Flashcards in Gen Peds CPS Deck (228):
What is the Rome III diagnostic criteria for functional constipation?
Criteria must be fulfilled at least once per week for at least 2 months before diagnosis can be made:2 or more of following in a child of at least 4 yo with insufficient criteria for diagnosis of IBS:1. 2 or few defectations in the toilet per week2. At least one episode of fecal incontinence per week3. History of retentive posturing or excessive volitional stool retention4. History of painful or hard bowel movements5. Presence of a large fecal mass in the rectum6. History of large diameter stools that may obstruct the toilet
When are the two periods of time when the developing child is most prone to functional constipation?
1. Toilet training2. Start of school
What is a "fleet enema"?-recommended for what age group?-what are side effects? (3)
Sodium biphosphate and sodium phosphate-recommended for children > 2 years only-side effects:1. mechanical trauma to rectal wall2. abdo distention or vomiting3. hyperphosphatemia, hypocalcemia
What is the potential side effect of use of mineral oil for constipation?-in which group is mineral oil contraindicated?
Lipid pneumonia if aspirated-contraindicated in infants because of this reason
What is distinguishing feature and benefit of Peg 3350 over other laxatives?
Does not cause electrolyte imbalance (only absorbed in trace amounts from the GI tract)
What is the dose of PEG for disimpaction and maintenance?
Disimpaction: 1.5 g/kg/day div BID x 3 dMaintenance: 0.4-1 g/kg/day (start high and then decrease as necessary)
What is a common reason for lack of response to stool softening therapy with PEG?
Inadequate dosing! Start high and then decrease as necessary
What is the evidence for docusate in pediatric constipation?
No evidence that docusate is effective!
What behavioural modification recommendations can be made to parents for treatment of constipation? (3)
1. Routine scheduled toilet sitting x 3-10 min once or twice a day2. Footstool to help increase intraabdominal pressure3. No punishment for not stooling during toileting time; yes praise and reward for stooling and toilet sitting
What is the recommended fibre intake for all children?-what is the evidence for fibre supplementation in children with constipation?
0.5 g/kg/day to max of 35 g/day-no evidence to support fibre supplementation
What is the next step if a child is unresponsive to adequate medical and behavioural management for constipation?
Consider time-limited trial of a cow's milk free diet = CMPI has been associated with chronic constipation
What is considered "normal" for stooling patterns in infants?
Remember that normal breastfed newborns may stool with each feeding or may not stool at all for 7-10 d
How long should children with constipation be treated for with stool softener therapy?
At least 6 months-should have regular BMs without difficulty before considering a trial of weaning maintenance therapy
What is the definition of fever or unknown origin?
Fever > 14 days with no etiology found after routine tests
What are the limitations of a rectal temperature? (5)
1. Can be slow to change in relation to changing core temp2. Accuracy depends on depth of measurement3. May be inaccurate if there is decreased local blood flow or stool presence4. Risk for rectal perforation (1 in 2 million)o 5. Can spread infection
What is the AAP recommendation on route of temp measurement as screen for fever in neonates? And why?
Ax temp due to risk of rectal perforation with rectal temps (even though risk is super low)-only used as a SCREEN since it has low sensitivity and specificity in detecting fever
What are the limitations of PO temp? (2)
1. Easily influenced by recent ingestion of food or drink and mouth breathing2. Relies on mouth being sealed and tongue being pressed down which is hard for young children or unconscious/uncooperative patients
What is the science behind tympanic thermometers?
Measure thermal radiation emitted from TM and ear canal (infrared radiation emission detectors)-amount of thermal radiation emitted is in proportion to membrane's temperature and blood supply to this is very similar in temp and location to the blood bathing the hypothalamus which is the body's thermoregulatory centre-not affected by crying, otitis media or earwax
According to the CPS statement on temperature measurement, what are the normal temperature ranges for:-rectal-ear-oral-axillary
Rectal: 36.6-38Ear: 35.8 - 38Oral: 35.5 - 37.5Ax 34.7 - 37.3
What are the limitations to tympanic temperature?
1. Influenced by ear canal's structure, meatus size and probe positioning (need an adequate seal to protect from ambient temperatures); especially difficult in young children
What is the recommendation for temporal artery thermometry?
May be a useful tool for screening children at low risk in ER but cannot yet be recommended for home use or hospital use when definitive measurements are needed
Overall, what is the recommendation on use of infrared tympanic thermometers?
Accurate, easy and safe to use and so it is an appropriate way to measure temps especially in older children-children < 2 yo should still have temp taken rectally until a better tympanic temp probe is designed
What is the recommended temperature measurement techniques for the following age groups:-birth to 2 yrs-5 yo
-birth to 2 yr: ax as screen rectal as definitive-2-5 yo: ax or tympanic as screen, rectal as definitive-5 yo: ax, tympanic (or temporal artery if in hospital) as screen, oral as definitive
What is the difference between bedsharing and cosleeping?
-Bedsharing: baby shares same sleeping surface with another person-Co-sleeping: baby is within arm's reach of another person but not on the same sleeping surface
Before 18 months, how fast do children's feet grow?-what about toddlers?
-<18 mo: Half a shoe size q2months-toddlers: half a shoe size q3months
When does longitudinal arch development occur in children?-what is flexible flatfoot?
Longitudinal arch development occurs before the age of 6-all children < 18 mo have flat feet because of a fat pad under the foot-flexible flatfoot: common in children < 6 yo (developmental variation and normal!!!) and does NOT need treatment (ie. corrective shoes, inserts, etc.) if asymptomatic!
What 3 characteristics of children lead to higher incidence of flatfoot?
1. Greater laxity of ligaments2. Obesity3. Shoe wearing in early childhood
What is the treatment and prognosis of intoeing, torsions, knock knees and bowlegs?-when should you consider referral to orthopedic surgeon?
Treatment: NOTHING. Orthotics are NOT beneficial in management of these things! Majority of torsional deformities resolve spontaneously by adulthood and rarely cause functional problems-refer to ortho if persists beyond age ~8 and if it causes functional impairment-corrective shoes or other interventions are NOT necessary if asymptomatic
A mom brings in her 6 month old baby and asks you "Does she need shoes?" What do you answer?
NO! Infants do not need shoes until they are walking-they are necessary for protection and that's pretty much it.
What questions should you ask when helping parents choose internet sites for high-quality health information? (4)
1. Is the host of the health info web site engaged in a conflict of interest?2. Is the info peer reviewed?3. Is the info up to date?4. Is the info presented based on proper evidence?
What type of hearing loss is the most common in neonates?
Sensorineural-genetic cause is found in 50%-of these, 70% have nonsyndromic deafness related to cochlear hair cell dysfunction (errors in production of protein connexin 26)
What is the hearing threshold for normal hearing in decibels?-mild hearing impairment?-moderate?-severe?-profound?
Normal: 0-20 dBMild: 20-40 Moderate: 40-60Severe: 60-80Profound: > 80
What are risk factors for neonatal sensorineural hearing loss? (5)-in what percentage of neonates with hearing loss can a risk factor be identified?
1. Family history of permanent hearing loss2. Craniofacial abnormalities including those involving the inner ear3. Congenital infections (bacterial meningitis, TORCH)4. Physical findings consistent with an underlying syndrome associated with hearing loss5. NICU stay > 2 days OR any of the following regardless of duration of stay:-ecmo-mechanical ventilation-ototoxic drug use-hyperbilirubinemia requiring exchange transfusion***Only about 50% of neonates found to have sensorineural hearing loss had an identifiable risk factor. The other 50% had no risk factors at all; this is why universal screening is so important!
What is the average age of diagnosis of hearing loss in unscreened children?-what about screened children?
24 months when there is an expressive language deficit-mild and moderate hearing losses aren't usually detected until school age-In screened children, average age of diagnosis is 3 months of age with intervention by 6 mo
What are the components of a successful screening test?
