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P97 Paediatrics Toronto Notes 2023

Physical Exam

• growth parameters

• screening examination (paediatric gait, arms, legs, spine exam)

• joint exam: inspection/palpation (swelling, erythema, warmth, tenderness,deformity), ROM

• adjacent structures (bone, tendon, muscle,skin)

• leg length

• neurologic exam

Investigations

• basic:CBC and differential, blood smear, ESR,CRP, x-ray

• as indicated:blood (ANA,RF,culture, viral/bacterialserology, CK, PTT,sickle cell screen,

immunoglobulins, complement), urinalysis,synovial fluid (cell count,Gram stain, culture),TB skin

test, imaging,bone marrow aspiration,slit lamp exam

<8>

Red Flags for Limb Pain

• Fever

• Pinpoint pain/tendemess

• Pain out of proportion todegree of

inflammation

• Night pain

• Weight loss

• Erythema

• Unexplained fractures

Lyme Arthritis

• see Infectious Diseases.1D22

• caused by spirochete Borrelia burgdorferi

• incidence highest among 5-10 yr

• do not treat children <8 yr with doxycydine (may cause permanent tooth discolouration)

Reactive Arthritis

• see Rheumatology, RH 27

• arthritis(typically the knee) follows bacterial infection, especially with Salmonella, Shigella, Yersinia,

Campylobacter, Chlamydia, and most commonly Streptococcus (post-streptococcal reactive arthritis)

• typically resolves spontaneously

• may progress to chronic illness or Reiter’ssyndrome (urethritis, conjunctivitis)

Septic Arthritis and Osteomyelitis

• MEDICAL EMERGENCY: prompt intravenous antibiotics, followed by 4 wk of oral antibiotics or 4 -6

wk of oral antibiotics if the hip is involved

• see Orthopaedic Surgery,ORI 1

Table 48. Microorganisms and Treatment Involved in Septic Arthritis/Osteomyelitis

Age Pathogens Treatment

Cloxaclllin * gentamicin OR cloxaclllin cefotaxime

Cefazolin (IV), then cephalexin (PO) OR doxacillin *

cefotaxime OR cefuroxime

CBS,S. aureus. Gram negative bacilli

Kingellakingae. Strep,spp.,Staph,spp., H. influenzae

type B

Pathogens as per neonate

Kingella kingae («4 yr),S. aureus Myr),S.pneumoniae. Cefazolin (IV), then cephalexin (PO)

Neonate

Infant (1-3 mo)

Child

Bti

Adolescent As above:also H. gonorrhoeae Ceftriaxone OR cefixime azithromycin

GAS = group A Strep; GBS *group BStiep

Adapted from La Saux N. Canadian Paediatric Society.Infectious Diseasesand Immunization Committee.Paediatr Child Health 2018:23{5]:336-343

Systemic Lupus Erythematosus

• see Rheumatology, RH 11

• autoimmune illness affecting multiple organ systems

• incidence 1 in 1000, more commonly age >10, F:M=10:1

• childhood-onset SLE vs. adult-onset SLE:children have more active disease,are more likely to have

renal disease, and receive more intensive drug therapy and have a poorer prognosis compared to

adults

Transient Synovitis of the Hip

•benign,self-limited inflammatory joint disorder, usually occurs alter URT1, pharyngitis, ADM

•key is to differentiate from septic arthritis

Epidemiology

•3-10 yr, M>F,more common on right side

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P98 Paediatrics Toronto Notes 2023

Clinical Features

• afebrile orlow-grade fever; pain typically occursin hips or knees(referred from hip)suddenly; painful

limp but full ROM (pain not as pronounced asin joint or bone infections); child does not look “toxic"

pain is not disabling and gradually worsens overfew days, can have sudden onset ofsymptoms

• symptomsself-resolve over 7-10 d

Investigations

• WBC within normal limits; HSR and CRP may be mildly elevated

• joint effusions maybe seen on ultrasound

aspirate joint and examine synovial fluid ifsuspiciousforseptic arthritis

MR1 if suspicious for osteomyelitis or periarticular pyomyositis

• diagnosis of exclusion

Management

• goal isto manage symptoms(anti-inflammatory medications and bedrest)

usually resolves within 24-48 h

Complications

• Legg-Calve-Perthes disease

Vasculitides

HENOCH-SCHONLEIN PURPURA

• most common childhood vasculitis, peak incidence 4-10 yr, M:H=2:1

• vasculitis of small vessels

• often have history of URT11-3 wk before onset ofsymptoms

Clinical Features

• clinical triad:1) palpable purpura, 2) abdominal pain, 3) arthritis

• skin: palpable, non-thrombocytopenic purpura in lower extremities and buttocks, edema,scrotal

swelling

• joints:arthritis/arthralgia involving large joints associated with painful edema

