2019

Question 1

Name three threats to the health of Canadian children posed by global climate change. (3)

Answer 1

Extreme weather events, with both physical and mental health effects; increasing air pollution; heat exposure illness; contaminated water sources; vector-associated infectious diseases; ozone depletion

Question 2

Why are children more sensitive than adults to air pollution? List two reasons. (2)

Answer 2

High rate of asthma w exacerbations triggered by air pollution; higher respiratory rates; immature lungs; more time spent outside; higher overall burden of exposure when starting in early life or prenatally

Question 3

A large wildfire has destroyed dozens of homes in your area, displacing many families. Please describe four ways in which the health of the children in these families may be affected. (4)

Answer 3

Injury or death from the disaster; long-term respiratory effects of particulate exposure; food and water shortages; overcrowding in emergency shelters; stress / PTSD; interruption of care for children with chronic health issues

Question 4

i) Name four risk factors for the development of iron deficiency anemia before age 2 years. (2) ii) What are four strategies for preventing the development of IDA in children with risk factors? (2)

Answer 4

i) preterm delivery or birth weight <2500 g, low socio-economic status, infants born to mothers with anemia or obesity, early umbilical cord clamping, male sex, exclusive breastfeeding for longer than 6 months, high cow’s milk intake, prolonged bottle use, chronic infection, lead exposure, low dietary intake of iron-rich complementary foods ii) introduce iron-rich foods by 6 months; consider introducing them at 4 months instead; encourage and facilitate access to traditional iron-rich foods in Indigenous communities; case-select infants for testing to assess benefit from oral supplementation

Question 5

Name two major sequelae of iron deficiency in early childhood. (2)

Answer 5

Neurodevelopmental delay, compromised immune response

Question 6

What is the recommended daily intake of iron for an infant 7 to 12 months of age? a) 11mg b) 22mg c) 33mg d) 44mg

Answer 6

a) 11mg

Question 7

If a term infant is not going to be breastfeeding, what are three reasons to recommend a high-iron formula rather than a standard formula? (3)

Answer 7

low socio-economic status, maternal anemia, low intake of iron-rich complementary foods, or living in an Indigenous community that may be challenged by poverty, food insecurity, high consumption of evaporated milk or cow’s milk, and a high burden of H pylori infection

Question 8

Which is an appropriate match between a patient and their iron supplementation? a) 2-month-old born at 2.1kg, formula-fed: a normal formula providing 1-2mg/kg/d of iron b) 8-month-old born at 2.4kg, formula-fed: a “premature” formula providing 2-3mg/kg/d of iron c) 5-month-old born at 1.9kg, breastfed: 1-2mg/kg/d oral iron supplementation d) 7-month-old born at 2.4kg, breastfed: 1-2mg/kg/d oral iron supplementation

Answer 8

a) 2-month-old born at 2.1kg, formula-fed: a normal formula providing 1-2mg/kg/d of iron

Question 9

What is the most important barrier to accessing contraception? a) social stigma b) financial cost c) misinformation around side effects d) lack of awareness of contraceptive options

Answer 9

b; “Canadian contraceptive care providers identify cost as the single most important barrier to access, and youth as the population most disproportionately affected by this barrier”

Question 10

Classifying oral contraceptive pills as “over-the-counter” medications has been proposed as a potential method of improving youth access to contraception. What is the main problem with this approach? (1)

Answer 10

OTC meds are not covered by insurance plans

Question 11

Bonus question: According to the CPS position statement, how many condoms does a couple require per year? a) 81 b) 82 c) 83 d) 84

Answer 11

c) 83

Question 12

There exist antenatal, perinatal, and postnatal strategies for preventing acute brain injury in preterm infants. Name two strategies in each of these categories. (6)

Answer 12

Antenatal: Celestone, MgSO4, maternal antibiotics for PPROM Perinatal: delivery in a tertiary centre, delayed cord clamping, prevention of hyperthermia Postnatal: antibiotics for suspected chorio until cx negative, cautious use of inotropes, neutral head positioning, avoidance of CO2 fluctuation, environmental optimization

Question 13

What is the ‘critical window’ (the highest-risk period) for acute preterm brain injury? a) The first hour of life b) The first 6 hours of life c) The first 24 hours of life d) The first 72 hours of life

Answer 13

d) The first 72 hours of life

Question 14

An infant at your centre is born at 28 weeks and 3 days gestation, weighing 1.1kg. Despite some initial respiratory effort, the infant’s breathing quickly worsens and the decision is made to intubate her. i) What size of endotracheal tube should be used, and to what depth should it be inserted? (2) ii) Which mode of ventilation should be used initially? (1) iii) Where will you target her PCO2 level in order to minimize the potential for respiratory and CNS complications? (2)

Answer 14

i) 3.0mm internal diameter, 7-8cm at the lip ii) Volume control iii) 45-55mmHg

Question 15

What are three aspects of care in HIV infected mothers? (3)

Answer 15

• identify women who have been infected with HIV - access to collaborative, coordinated HIV care by knowledgeable health care providers for pregnant women, mothers, and newborns - antepartum combination antiretroviral therapy, intrapartum antiretroviral therapy, postnatal antiretroviral therapy, and exclusive formula feeding of infants born to infected mothers

Question 16

What are the current vertical transmission rates of HIV from mother to baby in Canada? How about when no interventions are taken? (2)

Answer 16

Less than 2% As high as 25%

Question 17

What are 3 risk factors for increased transmission rates? (3)

Answer 17

Late or no prenatal care, injection drug use, recent seroconversion, regular unprotected sex with an HIV infected partner, diagnosis of STIs during pregnancy, emigration from an HIV endemic area, recent incarceration

Question 18

What is autism spectrum disorder, and how is it defined in the DSM-5? (3)

Answer 18

Autism spectrum disorder (ASD) is a neurodevelopmental disorder with onset in early childhood that is associated with a wide range of symptoms and ability levels. As defined by the (DSM-5), ASD is an encompassing diagnostic category that includes two symptom domains: 1) social communication impairments, and 2) restricted, repetitive patterns of behaviours and interests.