1. Test is reliable and accurate2. Test can lead to earlier diagnosis3. Little adverse effects of test4. Earlier detection has available and effective intervention5. Good long term outcome from earlier intervention
What are the two screening tests for hearing loss?-main similarities and differences?
***Both tests should be performed in infants > 24 hrs old and > 34 wks CGA-noninvasive1. Otoacoustic emission (OAE)-identifies conductive and cochlear hearing loss from level of external ear to the level of the outer hair cells in the cochlea-sound stimulus is sent to the auditory system via ear specific probes and then echoes returning from the outer hair cells of the cochlea are measured2. Automated auditory brainstem response (AABR)-identifes conductive, cochlear AND NEURAL hearing loss from the external ear to the level of the brainstem including assessment of 8th nerve function-records brainstem electrical activity in response to sounds presented to the infant via earphones
In a newborn with no risk factors for hearing loss, what is the indicated screening test for hearing loss?-in a child with risk factors for sensorineural hearing loss?-in a child who fails the 1st screening test?
2 step screen for infants with no risk factors: use OAE --> if fails --> move onto AABR-in child with risk factors for sensorineural hearing loss: start with AABR
What are cochlear implants?-what are current recommendations for their use?-what are children with cochlear implants at increased risk for getting?
Electronic devices surgically placed in the cochlea to provide stimulation to the auditory nerve = has been shown to be highly effective in hearing and language development-current recommendations: bilateral implantation for children who quality between 8-12 months ofa ge coupled with speech language therapy-increased risk of meningitis
What is the false positive rate for hearing screening tests?
What is the management of a child with confirmed hearing loss on screening and diagnostic testing?
1. Full hx and pe to rule out associated comorbidities or syndromes2. Consult ENT, ophtho, and genetics-need to confirm vision assessment to maximize sensory input3. CONSIDER neuroimaging studies, renal and cardiac evaluation based on findings
What is ankyloglossia?-what is the association with lactation problems, speech disorders or other oral motor disorders?-is there a way to classify or diagnose ankyloglossia?
Abnormally short lingual frenulum = may result in varying degrees of decreased tongue mobility-inconsistent association with problems!!!-there is no universally accepted definition or criteria for diagnosing ankyloglossia!
What is the recommended management for ankyloglossia?-indication for frenotomy?
Conservative! = no intervention required usually beyond parental education and reassurance-most babies with ankyloglossia don't have significant consequences and most are able to breastfeed successfully-indication for frenotomy: when complete fusion of the tongue is found (complete ankyloglossia)
What are the complications of frenotomy?
1. Bleeding2. Infection3. Injury to Wharton's duct4. Postoperative scarring resulting in worsened limitation of tongue movement
What is the mechanism of maintaining the circadian rhythm of the sleep-wake cycle?
Secretion of melatonin by the pineal gland in response to darkness
What are the two most common type of sleep disorders in the pediatric age group?
1. Delayed sleep phase type-initiation of sleep significantly later than the desired bedtime-sleep latency (time it takes between laying down to sleep and onset of sleep) takes longer than normal 30 minutes2. Behavioural insomnia of childhood-sleep onset association type (caregivers need to do certain things before the child goes or returns to sleep at night)-limit setting type (child stalls or refuses to go to bed or return to bed and the caregiver demonstrates unsuccessful limit-setting behaviours)
What are common medical conditions that can result in insomnia? (3)
1. Sleep apnea2. Anxiety3. Depression
What are components of good sleep hygiene? (8)
1. Consistent routine = stable bedtime and morning wake time2. Age-appropriate number of hours in bed3. Dark and quiet sleep space4. Avoiding hunger and eating prior to bedtime5. Relaxation techniques before bed6. Avoid caffeine, alcohol and nicotine7. Avoid tv, computers, video games8. Encourage reading prior to bedtime
In what age group can melatonin be used for treatment of insomnia?
Greater than 2 years old (no evidence to support use in children < 2 yo)
What is the 1st line treatment for delayed sleep phase type insomnia?-what about sleep-onset association type?-what is the 2nd line treatment?
***For both, SLEEP HYGIENE INTERVENTION IS 1st LINE! If this fails: then consider pharmacological therapy-Delayed sleep phase type: potential for melatonin to advance onset of sleep is high!-typical dose: 2.5-3 mg in children and 5-10 mg in adolescents 30-60 mins prior to desired bedtime-sleep-onset association type: supported by RCT showing improved sleep onset and sleep duration-same dose as above
What special populations might melatonin be effective in? (4)
1. ADHD2. ASD3. Intractable epilepsy4. Neurodevelopmental disabilities
What are the clinical features of plagiocephaly?-what is the expected course of positional plagiocephaly?
1. Unilateral flattening of the occiput2. Ipsilateral anterior shifting of the ear-expected course: incidence starts at 6 wks, increases to max at 4 months, then slowly decreases over 2 years with resolution of most cases
What are the risk factors for positional plagiocephaly? (7)
1. Male sex2. First born3. Limited passive neck rotation at birth (congenital torticollis)4. Supine sleeping position5. Exclusive bottle feeding6. Tummy time < 3 times per day7. Lower activity level with slower achievement of milestones8. Positional preference of sleeping with the head to same side
What condition is on the differential for positional plagiocephaly?-how can you differentiate on exam between the two?
Craniosynostosis = lambdoid suture involvement is the only craniosynostosis that causes occipital flattening and is very infrqeuent-will generally feel ridging of the affected suture with posterior displacement of the ear (as opposed to anterior displacement with PP)
How do you diagnose positional plagiocephaly?
Clinical diagnosis = only get skull xrays if there is clinical suspicion of craniosynostosis or worsening of head shape at an age when PP would be expected to improve
What are the ways to prevent plagiocephaly? (2)
1. Sleep placement: positioning the baby with his/her head to the foot or to the head of the bed on alternating days encouraging the baby to lie on the side of the head that allows them to look into the room2. Tummy time = awake time spent in prone position for at least TID x 10-15 minutes-this also aids in progress of developmental milestones that require prone position
What is the treatment for positional plagiocephaly?-what about helmet therapy?-side effects of helmet therapy?-what is the maximum age to consider helmet therapy?
Overall, for children < 4 months of age with mild-moderate assymmetry: physiotherapy program combining positioning with exercises where needed (congenital torticollis, positional preference or developmental stimulation) is superior to parental counselling for preventive measures without PT support***Helmet therapy: EXPENSIVE with lots of side effects thus is NOT recommended-have to wear 23 hrs/day, associated with contact dermatitis, pressure sores and local skin irritation-can consider in children in severe asymmetry regardless of age-maximum age to try helmet therapy is 8 months****these recommendations are not supported by evidence!
What 3 conditions should be ruled out in children with plagiocephaly?
1. Craniosynostosis2. Congenital torticollis3. Cervical spine abnormalities
What is a macrobiotic diet?
Not necessarily vegetarian but is based largely on grains, legumes and vegetables, may contain some animal products
What is the recommended protein intake for vegetarian children compared with nonvegetarians?-what are major plant food sources of protein?
Due to lower digestability of plant proteins, need to increase protein intake for vegetarian children:-< 2 yo: increase by 35%-2-6 yo: increase by 30%-> 6 yo: increase by 20%***Major plant food sources of protein:-legumes (beans and lentils), cereals, nuts and seeds, nut butters-each has different qualities and essential amino acids thus need a mixture of these to have good nutrition
What is the most common nutritional deficiency in children?
What is the recommended iron intake for vegetarian vs. non vegetarian children?-sources of iron in plant foods?
Vegetarians require 1.8x the iron intake of nonvegetarians because of different bioavailability-sources of iron: iron-fortified cereals, grain products, dried beans and peas, supplementation
Is zinc supplementation recommended for vegetarian children?
