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Flashcards in CPS statement volume 1 Deck (51):

The following is not associated with pacifier use:
a) increased otitis media
b) possible breastfeeding difficulties
c) dental problems
d) analgesic effect
d) increased risk of SIDS

d) Increased risk of SIDS
- studies show that SIDS may decrease the risk of SIDS, because of this should be cautious before routinely advising against use. (grade A evidence, level II-A)
Mitchell (New Zealand) - less pacifier use in SIDS babies than controls
Arnestad (Norway) - pacifier use may protect against SIDS
L'Hoir (Netherlands) - pacifier use less in SIDS cases, recommend in bottle babies
Fleming (UK) - babies who routinely use a pacifier but didn't for last sleep are higher risk of sids
Chicago (black urban population) - pacifier use lowered risk of SIDS
- lower auditory threshold, mechanical barrier for rolling, keeps tongue forward, baby is soothed so may not move as more in sleep, reduce GERD and apnea, increased CO retention and increase respiratory drive
May be associated with early weaning - but lots of confounders, evidence is not solid
- Early pacifier use should signal possible breastfeeding difficulties (evidence level I grade A)
pacifiers are superior to sucrose and glucose for analgesia


Which of the following is false about tooth development and pacifier use?
a)thumb sucking is recommended over pacifier use and is easier to wean
b) sugar, honey or corn syrup should not be put on a soother
c) Sucking habit should stop before permanent teeth erupt
d) Longer use of pacifier is associated with increased possibility of dental problems including openbite and cross bite

A) pacifier use is recommended over thumb sucking and is easier to wean

The commonly associated problems with pacifiers are dental caries, malocclusion and gingival recession, most studies these problems exist with prolonged (>age 5) or inappropriate use (sweetened pacifier)


What of the following is not true about pacifiers and otitis media?
a) may lead to early weaning of breastfeeding
b) is a fomite which is colonized with otitis media causing organisms
c) may impair the functioning of the eustachian tube
d) prolonged and more frequent use is more likely to increase the risk of otitis media

b) cultured 40 pacifiers found microorganisms in only 52.5% of pacifiers, most common was alpha hemolytic strep, negative for major pathogens that cause OM.

chronic otitis and tympanostomy tubes - 40% used pacifiers

prolonged and frequent use - should restrict use to sleep time and first 10 months of life, may reduce the associated risk between OM and pacifier use

Infants and children with chronic and recurrent otitis media should be restricted in their use of a pacifier (level II-A, grade A evidence)


Which is true of the following?
a) Those who used a pacifier were less likely than controls to be colonized with candida species
b) silicone pacifiers were more likely to be positive for Candida albicans than latex pacifiers
c) children who sucked their finger were less likely to have infection than those that sucked a pacifier
d) children who sucked pacifier and digit were at highest risk of infection

Answer: d) based on Avon study of 10 000 15 month olds in UK

a) pacifier users were almost twice as likely to be colonized with candida
b) more candida in latex pacifiers (smoother surface of silicone may protect) *remember that latex is sticky
c) opposite - children who sucked their finger were more likely to have reported infection than those that sucked pacifier


Which of the following pacifiers is safe under the Hazardous Products (Pacifiers) Regulations by Health Canada?
a) collapsible or hinged handle, loop of plastic that is 20 inches in circumference, N-nitrosamine levels 12 ppb
b) collapsible or hinged handle, loop of plastic that is 14 inches in circumference, N-nitrosamine levels 9 ppb
c) collapsible or hinged handle, loop of plastic that is 14 inches in circumference, N-nitrosamine levels 12 ppb
d) collapsible or hinged handle, loop of plastic that is 16 inches in circumference, N-nitrosamine levels 9 ppb


- need collapsible or hinged handle
- any loop of cord or other material attached cannot be > 14 inches in circumference
- level of n-nitrosamines (carcinogens leached from rubber) need to be


Non nutritive sucking with nasogastric feedings has been associated with all but the following:
a) comfort and state regulation
b) organizes oral motor development
c) better weight gain
d) lower incidence of NEC
e) longer hospital stay

e) both a recent systematic review (Hamilton) as well as past studies have shown that non-nutritive sucking decreased the length of hospital stay by 7 days
the other associations were not found in this particular study but has been commonly reported in the past

