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Flashcards in CPS statement Volume 2 Deck (54)
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1

Which of the following children fulfills the Rome criteria for functional constipation?
a) 4 year old with developmental delay with large fecal mass in the rectum and 2 or fewer defecations in the toilet per week
b) 3 year old with large fecal mass in the rectum and bowel incontinence
c) 10 year old with back pain and constipation
d)5 year old with straining with bowel movements and hard stools

d) is the answer

a) no because Developmental delay

Rome III diagnostic criteria **to provide criteria for research purposes - 2 or more criteria in a child with developmental age of at least 4
at least once per week for at least 2 months before diagnosis
with insufficient criteria for IBS
incontinence - secondary to withholding of stool lead to overflow diarrhea

1) Two or fewer defecations in the toilet per week.
2) At least one episode of fecal incontinence per week.
3) History of retentive posturing or excessive volitional stool retention.
4) History of painful or hard bowel movements.
5) Presence of a large fecal mass in the rectum.
6) History of large diameter stools that may obstruct the toilet.

Acronym is : PIRPOF
Poops 2 or less times in toilet /week
Incontinence once per week
Retention of stool
Painful/hard bowel movements
Obstruct the toilet
Fecal mass - in rectum

need 2 or more criteria, developmental age of at least 4 years, once/week for at least 2 months
NOT IBS

2

Which of the following about functional constipation is false?
a) high prevalence when children are entering school age
b) should do basic labs and abdominal X rays for all children with constipation
c) high prevalence when children are getting toilet trained
d) stool softeners don't make the bowel lazy and are safe for long term use



b) initial investigations and X rays only if suggestion of organic disease

parents often have misconceptions about bowel softeners making the bowel contract/spasm, people getting dependence on them, and minimally absorbed from the gut

toilet training time is often time with lots of constipation, therefore clinicians should support parents at this time.

3

Which of the following is not true of fecal impaction?
a) should initiate treatment with maintenance stool softeners
b) stool felt in the rectal vault
c)hard mass felt in the abdomen
d)history of overflow incontinence

a) need to make sure that don't mis diagnose impaction since maintenance stool softeners can worsen incontinence

don't need x ray to diagnose impaction

4

Which of the following methods of disampaction is not recommended?
a) 3 day PEG 3350 at dose of 1-1.5 g/kg/day (max dose 100 g/day)
b) daily enemas for 6 days
c) digital disampaction
d) nasogastric lavage with PEG solution

c) cannot be recommended may be harmful

a) this helped with disampaction for 95% of children, well tolerated
b) equally effective but potentially less well tolerated
d) for severe constipation; if volume of PEG not able to take orally, until the rectal effluent is clear

5

Which of the following about maintenance treatment for constipation is true?
a) should be started immediately upon diagnosing constipation
b)medical maintenance therapy with laxatives is less effective than behavioural
c) few well designed trials for laxative treatment in children
d) PEG 3350 should be the first line for all children with constipation based on evidence

c) the answer

a) need to dismpact first (to prevent overflow0) then promptly start maintenance therapy
b) more effective than behavioural treatments
d) hard to establish first line therapy

6

Which of the following is the best choice of treatment for maintenance treatment of constipation?
a) PEG 3350 at dose of 0.4-1.0 g/kg/day
b) docusate sodium at dose of 5mg/kg/day divided 3x/day or as a single dose
c) lactulose at 1-3 ml/kg/day in divided doses
d) milk of magnesium at 1ml/kg/day-3 ml/kg/day
e) sennosides at dose of 2.5-15 ml/day based on age

a) growing evidence that PAG 3350 best choice for treatment of paediatric constipation

b) no evidence that decussate helpful in childhood constipation (aka colace, don't work)

PEG 3350 more effective than lactulose, equal to MoM although better tolerated, Sennosides inferior to lactulose based on symptom control, relapse rate and side effects in 2 trials