No since zinc deficiency is quite rare-just recommend including zinc rich foods such as legumes, nuts, fermented soy products
In vegetarian children, which subgroup is most likely to be calcium deficient?-calcium rich foods?
Strictly vegan children are at highest risk for calcium deficiency-calcium rich foods: bok choy, chinese cabbage, kale, collards, cereals, juices, soy products -strictly vegan children/adolescents require additional supplementation to ensure recommended intakes
Is calcium content of breast milk affected by a vegan diet in the mother?
No it does not :)-however, after weaning of breastfeeding, should ensure baby gets adequate intake of calcium fortified foods such as fortified soy products, cereals, juices, leafy vegetables
What fat/fatty acids are deficient in a vegan diet?-what are the recommendations in making sure they get enough?
Deficiency in long-chain omega-3-fatty acids (DHA and EPA) = found in fish, seafood and eggs-vegans thus don't get this unless they eat sea vegetables or algae-recommendations: need adequate sources of the precursor linolenic acid (flaxseed, canola oils, walnuts and soy products) which are then converted into EPA and DHA-can also get microsupplements of microalgae
What vitamin deficiency is often seen in vegans and can have serious neurological consequences?-recommendations for intake?
1. Vitamin B12: only found in animal products (meat, eggs. etc)-recommendations: need supplementation or fortified foods for all strict vegan infants/children/adolescents-at least 3 servings of food rich in vitamin B12 in daily diet = fortified soy/nut beverages, cereals OR 5-10 mcg per day-keep in mind that vegetarian diets are usually high in folic acid intake and can therefore mask vit B12 deficiency anemia but children will still have neurological deficits from the vit B12 that can go undetected until too late
What are recommendations for vitamin D intake?-children < 1 yo?-children < 2 yo living above northern lattitude of 55 degrees, dark skin, or avoiding sunlight? Timing?-children > 1 yo
-Children < 1 yo: 400 U vit D OD-Children < 2 yo living above northern lattitude of 55 degrees/dark skin/avoiding sunlight: 800 IU Vit D in winter months from October to April-children > 1 yo otherwise: 200 U vit D OD (sunlight exposure x 20-30 minutes three times per week)
What is the recommended maximum fibre intake?-why do we set a max?
0.5 g/kg/d-set a max so that calories aren't diluted and there is no interference with absorption of minerals and essential nutrients
How do the birth weights of infants of vegetarian mothers compare with those of nonvegetarians?-what 2 vitamin deficiencies are of concern for infants of breastfeeding vegan mothers?
They are comparable!-vitamin deficiencies:1. Vit B122. Vit D-require adequate sources of both through fortified foods or supplementation during pregnancy and lactation
What is the recommended intake of vitamin D for all pregnant/lactating mothers during the winter months?
2000 U vit D OD
What is the likelihood that a lacto-ovo-vegetarian diet will meet nutrient needs for a growing child?-what about strict vegan diet?
Lacto-ovo-vegetarian diets are adequate to meet all nutrient needs!-strict vegan diet CAN meet the nutrient needs as long as there is intake of calorie-dense foods to provide for adequate growth so should monitor very closely
What are the specific recommendations for strictly vegan children in terms of: (don't need specific numbers, just increase/decrease/keep same)-protein intake-iron intake-zinc intake for breastfed infants of vegan moms-zinc intake for strict vegans-calcium intake-fatty acid intake-vitamin B12 intake
-protein requirements: need to increase to account for lower digestibility of plant protein-iron needs: need to increase iron fortified foods or supplementation-zinc intake for breastfeeding babies of vegan moms: need fortified foods after 7 months of age-zinc intake for strict vegans: need 50% more daily zinc -calcium intake: need to increase-fatty acid: need to take linolenic acid foods (flaxseed, canola oil, walnuts)-vitamin B12: need to have 5-10 mcg per day
What are the 5 key domains of a child's early development?
1. Physical2. Social3. Emotional4. Language/cognitive5. Communication skills
What is an EDI? :)
Early development instrument: population-based survey that kindergarten teachers fill out across the country to measure child development across the country
What criteria need to be met before a diagnosis of primary nocturnal enuresis can be made? (3)
1. Bladder control has never been attained2. Child must be > 5 yo3. Regular bed-wetting (more than twice per week)***Remember that this is a variation in the development of normal bladder control and may be associated with deep sleep patterns
What percentage of 5 yo children still have bedwetting?-8 yo?-15 yo?
5 yo: 10-15%-8 yo: 6-8%-15 yo: 1-2%
Where is the gene for enuresis?
Should you order a urinalysis in a child with primary nocturnal enuresis with normal history and physical exam?
NO! Low pretest probability of a true positive result on UA with potential of getting a false positive result!-thus only order if history or physical suggests to do so
How does an alarm device work in the management of nocturnal enuresis?-what does success of the alarm depend on?-in what age group is the alarm system most effective?
Teaches the child to respond to a full bladder when asleep -goes off when the child starts to void and teaches the child to wake up to the alarm and then transfer the waking to the sensation of a full bladder-worn on the body and runs on miniature batteries, sensitive to a few drops of urine-success depends on the motivation of the child and parent to be awakened-most effective in 7-8 yo
How long should the alarm device be trialed for nocturnal enuresis? -how long does it take to see an improvement?-when can you stop the alarm system if it is successful?-what is the "overlearning" method?
Need to trial the alarm system for 3-4 months as it may take up to 1-2 months to start seeing an improvement-initially, will see decrease in UO as opposed to totally dry night-can stop when there has been 14 consecutive dry nights-some people recommend "overlearning" which is when you reach 14 consecutive dry nights, then the child drinks extra fluid (2 glasses of water) before bed and do this until the patient has achieved 7 dry nights in a row, then can stop the alarm
What is the actual cure rate of primary nocturnal enuresis using alarm devices based on systematic overviews?
Just under 50% but this is still better than nothing so CPS recommends using it!
What are potential side effects of DDAVP for treatment of nocturnal enuresis?
1. Headache2. Abdo pain**For intranasal prep:1. Congestion2. Epistaxis
You have prescribed DDAVP to a child with nocturnal enuresis. Mom asks you when he should avoid consuming fluids in relation to when he takes the medication. What is your advice?
No fluids for one hour before and 8 hours after taking desmopressin
What are the options for treating primary nocturnal enuresis? (4)
1. Alarm system2. DDAVP (short-term)3. Imipramine4. Behavioural therapy
What is the evidence for use of imipramine in nocturnal enuresis?-dose?
Should only be used as 3rd line (after alarm system and DDAVP) given the possibility of accidental or deliverate overdoseMode of action is unclear but has immediate antienuretic response-recommended dose is 25 mg for children 6-12 yo and 50 mg for > 12 yo-give 1-2 hr before bedtime x 2 wk trial before adjusting dose. Can increase gradually to max of 50 mg-pretty effective, similar to DDAVP but relapse rate is high after stopping, similar to DDAVP
What are possible side effects of imipramine as treatment for primary nocturnal enuresis?
Personality changes, disturbed sleep patterns, headaches, changes in appetite, cardiac arrhythmias, seizures in overdose situations****overall, remember that it's a TCA!!!!
What is the evidence for behavioural therapy (ie. reward systems) for nocturnal enuresis?
They're shitty! Don't do it! How can you convince a child that bedwetting is nothing to be ashamed of if you give them a gold star for not doing it? -decreases self-esteem, increases family conflict and emotional problems
A mom presents with her 7 yo son who has primary nocturnal enuresis. She is very distressed about this and constantly brings up the fact that all the other kids his age have learnt how to not wet the bed. What is your advice?
