum Rating Scales, STAT, RITA-T
If the general developmental screen is concerning for ASD what should the next step be? If the next step is positive?
ASD specific rating scale
Who can do the diagnostic assessment for ASD? While they are waiting for the assessment what referral should be immediately sent?
Psychologist + pediatrician
They should see an early intervention service before diagnosis
Name two ways to make easier clinic visit for patients with ASD
Call family first to conduct first portion of visit virtually
Consider inviting family for a practice visit
First or last appointment of the day
Longer appointment slot
Parents bring comfort items
Rearrange room for sensory sensitivities
Common disorders to screen for or plan to manage in ASD (4)
Dental concerns (challenging and may need sedation)
Nutrition (need dietitian assessment)
GI issues (constipation, GERD, celiac) more common
Sleep disorders in 50-80%
Anxiety in 50%
ADHD in 30-50%
Depression (in older high functioning kids)
What are 2 behavioural interventions for ASD patients?
Early intensive behavioural therapy
Parent mediated interventions
Social skills training
CBT (for anxiety)
3 common triggers for worsening in ASD challenging behaviour
Physical environment Change in routine Puberty/developmental change Bullying Pain or physical ailment that cannot be communicated Communication frustration Social over stimulation
What are two common medication options to treat ASD aggression, self harm, or irritability when non-pharmacological therapy is not successful?
3 side effects of atypical anti-psychotics?
Extrapyramidal symptoms Drowsiness Metabolic syndrome Weight gain Prolactinemia
What are a few non-harmful complimentary medicine options for ASD (2)
Vitamin supplementation Dietary changes Massage Music therapy Animal therapy Therapeutic touch Reki
What is a harmful complimentary medicine option for ASD?
Hyperbaric oxygen Secretin Chelation Herbal products Antifungals Antibiotics
Cannibidiol oil (unclear if harmful but not recommended)
2 factors that provide better prognosis for ASD?
Timely access to behavioural interventions
Higher cognitive ability
How many hours before most major cardiorespiratory problems present in newborns?
6-12 h after birth
3 important topics to cover in healthy newborn parental discharge education
Infant feeding Newborn behaviour and and care Recognition of early signs of illness Infant safety (car seat, safe sleep) Infection control measures Smoke free environment importance Fever, sepsis, and when to go to hospital
3 important topics to cover in healthy newborn parental discharge education
Infant feeding Newborn behaviour and and care Recognition of early signs of illness Infant safety (car seat, safe sleep) Infection control measures Smoke free environment importance Fever, sepsis, and when to go to hospital
3 investigations or treatments all infants should have before discharge home.
NBS Hearing screen Bili and 24h Pulse ox screen Vaccines if needed Follow up arranged Vitamin K Ophthalmia neonatorum prophylaxis if regionally appropriate
When should healthy newborns follow up with a health care provider after birth?
Within first week of life unless discharged less than 48 from broth then it should occur by 72 hr of life
What should an infant have done prior to discharge? (3)
Fed with mother at least 2 times successfully
What should a physician ensure they have done on history or exam for info prior to discharge of a newborn?
Documented normal vitals
Weight, length, and head circumference
Assessment of psychosocial qnd environmental concerns
Reviewed maternal serology
Assessed antenatal and prenatal risk factors (GBS risk factors, etc.)
Ensure no more than 10% birth weight loss
Ensure breastfeeding mothers are giving vitamin D supplementation
In a returning traveller what are 4 investigations you should do and 2 to consider?
Must: CBC, liver enzymes, lytes, Cr, malaria smears, blood cultures, urinalysis +/- urine culture
Consider: stool culture(salmonella, shigella, camylobater, yersinia, e.coli), CXR, stool ova and parasites(cyclosora, cryptosporidium, entamoe bahistolytica), viral serology
What are the 3 most important travel related causes of fever in returning travellers?
Malaria (within 6 mo of return)
Travellers diarrhea and enteric fever (within 60 days of return)
Dengue (within 14 days of return)
3 risk factors for contacting infections while travelling
Low weight or nutritional status
Very young age (under 1 month)
What is the treatment for pinworm?
What is the type of malaria with highest mortality rate?
What are the stages in the biphasic response to typhoid?