**pacifiers should continue to be used in the NICU units in preterm or sick infant (level I grade A evidence)


Which of the following is not associated with increased risk of AOM?
a) young age
b) daycare attendance
c) orofacial abnormalities
d) household crowding
e) cigarette smoke
f) premature birth
g) breastfed
h) immunodeficiency
i) family history of OM
j) first nations/Inuit

NOT being breastfed is a risk factor for otitis media
young age is a risk because of anatomy of eustachian tube and low IgA levels
daycare attendance - increases exposures to viral infections, increased incidence of nasopharyngeal colonization with pathogenic bacteria
oropharyngeal abnormalities (include cleft palate)


Which of the following patients is appropriate for watchful waiting for acute otitis media?
a) 5 months old, afebrile, fluid behind the tympanic membrane and erythema
b) 7 months old, fever of 40, unable to sleep because of pain, fluid behind tympanic membrane and loss of bony landmarks
c) 1 year old with Down Syndrome, bulging membrane with gray discolouration, temperature of 38.5 C
d) 5 year old , previous history of multiple perforated otitis media, bulging membrane, otalgia and temperature of 38 for past 24 hours
e) 2 year old with otalgia, bulging tympanic membrane, temperature of 38.5, 24 hours of illness


Observation for 48-72 hours is appropriate for the following criteria:
age > 6 months of age
no immunodeficiency, chronic cardiac pulmonary disease, anatomical abnormalities of the head or neck, or history of complicated otitis media (suppurative complications or chronic perforation) or Down syndrome
not severe illness - otalgia mild, fever lower than 39 C without antipyretics
parents can recognize signs of worsening illness and can readily access medical care if child does not improve
if child worsens or doesn't improve and still has dx of OM, treat with Abx
need to tell the family about analgesia, either give them a delayed prescription or make a second appointment with the family.

Signs and Sx to make diagnosis of AOM
- signs of middle ear effusion (immobile TM or acute otorrhea +/- opacification of tympanic membrane +.- loss of bony landmarks +/- visible air fluid level behind the tympanic membrane ) and symptoms of inflammation which suggest the fluid is pus (bulging tympanic membrane with marked discolouration (hemorrhagic, red, grey, yellow), acute onset of symptoms (rapid onset of ear pain, or unexplained irritability in a preverbal child)


Which organism is most commonly isolated from AOM?
a) Moraxella catarrhalis
b) S. pneumo
c) H. influenza
d) Group A strep
e) Staph aureus

c) H. influenzae (non typable - aka non encapsulated so the vaccine doesn't help with these strains)
**has switched since intro of pneumococcal conjugate vaccine (used to be S. pneumo)
role of viruses - play an important role, but most of the time there is bacteria present
50% of H influenza spontaneously resolve whereas S. pneumo only 20% spontaneously resolve


Which of the following is false?
a) AOM resolves more rapidly with antimicrobials
b) 30 children have to be treated for one child to have resolution of symptoms at 48 hours
c) children with early bacteriological cure of AOM are at lower risk of early recurrence of AOM with same organism
d) 5 children need to achieve bacteriological cure to prevent one recurrence of AOM

b) 15 children have to be treated for one child to have resolution of symptoms at 48 hours


Which of the following is not a risk factor for antimicrobial resistant S. pneumoniae?

d) recent antimicrobial use within 3 months is the risk factor, NOT 8 months
daycare attendance > 4 hour per week with at least 2 unrelated children