Question 19

Name 2 strong risk factors for autism spectrum disorder. (2)

Answer 19

Male sex, genetic syndrome and positive family history

Question 20

Two signs of an emerging autism spectrum disorder prodrome in infants less than 1 year. (2)

Answer 20

Delayed motor control (persistent head lag), feeding and sleeping difficulties, excessive reactivity or passivity, no smiling, no eye contact, no babbling or gesturing, limited response to name.

Question 21

What are three specific treatment goals in autism spectrum disorder? (3)

Answer 21

Improving social functioning, play, verbal and non-verbal communication, functional adaptive skills, reducing maladaptive behaviours, promoting learning and cognition.

Question 22

In autism spectrum disorder, what are 2 specific associated issues or complications to monitor (not ddx’s)? (3)

Answer 22

Comorbidities (anxiety, ADHD, depression are ddx/comorbid/?part of ASD) a. Dental – difficult to get 2/2 sensory sensitivities, anxiety, language impairment etc b. Gastroenterology – prevalence of GI disorders higher, GERD, celiac, constipation c. Nutrition – 2/2 highly selective diet, watch for deficiencies (Fe) d. Sleep – latency, night/early AM awakenings, sleep hygiene, avoid screens

Question 23

What are 3 non-MD assessments that address autism spectrum disorder associated functional challenges? (3)

Answer 23

SLP, psychoeducational testing, occupational therapy, PT, IEP

Question 24

What are the three possible approaches toward an autism spectrum disorder diagnostic evaluation? (3)

Answer 24

Approach 1: When a child’s symptoms clearly indicate ASD, an experienced or trained sole paediatric care provider can independently diagnose ASD, based on clinical judgement and DSM-5 criteria, with or without data obtained using a diagnostic assessment tool. However, this approach is not sufficient for accessing specialized services in some Canadian jurisdictions. Approach 2: In the shared care model, a clinician has joint responsibility with another health care provider for patient care, which involves exchanging patient information and clinical knowledge. When a child’s symptom presentation is milder, atypical, or complex, or a child is under 2 years of age, a paediatric care provider may use information from an ASD diagnostic assessment tool, and consult with another health care professional with specialized knowledge (e.g., a psychologist) to inform a diagnosis. Approach 3: In a team-based approach, diagnostic assessment is performed by health care professionals in an interdisciplinary or a multidisciplinary team. While interdisciplinary teams work collaboratively in an integrated, coordinated fashion, multidisciplinary team members work independently from one another but share information, and may (or may not) reach a diagnostic decision by consensus. In some Canadian jurisdictions, only a team-based diagnostic approach is accepted for accessing specialized services.

Question 25

What are the three key objectives of the autism spectrum disorder diagnostic assessment? (3)

Answer 25

1. Provide a definitive (categorical) diagnosis of ASD. 2. Explore conditions or disorders that mimic ASD symptoms and identify co-morbidities. 3. Determine the child’s overall level of adaptive functioning, including specific strengths and challenges, and personal interests, to help with intervention planning.

Question 26

Name 4 of the 8 essential elements of an autism spectrum disorder diagnostic assessment. (4)

Answer 26

Records Review, Interviewing parents/family/caregivers, assessment for core features of ASD, comprehensive physical exam and additional investigations, consider differential diagnoses and co- occurring conditions, establish an ASD diagnosis, communicating ASD diagnostic assessment findings, comprehensive assessment for intervention planning

Question 27

Why should children receive inactivated polio vaccine (IPV) prior to using oral vaccine? (2)

Answer 27

Vaccinating with OPV is a rare cause of polio due to CVDP

Question 28

Complete the following table.

Answer 28

Question 29

What are four symptoms of hypoglycemia in a neonate? (4)

Answer 29

Jittery

Sz

Tremor

Cyanosis

Weak or high pitched cry

Limp

Lethargy

Difficulty feeding

Eye rolling

Question 30

List 6 infants at risk for hypoglycemia. (3)

Answer 30

Weight <10^th percentile – SGA

Weight > 90^th (LGA)

IUGR

Infant of DM

Preterm <37 weeks GA

Maternal labetolol

Late prem exposure to steroid

Prenatal asphyxia

Syndromes assosciated with hypoglycemia – beckwidth wideman

Question 31

At what blood glucose value for a neonate should a critical sample be collected, and what are 6 tests to include? (4)

Answer 31

Less than or equal to 2.8 after 72 hours of life; less than or equal to 2.6 before that time

Insulin

Elevated ketones

Cortisol

FFA

GH

Urine organic acids

Serum aminoacids

Betahydroxybuturate

VBG

Lactate

Question 32

A neonate has persistent hypoglycemia. How long should they be fasted for before being discharged from hospital? (1)

Answer 32

5-6 hours

Question 33

Baby has IUGR and IDM. 2 hours old and asymptomatic. First blood glucose is 2.4mmol/L. What is your next step in management? (2)