7

Which of the following medications and side effect are incorrectly?
a) PEG 3350 - electrolyte abnormalities
b) mineral oil - lipid pneumonia
c) Senna - idiosyncratic hepatitis
d) Milk of magnesium - hypophosphatemia
e) Phosphate enema - hypocalcemia

a)tasteless, odorless, no chance of electrolyte imbalances

b) mineral oil - lipid pneumonia if aspirated , theoretical risk of decreased absorption of fat soluble substances, not clinically substantiated
c)Senna - idiosyncratic hepatitis, melanosis coli, hypertrophic osteoarthropathy, analgesic nephropathy
d) MoM - in overdose, increased Magnesium, hypo PO4 and hypo Ca . infants can get magnesium poisoning (symptoms include apnea, cardiac, neurological)
e) phosphate enema - can cause local trauma to rectal vault, hyper phosphate, hypocalcemia,

**table in the CPS statement - the other is decussate sodium, causes abdo pain, cramps, diarrhea, glycerine suppository, no SEs, the others can generally cause some abdo cramps and bloating

parents should be advised to increase or decrease the dose until children have 1-2 soft stools/day, might get some leaking, emergency plan for disimpaction

8

Which of the following is not part of standard behavioural counselling for constipation?
a) should try to stool at the same time every day
b) a footstool while pooping can help a child valsalva
c) children should be punished for not stooling during toilet time
d) a stool diary can be helpful to parents, in conjunction with a Bristol stool chart

c) should use reward and praise for stooping as well as for sitting on the toiilet,

most people stool at the same time each day, within 1 hr of eating (reflex), usually in the am children should sit for 3-10 minutes (based on age)

9

Which of the following dietary changes has been shown to help with treatment of constipation in children in research studies?

a) maintain daily fiber intake of 0.5g/kg/day (max dose 35 g/day)
b) fiber supplementation beyond daily dose
c) Metamucil (psyllium )
d) Wheat dextrin (Benefiber)
e) Eliminating milk
f) Probiotics such as lactobacilli

a) maintaining regular fiber intake can help, but supplementing beyond likely doesn't help

there have not been studies on metamucil, or wheat dextrin, should make sure enough water taken in with fiber

*while excessive milk can lead to constipation, intolerance, there is little evidence that eliminating it helps with treatment of constipation. in certain kids with atopy, Cow's milk protein has been shown to make it worse. if kids fail other treatment, can consider trying a cow's milk protein free diet.

a balanced diet of fruits, grains and vegetables is recommended to treat constipation in children, carbs (especially sorbitol) found in prune, apple juice and pear can increase the fluid content of stoolsand increase frequency

study showed that using lactobacilli in conjunction with lactulose did not help, another study was inconclusive.

10

Which of the following is true about infants with constipation?
a) most commonly organic in cause
b) a breastfed newborn should stool with every feeding
c) mineral oil is a good choice of treatment for infants
d) evidence has shown that PEG 3350 is safe and effective at treating constipation in infants

a) still usually functional, but need heightened vigilance to identify organic causes
b) big range - from with every feeding to with every 7-10 days. formula fed infants have less variation.
c) nope, shouldn't use t consider it for treatment)

11

How long should a child be treated for constipation before considering weaning of treatment?
a) 2 weeks
b) 4 months
c) 6 months
d) 1 year

6 months
want to have regular soft bowel movements before weaning, lots of relapse and hard to treat, need lots of close follow up.
refer to GI when adequate treatment measures fail or suspicion of organic disease.

12

Which of the following is not an indication for a genital exam?
a) parental request
b) a teen being prescribed birth control during their annual visit
c) cases of suspected sexual abuse
d) look for endocrine abnormalities
e) monitor normal development of external genitalia

b) don't need to do for routine teen exam if not sexually active (with change in pap guidelines, unclear if we should still do pelvic exams on sexually active teens)

13

Which of the following is false?
a) older children should get consented for genital examination
b) for younger children, a parent or care-giver should be present and the process explained to both of them
c) if a child is refusing to cooperate with the exam, one should use force if necessary to ensure that the physical exam is complete
d) a parent or nurse should be present when performing a genital exam on a teen

c) never use force or restraint if child doesn't cooperate postpone the exam

positions for exam:
sitting cross legged on care givers lap
knee chest position (better view, more traumatic)
lateral decubitus for boys.