A two year old girl is started on amoxicillin 80 mg/kg/day divided tid, after 2 days she is still having fever and severe otalgia. What should you do?
a) give her amoxicillin/clavulanate, 90 mg/kg/day amox, 6.4 mg/kg/day clavulanate divided BID x 5 days
b) give her amoxicillin/clavulanate, 90 mg/kg/day amox, 6.4 mg/kg/day clavulanate divided BID x 10 days
c) Start ceftriaxone 50 mg/kg/day IM x 3 days immediately
d) Do immediate tympanocentesis to guide therapy

b) if initial therapy fails (i.e. no symptomatic improvement after 2-3 days) then try either
- amox/clav 90 mg/kg/day divided bid x 10 days
- if symptoms do not resolve with amox/clav, consider ceftriaxone 50 mg/kg/day IM x 3 doses, or consider referral to otolaryngology for tympanocentesis to determine the etiologic agent and guide therapy
**titrate treatment based on symptoms, since effusion can last for months, (symptoms should improve within 1-2 days, and resolve within 2-3 days) suggests that need to switch the antibiotics to one that targets both penicillin-resistent S. pneumo and beta-lactamase producing organisms
high dose amox - oral drug most likely to treat resistant S. pneumo


Which of the following statements is false?
a) amoxicillin has excellent middle ear penetration
b) first line therapy for OM in a previously healthy 3 year old is amoxicillin 75-90 mg/kg/day divided bid x 5 days
c) high dose amoxicillin is effective against penicillin intermediate and some resistant S. pneumoniae
d) if patient has a type 1 reaction to amoxicillin then cefprozil at a dose of 30 mg/kg/day divided bid should be used

d) type 1 reacion is urticaria or anaphylaxis, then should use macrolide (clarithromycin or azithromycin)
if not type 1, then can use second generation cephalosporin, if type 1 and then failed macrocodes, try clindamycin or quinolone in consultation with ID physician, or consider tympanocentesis to determine the etiologic agent and guide therapy

amoxicillin divided bid vs tid (some experts say that should divide it tid )


Who should not be treated with 10 day course of therapy?
a) 1 year old with non perforated AOM, 1st episode
b) 3 year old with perforated AOM
c) 5 year old being treated with Amox/Clav after failing Amox treatment
d) 8 year old being treated with azithromycin because of a penicillin allergy

d) 5 days is max course for azithromycin, 3 days is max course for ceftriaxone
patients who should get 10 day course:
state if they develop new URTI sx
If adverse effects within day 5-10 of Abx, reasonable to stop rather than prescribe an alternative


Which of the following is not a way to reduce chance of AOM?
a) wash hands
b) exclusive breastfeeding until at least 3 months of age
c) use a pacifier
d) limit daycare exposure for children


ways to reduce AOM
- hand hygiene, breast feed until 3 months of age (effect persists 4-12 months after breastfeeding ceases) - immunoglobulins in BM, also because no negative pressure generated in eustachian tube, pacifier use increases risk (up to 3 year old), limit daycare in 1st year of life, childcare centers with better hygiene procedures, maternal smoking in first year of life significant risk factor (especially in LBW infants)
influenza vaccine for healthy kids > 6 months and parents/caregivers - important role in pathogenesis, live attenuated intranasal vaccine prevents influenza-associated AOM in children 15-71 months of age, pneumococal vaccine limited efficacy again AOM because only 7 pneumococcal serotypes in current vaccine and there are likely "replacement disease" with non vaccine serotypes , newer vaccines will cover more serotypes and are conjugated to H flu


Which of the following is false about bedsharing?
a) more common in African-American, Asian and Hispanic households and in lower SES families
b) breastfed infants who share a bed with their mother feed more often and for a longer duration than solitary sleeping incants
c) promotes infant arousal and responsiveness of mother to the infant
d) increases sleep problems, sexual pathology , dependency
e) increases the risk of SIDS if he bedshares with people other than parents or usual caregiver

d) no evidence that it increases sleep problems, sexual pathology and dependency, even though common in lots of cultures, does not suggest that the medical community should promote it.