- Gastroenteritis and diarrhea
2. Hepatomegaly, thrombocytopenia, leukopenia, fever, myalgias, psych or neuro symptoms
What is the common cause if travellers diarrhea if onset less than 2 weeks after exposure? What if it has onset greater than 2 weeks after exposure?
- Rotavirus or bacterial infection
2. Post infectious diarrhea or giardiasis
What is the classic rash in dengue fever?
Erythematous and reticulate over thorax, face, and flexion areas
What are 2 biochemical findings in repeat dengue fever or hemorrhagic dengue?
Hyponatremia Hypoproteinemia Lymphocytosis Neutropenia Elevated liver enzymes
Present in circulatory shock
What are is the cause and time of onset of each of the following types of hemorrhagic disease of the newborn?
Early onset, classic, late onset
Early onset: 24 hours of life due to maternal meds
Classic: day 2-7 due to low intake of vitamin k
Late onset: 2-12 weeks and up to 6 months due to malabsorption and low intake
What is the dose of IM vitamin K in a newborn?
O.5 to 1 mg
In prems: 0.5 mg if under 1500g and 1 mg is over 1500g
What is the dose of PO dose of vitamin K
2 mg within 6 hr of birth and then at 2-4 wk of age and 6-8 wk of age.
1st line treatment of lice infections
Premethrin (1%) or pyrethrin
What is 2nd line treatment for lice
Isopropyl myristate (Resultz) age 4+
Dimeticone age 2+
Benzyl alcohol 5% age 6mo+
Is the presence of nits on the head diagnostic of a lice infection?
No. Nits are dead. You need at least 1 live louse to diagnose.
How many times and how far apart must premethrin doses be when treating lice?
2 doses 7 days apart
Do kids with lice need to stay home from school?
What are the percent of HIV positive mother’s that go on to have vertical transmission in Canada?
Risk factors for HIV vertical transmissions (4)
IV drug use Late or no prenatal care Recent illness and HIV seroconversion Regular unprotected sex with HIV positive partner STIs in pregnancy Emigration fr HIV endemic area
What should be done for HIV if a mother presents in labour with no HIV? What if she is unknown and only can be tested after delivery? What is mother refuses testing?
- Rapid HIV testing on mother
- Rapid HIV testing on mother
- Rapid infant antibody testing
What should be done if mother or infant rapid HIV antibody testing comes back positive? (2)
Send confirmatory antibody testing
Infant HIV PCR within 48 hr of birth
Start prophylaxis before 72 hr post delivery
What should be done if infant HIV PCR comes back positive?
Start antiretroviral therapy
What should you do of there is strong suspicion for HIV infection acutely in pregnancy or while breastfeeding but negative antibodies?
Send maternal PCR since antibodies may not yet be positive.
What are CBC findings seen on infants exposed to antiretroviral therapy for HIV?
If an infant has a mother with confirmed HIV in pregnancy what 2 things should you do when they are born?
Send for HIV PCR
If a mother has negative HIV testing early in pregnancy but is at high risk of HIV exposure in pregnancy when should you repeat the test?
3rd trimester before 36 weeks
What are the benefits of cooling infants on term infants that meet criteria?
Decreased moderate to severe neurodevelopmental delay
What are the criteria for cooling an infant with HIE?
Over 36 weeks and with moderate-severe HIE who are under 6 hr life and meet A or B
A. Cord oH under 7 and base deficit more than -16
B. pH 7.01-7.15 or base deficit -10 to -15.9 AND history of acute perinatal event AND APGAR under 5 at 10 min
What are 4 side effects of hypothermia
Bradycardia Hypotension Thrombocytopenia PPHN SCF
What is the optimal temperature for cooling infants with HIE?
How long should cooling for HIE last for?
Why don’t we cool pre infants with HIE
What happens to medication metabolism when an infant is cooled for HIE?
Slows down so less drug clearance and lower doses may be needed
4 complications of HIE?
CP Blindness Behavioural difficulties Seizures Cognitive deficits SNHL
Which immunodeficiencies can receive most lvyie vaccines? Which can receive only live viral vaccines?
- IgA deficiency, IgG subclass deficiency, complement deficiencies, anatomical or functional asplenia, HIV without severe immunocompromise
- Phagocyte or neutrophil disorders
How long before someone is going to be immunocompromise can you give live and inactive vaccines?
Live - 4 weeks
Inactive - 2 weeks
How long after stopping high dose steroids, immunosuppressive chemo, or anti B cell antibody can a live vaccine be given?
