CPS Statements

Question 1

Imaging the term neonatal brain: what area does US not visualize well?

Answer 1

The convex surfaces and the posterior fossa.

Question 2

Imaging the Term Neonatal Brain: What is another con of US modality to image the term neonatal brain?

Answer 2

It may miss some subtle grey and white matter anomalies if the operator is less experienced.

Question 3

Imaging the Term Neonatal Brain: When is it appropriate to get a CT head on a neonate?

Answer 3

When the infant is too sick to have an MRI with the length of time that it requires for the MRI or in trauma situation to look for fractures.

Question 4

Comprehensive care of the ambulatory child with cerebral palsy (GMFCS I and II): A Canadian perspective: What is the definition of CP?

Answer 4

• heterogeneous group of:
  1. non-progressive
  2. neurodevelopment conditions characterized by impairments in motor function that limit activity, and are
  3. caused by a disturbance to the developing fetal or infant brain
  4. associated with altered sensation or perception, intellectual disability, communication and behavioral difficulties, seizure disorders, and musculoskeletal complications.

Question 5

Comprehensive care of the ambulatory child with cerebral palsy (GMFCS I and II): A Canadian perspective: What are the common early warning signs that should trigger further evaluation for CP include?

Answer 5

1. Hand preference before 12 months
2. Stiffness or tightness in the legs before 12 months
3. Inability to sit by 9 months
4. Persistent fisting of hands beyond 4 months
5. Delays or asymmetry in movement or posture

Question 6

Comprehensive care of the ambulatory child with cerebral palsy (GMFCS I and II): A Canadian perspective: what is the GMFCS for I and II?

Answer 6

I: walk without limitations and only experience difficulties with speed, balance, and coordinating more advanced motor skills.
II: walk well on flat and familiar surfaces but require support when navigating uneven surfaces, crowded areas, and long distances

Question 7

Comprehensive care of the ambulatory child with cerebral palsy (GMFCS I and II): A Canadian perspective: What are the 9 categories (Clinical Pearls) to monitor for children with CP with GMFCS I and II?

Answer 7

1. Pain:
2. Seizures
3. Nutrition and Feeding
4. Vision
5. Hip Surveillance
6. Scoliosis
7. Hypertonia
8. Developmental Surveillance
9. Wellness Participation
   function, family, fitness, fun, friends, and future

Question 8

Non-IgE-mediated food allergy: Evaluation and management. What are the 2 most common types of non -IgE mediated food allergy?

Answer 8

• food protein-induced enterocolitis syndrome (FPIES) = 0.34%
• food protein induced allergic proctocolitis (FPIAP) = 0.16%

Question 9

What is the underlying pathophysiology related to FPIES or FPIAP?

Answer 9

• T-cell mediated inflammation (but poorly understood)

Question 10

what are the FPIES Clinical manifestations (7 points)

Answer 10

• ages of onset 2-7 months (often with introduction of solids or formula into the diet)
• acute: profuse, repetitive vomiting, with pallor or lethargy, 1-4 hours after ingesting a trigger food
• can be on first exposure or after a period of tolerance
• diarrhea can occur 5-10 hours later (more severe cases)
• rare and severe cases: hypothermia, LOC, hypotonia, acidemia, methemoglobinemia
• no skin or resp findings (as not IgE mediated)
• chronic FPIES may be on the differential of FTT, chronic diarrhea, malabsoroption syndromes

Question 11

What are the clinical manifestations of FPIAP? (3 points)

Answer 11

• intermittent slow onset hematochezia in an otherwise healty growing infant, in the first 6 months of life.
• typical onset is 1-4 weeks post delivery
• no associated emesis, diarrhea, or FTT

Question 12

Acute Management for FPIES?

Answer 12

Acute Management?

• typical management for dehydration
• mention of ondansetron if minimum weight 8 kg
• consider IV methylpred 1 mg/kg, no studies demonstrating efficacy
• No acute management needed for FPIAP

Question 13

What are the most common Food triggers in FPIES?

Answer 13

1. milk - 67%
2. Soy - 41%
3. Grains (rice> oat> wheat> corn> barely) 25.3%
4. Egg - 11%
5. Meats/fish < 10%
6. Vegtetables
7. Fruits
8. Peanuts/tree nuts

Question 14

What is the Long term Management of FPIES?

Answer 14

• eliminating the trigger food! relying largely on clinical history
• oral Food challenge by allergist (Second line)
  
  • An OFC would only be recommended if the infant’s history is unclear, such as in the absence of a clear trigger food, an atypical symptom time course, or lack of symptom resolution with trigger food elimination
• can also do an OFC to assess if the FPIES has been outgrown
• not recommended: stool testing, endoscopy, radiography
• Do not need to avoid warning labels for foods or carry epi-pen

Question 15

What bout multiple food triggers in FPIES?

Answer 15

• occurring in about 30% of patients with FPIES

Question 16

in a patient with FPIES, should we avoid other common trigger foods?