Which of the following decreases the risk of SIDS?
a) sleeping in the prone position
b) room sharing
c) bed-sharing with a mother who smokes
d) bed-sharing with an adult who is fatigued or impaired by alcohol or drugs
e) use of soft bedding, pillows and covers in all sleep environments


infants should sleep on their back in a crib meeting the Canadian Government Safety standards for the first year of life (parents room first 6 months)


Which of the following is true about smoking mothers:
a) mothers who smoke during pregnancy do not increase the risk of SIDS after birth
b) Passive exposure to cigarette smoke in the environment does not increase risk of SIDS
c) When there is exposure to cigarette smoking (either pre or postnatally) the risk of SIDS is not further increased with bedsharing
d) mothers should be counselled to prevent maternal smoking starting as early as possible

smoking during pregnancy increases SIDS risk, passive smoke increases SIDS risk, bedsharing further increases SIDS risk even more than just smoking


Which of the following qualifies as a sleep environment that is considered safe?
a) air mattress
b) car seat
c) makeshift bed on the floor
d) in a crib with a thin blanket only

d) - shouldn't have quilts, comforters, bumpers etc.


Studies about safe sleep environment for infants has shown all but the following:
a) prone sleeping and exposure to tobacco products during and after pregnancy are potent SIDS risk factors
b) recent changes in usual sleep environment of the infant (i.e. sleeping prone or bedsharing for the first time) presents the highest risk for sudden death
c) 18% of deaths in a Quebec study were in recognized unsafe sleeping environments, the most frequent being presence of pillows on the bed
d) Sleep sharing on a sofa has a particularly increased risk of SIDS

Answer is C) **see data below

no rCTS done nor can be done
Case Control studies New Zealand Cot Death study , CESDI study, Chicao Infant Mortality Study, European Concerted action on SIDS:
- prone sleeping, exposure to tobacco products, recent change in sleep environment, unsafe sleeping environment (soft surface, pillow use, bedsharing other than with parents alone, sofa sharing, bedsharing with alcohol or tiredness

Case Series CPSC databases:
- most deaths attributed to suffocation or strangulation caused by entrapment of the child's head in various structures of the bed, risk of bedsharing in this study could not be accurately calculated

No case control or case series describing available Canadian Data, prelim results from recent case series in Quebec (1991-2000) showed that 18% of deaths in recognized unsafe sleeping environments, #1) unaccustomed prone sleeping #2) pillows on the bed #3) sofa sharing. 93% of the time the sleeping arrangement was new for the infant on the night of death. 57% of infants bedshared with a parent, 14 cases in unsafe sleeping environment, couldn't calculate risk because no control group


Which of the following statements is true about ways to prevent allergy in high risk infants?
a) Avoiding milk, egg, peanut or other potential allergens during pregnancy helps to prevent allergy
b) Introducing a specific solid food later (i.e. after 6 months) can prevent food allergy
c) For women who will not breastfeed, hydroyzed cow's milk based formula may prevent atopic dermatitis compared to intact cow's milk formula
d) Skin or IgE testing before a first ingestion should be done prior to introducing a food
e) Pediatricians recommend inducing tolerance by introducing solid foods at 4-6 months of age


e) need more research on early intro of foods to prevent food allergy, cannot recommend at this time
regular ingestion of newley introduced foods needed to preserve tolerance, skin testing not encouraged since risk of confusing false positives (refer to allergist instead for anxious families, who may consider a oral food tolerance), introducing food late does not reduce (and may increase) the chance of allergy

infants considered high risk for development of allergy has first degree relative (parent or sibling) with atopic dermatitis, food allergy, asthma or allergic rhinitis, the statement applies to infants at high risk for developing allergies but the studies in this statement did include some non high risk infants also

current studies in progress for when to introduce allergen foods:
LEEAP study UK: early intro (4-10 months) of peanut protein vs. delayed (3 years)
EAT study: no increased allergy risk kids, regular consumption of allergenic foods from 3-6 months of age


Which of the following is false in terms of feeding and allergy prevention in high risk infants?
a) mom's should breastfeed exclusively for the first 6 months
b) clear evidence that breastfeeding prevents allergy
c) the total duration of breastfeeding (at at least 6 months) may be more protective than exclusive breastfeeding for six months
d) fully hydrolyzed casein formula is more likely to be effective in preventing atopic dermatitis in high-risk infants than partially hydrolyzed whey formula
e) soy formula does NOT have a role in allergy prevention

B) NOT clear evidence that breastfeeding prevents allergy, but we do know it has all the other great benefits so we should do it anyways