1. Assure mom that this is a normal variation of development and that 6-8% of children his age still have primary nocturnal enuresis.2. Assure child's access to the toilet3. Avoid caffeine-containing foods and excessive fluids before bedtime4. Have the child empty the bladder at bedtime5. Preserve the child's self esteem6. Include the child in morning cleanup in a nonpunitive manner7. If this is not distressing for the child, you don't have to treat!! If it is distressing, then treat.****Your primary goal should be to minimize the emotional impact on the child
What is the most effective therapy for primary nocturnal enuresis?
Conditioning alarm system but only successful in long term in <50% of children
What are individuals with ADHD at increased risk of in their future?
1. Reduced quality of life2. Increased risk for injuries3. Behaviour problems4. Difficulty in school (academically and socially)
True or false: treatment with stimulant medication in ADHD is associated with a reduced risk of poor social outcomes, such as developing drug or alcohol addiction.
What is the difference between the terms "efficacy" and "effectiveness"?
Efficacy: how well a treatment works under tightly controlled study conditions-effectiveness: how well a treatment works in a natural setting in real-world conditions
Why is there very little difference in efficacy between XR and IR preps of stimulant medications but significant differences in effectiveness?
Efficacy during school hours is similar for XR and IR preps of stimulant medication but there is a difference in effectiveness (ie. how well a treatment works in real world setting) because there may be decreased compliance with immediate release meds where you have to take it multiple times a day-plus, there is a stigma associated with taking these medications at school as well as the disruption to the school routine-multiple studies showing that children treated with XR meds were less likely to switch, discontinue or have gaps in their treatment compared to children prescribed IR meds
True or false: Children with ADHD prescribed XR stimulant medication were more likely to visit an ED and more likely to be hospitalized than those prescribed IR meds.
FALSE!!! These children are LESS likely to have these things happen
What should be first line treatment for ADHD?
Extended release stimulant medication (ie. methylphenidate)-improves adherence-reduces stigma of having to take the medication at school-reduces problems schools have in storing and administering controlled drugs-pharmacokinetic profiles
What is the definition of "diversion" of medication?-what about "misuse"?
Diversion: transfer of medication from one patient from whom it is prescribed to another patient for whom it is not prescribed-"Misuse" use of nonprescribed medications or the use of prescribed medications at doses, times or in combinations other than for which they were prescribed
Which type of stimulant for ADHD treatment is more likely to be misused by recreational drug users?
Immediate release methylphenidate (as compared to XR MPH)
Why is the XR stimulant less abused by drug users?
The coating mechanism of XR preps make the active stimulant more difficult to extract and less likely to produce euphoria thus much less likely to be diverted or misused than immediate release preps
Fill in the blank: most children in Western countries achieve bladder and bowel control between ____ and ___ months of age.-what is the average time from the initiation of toilet learning to the attainment of independent toileting?
24-48 months of age-avg time from initiation of toilet learning to attainment of independent toileting: 3-6 months
At which age should toilet learning begin?
There is no specific age at which this should begin!-based on child's readiness
What two physiological processes are necessary for bowel and bladder control and at what age are they achieved in a child?
1. Reflex sphincter control2. Myelination of extrapyramidal tracts-usually achieve this by 18 months of age
What are signs of a child's toilet learning readiness? (7)
1. Able to walk to the potty chair 2. Stable while sitting on the potty3. Able to remain dry for several hours4. Receptive language skills allow the child to follow simple one- and two-step commands5. Expressive language skills permit the child to communicate the need to use the potty with words or reproducible gestures6. Desire to please based on positive relationship with caregivers7. Desire for independence and control of bladder and bowel function
When should anticipatory guidance about toilet learning be provided to parents?
At child's first year visit-need to emphasize that the age for toilet learning is flexible and that the family needs to be ready to dedicate a lot of time to the process-should NOT be initiated at a stressful time in the child's life (ie. after a move or the birth of an ew sibling)
What are ways that a parent can facilitate a child's toilet learning? (7)
1. Decide on the vocabulary to use2. Ensure the potty chair and position are easily accessible and allow the child to watch his or her parents use the toilet3. If a regular toilet is used, use a toilet seat adapter and a foot stool4. Encourage the child to tell a parent when they need to voice. Give praise upon success, even if the child tells the parent after the fact. Learn the child's behavioural cues when he or she is about to void.5. Encourage the child with praise. Do not expect immediate results, expect accidents. Avoid punishment or negative reinforcement.6. Ensure cooperation of all caregivers to provide a consistent approach7. After repeated successes for one week or more, suggest the use of cotton underwear or training pants. Make this a special moment. Children who experience a series of accidents soon after trying cotton underpants or training pants should be allowed to return to diapers without shame or punishment.***do not use material rewards
What is the process of toilet learning you should recommend to parents?
1. First, encourage the child to sit fully dressed on the potty.2. Next, encourage the child to sit on the potty after a wet or soiled diaper has been removed and place the soiled diaper in the potty to demonstrate its function3. At a later date, lead the child to the potty several times a day and encourage them to sit on it for a few minutes without wearing a diaper.4. Encourage the child to develop a routine of sitting on the potty at specific times during the day (ie. after waking in the morning, after meals, before naps and bedtime)
A mother brings her toddler to you and is concerned that her toddler is throwing tantrums every time she tries to get him to use the potty. What do you advise?-when should a referral to a general pediatrician or developmental pediatrician be required?
If the child is expressing toileting refusal, this means the child is NOT ready!-take a 1-3 mo break from training to allow trust and cooperation to be reestablished between parent and child.-If repeated attempts are unsuccessful or if the child is older than 4 years, referral is appropriate to explore aspects of parent-child relationship and to rule out physical/neurodevelopmental abnormalities
What is the most effective test for amblyopia?
Determinatin of visual acuity by noninvasive testing
True or false: Uncorrected amblyopia is a significant risk factor for total blindness, in the case of injury or disease in the better functioning eye
When should visual assessments occur (as per recommendations from AAP and American Academy of Ophthalmology)?
At birth and at all routine health supervisory visits-visual acuity specifically should be assessed at the preschool stage as well as when there is a visual complaint
What is the definition of:-amblyopia-refractive error-strabismus-pseudostrabismus-cataract
-Amblyopia: reduced vision in the absence of ocular disease, occurs when the brain does not receive a clear image (ie input) from the retina -refractive error: inability of the eye to focus the image which is usually correctable with a lens-strabismus: misalignment of the eye in any direction (constant or intermittent)-pseudostrabismus: occurs when broad nasal bridge covers the nasal sclera unequally-cataract: opacification of the crystalline lens
When should babies start doing the following:-face follow-visual following-visual acuity measurable
-face following: from birth to 1 mo-visual following: 3 mo-visual acuity measurable: 42 months 3.5 years old
What is the red reflex?-cornea light reflection?
Red reflex: reflection of orange red light from the RETINA through the pupil-cornea light reflection: small focal bright white reflection of light on the cornea which should be symmetrically positioned close to the centre of each cornea
What is the cover-uncover test?
Cover one eye at a time while the child fixates on a target-uncovered eye should NOT move-covered eye should also not reposition when exposed-if any movement occurs during this test, providing vision is good and fixation is well maintained, need a referral to ophtho
When testing for vision with an eye chart, how far away should the child be from the chart?
3 m, one eye at a time (suspected better eye first)
What vision screening should occur for a newborn-3 mo of age? (2)-what about in a high risk newborn?
1. Complete exam of skin and external eye structures: conjunctiva, cornea, iris and pupils2. Inspection of red reflex to rule out lenticular opacities or major posterior eye disease-failure of visualization or abnormalities of the red reflex = urgent referral to ophthalmologist***High risk newborns (retinopathy of prematurity, family history of hereditary ocular diseases such as congenital glaucoma) should be examined by an ophthalmologist
What vision screening should be performed for a child 6-12 mo of age? (4)
1. Complete examination of skin and external eye structures2. Red reflex3. Cornea light reflex and cover-uncover test to check for ocular alignment (rule out strabismus)4. Fixation and following a target should be observed
What vision screening should be performed for a child 3-5 years of age?