• GI:abdominal pain,G1bleeding, intussusception

• renal:microscopic hematuria, IgA nephropathy, proteinuria, HTN,renal failure in <5%

Investigations

• no routine investigations performed - diagnosis is mainly based on clinical features

• urinalysis (blood, protein creatinine ratio),serum (urea/electrolytes, creatinine, albumin, elevated

IgA)

• skin/renal biopsy -IgA deposition

• ultrasound -intussusception/perforation, testicular pain/swelling

• rule out other autoimmune conditions/vasculitides

Management

• mainly supportive (e.g. elevation for edema)

• anti-inflammatory medications for joint pain,corticosteroidsfor select patients

• monitor for protein on urinalysis and hypertension every month for 6 mo to check for renal disease,

which may develop late (immunosuppressive therapy ifsevere)

Prognosis

• self-limited, resolves within 4 wk

• recurrence in about one-third of patients

• long-term prognosis dependent on severity of nephritis

KAWASAKI DISEASE

• acute vasculitis of unknown etiology (likely triggered by infection)

• medium-sized vasculitis with predilection for coronary arteries

• most common cause of acquired heart disease in children in developed countries

• peak age: 3 mo-5 yr;Asian people>Black peoploWhite people

Diagnostic Criteria

• fever persisting >5 d AND £4 of the following features

1. bilateral, non-exudative conjunctival injection

2. oral mucous membrane changes (fissured lips,strawberry tongue, injected pharynx)

3. changes of the peripheral extremities

acute phase: extremity changes including edema of hands and feet or erythema of palms or

soles

subacute phase: periungual desquamation

Kawasaki Diagnostic Criteria

Warm CREAM

Warm:>5 d fever

Conjunctival injection

Rash

Edema of hands and feet

Adenopathy

Mucosal changes

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P99 Paediatrics Toronto Notes 2023

polymorphous rash

5. cervical lymphadenopathy >1.5 cm in diameter (usually unilateral)

•exclusion of other diseases (e.g.scarlet fever, measles)

•incomplete Kawasaki disease:fever persisting >5 d and 2-3 of the above criteria

further evaluation dictated by CRP, ESR, and supplemental laboratory criteria

Management

•initial therapy:lVlg (2 g/kg) and low dose of ASA (3-5 mg/kg/d, max 325mg/d)

•lVlg within 10 d of fever onset reduces risk of coronary aneurysm formation

•if fever persists 24-36 h after lVlg, repeat lVlg treatment at the same dose; ifsecond dose fails, trial a

third lVlg treatment, IV pulse methylprednisolone or consult rheumatology for next steps

•baseline 2D-echo and follow-up periodic 2D-echo (usually at 2 and 6 wk)

Complications

•coronary artery vasculitis with aneurysm formation occurs in 20-25% of untreated children, <5% if

receive lVlg within 10 d of fever

•50% of aneurysms regress within 2 yr

•anticoagulation for multiple or large coronary aneurysms

Common Medications

Table 49. Commonly Used Medications in Paediatrics

Drug Name Dosing Schedule Indications Comments

10-15 mg/kg/dose PO q4-6 h PUN Analgesic, antipyretic Not to exceed 60 mg

' kg/d in neonates

or 75 mg/kg /d in older children to a

max of 4 g/d

Causes hepaloloxicily at high doses

acetaminophen

80- 90 mg/kg/d P0 divided q8 h Otilis media

0.6 mqfkg PO x1

0.6 rncj/kgid P0 lor 2 d

Moderate dose - 250-500 pg/d

divided BID

Nigh dose - >500 pg /d divided

amoxicillin

Croup

Acute asthma

dexamelhasonc

llulicasone (Movent )

BID

ibuprofen 5-10 mg/kg/dose P0 q6 -8 h Analgesic, antipyretic Use cautiously in patientswith liver

impairment, history of Gl bleeding

or ulcers

Side effects:dark stool,constipation,

dark urine

6 mg / kg/d elemental iron P0 once Anemia

daily or divided TID

Compaction:1-1.5 g/kg/d x3 d

Maintenance:starling dose at

0.4-1g /kg

iron

polyethylene glycol 3350 (PEG)