No studies have looked at the role of amino acid formulas in allergy prevention
one recent study that said that supplementing with cow's milk formula may reduce alley (cow's milk) but since this goes against all the existing recommendations, more studies are needed
the current evidence only looks at atopic dermatitis, unclear if long term effects, therefor no clear recommendations on formula can be made


Which of the following is true?
a) breastfeeding meets all of the nutritional requirements of both term and preterm infants until they are 6 months old
b) CPS recommends exclusive breastfeeding until 1 year old
c) the upper limit for continued breastfeeding is 2 years old
d) breastfeeding duration has been found to be related to mother's age

**D) 11% of mothers 25-29 continued to breastfeed exclusively for 6 months, compared to 20% of mothers 35 or older

a) breastfeeding (with a few exceptions) meets all the nutritional requirements of healthy term newborns with vitamin D supplementation
b) exclusive breastfeeding until 6 months old
c) no upper limit established,continue BF until 2 years and beyond

in 2008 87% of babies were breastfed for some period of time, only 16.4% were exclusively breastfed for 6 months. most common reason for weaning was return to work.

when early weaning was introduced, infant mortality increased


Which micronutrients are infants at highest risk of being deficient in if solid food introduction is delayed beyond 6 months of age?
a) fat
b) iron
c) zinc
d) vitamin E

**this study follows older wearing infants 12-18 months of age
B) Picciano study iron deficiency anemia is the biggest one
grains, whole milk, dairy products and meats important sources of iron, vitamin E and zinc. by 4-6 months the iron stores from birth are diminishing, necessitates the introduction of iron-containing foods at 6 months of age for all infants **some gouts recommend iron supplementation after the first weeks of life or at four months of age, if delay in iron fortified foods, need to consider supplementation
iron from meats has the best bioavailability
**after 6 months breast milk can't provide enough protein anymore, need to add other sources of protein, also need roughage
gradual wean is when the infant starts to eat more other foods while still breastfeeding on demand


Which of the following is not an absolute contraindication to breastfeeding? absolutely contraindicated in breastfeeding?
a) antimetabolites (ie azathioprine) use by mom
b) radiopharmaceuticals therapeutic use by mom
c) ongoing maternal cocaine use
d) child's sudden illness

child' sudden illness is not a contraindication
**very few drugs are absolutely contraindicated in breastfeeding
absolute include 1. antimetabolites 2. therapeutic levels of radiopharmaceuticals 3. most drugs of abuse
*marijuana not shown to increase neonatal risk but no great studies
most common reason that mom's give for weaning is perceived low milk supply


Which of the following is false :
a) most infants with ankyloglossia are able to breastfeed successfully
b) frenotomy is recommended for all children with ankyloglossia
c) frenotomy may be considered if there is significant tongue tie and major breastfeeding problems
d) frenotomy should be performed by a clinician experienced with procedure and appropriate analgesia

b) not recommended unless association between significant tongue-tie and major breastfeeding problems
Ankyloglossia - no universally accepted definition or practical objective criteria for diagnosing ankyloglossia
definitions have been based on oral anatomic characteristics (i.e. fusion between tongue and the floor of the mouth) or based on functional impairment (i.e. can't put tongue past the incisal edge of the lower gingiva and other signs of decreased tongue mobility), no accepted standard
classified based on the degree of fusion between the tongue and the floor of the mouth
incidence approx 4-10% of ankyloglossia, have not definitively shown that ankyloglossia leads to breastfeeding problems


Which is not a possible complication of tongue-tie release?
a) bleeding
b) infection
c) injury to parotid duct
d) post operative scarring

C) actually injury to Wharton's duct (aka submandibular duct)
post op scarring may limit tongue movement even more and need a second operation
excision with lengthening is more complicated with less chance of scarring but has more risks of GA


Which is false about recommended protein intake for vegetarian children :
a) adjusted 10-15% compared to non vegetarians because plant proteins have lower digestibility
b) soy protein can meet needs as well as animalprotein
c) wheat protein has the same amount of usable protein as animal protein
d) Major plant food sources of protein are legumes, cereals, nuts and seeds and their butters

c) wheat protein may have 50% less usable protein than animal protein
each plant protein