1. Complete exam of skin and eye structures2. Red Reflex3. Fixation and following4. Cornea light reflex and cover-uncover test to rule out strabismus5. Visual acuity testing with age-appropriate tool
True or false: routine comprehensive professional eye exams of healthy children with no risk factors have a proven benefit in decreasing visual issues
NO! There is NO proven benefit of this!
What is the risk of acquiring a respiratory infection while on a flight?-what percentage of bacteria and viruses is removed by high-efficiency particulate filters in pressurized cabins?-what are other factors that are protective against airborne spread of illnesses on a flight?
Small risk: since transmission of resp infections is usually by direct contact, the risk is no different than to travellers on a bus or a train-99.9% of bacteria and viruses from the cabin air is removed by filters-other factors: air exchange is higher on a flight (15-20x/hr, compared to 5-12 in homes/offices), air flow occurs from top to bottom and not front to back
What is the percentage of oxygen in a typical cabin on a flight?
What can help you determine if a child with cystic fibrosis will require supplemental oxygen during a flight?
What is the hypoxia altitude simulation test?-what is a fail?
aka HAST = used for simulating airplane cabin environment by creating a mixture of 85% nitrogen and 15% oxygen-PaO2 on an art gas < 55 mmHg is a fail and suggests need for supplemental O2 on an aircraft-unknown how comparable these values are for children though
What cardiovascular conditions are CONTRAINDICATIONS to commercial airline filght? (3)
1. Uncontrolled hypertension2. Uncontrolled SVT3. Eisenmenger's syndrome
Which patients are recommended for evaluation of potential hypoxemia before air travel? (7)
1. Known or suspected hypoxemia2. Known or suspected hypercapnea3. COPD or restrictive lung disease4. Patients already using supplemental oxygen5. Hx of previous difficulty during air travel6. Recent exacerbation of CLD7. Chronic conditions that may be exacerbated by hypoxemia
Which children are at high risk of developing DVT on flights?
1. Thrombophilia2. Previous thromboembolism3. Malignancy4. Major surgery within 6 wks-may need prophylaxis with low molecular weight heparin or ASA AFTER consultation with a thrombosis specialist
What are the recomendations for flying in people with sickle cell anemia?
Due to reduced oxygen pressure, risk for crisis episode during flight-medical oxygen should be available for these children during flight if altitudes are > 7600 ft (ESPECIALLY if they have splenomegaly and higher blood viscosity)
What is barotrauma in flights?-how can parents help their children with getting rid of this?
Barotrauma = consequence of the inability to equlibrate the pressure differential (especially during landing or takeoff)-most people including older children can equilibrate the pressure by yawning, swallowing, chewing or valsalva -infants and young children: parents should encourage them to drink or chew since they often can't do these things themselves and may just try
What is barotitis media?-associated factors? (4)-prevention? (4)
Inflammatory change (acute or chronic) of the middle ear secondary to barotrauma = sudden ear pain, impaired hearing, vertigo and rupture of the tympanic membrane-associated factors: 1. nasal congestion2. previous ear pain3. recurrent otitis media4. adenoidal hypertrophyPrevention:1. Teach kids how to do valsalva in flight2. Tympanostomy tubes3. Treat nasal congestion or sinus infection before a flight4. Topical nasal congestant can help if used at least 30 minutes before takeoff and landing
You have diagnosed a child in your clinic for an AOM. They have an upcoming flight in a month. Mom asks you, when is the sooner a child can fly after an AOM?
May fly safely 2 weeks from diagnosis but should be re-evaluated before air travel-if the diagnosis of AOM is made within 48 hrs of a flight that can't be postponed, child should be provided with appropriate analgesia-this is all based on expert opinion only -can consider using a topical nasal decongestant before takeoff and landing
True or false: peanut dust can be distributed through ventilation system on an airplane and can cause an allergic reaction.
True..but at least 25 passengers would have to be eating peanuts at the same time-most airlines have removed peanuts now as a snack-counsel all allergic children to have epi pen and antihistamines on the aircraft
A child in your practice with type 1 diabetes will be taking a long flight crossing time zones. Mom asks you about adjusting insulin. What do you say?
If travelling east and the day is shortened by more than 2 hrs, need to decrease the amount of intermediate or long acting insulin-if flying west, and the day is lengthened by more than 2 hours, more units of insulin is needed
What are 3 alternatives to antiemetic drugs for air sickness?
1. Directing cool ventilated air to the face2. Gazing at the horizon3. Selecting a seat away from the rear of the cabin
What are the concerns with using medications such as gravol, chloral hydrate for behavioural control of children onboard an aircraft?-what are alternatives to help parents prepare their child for travelling?
1. Oversedation = combined with hypoxia in flight could be dangerous2. paradoxical irritability-to prep child for travelling, parents could show their children books about plane travel, explain different steps needed and take practice trips to the airport. Relaxation techniques can work too!
True or false: melatonin is recommended for children with jet lag as an effective treatment.
FALSE! Recent meta analysis did not show any benefit for its use in children with secondary sleep disorders or jet lag
A mother asks you what she should do with her son's feeding tube before their flight. What do you recommend?
Due to changes in cabin pressure, can get gas expansion in feeding tubes or urinary catheters which then introduce air into a hollow visuc THUS need to cap these all off during takeoff and landing
What are the recommendations for orthopedic casts during a flight?
If fracture was recent (48 hrs ago), plaster or fibre glass cast should be bivalved to prevent pain and circulatory issues-should also provide children with analgesia and instructions for proper limb elevation
What are the recomendations on using a car seat on a flight?
AAP recommends mandatory federal requirement for restraint use for children on an aircraft BUT this is a recommendation so far only-CPS does say in recommendations that holding an infant or child on a caregiver's lap is improper restraint and has the potential to contribute to injury on an aircraft, particularly in the event of turbulence-some kids can still fly in their parents' laps-studies have shown that if child safety seats are used, mortality can be decreased
What country are most children currently adopted internationally from?
True or false: the North American Council on adoptable children says that a family of the same racial or ethnic background is both preferable and better able to provide children with the skills and strengths to combate racism.
TRUE!-they also believe that transracial adoption is preferable to long term foster care however and should be considered when a suitable family of the same race cannot be found
When do children become aware of racial differences?-other milestones in terms of racial identify?-what about for children who are adopted by parents of a different race?
3 years old = become able to distinguish between skin color and hair texture-at 3-7 yo: become aware of labels and emotional responses associated with various racial groups and begin to see what it means to be different from another race-7 yo: begin to understand racial permanence-adolescence: exploration of racial and ethnic identity-adopted children: when they become teens, physical differences between themselves and their parents become more apparent and may create feelings of isolation
Which of the following is false according to one study mentioned in CPS statement :P:a. Forming a positive and unambigous identity was more problematic for black children in white families than for children adopted by same-race familiesb. Black children with white parents tended to devalue their black heritage and renounce similarities or allegiances to black peoplec. Same-race and transracial adoptees had significantly different self-esteem scoresd. Families whose children attended racially integrated schools or lived in integrated communities tended to have children who felt more positively about themselves as black people.-what do other studies say about this?
C! Self-esteem scores are SIMILAR!-other studies hav found that most develppmental problems could be traced to preadoption experiences and that most adoptees adapted reasonably-multiple studies have shown few recorded differences in behavioural problems, quality of life and self-esteem between intercountry adoptees and other adolescents and young adults-build just as good relationships with adoptive parents and siblings
What factors may negatively affect a child's outcome if they are adopted into a transracial family? (4)
1. Older age at time of adoption2. History of abuse or neglect3. Institutionalization4. Health problems
A white couple is planning to adopt a non-white child. What recommendations can you make as their pediatrician to promote the child's healthy development?