High dose steroids: 1 month
Chemo: 3 months
Anti B cell therapy: 6 months
How long after getting a bone marrow transplant can you get a live or inactive vaccine? How long after giving a bone marrow transplant?
- Live: 24 months, inactive: 3-12 mo
2. 4 weeks
How long after getting a solid organ transplant can you get a live or inactive vaccine? How long after giving a solid organ transplant?
- Never live. 3-6 mo for an inactive vaccine
2. 4 weeks
How long after receiving IVIG or specific immunoglobulin should you wait before vaccines?
3-11 months for live vaccines
Immediately for inactive or oral or intranasal live vaccines
What are 5 ways to improve pediatric medication safety and access in Canada?
- Establish a pediatric advisory board to regulate, reimburse, and research pediatric medications
- Health Canada can solicit and review peds med data and work on setting pediatric standards and benchmarks for regulation and reimbursement
- Health Canada can promote priority pediatric medications and child friendly formulations and review SAP program
- National resource on pediatric prescribing and dosing
- Invest in pediatric drug research and infrastructure.
5 problems with pediatric meds in Canada
- Health Canada does not look for peds data when regulating meds even if available
- Most meds are off label
- Not peds friendly formulations and co m pounding increases risk and decreases consistency
- More rare disease so meds more expensive
- Dependency on SAP for essential meds
4 risk factors for invasive group A strep
HIV Cancer Heart disease Diabetes Lung disease Alcohol abuse Injection drug use Postpartum period Recent pharyngitis Varicella Recent soft tissue trauma NSAID use
What is the definition of invasive group A strep?
Isolation of group A strep fo a sterile site with or without clinical evidence of severe invasive disease.
4 presentations of severe invasive GAS
Soft tissue (muscle, fat, etc.) necrosis
Pneumonia (only if pleural effusions)
TSS diagnostic criteria
Hypotension and at least 2 of the following
- renal impairment (Cr x 2 upper limit)
- coagulopathy (plt under 100 or DIC)
- liver function abnormality (enzymes over 2x upper limit)
- macular erythmatic rash that can desquamate
- other life threatening condition
4 clinical signs of nec fasc
Severe pain Rapid progression Hemodynamic instability Toxic appearance Woody induration Hyperesthesia or anesthesia Crepitus if polymicrobial
What is the antibiotic therapy for suspected and confirmed invasive GAS?
Suspected: Beta lactam + beta lactamase inhibitor (piptazo, clox)
Clinadamycin (only for 48 hr)
+/- vanco is possible MRSA
Confirmed: penicillin and clinadamycin
Consider IVIG for 1 day in either
What med should not be given in invasive group a strep?
What would count as a close contact of someone with invasive group A strep?
Household contact with 20 h total or 4 h/day in last 7 day
Anyone sharing a bed or sexual relations
Direct contact with mucous membrane or oral and nasal secretions
IVD user sharing needles
Family or child home care children and staff
Who gets post exposure invasive GAS prophylaxis?
Children in daycare with multiple cases within a month or during concurrent varicella out break
What is first line chemoprophylaxis and time it is given for invasive group a strep? Second line?
Cephalexin within 24 hr of detection
Second line if not tolerated is clarithromycin or clinadamycin
Why are RSV and rotavirus easy to transmit in a pediatric office?
Low infective dose and remains on inanimate objects for a prolonged period
What are 3 easily transmissible infections in pediatric offices through stethoscope diaphragms, blood pressure cuffs, and thermometer bases?
MRSA VRE Rotavirus RSV C diff
What precautions for patients for hep A and how long should they be taken?
Contact. 7 days since onset of symptoms
For measles how long should airborne precautions be used?
4 days from rash onset.
What is TB infectious? (3)
Untreated cavitary lesion Laryngeal disease Smear positive sputum Extensive lung involvement Disseminated congenital infection
5 ways to reduce infection spread in outpatient office
Have policy on hygiene and review ever 2 yr
Have hand washing station in every space
Patients that are immunocompromised or with infectious symptoms (particularly travel in last 21 days) should be in room not waiting room
Space patient times out to limit exposure
Remove toys from waiting room
Clean mouse and keyboard daily
Disposable paper to be used in between patients
Avoid multidose medication vial
Staff should be vaccinated and regular TB screening
4 times for hand hygiene in pediatric office
After contact with patient Before contact with patient After secretion contact Before procedures After handling live vaccine After touching contaminated surfaces After and before touching sterile meds After removing gloves
What is the best measure of iron stores?