1-2 mg/ kg/d P0 x5 d

3- 4 mg/kg/dPO then taper to 1-2 IIP

mg/kq /d

P0 once platelet count >30 x Nephrotic syndrome

Oral prednisone is bitter tasting,

consider using prednisolone

prednisone/prednisolone Asthma

109/1

60 mg/ml/d P0

0.01- 0.03 mt/kg/dose in 3ml NS Acute asthma

via nebuliaer q0.5-4h PRN

100-200 pg/dose prn.max 4 -8

puffs frequency q4 h

Can cause tachycardia, hypokalemia,

restlessness

salbutamol (Ventolin')

Maintenance treatment for

asthma

Source:LeuE.(2009) The 2010-2011Formulary - The Hospital lot Sick Children

L J

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PI00 Paediatrics Toronto Notes 2023

Landmark Paediatric Trials

Trial Name Reference Clinical Trial Details

NUTRITION

NEJM 201S;372(9):803-813 Purpose: To assess the impact of peanut avoidance andconsumption on the development of a peanut allergy ininfants at high risk for the

allergy.

Methods:RCT consisting of 640 infants aged between 4 and 11 mo with severe eczema,egg allergy,or both.Infants were randomized to

consume or avoid peanuts until the age of 60 mo. The primary outcome was the proportion of infants that developed a peanut allergy.

Results: The infants randomized to consume peanuts resultedin a smaller proportion of children developing peanut allergies (1.9%) when

compared to the group that avoided peanut consumption (13.7%).Increased levels ol peanut- specific lgG4 antibody was prevalent in the

consumption group.Raised litres of peanut-specific IgE antibodies were prevalent in theavoidance group.

Conclusion:Prevalence ol peanut allergy at 60 months of age was significantly reduced in the consumption group.

LEAP

DIABETES

10DAY NEJM 2012;366|24):2247 Purpose:1o assess the efficacy of different treatment regimens in attaining glycemic control in youth with type 2 diabetes.

Methods:RCT consisting of 699 patients between the ages of 10 and17 yr with recent onsetI2DM.Patients were assigned to continue

metformin alone,or inconjunction with tosiglilazone,or a lifestyle modification focused on weight loss.Ihe outcome of interest was loss of

glycemic control indicated by glycated hemoglobin levelol >8% for at least 6 mo.

Results:Metformin alone resulted in a 61.7% failure rale, metforminnosiglitazonc resulted in a failure rate ol 38.6%. and

melfotmuHifoslylc intervention resulted in a failurerate of 46.6%.

Conclusion: Metformin plus rosiglitarone was significantly belter than metformin alone in achieving glycemic control within youth.

Metformin plus lifestyle intervention did not have a signilicant impact on glycemic control when compared to metformin alone

ELLIPSE NEJM 2019:381|7):637 Purpose: To assess Ihe efficacy ol liraglutlde in combination with metlormin as a treatment for type 2 diabetes inyouth.

Methods: RCT consisting ol 134 patients between the ages ol 10 and17 yr with a BMI greater than Ihe 86th percentile and a glycated

hemoglobin levelbetween 6.5 and 11%.Patients wererandomized to receivemetformin alone or metlorminincombination with

liraglutide.The outcomeol Interest was the change In glycatedhemoglobin level alter 26 wk ol treatment.

Results: Alter 26 wk.treatment with metlormin alone resultedin a 0.42% inciease in glycated hemoglobin levels and treatment with

metlormin and liraglutide in combination resultedin a 0.64% decrease in glycated hemoglobin levels. Youth taking liraglutide reported

Increased overalladverse events and gastrointestinal adverseevents.

Conclusion: Metlormin

-liraglutide combination therapy demonstrated increased elticacy in maintaining glycemic control compared to

metlormin monotherapy.

RESPIRATORY SYNCYTIAL VIRUS

MELODY N Engl J Med.2022;386|9):837 Title: Nirsevimab lor Prevention of RSV inHealthy Late-Preterm and Term Infants.

Purpose: To study the efficacy and safety ol Nirsevimab,amonoclonal antibody against RSV.inlate preterm and full-term babies.