** we need protein to get essential amino acids


What percentage of children have problems with sleep initiation and maintenance?
a) 35-45%
b) 45-55%
c) 10-15%
d) 15-25%

d) 15-25%


Which of the following is not associated with the significant frequency of sleep disorders?
a) exposure to electronic media/screen light
b) caffeine
c) participation in sports
d) cigarette smoking
e) alcohol

c) the rest are all associated with it, mechanism is because of decreased secretion of melatoning by the pineal gland


The most encountered sleep problems in childhood include all but the following:
a) delayed sleep phase
b) behavioural insomnia - sleep onset association type
c) behavioural insomnia of childhood - limit setting type
d) all of the above


sleep phase type - initiaion of sleep later than the desired bedtime
sleep latency> 30 minutes, associated with difficulty awakening in the morning

sleep-onset association - need special conditions for child to go to sleep or return to sleep
limit setting - child refuses to go to bed and caregie has unsuccessful limit-setting behaviours


A 10 year old child comes to you with trouble sleeping, needing 2 hours to fall asleep. Your initial history and counselling should include all but which of the following?
a) determine if patient shows any signs of anxiety, depression
b)counselling to have a stable bedtime, avoid hunger and eating prior to bedtime, avoid screen time prior to bed
c) immediate initiation of melatonin at 5 mg SL QHS
d) determine if patient snores, has frequent arousals overnight


evaluation of sleep disorders should include consideration of medical conditions that lead to insomnia sleep apnea, anxiety, depression and inappropriate use of media at bedtime

consulting should include stable bedtime and wake time, age appropriate number of hours in bed, dark/quiet sleep space, avoid hunger ad eating prior to bedtime, relation techniques before bed, avoid caffeine ,alcohol and nicotine, avoid TV, computes and video games and encourage reading prior to bedtime

limit setting type of behavioural insomnia will respond to this type of intervention, might take time to resolve, may have refractory cases


Which of the following statements regarding melatonin use in Canada is false?
a) is considered to be a "natural health product"
b) standards of preparation in Canada are governed by the natural health products regulation and the food and drug act (since 2004, most recent update 2010
c) only short acting forms of melatonin are available
d) products claiming to contain the same amount of melatonin are not necessarily bioequivalent
e) melatonin use is considered "off-label" for children and teens sleep problems as per Health Canada

c) short and long acting forms are available


Which of the following is true?
a) melatonin is the only medication studied for insomnia in children that is considered safe and effective for short-term use
b) there is evidence to suggest that melatonin is safe for children of all ages
c) short acting forms of melatonin are used for sleep initiation and maintenance
d) long acting forms of melatonin are used for sleep initiation


b) no evidence that safe for children


A 10 year old girl takes 2 hours to fall asleep, despite having good sleep hygienic and otherwise good health. Which dose of melatonin would you recommend?
a) 2.5 mg 30 minutes before bedtime desired
b) 2.5 mg 2 hours before bedtime
c) 5 mg 30 minutes before bedtime
d) 10 mg 60 minutes before bedtime

melatonin use for delayed sleep phase type (circadian rhythm disorder)
dose typically used is 2.5-3 mg in children
5-10 mg in adolescents
administer 30-60 minutes prior to desired bedtime
studies are usually open-label or carried out in adults


Which is false regarding the studies regarding the use of melatonin in sleep-onset association disorder
a) randomized, double-blind, placebo controlled
b) showed to improve sleep onset and duration in school age children who received 5 mg (compared to placebo)
c) measures of health status and sleep improved more in the melatonin group
d) a few patients felt cold, dizzy or decreased appetite throughout the treatment

d) all these effects resolved within 3 days


Which of the following statements regarding ADHD and sleep is false?
a) Patients with ADHD on stimulants may have increased sleep difficulties
b) On a study of ADHD patients on stimulants, melatonin decreased with sleep onset from 91 to 31 minutes in children who had not responded to sleep hygienic measures
c) In a study of ADHD children not on a simulate, sleep onset decreased by 44 minutes and total time asleep increased with melatonin and sleep onset increased by 12 minutes with placebo. headache, dizziness and abdo pain occurred in the melatonin group
d) The improvement in sleep in patients who received melatonin lead to improved behavioural, cognitive performance and quality of life

the answer d) did not translate into these measures (based on the second study, ADHD patients not on stimulants)

b) 5/27 had improvement with sleep hygiene measures
c) the headaches, dizziness and abdo pain did not need treatment or withdrawal from study