Answer 33

Can give dextrose gel and BF or feed 5ml/kg and BF

Check glucose after 30 minutes

If tolerating and sugar is above 1.8 then decide

Above 2.6 – continue

Below 2.6 – repeat above step

Question 34

Baby A is LGA and Baby B is SGA. They both remain asymptomatic throughout their hospital stay. At how many hours of life can each have their hypoglycemia protocol discontinued? (2)

Answer 34

Baby A: 12 hours

Baby B : 24 hours

(Assuming feeding established and all sugars above 2.6mml/L)

Question 35

Complete the following table with four items per box, describing the known risks and benefits of digital media on mental and developmental health in both school aged and adolescent children. (8)

Answer 35

Question 36

List 2 positive and 2 negative effects of screen time on physical health. (4)

Answer 36

Benefits: digital fitness wear can help with physical activity. Some digital activities like Wii can help with fitness

Risks: texting and driving. More snacking when watching tv. More sedentary. Increased sleep problems.

Question 37

Describe the 4 M’s of media use. (4)

Answer 37

Manage

Make regular media plans, and individuals time and content

Be present

Discourage media multitasking, especially during homework

Learn about parental controls

Get kids passwords

Speak about acceptable and unacceptable online behavior

Meaningful

Prioritize daily activities like homework, sleep, PA, and face to face interaction over screen

Prioritize activities that are educational active or social

Help children and teens to choose developmentally appropriate content

Be part of their media life, like when they play video games

Model

Encourage parents to review their own use

Remind kids the dangers of texting and headphones during driving, walking, biking

Turn screens off when not in use

Avoid screen 1 hour prior to bed

Monitor: look out for signs that things are problemetic

Bored or angry without screen

Oppositional behavior

Screen use that interferes with sleep

Screen time that interferes with offline play

Negative emotions with online interactions

Question 38

Regarding flu vaccines:

i) Which flu vaccine or vaccines (IIV vs LAIV) may the following patients receive? (5)
a. 7 mo with febrile seizures
b. 9yo, JIA under Methotrexate
c. 15yo, BMI 28
d. 10yo, came to ED 6 days ago for wheezing
e. 14yo, migraines
ii) Among them, who is at high risk of influenza-related complications or hospitalizations? (1)

Answer 38

a. IIV
b. IIV
c. LAIV or IIV
d. IIV
e. LAIV or IIV
ii) A, B and D

Question 39

What is the “ABC” approach that clinicians may use to strengthen their relationship with families? (5)

Answer 39

Ask questions

Build on each family’s relational strengths

Counsel with family-centred guidance

Develop plans for changing behaviours related to sleep or discipline, as needed, and

Educate about positive parenting strategies.

Question 40

What are three non-medical issues for which parents routinely seek pediatric advice? (3)

Answer 40

Crying

Sleep

Difficult behavior

Question 41

Which of the following is true:

a) Sleep interventions strategies should be introduced before 6 months of age
b) Concerning sleep, focus should be put on night-waking prevention
c) These different interventions can also easily be used the same way for children with special medical and developmental needs
d) Targeted use of time-outs should not necessarily be excluded for specific misbehaviors in older than 3 yo
e) Vast majority of children and parents with emotional and behavioral problems are identified

Answer 41

d) Targeted use of time-outs should not necessarily be excluded for specific misbehaviors in older than 3 yo

Question 42

Concerning lead:

a) Neurodevelopmental manifestations are only present at higher levels
b) Blood assay allows diagnosis of long-term lead toxicity
c) Low-lead level exposure is often asymptomatic
d) The reference level is 5 mcg/l because it is the safe threshold
e) When exposure ceases, lead is rapidly excreted

Answer 42

c) Low-lead level exposure is often asymptomatic

An elevated venous BLL is the ‘gold standard’ to confirm recent lead exposure, always remembering that the half-life of lead in red blood cells is approximately 45 days.

Question 43

What is the recommended bloodwork panel when suspecting a low-level lead exposure? (4)

Answer 43

Blood lead (venous sample)

CBC

Ferritin

Calcium, protein, albumin

Question 44

Concerning risk of food allergy in high-risk children:

a) Breastfeeding should be promoted to 2 years and beyond
b) The consensus for definition of high-risk children is clearly defined
c) Early introduction of wheat and cow’s milk protein has also been strongly proved to be beneficial on multiple randomized trials
d) Parents should increase the delay between introduction of each new allergenic food
e) For no or low-risk patients, introduction of complementary foods is recommended at 4 months of age

Answer 44

a) Breastfeeding should be promoted to 2 years and beyond

Question 45

What are 3 examples of severe invasive GAS infection? (3)

Answer 45

• Streptococcal toxic shock syndrome
• Soft tissue necrosis (Necrotizing fasciitis, myositis, gangrene)
• Meningitis
• Pneumonia (with GAS isolated from pleural fluid – not from BAL as not considered sterile)

(Need isolation of GAS from sterile site for confirmed IGAS)

Question 46

What are 3 examples of non-severe IGAS infection? (3)

Answer 46

• Bacteremia
• Cellulitis
• Wound infection
• Soft tissue abscess
• lymphadenitis
• septic arthritis
• osteomyelitis

Question 47

For whom is chemoprophylaxis indicated with exposure to invasive GAS infections? Give 3 examples. (3)

Answer 47

. Only for exposure to severe infection

-all close contacts who have been exposed during 7 days before onset to 24 hours following Abx initiation

Close contacts:

• household contacts (20 hours over past 7 days)
• shared bed/sex if non-household
• mucous membrane contact or unprotected contact with open skin lesion of index case
• IVDU with needle sharing
• children and staff in home day care