14

Which of the following statements is false?
a) Internet sites in Canada with health information are strictly regulated
b) there is evidence that the paediatrician has a role in guiding the parent to find websites that provide high quality information about children
c) most parents will access health information on the internet and use it to make decision regarding their child's health, often without discussing it with their physician

a) no regulations about what can be on the internet

15

Which of the following is not a key criteria when evaluating a website that provides good information for families?
a) no conflict of interest
b) peer reviewed information
c) up to date information
d) based on expert opinion

d) expert opinion is not the best, since it is still just an opinion, experimental studies are the best.

16

At which age to most children in the Western world achieve bowel and bladder control?
a) ages 2-4
b) ages 18 months - 3 years
c) ages 3 years - 5 years
d) ages 1-3 years

a)

physiological readiness at 18 months usually, other aspects of readiness can vary, should discus at 1 year visit.

17

Which of the following statements is true?
a) boys usually achieve bowel and bladder control before girls
b) bowel and bladder control are typically obtained at the same time
c) the average age of initiation of toilet training to achievement of independent toiling is 3-6 months
d) daytime and nightime continence are typically achieved simultaneously

c) the answer

a) girls are first
b) often bladder control first
d)daytime then nightime

lots of variability, no particular age where toilet training should start

18

Which of the following children is likely ready for toilet training?
a) 18 month old who is not yet walking
b)1 year old who is walking and can follow one step command
c) 2 year old who can sit on the potty and indicate when they have to use the potty
d) 3 year old with autism and inability to communicate verbally

c)

likely steps needed for toilet training

- physiological readiness - obtained by 18 months usually , reflex sphincter and myelination of long pyramidal tracts

other steps:
- able to walk to potty chair or adapted toilet seat
- stable on potty chair or adapted toilet seat
- able to follow simple (one step and two step )command
- able to communicate need for potty verbally or with gestures
- desire to please caregiver
- desire for independence and control of bowel/bladder
- able to stay dry for several hours

19

Which of the following is false?
a) when child is 18 months paediatrician should assess a child's readiness for toilet training
b) a child who has recently moved or acquired a new sibling is likely not at the best moment to start toile training
c) encouraging a child with praise is a better approach than reprimanding them for accidents
d)allowing the child to watch a parent use the toilet is not helpful
e) a potty chair is typically more helpful than an adult toilet in the early stages

d) allowing them to watch parents helps

how parents can facilitate toilet training:
- decide on language to use
- ensure potty chair and position are easily accessible
- if using regular toilet then use adapter and foot stool
- encourage child to tell parent when voiding, even if after the fact praise them, learn signs that child is about to use the toilet
- expect accidents, avoid negative reinforcement
- consistent between caregivers
- when you get there ( 1 week or more of consistent success), use cotton underpants or training pants, make this an important moment, if they have accidents, let them return to diapers without making it a bit deal

20

In which order should the following steps of toilet training typically be undertaken?
a) sit on potty with diaper removed several times a day
b)sit on potty after soiled diaper removed
c) try out cotton underpants/training pants after a week of using the potty
d) sit fully dressed on potty
e)a routine of sitting on the potty at a specific time each day

d), b) (may want to put diaper in the potty to show it's function), a), e) , c)

using this method may have success in a few weeks

**child centred approach, keep cultural background in mind.

21

Which of the following approaches to toileting refusal is false?
a) if a child refuses to have bowel movements in the toilet, should allow them to return to diapers to prevent constipation and painful bowel movements
b) organic causes of toilet training failure are common
c) if a child exhibits toileting referral, should take a break for 1-3 months
d) constipation can delay toilet training

b) rare, usually the child is simply not ready, if not ready don't do toileting battles, will slow things down

a) true, since this could further delay the toiling process

the rest are true
d) should treat the constipation to help with toilet training

22

Which of the following children would not consider consider referring to a general paediatrician or developmental paediatrician?
a) 5 year old who is still not toilet trained
b) 2 year old whose first attempt at toilet training did not succeed and is currently on a 1-3 month hiatus
c) 3 year old who has failed 4 attempts at toilet training

c) consider referral if older than 4 years or repeated failures, most children are ready after 1 break