Ferritin - but these are inaccurate if there is inflammation
What are the two types of non anemic iron deficiency?
Low urine stores (low ferritin)
Decreased iron transport (low transferrin saturation)
4 risk factors for iron deficiency under 2 years old
Preterm or LBW (under 2500g) Low SES Mother with anemia or obesity Early umbilical cord clamping Male Breastfeeding only over 6 months High cows milk intake Prolonged bottle use Chronic infection Lead exposure Low intake of iron rich foods Indigineous H.pylori (in older kids)
How much iron supplementation is recommended preventatively for infants born weighing under 2000g or between 2000-2500g?
2000 g 2-3 mg/kg/day for first year
2000-2500g 1-2 mg/kg/day for 6 mo (starting between 2-6 wk of age)
What age does health Canada recommend introduction of cow’s milk and how much?
Limit of 750 mL a day
How much iron should a normal healthy infant 7-12 months old get in their diet daily?
What is the dose of iron for treatment of IDA and what should be eaten with it to improve absorption?
How long is the minimum therapy?
Take with vitamin C source
Minimum 3 months
5 symptoms of lead toxicity
Headache Abdo pain Anemia Constipation Vomiting Clumsiness Sombolenxe Stupor Renal failure Seizures Cognitve function impairment Hyperactivity Hearing impairment Speech delay Inattention
What part of the body is lead normally stored in? What can trigger its release?
Puberty, growing, stress, pregnancy, malnutrition
What are 3 common sources of lead?
Food (lead in cans from outside Canada, bullet in wild game, food grown on old industrial sites)
Dust and soil
Mouthing lead containing products
What are 4 risk factors for lead exposure that you should test lead levels in if there is also a neurodevelopmental delay?
Friend or sibling with lead poisoning
Pica or eating paint chips
Living in a house built before 1960
Emigrate for adopted from a country with high lead levels
What nutritional deficiencies also increase the chance of developing lead intoxication?
Ca, zinc, iron (or maternal deficiencies of these) or other divalent ions
What 4 investigations should be done when lead exposure is suspected?
Ca, protein, albumin
Above what blood lead lead level should it be investigated and lead exposures eliminated?
Does a low lead level rule out lead intoxication?
No because 1/2 life of RBC is 45 days and lead stored in bone so exposure could have been earlier
What are 3 long term consequences if lead exposure?
If blood level is between 5-14 what are 3 steps to take and when do you retest levels
- Reduxe potential exposures
- Plan for full neurodevelopmental assessment
- Contact public health
- Encourage iron sufficiency with testing levels and encouraging fresh fruit with each meal to add vitamin C and increase iron absorption
Retest levels I’m 1-3 months to ensure not rising
What extra steps should be taken for children with lead levels between 15-44 compared to those from 5-15?
Consider abdominal x-ray and if foreign object is found it should be removed
Contact poison control
Repeat levels in 1-4 weeks to confirm it is real
What extra management is required for lead levels above 44 compared to power levels? (2)
Repeat levels in 48 hr to confirm result
Consider hospitalization for chelation
What can opioid exposure in utero cause in newborns?
Prematurity Low birth weight Increased spontaneous abortions SIDS Neurobehavioural abnormalities NAS
What do NAS symptoms start and how long do they normally last?
Start in 48-72 hr and last 10-30- days
What do NAS symptoms start and how long do they normally last?
Start in 48-72 hr (5 days if methadone) and lasts 10-30- days
Which infants are at the lowest risk of NAS?
What are 5 symptoms of NAS?
High pitched cry Poor sleep Hyperactive Tremors High muscle tone Myoclonic jerks Sweating Hyperthermia Yawning Mottling Sneezing Nasal flare Tachypneic Excessive sucking Reflux Loose stools Poor feeding
4 non pharmacologic interventions for NAS
Skin to skin Swaddling Gentle walking Quiet environment Minimal stimulation Lower lighting Developmental positioning Music or massage therapy Breastfeeding
3 meds that can be used to treat NAS
Morphine Methadone Phenobarbital Clonidine Buprenorphine
What criteria must be met for MAID?