Tell parents to:1. Recognize that children's knowledge and understanding of their cultural history are important2. Help children develop pride in their racial identity and coping skills to deal with racism3. Role play ways to deal with racism4. Encourage opportunities for the child to learn about and participate in their birth culture (ie. celebrate ethnic festivals, take vacations to their birth place, be friends with people from the same ethnic background as the child)5. Recognize the child's racial identity rather than denying it or acting as if race doesn't matter6. Help same-race siblings develop ways to cope and confront teasing by peers about their transracial sibling
Explain the "like cures like" law in homeopathy.
Law of similars or "like cures like" = a substance can "cure" in a patient the same set of symptoms it can induce in a healthy individual-choose plants/minerals/etc based on the patient's SYMPTOMS and not the underlying condition (ie. if asthma in a patient causes predominantly MUCUS, then would choose one thing vs. if asthma in a patient causes predominantly COUGH, then would choose another thing)-then you dilute the shit out of it...the higher the dilution, the more potent the medicine-this is thought to be because during dilutions, a "memory" of the original substance is imparted to the water molecule....wtf.
True or false: there are no published trials analyzing the effects of over the counter pediatric homeopathic preparations.
TRUE!!!!-this is because there is tremendous variability in the methods of practising homeopathy from one practitioner to another so it's difficult to conduct, analyze, compare and reproduce
Are there safety concerns with properly prepared homeopathic products?
Not really - few side effects because they are so diluted that it's mostly water.
What are the major areas of concern with homeopathic care for children?
1. Homeopaths often do not refer children for conventional care OR parents may delay seeking medical attention while awaiting results from homeopathy2. Negative attitude towards immunizations disseminated by some homeopathic practitioners
What are the factors that need to be in place before effective discpline can occur?
1. Needs to be given by an adult with an affective bond to the child2. Consistent, close to the behaviour needing change3. Perceived as "fair" by the child4. Developmentally and temperamentally appropriate5. Self-enhancing ultimately leading to self-discipline
What questions should you ask parents in a psychosocial interview to inquire about discipline? (4)
1. What are your attitudes towards discipline?2. Who disciplines and what is the type of discipline used?3. Discussion of difficulties or problems with discipline4. What are parental stressors?
What are 3 main areas of daily routine life that tend to be problematic in a child's life, resulting in parents wishing to discipline?
1. Feeding2. Toilet training3. Beedtime struggles
What is the foundation of effective discipline?
RESPECT!-child should be able to respect the parent's authority and rights of others-inconsistency in applying discipline will not help a child respect their parents and same goes for harsh discipline-thus need to apply discipline with mutual respect in a firm, fair, reasonable and consistent way
True or false: time-outs, spanking or consequences is the best way to discipline an infant.
Uh, of COURSE false!-discipline with infants should never involve these things!
A mother with a 1 year old toddler comes in for disciplinary advice. What principles do you recommend?
1. In early toddler stage, it is normal and necessary for toddlers to experiment with the physical world and to exercise their own will versus that of others2. THUS, parental tolerance is recommended3. Discipline should focus on ensuring the toddler's safety, limiting aggression, preventing destructive behaviour.4. If child is playing with a dangerous object, remove the child or the object with a firm "NO" or a very brief verbal explanation "NO - HOT". Redirect to an alternative activity and remain with the child to supervise and make sure behaviour does not recur5. Early toddlers are very susceptible to fears of abandonment and should not be kept in time out away from the parent. Can separate for a few seconds or minutes within the same room.
What are the principles of discipline for a late toddler (2-3 yo)?-example: toddler throws a tantrum in the store. What do you recommend?
Tend to have temper tantrums when realizing limitations to independence and self-assertion; emphasize to parents that this is not anger or willful defiance1. Tell caregiver to have empathy in regards to this2. Set limits and routines3. Knowing the child's pattern of reactions means you can prevent the situations from occurring that trigger frustrations4. Once the temper tantrum stops, then the parent can give simple verbal explanation and reassurance, then direct child to another activity away from the scene of the tantrum-tantrum in store: remove the child from the place of misbehaviour. Hold the child gently until the toddler gains control, then give a short verbal instruction or reassurance followed by supervision
What are disciplinary strategies for preschoolers and kindergarten age children? (3-5 yo)
1. Time out can be used if child loses control2. Redirection or small consequences related to and immediately following the misbehaviour is also useful3. Approval and praise are the most powerful motivators for good behaviuor4. Lectures do NOT work well!!!
What are some ways that parents can use rules and limits to promote effective discipline? Giant list....
1. Reinforce desirable behaviour and praise positive behaviour2. Avoid nagging and making threats without consequences3. Apply rules consistently4. Ignore unimportant and irrelevant behaviour (eg. swinging legs while sitting)5. Set reasonable and consistent limits with realistic consequences (ie. don't ground for a month)6. Prioritize rules: give top priority to safety, then to correcting behaviour that harms people and property, then to behaviour like whining/temper tantrums/interrupting, etc.8. Know and accept age appropriate behaviour (ie. accidentally spilling a glass of water is normal behaviour and shouldn't be punished!)
What are useful tips for applying consequences in discipline?
1. Apply consequences asap2. Do not enter into arguments with the child during the correction process3. Make consequences brief (ie. time out should be one minute per year of the child's age to a max of 5 minutes)4. Parents should mean what they say and say it without shouting at the child5. Follow consequences with love and trust and ensure the child knows the correction is directed against the behaviour and not the person. MODEL FORGIVENESS AND AVOID BRINGING UP PAST MISTAKES
Why is time-out so effective as a disciplinary technique for children 2-school age?-tips on how to give effective time-out? (ie. when should it be introduced? Duration, etc.)
Prevents the child from receiving attention that may inadvertently reinforce inappropriate behaviour-tips: 1. Must be used unemotionally and consistently every time the child misbehaves2. Introduce time out by 24 months3. Pick the right place (ie. time-out place should not have built in rewards)3. Time out: 1 minute per year of the child's age, to max of 5 mins4. Prepare the child by briefly helping them connect the behaviour with the time-out: "no hitting"5. Parents should avoid using time out for teaching or preaching. When the child is in time out, he should be ignored6. Parent is the time keeper7. After time out is over, it is over. Create a fresh start by offering a new activity. Do not discuss the unwanted behaviour, just move on. ****do NOT instill shame, guilt, loss of trust or sense of abandonment!
True or false: Discipline is about changing behaviour, not about punishing children. :)
True or false: most children who have not mastered reading by the end of grade 3 will never catch up.
What are the direct effects of low literacy on health (4)?
1. Incorrect use of medications2. Failure to comply with medical directions3. Errors in administration of infant formula4. Safety risks in community, workplace and home
What are the indirect associations between low literacy and health? (6)
1. Higher rates of poverty2. Higher than average rates of occupational injuries3. Higher degrees of stress4. Unhealthy lifestyle practices: smoking, poor nutrition, infrequent physical activity, lack of seatbelt use or wearing of bike helmets, decreased breastfeeding5. Limited access to and understanding of health info6. Inappropriate use of medical services
Out of all parent-child activities, what is the best way to expose the child to language?
Reading!!! Especially when dialogic reading occurs (when parent uses questions to encourage the child to participate beyond being a passive listener)-reading aloud by parents is the SINGLE MOST IMPORTANT activity for building the knowledge required for eventual success in reading
What are the 3 components of the reach out and read model for clinic-based literacy intervention?
1. Anticipatory guidance regarding literacy development by pediatricians at each well child visit2. The provision of a new, developmentally appropriate book at each visit; if possible, provide a library card application and prescription to read a fun book3. Literacy rich waiting rooms including volunteers who demonstrate book sharing-parents receiving this intervention are 4-10x more likely to read frequently to their children with greatest effect among the poorest families (intervention is most beneficial to those who need it the most)
What are some questions to ask about family literacy at health care visits?