In autistic children, studies have shown all but the following:
a) improved sleep latency with melatonin
b) improved total sleep duration
c) unchanged frequency of night awakenings
d) continuation of melatonin after completion of one study

c) showed improvement in night awakenings

67% of autistic children have reported sleep difficulties

study a) double blind, crossover, RCT of 11 children , 5 mg melatonin
sleep latency 2.6 h to 1.06 hour, night awakening 0.35 to 0.08 total sleep 8.05 to 9.84, all the kids continued on melatonin after study due to parents request

study b) open label in 107 children with autism spectrum d/o, looked at parent reports
doses 6 year old 1.5 mg dose, increase to 3 mg if no response, then consider 6 mg. no longer sleep concerns - 25%, 60% improved but still concerns, 6% improve initially but then returned problems 3-12 months (despite dose increase), continued sleep problems 15%, 1% worse with melatonin treatment

melatonin may help children with intractable epilepsy, neurodevelopment disabilities, Angelman syndrome

overall, adverse effects mild and self limited, always try sleep hygiene first, limitations, small number of RCTs, small number of subjects, no long term studies


At which age is the incidence of positional plagiocephaly the greatest?
a) 6 weeks
b) 4 months
c) 2 years
d) none of the above

b) greatest at 4 months

striking at 6 weeks, increases to maximum at 4 months then decreases over 2 years

16% - six weeks, 19.7% at 4 months, 6.8% at 12 months and 3.3 % at 24 months


Which of the following does not increase the risk of positional plagiocephaly?
a) congenital torticollis
b) first child
c) female sex
d) supine sleeping position at birth and 6 weeks
e) bottle feeding only
f) tummy time

c) female sex - male sex increases the risk of positional plagiocephaly


Which of the following is not associated with positional plagiocephaly?
a) dysmorphisms and syndromes
b) congenital torticollis (limited neck rotation at birth)
c) abnormalities of the cervical spine
d) cranial asymmetry with posterior displacement of the ear on the side ipsilateral to occipitomastoid bossing

d) is associated with craniosynostosis
craniosynostosis vs positional plagiocephaly
- of lamboid sutures, causes occipital flattening, relatively infrequent, may have ridging of the affected suture, also has cranial asymmetry with posterior displacement of the ear on the ipsilateral side vs ipsilateral anterior displacement of the ear with PP
torticollis should be treated with physio, as torticollis improves, so should the positional plagiocephaly


Which of the following patients with positional plagiocephaly do not need an X ray of the skull?
a) 18 month old with worsening plagiocephaly
b) 4 month old with ridging and ipsilateral posterior displacement of the ear
c) 2 month old with anterior displacement of the ear

c) ** clinical diagnosis, X rays only helpful when clinical suspicion of craniosynostosis or when worsening of head shape at age when positional plagiocephaly should improve
PP does not reduce the accuracy or necessity of serial head circumference measurements


Which of the following measures should be suggested to prevent positional plagiocephaly?
a) position baby with head at the foot of the bed only
b) tummy time 3 times per day for 10-15 minutes each time
c) sleeping prone

b)These babies will require more effort to lay them supine in a position counter to their preference to limit the risk of developing PP [2].


