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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