Grevious and irremediable medical condition
Capable of informed consent
What are the recommendations for drug coverage for pediatric patients in Canada?
Universal comprehensive pharmacare for all kids
Need comprehensive list of drugs covered across all of Canada
Pediatric drug approval should be modernized
Government should support pediatric drug trials and research
What are 5 ways to make a good rapid response team in a pediatric setting?
Criteria for activation of team Education about clinical deterioration Standard vitals monitoring on the ward Quality monitoring process Expertise and training in pediatrics Sim based training Planned response arm
What are the 3 ps of reducing pediatric pain?
4 physical techniques to reduce pain in procedures?
Sitting upright Distracting words Family presence Breastfeeding Sucrose (0.5-2mL) Non nutritive sucking Skin to skin Swaddling infants Chose less painful approaches Reduce and group blood work when possible
4 psychological techniques to reduce pain during procedures
Prepare them Distraction Deep breathing Hypnosis Music therapy
Name 3 topical anesthetics that can be used in needle procedures and which has the fastest onset
Lidocaine (EMLA) Liposomal lidocaine (Maxilene) Ametocaine (Ametop) Vapocoolant spray (pain ease) * fastest immediate onset
(Consider nitrous oxide when not sufficient)
What is the biggest side effect of topical lidocaine? What are the other contraindications?
G6PD, heart block, severe liver disease
What factors increase viral transmission risk with a needle stick injury?
Bigger needles Hollow bore Blood injected High concentration of virus in blood Deeper penetration
If exposed to a needlestick at risk for HepB transmission what should be done for a child that is anti-HBsAg postivie or or negative or fully vaccinated but unknown anti-HBsAg.
Unknown: give HBV vaccine if results are pending for anti-HBsAg more than 48 hr
Negative: test for hep B antibody and antigen and if both negative HBIG and HBV vaccine within 7 day if injury
What type of needle stick injury is at risk of HIV transmission
Hollow bore needle with blood in it and injected into body or mouth
When the user has or IV drug user population is known to have high risk of HIV
When should a tetanus vaccine or immunoglobulin be given for an injury?
Vaccine: more than 10 years since vaccine or 5-10 years since vaccine and wound is dirty
If: only if greater than 10 years since vaccine and a dirty wound
What blood should be done on a child after a needlestick injury?
HBV, HIV, and HCV antibodies and antigens
How soon over a needlestick injury should HIV prophylaxis be started if it was high risk?
1-4 h of injury
No later than 72 hr
How long after a needlestick should someone get a repeat HBV vaccine if they were antibody negative?
4 weeks and again 6 mo
How long after a needle stick should HBV, HIV, and HVV blood work be done
4-6 wk: anti HIV antibody
3 mo: anti- HIV antibody and anti-HCV antibody
6 mo: anti- HIV antibody and anti-HCV antibody and antiHBsAg antibody
What methods can be used to provide neuroprotection in prem infants?
Maternal steroid (under 35 wks) Maternal antibiotics (under 33 weeks) MgSO4 (under 34 weeks) Normothermia (under 32 week) Avoiding inotrope use Permissive hypercapnia (under 33 wk) Delayed cord clamp Volume targeted ventilation Neutral head position Decreased transportation and noise Good nutrition
When should premature infants have a blood culture drawn and antibiotics started?
Under 33 weeks and chorioamnionitid, preterm labour, PPROM, unexplained onset of nonreassuring fetal status, rupture of membranes more than 72 hr
How long before birth should you aim to give steroids to a mother in premature labour?
What is the definition of hypotension in a newborn infant?
Under 30 mmHg or MAP less than infants GA
What does a preterm newborn need to start inotropes on top of hypotension?
Prolonged cap refill
Decreased urine output
What are the ABCDEs of parent child relationship building?
Ask questions Build on family relational strength Counsel with family centred guidance Develop plans for challenging behaviours related to sleep and discipline Educate about positive parenting
What are 5 principles to clinicians supporting positive parenting?
Help build loving relationships Accept that there is reasons for all behaviour Help mitigate effects of ACEs Recognize and respect differences Be aware of good family resources
Name 3 positive parenting strategies when dealing with problematic behaviours
Use I statements
Use time ins (connect and redirect)
Avoid using words like no, stop, don’t
Focus on why the behvoiur is occuring and let go of previous events or patterns
Communicate comfort and empathy (kneel down, gentle head nod)
Wait until child and parent are emotionally ready to re-engage
What does the REDIRECT acronym stand for in positive parenting?