Question 48

What is the recommended chemoprophylaxis agent for contacts exposed to IGAS infections? What is the window to start? (2)

Answer 48

• Cephalexin 25-50 mg/kg/d divided BID or QID for 10 days
• within 24 hours of identifying case preferred, but up to 7 days of identifying case

Question 49

What are 2 identified risk factors for IGAS infections in children? (2)

Answer 49

• Recent pharyngitis
• Varicella
• Recent soft tissue trauma
• NSAID use

Question 50

What are the diagnostic criteria for streptococcal toxic shock syndrome? (4)

Answer 50

-Isolation of GAS from sterile site

AND

-Hypotension

AND

2 of:

• Renal impairment (Cr 2x ULN)
• Coagulopathy (Plt < 100 or DIC)
• LFT abnormality (Transaminitis or bili 2x ULN)
• ARDS
• Generalized erythematous macular rash that may later desquamate

Question 51

What are 3 clinical features that suggest Necrotizing Fasciitis? (3)

Answer 51

• Pain out of proportion
• toxic appearance
• hemodynamic instability
• rapid rate of progression
• woody induration

Question 52

What is the empiric management for suspected toxic shock syndrome? (3)

Answer 52

-Cloxacillin and Clindamycin

(need to cover staph and GAS since clinically indistinguishable)

(consider adding Vanco if high rates of MRSA)

-Consider IVIG if severely ill or refractory to aggressive fluid resuscitation (1 g/kg x1)

Question 53

What is the empiric treatment for necrotizing fasciitis in a previously healthy child with no risk factors? (1) What is the empiric treatment for necrotizing fasciitis in a child with a history of a recent GI surgery? (1)

Answer 53

Healthy: Penicillin + Clindamycin

GI surgery: Pip-tazo or Carbapenem + Clindamycin

(Consider broad coverage for gram +/gram -/anaerobes if chemotherapy, recent GI surgery, penetrating trauma, abdominal/pelvic focus, pregnancy complications)

Question 54

Name 4 medical conditions that render a child significantly immunocompromised. (4)

Answer 54

• HSCT recipient within 2 years of transplant (or still on the drugs)
• Solid-organ transplant recipient forver
• Current or recently treated malignancy
• Aplastic anemia
• Asplenia (esp. towards encapsulated organisms)
• HIV infection (esp if CD4 < 200/mL in 5+ yo or < 15% in <5 yo)
• SCID

Question 55

Name 3 classes of medications that cause immune compromise. (3)

Answer 55

• High dose steroids (>2 mg/kg/d for 2+ weeks)
• Cancer chemotherapy (eg Cyclophosphamide)
• Antimetabolites
• Transplant-related immunosuppressive drugs (eg cyclosporine, tacrolimus)
• Biologics (Etanercept, adalimumab, rituximab, alemtuzumab)

Question 56

What are 3 ways we can build a protective environment for immunocompromised children? (3)

Answer 56

• Routine immunizations for patient (unless contraindicated, such as in live vaccines)
• UTD immunizations for HCP and caregivers (Esp. live vaccines)
• Healthcare facilities ensure infection prevention and control procedures are in place
• Hand hygiene

Question 57

What are 5 day-to-day activities after which hand hygiene should be performed to minimize risk to the immunocompromised child? (5)

Answer 57

• Before eating/preparing food
• After urinating/defecating
• After touching body fluids/excretions
• After touching plants/soil
• After collecting/depositing garbage
• After being outside the home
• After touching animals

Question 58

What type of illness can cryptosporidium cause in immunocompromised children? (1)

Answer 58

Prolonged diarrheal illness

Question 59

What are 3 bugs associated with the hot tub? (3)

Answer 59

• Pseudomonas
• Legionella
• Mycobacterial infections

Question 60

For immunocompromised children, what are 3 preventative measures to reduce the risk of each of the following: (6)

a) foodborne illnesses?
b) respiratory infections?
c) waterborne illnesses?
d) animal-related disease exposures?

Answer 60

a) -pasteurization (milk, fruit, veg)
- Avoid cheeses that are from raw/unpasteurized milk
- Avoid raw meat/seafood/eggs)
- wash raw vegetables even if “prewashed”
- avoid cross contamination when preparing foods
b) -Avoid contacts with resp illnesses
- Notify treated MD at first sign of resp illness in child during flu season
- Inform HCP if influenza in household
- Minimize exposure to crowded environments
- Avoid exposure to tobacco smoke
- Avoid risk of fungal exposure
- Minimize exposure to construction/excavation sites
- Minimize cave exploring, barns, turning compost piles
- Don’t smoke weed
c) -Don’t drink tap water when boil water advisory
- Drink bottled or boiled water when travelling in areas with suboptimal saniation
- Don’t drink well water unless properly screened/monitored
- Don’t drink water from rivers/lakes
- Don’t use hot tubs
- Clear abrasions with safe water
- Don’t swim in potentially contaminated water
d) -acquire pet when child is less immunosuppressed
- prospective pet should have full work-up from vet
- Avoid reptiles, chicks, ducklings (salmonella)
- Avoid ill animals
- Don’t clean birdcages or litter boxes if possible
- Don’t clean aquarium if possible

Question 61

For the following animal types, list the associated infection risk: reptile, common house mouse, kitten, old cat, puppy. (5)

Answer 61

• reptiles: salmonella
• house mouse: lymphocytic choriomeningitis virus (LCMV)
• young cat: Bartonella
• Old cat: Toxoplasma gondii
• Puppies: campylobacter

Question 62

What are 2 recommendations for travelling with immunocompromised children? (2)