**identifying for special needs kids is equally important, same stages but may be hampered by unique circumstances, i.e. social or adaptive delays as well as medications and when parents are ready to begin the process

23

Which of the following statistics is false?
a) 5-10% of preschoolers have visual difficulties which if left untreated can interfere with proper development of visual acuity
b) major refractive errors occur in 5-7% of preschoolers
c) early screening has been associated with a decrease in amblyopia and improved acuity by 60%
d) a Cochrane review found that there was significant evidence from RCTs that screening programs are necessary to prevent amblyopia

d) false, not enough RCTs to analyze importance of screening programs on the prevalence of amblyopia (does not mean that not beneficial just that there isn't great evidence yet

the rest are true

c) randomized longitudinal studies

24

Which of the following is not a recommendation by the AAP and AA of Opthalmologists:
a) visual acuity should be assessed at preschool age
b) visual assessment only starting at age 1
c) visual assessment all health supervision visits
d) anatomy and function should be checked at all visits

b) visual assessment starting at birth and at all health supervision visits

25

Which of the following children does not need referral to a specialist?
a) ex prem 26 week with 4 month NICU stay
b) 4 month old with Down Syndrome at initial visit
c) family history of congenital glaucoma
d) healthy 1 year old

d) don't need professional eye exam for healthy children with no risk factors

FHx of congenital glaucoma/strabismus

26

Which of the following statements about photo screening is false?
a) the negative predictive value of photo screening is 10%
b)AAP recommended photo screening in 2002
c)can identify significant refractive errors and opacities in the reflex
d) a recent study showed that photo screening is cost effective and has a PPV of 80%

a) negative PV has not been established so safety not established

not an appropriate tool for office paediatrics

study #1) US and Taiwan, cost effective, PPV 80%, #2) Alaska - PPV 95%

digital camera like equipment, not fully compared with traditional methods of acuity assessment

27

Please pair the following terms and definitions
a) amblyopia
b) strabismus
c) refractive error
d) cataract

1) inability of eye to focus image
2) misalignment of eye in any direction
3) opacification of crystalline lens
4) reduced vision in absence of ocular disease

a - 4), common causes are strabismus and refractive error, brain doesn't recognize the input
b- 2 can be constant or intermittent, pseudo strabismus when broad nasal bridge covers the nasal sclera unequally, determine with corneal light reflex
c- 1 inability of eye to focus image, usually correctible by lens
d - 3

28

Which of the following ages and landmarks about visual development is false?
a) face follow 0-4 weeks
b) visual follow - 3 months of age
c)visual follow 6 months of age
d) visual acuity measurement with appropriate chart - 42 months

c) the rest are true

29

Which of the following vision screening tools is most appropriate for a 6 year old child?
a) LogMAR chart
b)LogMAR Snellen chart
c) HOTV chart
d) Allen chart

b) is the answer

should use the tool that is the highest level recognized by the child

LogMAR - 42 months
LogMAR Snellen chart - 6 years
HOTV chart - 36 months
Allen chart too culturally specific to be helpful

test at 3 meters, better eye first, these screening tools are for people with minimal training (physicians, public health nurses)

30

Which of the following is an appropriate exam for the age of the child?
a) newborn to 3 months of age- red reflex, exam of skin and external eye structures
b) 3-5 years of age - red reflex, external structures, cover - uncover test
c) 6-12 months - red reflex, ocular alignment including cover uncover and corneal light reflex, fix and follow, visual acuity
d) 6 years and more - routine comprehensive examination

a) red reflex - if not there, urgent referral to ophtho

b) should also do visual acuity testing
c) too young for visual acuity
d) routine exam by professional no proven benefit, should do screening with routine exams and examine whenever complaints occur