Reduce words Embrace emotions Describe without lecturing Involve the child in discipline Reframe no to yes Emphasize the positive Creatively approach w discipline situation Teach
How long does a CD4 count need to be in HIV to be immunocompromised?
Age 5+: less than 200
Under 5: less than 15%
What are 4 immunosuppressive classes of medications?
Antimetabolites Chemotherapeutics Transplant immunosuppressants Biologics High dose corticosteroid +20 mg prednisone daily of over 10kg or 2 mg/kg/day of under 10kg
What are 5 ways to reduce respiratory or water borne infection in immunocompromised kids?
Vaccinate them and family Good hand hygiene Avoid anyone with resp illness and crowded locations in viral season Avoid tobacco smoke exposure Avoid exposure to fungi Drink tap water Avoid hot tubs Avoid swimming on contaminated water
List 5 ways to avoid foodborne and animal borne illness in immjnocompromised kids.
Pasteurized products Avoid raw meat or seafood or eggs Wash raw veggies thoroughly Avoid food cross contamination Avoid contact with ill animals Avoid cleaning litter boxes, bird cages, or fish tanks Wash hands after playing with animals
What are 2 risk factors for disseminated non typhi salmonella?
Kid under 3
When should a patient with stool positive for non typhoid salmonella have a blood culture sent
Under 3 months
Or if visited a resource poor area in last 2 months and unsure type of salmonella
What antibiotic should be used to treat typhoid fever?
Azithro or ceftriaxone if systemically unwell
When do you use antibiotics in nontyphoidal salmonella?
When their is invasive infection or bacteremia
What do you do with salmonella typhi positive stool and negative blood culture with systemically well child
No treatment unless immunocompromised or under 3 months
What should you do if blood cultures become negative after 48 hr in ctx in a child with non disseminated s.typhi. What if it is disseminated or not negative at 48 hr?
Switch to azithromycin
Consult ID and continue IV for up to 10+ days in patient
When can a child with varicella return to school?
Any time they feel well enough unless it is a camp for immunocompromised children then they should all be excluded until no more lesions.
This is because most infectious before rash and sickest kids stay home have highest viremia and break through disease in vaccinated kids is usually milder
What is the size criteria for a large local reaction to an insect sting?
10 cm or more
What is required to be a candidate for venom immune therapy? (2)
Systemic reaction to hymnoptera sting
Positive hymnoptera skin test
What would be indications for someone with hymnoptera allergy to carry an EpiPen
Near fatal reaction Severe honey bee allergy Elevated serum tryptase level Underlying medical condition Those with frequent and unavoidable exposure
Do you need to allergy test and give and EpiPen to a systemic skin only reaction (full body hives) to a hymnoptera bite?
3 ways to avoid stinging insects
Don’t walk barefoot outside
Careful when eating and drinking outdoors
Avoid opaque cans or straws
Wear gloves, long sleeves in high risk area or garden
Remove all insect nests around the home
What are the 7 most common allergens in children?
Cow's milk Egg Peanut Tree nuts Fish Shellfish Wheat Soy
What are 2 biggest risks factors for food allergy?
Personal history of atopy
1st degree relative with atopy
When should allergenic foods be introduced to infants at high risk of food allergy?
4-6 no when developmentally ready
Other than early allergenic food introduction how can you prevent food allergy in high risk infants?
Breastfeeding until 2+ years
Introduce allergenic foods only one at a time
Offer allergenic foods a few times a week to maintain tolerance
What are 6 red flags for inflicted trauma in a young child with a fracture?
No history of trauma Mechanism not compatible with age or stage History changes Delay in seeking help Under 1 year age Multiple fractures Fractures of different ages Presence of other injuries
What are high risk fractures for inflicted trauma?
Rib Metaphyseal Humerus fracture under 18 mo Femur fracture when nonambulatory Scapula Sternal Spinuous process
Name 4 causes of easy fractures other than accidental
Birth related OI Menkes Infantile cortical hyperostosis Hypophosphatasia Tickets Osteopenia of prematurity Copper deficiency Chronic renal insufficiency Scurvy Congenital syphilis Osteomyelitis Hypervitaminosis A Methotrexate toxicity LCH Leukemia
What investigations should be done in all suspicious fractures for NAI?