Answer 62

• Visit travel clinic
• Special attention to hand hygiene in airport, etc.
• Health passport (lists meds, immunizations, describes conditions, HCP contact info)

Question 63

What proportion of Canadians do not have prescription drug coverage? (1)

Answer 63

-1 in 5 (20%)

Question 64

What are the 4 unique challenges faced by children and youth in accessing safe, effective, prescription drugs? (4)

Answer 64

• Children are vulnerable population warranting special attention
• Children have unique prescription drug needs that differ from adults
• Children have experienced significant regulatory neglect (therefore poor availability of paediatric drugs in Canada)
• Drug therapies for children provide significant return on investment that may not be captured by current assessment processes

Question 65

What are the most commonly used drugs for children? (1)

Answer 65

Antibiotics prescribed for short term use

Question 66

What are the most commonly prescribed medications for a chronic condition in peds? (1)

Answer 66

Asthma inhalers

Question 67

What is the challenge with rare diseases in paediatrics when considering drug needs? (1)

Answer 67

• diseases are individually rare, but relatively common when considered together (1 in 12 Canadians affected by a rare disease)
• Excluding drugs for rare diseases would lead to many children not have access to necessary medications

Question 68

What is a “postal code lottery” when talking about access to medications? (1)

Answer 68

-Significant variability between provincial drug plan coverage for high-cost drugs for rare diseases means that coverage depends on where you live

Question 69

Why can it be challenging to children to take medicines designed for adults? (2)

Answer 69

• Many children can’t swallow pills and require liquid formulations, which may need to be done at a compounding pharmacy leading to inconsistent taste and drug uniformity (dosage, bioavailability, etc.)
• Need flexible dosing because of dependence on weight/BSA

Question 70

What proportion of paediatric prescriptions are off-label in Canada? What does off-label mean? What is the risk of off-label prescribing? (3)

Answer 70

• 80%
• Off-label means that it is being prescribed for a condition/population that is not part of product monograph as determined by Health Canada. This does not mean there is not good evidence for use
• Off-label prescribing means that children are not receiving the same regulatory protections as adults (companies rely on off-label prescribing to not have to go through expensive/long process of applying for paediatric approvals since it is not required in Canada)

Question 71

What are 3 factors that may lead to an underappreciation of the return on investment of covering pediatric drugs? (3)

Answer 71

• lack of pediatric clinical/economic data needed to make calculations
• don’t account for costs supplementary services required if conditions not treated (eg special education services if untreated ADHD)
• Don’t capture the burden on caregivers/families (parents missing work, etc.)
• False equivalence between commercial and compounded formulations

Question 72

What are 5 recommendations for policymakers in establishing a pharmacare program that addresses the unique needs of Canadian children? (5)

Answer 72

• Development and implement pharmacare plans that mandate universal and comprehensive drug coverage for children
• Consistent across Canada (no postal code lotter)
• Engage with First Nations, Inuit, Méis
• Include coverage for meds for rare diseases
• Develop a comprehensive, evidence-informed, national list of paediatric drugs for inclusion in a national pharmacare program
• Inclusion decisions guided by paediatric experts informed by best evidence
• permanent Expert Paediatric Advisory Board at Health portfolio levels
• Recognize value of commercial formulations over compounded formulations
• Develop detailed dosing and compounding instructions for non-commercially available drugs
• Modernize process for drug approval and oversight
• Health Canada proactively request manufacturers include paediatric-specific data if paediatric use can be expected/anticipated
• Health Canada create expedited process to support review of paediatric products used in other trusted jurisdictions
• Support paediatric drug trials
• Paediatric outcome data should be studied
• Research budgets should have dedicated funding for paediatric drug studies

Question 73

What are the 3 different types of approaches to minimizing pain and distress during procedures? (3)

Answer 73

• Physical
• Psychological
• Pharmacological

(3 P approach)

Question 74

What are 2 positioning strategies to decrease a child’s distress during procedures? (2)

Answer 74

• Sit child upright rather than lying down
• Hugging/comforting rather than restraining

Question 75

What are 3 infant-focused strategies to decrease distress during procedures? (3)

Answer 75

• Breastfeeding
• Sucrose (part 2 min before procedure, rest during procedure)
• non-nutritive sucking
• rocking/holding
• Skin-to-skin (Kangaroo care)
• Swaddling

Question 76

What are 2 ways to cause less procedure-related pain? (2)

Answer 76

• choose venipuncture over heel lances
• Grouping bloodwork/IV insertions
• Avoid routine daily bloodwork

Question 77

What are 3 psychological strategies to decrease a child’s distress during procedures? (3)

Answer 77

• Preparation (Explain procedure to child in advance if 4+ yo, explain to parents as well)
• Distraction (bubbles, story, video) in 2+ yo, empower by asking and attending to their preference
• Deep Breathing (pinwheel, bubbles)
• Hypnosis
• Music Therapy

Mnemonic

“Please Don’t Deeply Hurt Me”

Question 78

What are 3 topical anaesthetics that can be used prior to needle procedures? (3)

Answer 78

• EMLA (lidocaine-prilocaine)
• Maxilene (Liposomal lidocaine)
• Ametop (Aemthocain/tetracaine
• Pain ease (Vapocoolant spray)

Question 79

What systemic side effect is associated with EMLA cream? (1)

Answer 79

. -Methemoglobinemia (likely due to prilocaine)

(also vasoconstriction and hypersensitivity)

Question 80

What has a faster onset of action, EMLA or Maxilene? Which lasts longer? (2)