1. Frequency of book sharing2. Access to children's books in the home3. Use of books in children's routines4. Caregivers' literacy levels
What are ways physicians can promote literacy for families?
1. Address low literacy as a child health problem beginning at birth and continuing through adulthood2. Inquire about family literacy at each health care visit3. Include literacy promotion in routine clinical practice: provide developmentally appropriate books, etc.4. Encourage parents and child care providers to look at books daily with their children beginning at birth! If the caregivers have a low literacy level, singing, storytelling and talking about pictures in their native language should be encouraged5. Encourage families to get a library card and visit the library regularly6. Ensure that clinic waiting areas encourage literacy
What are examination room techniques for promoting literacy?
1. Bring book early in the exam and do not save for end of visit2. Hand book to child right away, watch how child handles it, listen for language, and watch parent-child interaction3. Listen for words elicited by the books and pictures4. Compliment the parent on the child's interest in the book, the child's ability to handle the book and turn pages5. Inquire about favourite books and use of books in child's routine6. Help parents see that their child's interest in books is related to language development and intelligence7. Model reading aloud for parents and discuss what you ar doing and why
Do pacifiers lead to early weaning off breastfeeding?
Conflicting data: multiple studies however, have shown that maybe pacifier use is a marker of breastfeeding difficulties or reduced motivation to breastfeed rather than a true cause of early weaning-due to many possible confounders and biases, exact cause and effect nature of pacifier use and early weaning is unknown
Do pacifiers increase risk of otitis media?
Yes...it is a risk factor in the development of otitis media but is only ONE of the factors!-increases risk more with prolonged and more frequent use-it is NOT because pacifiers carry AOM organisms (usually only carry yeast)
Do pacifiers increase risk of dental caries?-when should pacifier use stop?
Yes but only if prolonged use (> 5 yo) or inappropriate use (sweetened pacifier)-the longer the use, the stronger the association with openbite and crossbite-pacifier use should stop before permanent teeth erupt (ie. before 12 months of age)
Do pacifiers prevent SIDS?
Currently, there is no recommendation to use pacifiers to reduce the risk of SIDS based on the available evidence BUT there are a few studies that show there may be an association between pacifier use and reduced risk of SIDS-so overall, evidence is sufficient that pediatricians should be cautious before advising against their use
What are the benefits of pacifier use in preterm infants?
Leads to non-nutritive sucking which is associated with:1. More rapid weight gain2. Lower incidence of nec3. Earlier hospital discharge4. Provides comfort5. Organizes oromotor development
True or false: infants and children with chronic or recurrent otitis media should be restricted in their use of a pacifier.
What are 3 barriers to health care for children in foster care?
1. Difficulty accessing services2. Lack of consistent care or follow up due to temporary placements3. Lack of or inadequate medical records
What are the risk factors for a child to need foster care? (9)
Parent factors:1. Drug and alcohol addiction2. Prenatal alcohol or drug use3. Violence4. Cognitive or functional impairment of parents with little resources or support5. Family history of mental health disorders6. Previous involvement with child welfare systemChild factors:7. Severe behaviours or complex medical problemsEnvironment factors:8. Extreme poverty9. Homelessness
What is Jordan's principle?
Child-first principle used in Canada to resolve jurisdictional disputes within and between governments regarding payment for services provided to First Nations children-when a jurisdictional dispute arises between provincial/territorial or federal governments OR between two departments within the same government regarding payment for services of a Status Indian child, the government or ministry/department of first contact must pay for the services without delay and then figure out the dispute later-this is based on the non-discrimination provisions of the UN convention on the rights of the child that doesn't allow differential treatment on the basis of race or ethnic origin
Who is the legal guardian while a child is in foster care?
Usually the child protection worker-of course foster and birth parents or group home may also be part of the contact but the child protection worker is the person who will provide consent
What are the minimum requirements recommended for the health supervision of children in foster care? (3)
1. Initial medical visit within 24 hrs of placement2. Comprehensive follow up visit within 30 days of placment3. Routine screening for development, mental health, dental health, STIs
What are common health care issues seen in children in foster care?
1. Poor hygiene2. Underimmunization3. Dental neglect4. Behavioural issues: ADHD, negative peer involvement, aggression, emotional issues5. Learning disability, developmental delay6. Substance-abuse related birth defect7. Chronic medical conditions such as asthma, derm issues, ophtho issues8. Contraception issues for adolescents***This is in addition to medical issues that children may already have that increases their risk of being in foster care (ie. hx of developmental delay or physical disability increasing chance of being abused)
During an initial assessment of a child in foster care, what screening tests should be considered?
Routine ordering of tests is not recommended BUT consider as needed: CBC, ferritin, lead level, HIV, Hep B and C titres, beta-HCG, cervical or urethral swabs for STIs
True or false: children who are either currently or previously in foster care should be monitored more frequently than the general peds population.
What is the Greig Health Record?-how often are preventive health care visits recommended?
For children 6-17 years old: template for periodic health visits-preventive health care visits are recommended q1-2 yrs
True or false: there is evidence to support the exclusion of counselling for breast and testicular self exams as well as screening maneuvers for scoliosis.
TRUE-screening for scoliosis is still recommended by the american academy of ortho surgeons and AAP but there is little evidence to support this position!-there is evidence that asymptomatic individuals have a mild clinical course and interventions will not improve back pain or quality of life
What 5 physical exam findings are ALWAYS recommended in every periodic health supervision visit? (ie. on the Greig Health Record)
1. Height2. Weight3. BMI4. Blood pressure5. Visual acuity
What is the adult BMI cut off for overweight? What about for obese?-at what age should you start using BMI instead of weight for age?-what are the cut-offs are underweight, overweight and obese in children?
BMI cut off for overweight: >25 kg/m2-obese: > 30 kg/m2-for children > 10 years old, need to use BMI and not weight for plotting-in children: we don't have a BMI number for cutoff, instead use growth percentiles after you plot BMI-underweight: 97th percentile
Is chlamydia screening in sexually active adolescent females recommended?-what about gonorrhea?
CDC recommends screening adolescent females annually-gonorrhea: only screen in communities with a high prevalence of gonorrhea
What is the leading cause of absenteeism from school and work for adolescent females?
What is the main nutritional problem in adolescent girls worldwide?
Anemia-especially in women with heavy menses
True or false: the WHO recommends supplements (ie. vitamins) for all children.
FALSE! WHO recommends supplements for specific nutrient deficiencies but suggests that using food sources is important for making corrections for dietary deficiencies!
What is the rate of CAM use in healthy children?-what about children with chronic, recurrent or intractable conditions?
-healthy children: 20-40%-chronic, recurrent or intractable conditions: >50%
What is the upper limit recommended for occupational noise exposure?-rock concerts and personal music players can reach an intensity of what?
-Recommended for occupational noise exposure: 85 dB-rock concerts/music players: 110-120 dB
How much sleep do adolescents require?
9-9.5 hrs of sleep per night
At what age should children be using booster seats?
Good evidence for use of booster seats for children ages 5-7-in Canada, there is a lot of variation in booster seat legislation though
What is the MINIMUM age of operation of ATVs and snowmobiles recommended by CPS and AAP?
16 years old-children should also not ride as passengers due to risk of serious head/brain/pelvic/spinal cord injuries
What are the two most important preventive strategies for drowning/near drowning?-when can swimming skills be learned most efficiently?
1. Active supervision2. Pool fencing-swimming skills learned most efficiently at 5 yo
A workweek of ____ hours or more is associated with emotional distress in adolescents. Fill in the blank.
What is the only routine lab investigation recommended to be completed during a periodic health visit?-when should lipid and plasma glucose screening occur?