CBC Renal function and liver function CA, phos, ALP urinalysis When indicated vit D 25 OH, PTH, Cu, ceruloplasmin
What imaging should be done in suspected NAI fractures? What imaging should you consider?
Skeletal survey immediately and again at 2 weeks if high suspicion but initial scan is negative
How must guns be stored in the home?
Away from children
Stores separately from ammunition
Remove from home is child with mood disorder or substance use
How should you manage BB gun or air soft gun shots?
Same as any other fun due to risk for high impact trauma
List 4 risk factors for influenza related complications
Under 5 years Over 6 months with chronic health conditions Indigineous people Chronic care facility residents Pregnant women Over 65
When should you give a neuraminidase inhibitor for influenza even after 48 hr of symptom onsey
Underlying medical condition or other risk factors (other than young age) can be considered
Severe or progressive symptoms
Typical duration of neuroamindase inhibitors for influenza
What is the best time interval to get neuroamindase inhibitors started after symptom onset
What is a contraindication to neuroamindase inhibitors?
Under age 1
What is the definition of hypoglycemia in the first 72 he ofnpofe
What is the cut off for persistent hypoglycemia after the first 72 hr of life?
6 risk factors for neonatal hypoglycemia
SGA IUGR LGA IDM Under 37 wk gestation Labetolol in mother Late prem exposure to antenatal steroids Perinatal asphyxia Metabolic conditions Syndromes with hypoglycemia (BWS)
What are the most common causes of neonatal hypoglycemia?
Impairment of gluconeogenesis (not enough substrate)
When can you stop screening for hypoglycemia in infants that are LGA IDM when the glucose remains above 2.6?
When can you stop screening for hypoglycemia in infants that are SGA or preterm infanta when the glucose remains above 2.6?
What blood glucose do you draw a crotical sample for in the first 72 hr of life and after?
Before 72 hr: 2.6
After 72 hr: 2.8
How long should a patient be able to days before discharge home if they had neonatal hypogylcemia?
How do you treat asymptomatic neonatal hypoglycemia with BG above 1.8 and how soon after do you recheck?
IV glucose if not PO intake 80mL/kg/day D10
Repeat glucose in 30 min
How do you treat symptomatic neonatal hypoglycemia or BG under 1.8?
2 mL/kg bolus D10
4 medications to treat hyperinsulism im NICU?
What are barriers to youth accessing contraceptives?
Cost (LARC, patch, and ring rarely covered)
Lack of confidentiality
Cost of condoms
Recommendations to improve compliance and uptake of contraceptives in youth (4)
Contraceptives in clinic
Fund full cost of all contraceptives
Ensure insurance companies do not report contraceptive use of dependents
If contraceptives are over the counter should ensure no cost until age 25
What are 3 mechanisms by which high flow works?
Minimized inspired room air
Washes out anatomical dead space
Small amount of PIP and PEEP
Upper and lower airway resistance reduced
3 conditions responsive to high flow?
OSA Heart failure Bronchiolitis Asthma Pneumonia or pneumonitis
What is the starting and max dose of high flow?
1-2 L/kg/min with max of 2 L/kg/mim
What FiO2 should you start high flow at?
When should you wean the flow of high flow? When should you wean the FiO2?
- When there is decreased WOB
2. When there is increase in sats
3 contraindications to high flow?
Severe upper airway obstruction
What are 3 techniques to help encourage families to get a vaccine?
Don’t kick out of practice
Telling compelling true story
Use presumptive and motivational interviewing techniques
Use simple and clear language
Use the term community protection instead of hers immunity
Do not bring up vaccine myths they don’t mention
What population in men B most common in? Men C?
B: under age 5
Who should receive the men B vaccine and when should they get it?
High risk: asplenia, complement deficiency, primary antibody deficiency, HIV. Lab worker with meningococcus, military persons, travellers to endemic areas. Or close contact with Men B
2 mo, booster 1 year, every 3-5 years until age 7 then every 5 years
Who should get the MenC vaccine
All kids at 12 mo age and booster age 12
What can ciprofloxacin cause in children?
What can ceftriaxone cause in infants under age 1?
What can erythromycin cause in infants under age 2 mo?
What can tetracyclines cause in children?
What can septra cause I’m infants under 2 months?