Answer 80

• Maxilene is faster (30 min vs 60 min onset)
• Maxilene last longer (EMLA last 1-2 hours, Maxilene is longer…)
• Basically Maxilene is just better

Question 81

Name 3 contraindications to EMLA. (3)

Answer 81

• Allergy to component
• application on mucosae
• Methemoglobinemia
• G6PD
• Relative contraindication (Caution) = heart block or severe hepatic disorder

Question 82

What analgesia should be provided for non-urgent LPs? (2)

Answer 82

• topical local anaesthetic followed by injected lidocaine
• +/- sucrose
• +/-nitrous oxide

Question 83

When sutures are required for a procedure in ER, what type of sutures should be used and why? (2)

Answer 83

-absorbable sutures to avoid distress of suture removal

(as good as non-absorbable for cosmetic outcomes and infection rates in areas of low tension)

Question 84

What pain control methods are recommended for radiography of suspected fractures/dislocations? (3)

Answer 84

• immobilization and icing
• Ibuprofen (preferred over Tylenol)
• Intranasal fentanyl (1-2 mcg/kg)

Question 85

Which of the following statements is FALSE with respect to ITP?

1. The cause of ITP is not usually known, but the condition can be triggered by a viral infection
2. ITP affects approximately 5 in 100,000 children per year, most commonly between age 2 to 5 years
3. Most children present with mild bruising and petechiae
4. The most serious complication of ITP is intracranial hemorrhage
5. The typical natural history is self-resolution within 1 month in 75% to 80% of cases

Answer 85

The typical natural history is self-resolution within 1 month in 75% to 80% of cases

Question 86

Which of the following statements is FALSE with respect to treatment of ITP with IVIG?

1. Side effects include headache, nausea, vomiting, fever, rash, and hemolysis
2. It is effective >80% of cases
3. Increase in platelets usually occurs within 24 hours
4. Baseline immunoglobulin levels should be measured in all patients prior to administration
5. Should be used in patients where more rapid increase in platelet count is required

Answer 86

Baseline immunoglobulin levels should be measured in all patients prior to administration

Question 87

In the absence of overt trauma, which of the follow fractures has the STRONGEST association with inflicted injury?

1. Rib fractures
2. Metaphyseal fractures
3. Humerus fracture <18 months
4. Femur fracture in a non-ambulatory child
5. Supracondylar fracture

Answer 87

Rib fractures

Question 88

The MOST common cause of fractures in children <3 years of age hospitalized in the USA is:

1. falls
2. child abuse
3. motor vehicle accidents
4. underlying metabolic disorder
5. underlying bone disorder

Answer 88

falls

Question 89

A 9-month-old girl is admitted with pneumonia and chest x-ray reveals multiple rib fractures. Recommended investigations include all of the following EXCEPT:

1. Complete blood count
2. Coagulation tests including factors VIII and IX
3. Renal and liver function tests
4. Serum calcium, phosphate and alkaline phosphatase
5. Urinalysis

Answer 89

Coagulation tests including factors VIII and IX

Question 90

A 6-year-old girl is admitted with GAS septic arthritis and remains stable and non-toxic. Which of the following chemoprophylaxis agents is the preferred choice for her 4-year-old brother who has a penicillin allergy?

1. First-generation cephalosporins (e.g. cephalexin)
2. Second- or third-generation cephalosporins (e.g. cefuroxime axetil and cefixime)
3. Macrolides (e.g. erythromycin, clarithromycin and azithromycin)
4. Clindamycin
5. None of the above

Answer 90

None of the above

Question 91

Which of the following statements about necrotizing fasciitis (NF) is INCORRECT?

1. Crepitus is more strongly associated with GAS-related NF, than with polymicrobial or clostridial NF.
2. Clinical features associated with NF include: severe pain or tenderness (often out of proportion to clinical appearance), toxic appearance, hemodynamic instability, rapid rate of progression, and ‘woody’ induration.
3. GAS-related NF cases are more likely to be associated with a generalized rash, pharyngitis, conjunctivitis, and/or strawberry tongue.
4. Empiric regimens may include either a beta-lactam-beta-lactamase inhibitor (i.e., piperacillin-tazobactam) or a carbapenem, in combination with clindamycin, with consideration of adding vancomycin for MRSA coverage depending on local prevalence and risk factors.
5. In otherwise healthy children with no risk factors for organisms other than GAS, penicillin plus clindamycin may be chosen as initial therapy.

Answer 91

Crepitus is more strongly associated with GAS-related NF, than with polymicrobial or clostridial NF.

Question 92

Which of the following is TRUE about Salmonella typhi infection?

1. Bacteremia is presumably always present
2. It presents most commonly with bloody diarrhea
3. The incubation period is typically 48-72 hours
4. ItismostcommonlyacquiredinAfrica
5. Stool cultures are positive in about 80% of cases

Answer 92

Bacteremia is presumably always present

Question 93

Which of the following is NOT a common source of non-typhoidal Salmonella infection?

1. Eggs
2. Ground beef
3. Produce
4. Reptiles
5. All of the above are common sources

Answer 93

All of the above are common sources

Question 94

Which one of the following organisms is MOST COMMONLY found on blood culture in fully immunized children with osteoarticular infections?

1. Kingella kingae
2. Staphylococcus aureus
3. Haemophilus influenzae type b
4. Streptococcus pyogenes
5. Streptococcus pneumoniae

Answer 94

Staphylococcus aureus

Question 95

Acute osteomyelitis is MOST COMMONLY found in which location in long bones?