Rubella titre for adolescent females-other tests are based on index of suspicion on hx/pe-lipid and plasma glucose screening: should be performed on overweight or obese children over the age of 10
What is the most sensitive and specific measurement for iron deficiency?
Ferritin!!!! (NOT hemoglobin)
What is the most common form of therapy provided by chiropractors?-evidence of effectiveness?
Spinal manipulation-systematic review of RCTs showed insufficient evidence to prove that spinal manipulation is useful for treating acute or chronic low back pain-no studies have been published on chiropractic treatment of back pain in peds population
What is the most worrisome complication resulting from chiropractic cervical manipulation?
Vertebrobasilar accidents (stroke) from cervical artery dissection leading to ischemia
What are two concerning complications from chiropractic use in children?
1. Complications such as vertebrobasilar accidents from neck manipulation2. OF GREATER CONCERN THOUGH: chiropractors may attempt to treat acute pediatric conditions, leading to a delay in appropriate medical therapy or the refusal of families to seek conventional treatment
What is the position of the American Chiropractic association on vaccination? What about the Canadian Chiropractic association?
Americans: think vaccinations have risks and therefore supports conscience clause in compulsory vaccination laws-Canadians: accepts vaccination as a cost effective and clinically efficient public health preventive procedure
What are the recommended ratios for child to caregiver ratios based on the following age groups:-children < 24 mo-24-30 mo-31-36 mo->36 mo
Children < 24 mo: 3:1-24-30 mo: 4:1-31-36 mo: 5:1->36 mo: 7:1-these ratios are thought to promote more child to caregiver interactions to facilitate development
What does a cochrane collaboration review conclude about the behaviour and developmental outcomes of children in child care centers?
Found a positive effect on IQ, school achievement, behaviour, decreased criminal behaviour, lowered teenage pregnancy rate-interpret these results with caution since the RCTs included may have had confounding factors such as parental training and low ratios between children:caregivers that are not realistic in real life
True or false: the quality of daycare is a better predictor of behaviour outcome than age of starting daycare or percentage of time spent in daycare
What are the recommendations on what qualifications child care staff should have in order to work at a child care centre?
Should have some training in early childhood education in order to improve child care quality
True or false: children who spend more time in nonparental child care have a reduced risk of unintentional injury.
True! This might be because these places provide more supervision and/or safer play equipment
What are the two categories of child care injuries? (ex of each)
1. Child factors: falls, collisions, pinching, biting, pushing, hitting, etc. (way way more common cause of childcare injuries)2. Environmental factors: wet floors, sharp objects, objects on floor, equipment or furniture (less common cause)**this suggests that while safe equipment and design are helpful, appropriate supervision of child is more critical
True or false: An injury reporting procedure and form should be available in all child care centres and all staff should be trained in basic first aid and CPR
Which immunizations should child caregivers have?
1. Annual flu vaccine2. Ensure tetatnus, diphtheria and pertussis are current
Daycare exclusion: when should the following children be allowed to return to daycare?-respiratory infection-GAS pharyngitis-Bacterial conjunctivitis-diarrhea
Respiratory infection: when well enough to participate in all activities-GAS pharyngitis and bacterial conjuncitivits: after 24 hrs of antibiotic therapy-diarrhea: once their stool can be contained in a diaper, controlled in a toilet trained child and if there are NO signs of bacterial enteritis (fever/blood/mucus in stool)
What guideline should be used as a point of safety reference for child care centers?
Well Beings book!!! = offers guidelines on how to conduct safety audits on a weekly, monthly, seasonal and yearly basis
What should occur at an enhanced 18 month primary care visit?
1. A physician-prompt health supervision guide with evidence-informed suggestions (such as the Rourke Baby record)2. Developmental screening tool (Nipissing District Developmental screen, Ages and Stages Questionnaire are good examples) to stimulate discussion with parents about their child's development3. Screen for parental morbidities (mental health problems, abuse, substance misuse, physical illness)4. Promotion of early literacy activities for every family5. Provide families with info about community based early childhood development resources (ie. parenting programs, libraries, community centres, etc.)
What are the 4 ways that Canadians pay for dental care?
1. Third-party insurance (employment-related dental coverage2. Private dental insurance3. Out of pocket4. Government subsidized programs (eg. First nations non-insured health benefits or veterans' affairs)
What dental services do most publicly delivered pediatric dental programs in Canada include?
Only emergency or basic treatment for recipients of financial assistance or for children in low-income families. The comprehensiveness of these programs differs significantly among provinces and terriroties in terms of types of services covered, age restrictions and limits on the frequency of dental visits
What are the recommendations for flouride varnish for decreasing dental caries?-What about fluoride mouth rinse?
Biannual varnish application should be completed for high risk populations such as First Nations children-fluoride mouth rinses should be used regularly as they have been shown to reduce tooth decay regardless of other fluoride sources**Overall: the CPS and Canadian Dental Association support fluoride supplementation through water supply and topical application/mouth rinses
What is the most common causal organism for dental caries?-modes of transmission?-window of infectivity?
Streptococcus mutans-vertical transmission: from caregiver to infant-horizonal transmission: from kid to kid in daycare for example-window of infectivity: early infancy
Which populations have the highest burden of dental disease? (4)
1. Low income families2. Aboriginal children3. New immigrants4. Children with special health care needs**These marginalized populations often have limited or no access to oral health care
Why are "the working poor" more vulnerable to receiving poor support for dental care?
Their employment status renders them ineligible for dental care under publicly funded programs while the jobs they hold seldom offer employment-related health insurance
When should children have their first dental assessment?
Canadian Dental Association: dental assessment should occur for infants within 6 months of their first tooth appearing and no later than one year of age-important for examination, risk assessment and anticipatory guidance for parents to prevent dental disease
Is there any benefit to delaying the introduction of any specific solid food (including peanuts, eggs, fish) beyond six months of age to prevent development of food allergies?
NO! No evidence of benefit! Some studies suggest that delay may actually increase food allergyWhether there is any benefit of introducing the solid food BEFORE six months of age in prevention of allergies is still up for debate - major randomized controlled trials are in progress right now to figure this out!
What defines an infant as "high risk" for developing a food allergy?
Infants with 1st degree relative (parent or sibling) with atopy:1. Eczema2. Allergic rhinitis3. Asthma4. Food allergy
Is there any evidence in maternal dietary restrictions during pregnancy to decrease risk of atopy in infants?-What about maternal diet restriction while breastfeeding?
NO! Recent Cochrane review found little evidence that avoiding milk, egg, or other potential allergens during pregnancy reduced the risk of atopic eczema or asthma in infants-Breastfeeding: No evidence that it prevents allergic conditions (except maybe eczema but study quality was poor)**Also risks of maternal undernutrition and potential harm to infant from avoiding these foods is significant!
How long should exclusive breastfeeding ideally occur for?-What about for infants at high-risk of developing food allergies?
At least until 6 months of age-For infants at high-risk of developing food allergies, some studies have suggested that introducing foods early at 4 months of age while continuing breastfeeding may decrease atopy-Total duration of breastfeeding (at least six months) may be more important than exclusive breastfeeding for six months
Is there any evidence on which formulas may decrease risk of infant allergies?-Does soy formula have a role in allergy prevention?
No conclusive evidence - studies aren't great, some are sponsored by formula companies-However, there is consensus that soy formulas do NOT have a role in allergy prevention!-If you have to choose, consider a hydrolyzed cow's milk based formula (limited evidence that it might protect against eczema compared with intact cow's milk formula)
In an infant at high risk of developing allergies, should routine skin or specific IgE blood testing before first ingestion be performed?
No! This is because of high risk of potentially confusing false-positive results
What is the recommended method of discipline for older children?
1. Withdrawal of privileges or reward positive behaviour2. Model good behaviour3. Discipline should be fair and consistent