Answer 16

In the absence of a history of reaction, however, avoiding common FPIES triggers during infancy is not recommended

• Because IgE-mediated food allergy is more prevalent and generally more difficult to outgrow, the risk of developing an IgE-mediated allergy to foods such as peanut or egg outweighs the benefit of delayed introduction to manage or prevent FPIES
• Introducing commonly allergenic solids at around 6 months of age (and not before 4 months), especially if the child is at risk for IgE-mediated allergy, is recommended

Question 17

Treatment of Cows milk FPIES? (3 points)

Answer 17

• cow’s milk FPIES, extensively hydrolyzed formula should be considered as a feeding alternative
• cross-reactivity between cow’s milk and soy-based formulas is low, such that soy-based formula can be considered as an alternative for feeding infants over 6 months of age
• some infants may require an amino acid-based formula

Question 18

Treatment of Grain-induced FPIES?

Answer 18

• rice or oats have high cross-reactivity, avoid both!
• reasonable to introduce other grains
• growth and nutrition must be closely monitored

Question 19

FPIAP long term management

Answer 19

• typically resolves with the elimination of Cows milk protein (and often soy)
• next steps are egg and corn to eliminate
• or changes to extensively hydrolyzed formula

Question 20

What is the prognosis of FPIES and FPIAP?

Answer 20

• FPIES: high spontaneous rate of resolution, often in early childhood.
  
  • 35% by 2 years of age,
  • 70% by 3 years of age, and
  • 85% by 5 years of age
• solid food related FPIES may resolve later than cows milk or soy FPIES
• Medically supervised OFCs may be considered as early as 12 to 18 months after the most recent reaction
• FPIAP: typically resolves by 1 year of age, can then introduce both one at a time, consider slow reintroduciton

Question 21

When do we refer to an allergist in non-IgE mediated food allergy?

Answer 21

• young children with FPIES should be referred to an allergist who can offer OFCs for evaluation, especially before reintroducing a trigger food into the diet.
• or if family is hesitant to introduce new foods
• skin prick tests are a second line reason for referral, high false positive rate. (measuers food specific IgE levels for a trigger food, can have prognostic implications)
• for FPIAP, if trigger can not be identified, or symptoms are not responding to typical food eliminations

Question 22

Non-IgE-mediated food allergy: Evaluation and management . Practice Pointss

Answer 22

• Acute management of FPIES includes fluid resuscitation or IV/IM ondansetron (or both). No acute management of FPIAP is necessary.
• Long-term management of both FPIES and FPIAP involves eliminating the trigger food from the infant’s diet.
• Avoiding cross-reactive foods and precautionary labelling are generally not required.
• Using an epinephrine autoinjector is not required for FPIES or FPIAP.
• Closely monitoring nutrition and growth, especially when there are multiple trigger foods or food avoidances, is essential.
• Both FPIAP and FPIES have high rates of resolution in early childhood. Reintroducing a trigger food at home can occur with FPIAP. For FPIES, reintroduction should occur under medical supervision.

Question 23

Timing of introduction of allergenic solids for infants at high risk: CPS statement
What is the incidence of food allergy in Canada?

Answer 23

2-10%

Question 24

What are the most common food that cause allergies in children in Canada?

Answer 24

cow’s milk, egg, peanut, tree nuts, fish, shellfish, wheat and soy

Question 25

What foods might have a benefit to introduce before 6 months in infants who are high risk?

Answer 25

egg and peanut

Question 26

Which infant is at high risk for Food allergy?

Answer 26

a personal history of atopy, including eczema, or having a first-degree relative with atopy (e.g., eczema, food allergy, allergic rhinitis, or asthma).

Question 27

What is the evidence for early introduction of allergenic solids?

Answer 27

• meta analysis: introducing egg between 4-6 months of age reduced rate of egg allergy (RR = 0.56)
• early peanut introduction between 4-11 months reduced the rate of peanut allergy (RR = 0.29), relative risk reduction of up to 80%
• data on whether to introduce foods at the 4 vs 6 months is limited
• trials ongoing

Question 28

Timing of introduction of allergenic solids for infants at high risk: CPS statement
 Practice Points (7)

Answer 28

• Infants considered to be at high risk for allergic disease have either a personal history of atopy or a first-degree relative with atopy.
• For high-risk infants, and based on developmental readiness, consider introducing common allergenic solids at around 6 months of age, but not before an infant is 4 months of age.
• For infants at no or low risk for food allergy, introducing complementary foods at about 6 months is recommended.
• Breastfeeding should be protected, promoted and supported for up to 2 years and beyond.
• Allergenic foods should be introduced one at a time, to gauge reaction, without unnecessary delay between each new food.
• If an infant appears to be tolerating a common allergenic food, advise parents to offer it a few times a week to maintain tolerance. If an adverse reaction is observed, advise parents to consult with a primary care provider about next steps.
• The texture or size of any complementary food should be age-appropriate to prevent choking. For young infants, smooth peanut butter can be diluted with water or mixed with a previously tolerated puréed fruit or vegetable, or with breast milk [12][21]. For older infants, smooth peanut butter can be spread lightly on a piece of thin toast crust, or a peanut puff product could be offered [12].