1. Metaphysis
2. Diaphysis
3. Growth plate
4. Proximal epiphysis
5. Distal epiphysis

Answer 95

Metaphysis

Question 96

Assessment for neonatal hypoxic-ischemic encephalopathy, according to the CPS statement, includes all of the following EXCEPT:

1. Posture
2. Heart rate
3. Spontaneous activity
4. Deep tendon reflexes
5. Primitive reflexes

Answer 96

Deep tendon reflexes

Question 97

Which is the CORRECT target rectal temperature for whole body cooling?

1. 33.0°C±0.5°C
2. 33.5°C±0.5°C
3. 34.0°C±0.5°C
4. 34.5°C±0.5°C
5. 35°C±0.5°C

Answer 97

33.5°C±0.5°C

Question 98

You are the paediatrician caring for a newborn with severe encephalopathy following placental abruption in a community hospital. Following consultation with your local referral centre, you should initiate all of the following cooling measures EXCEPT:

1. Turning off the overhead warmer
2. Removing the newborn’s hat
3. Not dressing the newborn in clothing
4. Removing the blanket
5. Using a cooling blanket

Answer 98

Using a cooling blanket

Question 99

Which of the following statements about heated, humidified high-flow nasal cannula (HHHFNC) therapy is INCORRECT?

1. HHHFNC therapy provides warmed, humidified oxygen at flow rates that deliver higher oxygen concentrations and some positive airway pressure compared with standard low-flow therapy
2. Compared with continuous positive airway pressure (CPAP), which delivers gas flow at changing rates to maintain constant and positive intrathoracic pressure during inspiration and expiration, HHHFNC provides a constant, steady flow of gas
3. HHHFNC can deliver 100% O2 to older children and adults and is well-tolerated
4. Extensive paediatric literature exists to support the role of this therapy in reducing need for invasive ventilation and intubation
5. HHHFNC oxygen therapy minimizes or eliminates the inspiration of room air (and the subsequent dilution of supplemental high fraction of inspired oxygen [FiO2] gas) that occurs during low-flow oxygen therapy, using supplemental gas flow rates that ‘wash out’ anatomic dead space

Answer 99

Extensive paediatric literature exists to support the role of this therapy in reducing need for invasive ventilation and intubation

Question 100

HHHFNC therapy is contraindicated in which of the following conditions?

1. Bronchiolitis
2. Severe upper airway obstruction
3. Asthma
4. Pneumonia
5. Heart failure

Answer 100

Severe upper airway obstruction

Question 101

In children who have a moderate to severe asthma exacerbation, which of the following therapies may reduce the need for hospitalization and the risk of relapse after initial treatment, and may also facilitate an earlier discharge from the hospital?

1. Doubling the dose of inhaled corticosteroids
2. Systemic steroids
3. Regular salbutamol q4h
4. Removing the exacerbating trigger
5. Starting montelukast from the onset of the exacerbation, for a minimum of 7 days

Answer 101

Systemic steroids

Question 102

In an asthma exacerbation, ipratropium bromide may be used:

1. Instead of a beta agonist
2. In combination with a beta agonist prn
3. In combination with a beta agonist for the first 4 hours while in the ED
4. In combination with a beta agonist for the first 1 hour, every 20 minutes
5. Not recommended for use

Answer 102

In combination with a beta agonist for the first 1 hour, every 20 minutes

Question 103

Which of the following side effects is associated with magnesium sulphate?

a. Rebound bronchoconstriction and desaturation

b. Hypertension
c. Hypotension
d. Hypokalemia

e. Tachycardia

Answer 103

Hypotension

Question 104

ith respect to asthma exacerbation, admission should be considered if any one of the following apply, EXCEPT:

1. ß2-agonists are needed more often than q4h after 4 to 8 h of conventional treatment
2. The patient deteriorates while on systemic steroids
3. An ongoing need for supplemental oxygen
4. A worsening wheeze
5. Persistently increased work of breathing

Answer 104

A worsening wheeze

Question 105

A previously healthy 15-year-old girl presents with fever and generalized erythematous rash. She is hypotensive with low platelets, elevated creatinine and liver enzymes. Initial empiric antimicrobial therapy should include:

1. cloxacillin
2. clindamycin
3. penicillin
4. cloxacillin and clindamycin
5. penicillin and clindamycin

Answer 105

cloxacillin and clindamycin

Question 106

You hesitate to admit the above patient to the General Pediatrics unit and reassess in an hour. The condition seems to be refractory to initial aggressive fluid therapy. According to the CPS statement, which additional treatment(s) should be considered at this time?

1. Clindamycin
2. IVIG
3. NSAIDs
4. IVIG and NSAIDs
5. Steroids

Answer 106

IVIG

Question 107

A 5-year-old girl is admitted with septic arthritis of the right hip. She underwent surgery for debridement of the joint and has been on intravenous cefazolin for the past four days. She has clinically been improving and today is afebrile and able to weight bear. Her CRP remains elevated at 28 mg/L (from 148 mg/L on presentation). Which of the following is the BEST next step?

1. Continue intravenous cefazolin until her CRP normalizes, and then switch to oral cephalexin to complete a 3-week course of antibiotics
2. Continue intravenous cefazolin until her CRP normalizes, and then switch to oral cephalexin to complete a 6-week course of antibiotics
3. Request PICC insertion to complete a 6-week course of intravenous cefazolin
4. Switch to oral cephalexin to complete a 3-week course of antibiotics
5. Switch to oral cephalexin to complete a 6-week course of antibiotics

Answer 107

Switch to oral cephalexin to complete a 6-week course of antibiotics

Question 108

A 2-year-old previously healthy boy presents with a 1-week history of periumbilical abdominal pain and diarrhea, along with a 3-day history of fever. He saw his family physician 5 days ago and stool cultures were sent. His parents are concerned that the fever does not seem to be resolving. He has been drinking and voiding well. The family travelled to India to visit family 3 weeks ago.