Which of the following regarding treatment for positional plagiocephaly is false?
a) a randomized control trial showed that physiotherapy combining positioning with exercises is superior to parental counselling for preventative measures alone
b) there have not been RCTs to compare moulding therapy to repositioning therapy
c) Cohort studies on the benefits of moulding have had more severe asymmetry in the moulding group
d) Cohort studies on moulding included older children in the moulding group
e) Cohort studies included older children in the moulding group who had not responded to repositioning
f) Studies overall don't suggest that moulding helps with improvement in skull shape

f) despite the flaws, overall the evidence suggests the rate of improvement in skull shape in favour of moulding treatment (1.3 x improvement with moulding vs. repositioning(but similar end outcome in both groups)

positioning treatment similar to preventative measures, combine with exercise when needed (i.e. for congenital torticollis, positional preference or developmental simulation)

**use of moulding (helmet therapy - controversy because of significant direct marketing , expensive, not always covered by insurance and potential side effects, worn 23 hours a day so can cause contact dermatitis, pressure sores and local skin irritation
no consistent or objective method to assess the severity of skull asymmetry so studies not great


Which of the following patients should consider moulding (helmet) therapy?
a) 3 month old with mild positional plagiocephaly
b) 10 month old with severe plagiocephaly
c) 6 month old with severe asymmetry
d) 1 year old with moderate plagiocephaly


consider for severe pp at any change
maximum age for helmet at 8 months, no studies stratified on age or severity so not great evidence to support

**helmt influences rate of improvement but not final outcome

for mild-moderate 4 months or younger, repositioning tx (physio and positioning better than watchful waiting)


Which of the following is true?
a) nearly all children

a) true - THE ANSWER

b) physically normal children should not need corrective footwear
c) is a common finding
d) small proportion last till age 10, rarely leads to these problems if it persists into adulthood


Which of the following groups of people does not have a higher incidence of flatfoot in studies ?
a) overweight
b) those who wore shoes in early childhood
c) taller children
d) greater laxity of ligaments

c) the others were found to have higher incidence of flatfoot

higher in kids who wore shoes at age


Shoe inserts or corrective shoes to treat flat foot:
a) has no impact on the development of flatfoot
b) may negatively impact the child's self esteem by treating "abnormal feet"
c) has no impact on improvement of flatfoot (compared to no treatment wearing conventional leather shoes) after 3 years follow up
d) should be considered for asymptomatic as well as asymptomatic children with flatfoot

d) only for symptomatic children (pain with walking) to rule out underlying disorders

Infants do not need shoes until they are walking (Level III-A)
Shoes are necessary for protection. They should be well fitting, soft, light weight, and have cushioned soles (Level III-A)
Orthotics are not beneficial in the management of physiological flexible flatfoot (Level I-B), developmental intoeing, and mild torsional deformities (Level III-B).
Orthopaedic referral is necessary when a child experiences functional disability or pain in association with foot or lower leg abnormalities (Level III-B).


Which of the following conditions is unlikely to resolve spontaneously by adulthood?
a) intoeing secondary to tibial torsion
b) non reducible metatarsus adductus
C)intoeing secondary to femoral torsion
d)metatarsus adductus


the others are torsional deformities that resolve into adulthood


Which treatment and condition is paired incorrectly?
A)simple metatarsus adductus-stretching exercises
B) non reducible metatarsus adductus-May need casting/splints in early infancy
C) metatarsus adductus-sitting in w position
D) persistent intoeing with tibial torsion leading to functional impairment, pediatric surgery referral for possible gait plates to reduce tripping
E) flexible excessive pronation of the feet - options for orthosis or no treatment

C) w position can make it worse

In an rct, flexible deformity did not improve further with treatment(ortho sis) vs not, treatment did not affect pain mobility did not depend on severity of pronation


Which of the following statements is false?
a) bowlegs and knock-knees are variants of lower leg development should resolve usually by age 8
b) corrective shoes and insoles can be benefical to the resolution of bowlegs and knock-knees
d) if bow-legs and knock knees persist beyond age 8 and causes functional impairment, should refer to ortho

incorrect - corrective shoes and insoles don't have any beneficial effects on the resolution of developmental bowlegs and knock knees

corrective interventions only necessary if significant functional impairment, or if develops at age 8-10 years , or if pain

potential harms of treating physiological flat feet, knock knees or bow legs include - weakening of feet by decreasing normal muscle activities of the feet, cost, stigma of disease, self esteem