Vital signs are stable with temperature of 39.1 C. He appears well with moist mucous membranes. There is mild generalized abdominal tenderness.

You see that the stool culture has just come back positive for Salmonella (not yet typed). After sending a blood culture, which one of the following is the best next step?

1. Start oral azithromycin and follow up in clinic in 24 hours
2. Start oral ciprofloxacin and follow up in clinic in 24 hours
3. Start IV ceftriaxone and admit to hospital
4. Do not start antibiotics and follow up in clinic in 24 hours
5. Start IV fluids and admit to hospital

Answer 108

Start IV ceftriaxone and admit to hospital

Question 109

You are called to a STAT C-section for a mother with known vasa previa presenting with bleeding at 37 weeks’ gestation. The baby is delivered with poor tone and no cry or spontaneous respirations. He is brought to the warmer. Initial heart rate is 60 bpm, but quickly increases above 100 bpm with effective PPV. After 5 minutes, he gasps intermittently but does not have sustained respirations, requiring continued PPV. He is intubated after requiring PPV for 10 minutes. You assign Apgar scores of 1, 3 and 6 at 1, 5 and 10 minutes, respectively. The arterial cord gas returns at 7.02/78/18/-14. On neurologic exam, you note the baby to be lethargic with decreased spontaneous activity and tone. Pupils are 2 mm and responsive. Suck reflex is weak.

Based on the CPS statement, what level of encephalopathy does this baby have? Does this baby meet criteria for initiation of therapeutic hypothermia?

1. Mild encephalopathy, meets criteria for therapeutic hypothermia
2. Moderate encephalopathy, meets criteria for therapeutic hypothermia
3. Moderate encephalopathy, does not meet criteria for therapeutic hypothermia
4. Severe encephalopathy, meets criteria for therapeutic hypothermia
5. Severe encephalopathy, does not meet criteria for therapeutic hypothermia

Answer 109

Moderate encephalopathy, meets criteria for therapeutic hypothermia

Question 110

A 6-month-old baby boy weighing 7 kg is admitted with bronchiolitis. He is able to maintain adequate oxygen saturations but has worsening respiratory distress with retractions, tachypnea, grunting and nasal flaring after being initiated on HHHFNC therapy 10 L/min with FiO2 of 50%. According to the CPS statement, initiating HHHFNC therapy worsens respiratory distress in some patients, due to breath- stacking or auto-PEEP and work of breathing may improve with:

1. a reduction in flow to 7 L/min
2. an increase in flow to 14 L/min
3. an increase in FiO2 to 100%
4. a decrease in FiO2 to 21%
5. both b and c

Answer 110

a reduction in flow to 7 L/min

Question 111

A 10-year-old boy with a known history of persistent asthma presents with a viral-induced asthma exacerbation. At triage, his SpO2 is 89% on room air, he is able to speak only in words, and has significant respiratory distress with nasal flaring, accessory muscle involvement and audible wheeze.

His exacerbation may be classified as:

a. mild
b. moderate
c. severe
d. severe to impending respiratory failure

Answer 111

severe

Question 112

Initial minimal treatment for a child with severe asthma exacerbation should include:

oxygen, salbutamol and ipratropium x 3 doses by MDI, oral steroids

oxygen, salbutamol and ipratropium x 3 doses by nebulizer, oral steroids

oxygen, salbutamol and ipratropium x 3 doses by nebulizer, IV steroids

oxygen, salbutamol and ipratropium x 3 doses by nebulizer, IV steroids and IV magnesium sulphate

Answer 112

oxygen, salbutamol and ipratropium x 3 doses by nebulizer, oral steroids

Question 113

Consider doing a blood gas in a patient with severe asthma exacerbation if he:

1. does not respond to the initial treatment provided
2. deteriorates while already on systemic steroids
3. had a history of previous admission to ICU requiring intubation
4. does not improve despite maximal aggressive therapy

Answer 113

does not improve despite maximal aggressive therapy

Question 114

What would a normal CO2 signify in a severe asthma exacerbation?

1. The exacerbation is not severe
2. The patient is anxious
3. Impending respiratory failure
4. An appropriate respiratory compensation

Answer 114

Impending respiratory failure

Question 115

A 4-year-old boy presents with bruising, petechiae and resolved mild epistaxis. He is found to have a platelet count of 9 x 109 with normal hemoglobin of 110 g/L, WBC of 7 x 109/L, and normal differential and cellular morphology on smear. He is otherwise well with no red flags on history or physical. Which of the following is the most appropriate next step?

1. Observation
2. Bone marrow aspiration
3. Oral prednisone 1 mg/kg/day orally for 4 days
4. Oral prednisone 1 mg/kg/day orally for 4 days following bone marrow aspiration
5. Both a) and c) are reasonable in this case

Answer 115

Observation

CPS says this is first line if no or mild bleeding

Question 116

Patient with ITP returns the next day with melena, platelets of 2 x 109/L and a hemoglobin of 92 g/L. He is somewhat pale but otherwise well with stable vitals. Which of the following is the most appropriate next step?

1. Stool sample for fecal occult blood
2. Observation
3. Oral prednisone
4. IVIG
5. Upper endoscopy

Answer 116

IVIG

(IV steroids too)