Methods:RCT consisting of 1490 Infants born at gestational age of 35 wk were randomized in a 2:1ratio to receive nirsevimab or a

placebo, respectively.The outcome of interest is the presence of RSV infection within150 d of treatment dosage.

Results:RSV Inlections occurred within 1.2% of intanls in the nirsevimab group and 5% olpatients In the placebo group.

Conclusion: Use ol nirsevimab results in effective protection ol preterm and full-term infants from RSV infection.

ASTHMA

N Engl J Med 2022: 386:2071- Titlc:Albuterol-Budesonide Fixed-Dose Combination Rescue Inhaler for Asthma

Purpose: To assess the efficacy ol budesomde (corticosteroid) in combination with albuterol (bronchodilator) as a rescue medicine lor

asthmatic patients.

Methods:RCT consisting of 3132 patients aged 4 11yr with uncontrolled moderate to severe asthma.Patients were randomized to receive

inhaled albuterol (180 pg) and budesonide|160 pg),albuterol (180 pg) and budesonide (80 pg). or 180 pg olalbuterol alone for 24 wk of

rescue treatment. The outcome of interest was the presence of a severe asthma exacerbation.

Results:In the higher dose combination-treated group the risk of severe exacerbation was lowered by 26% when compared to the albuterol

monotherapy.

Conclusion:Use of albuterol in combination with budesonide as a rescue therapy reduces the risk of severe asthma exacerbation compared

to albuterol monotherapy.

MANDALA

2083

References

Advisory Committee Statement National Advisory Committee on Immunization.Volume 28.ACS-2.

Albright EK.Current clinical strategies:Paediatric history and physical examination.4th ed. California:Current Clinical Strategies Publishing:2003.

Amato RSS.Nelson's essentials of paediatrics.4th ed.Philadelphia:W8 Saunders:2002.Human genetiesand dysmorphology:p.129 -146.

American Academy of Pediatrics Subcommittee on Chronic Abdominal Pain.Chronic abdominal pain inchildren.Pediatrics 2005:116:812.

American Academy of Pediatrics Task Force on Circumcision.Circumcision policy statement.Pediatrics 2012:130|3):585-186.

American Academy of Pediatrics.Committee on guality improvement:subcommittee on urinary tract infection.Practice parameter:the diagnosis,treatment,and evaluation of the initial urinary tract infection in

febrile infants and young children.Pediatrics1999;103|4pt1):843.

American Academy of Pediatrics.RedBook: 2009 report of the committee DO infectious diseases.28th ed.Illinois:American Academy of Pediatrics:2009. Haemophilus influenzae infections:p.314.

American Academy of Pediatrics.RedBook:2009 report of the committee on infectious diseases.28th ed.Illinois:American Academy of Pediatrics;2009. Pertussis (whoopingcough);p.504.

American Dental Association Council on Scientific Affairs.Fluoride toothpaste use for young children.JADA 2014:145|2):190-t91.

American Diabetes Association.13.Children and adolescents:standards of medical care indiabetes - 2020.Diabetes Care 2O20;43(Suppl1):S163-82.

Anner JM.Growth andmaturation during adolescence.Hutr Rev1981;39|2):43-55.

Baker RD.Greer FR.Committeeon Nutrition AmericanAcademy of Paediatrics.Diagnosis andpievention of iron deficiency andiron- deficiency anemia in infants andyoung children (0-3 yr of age).Paediatrics

2010:126:1040-1050.

Baraff LJ.Lee SI.Schriger OL.Outcomes ol bacterialmeningitis in children:a meta-analysis.Pediatr Infect Ois J 1993:12:389.

Baren J.Rothrock S,Brennan J.et aL Paediatric Emergency Medicine.Saunders Elsevier;2008.Apparent life-threatening events:p.269-272.

Barrington KJ.SankaranK.Guidelines for detection,management and prevention of hyperbilirubinemia in term and late preterm newborninfants.Pediatr ChildHealth 2007:12:18-128.

Behrman RE.Vaughan VC.Nelson textbook of paediatrics.13th ed.Philadelphia:W.B.Saunders;1983.

Belanger SA.Caron J.Evaluation of the child with global developmental delay and intellectual disability.Paediatr Child Health 2018:23:403 -410.

Benninga MA,FaureC.Hyman PE,et at.Childhood Functional Gastrointestinal Disorders:HeonateJToddler.Gastroenterology. 2016:150(6|:1443-55.

BergmanI.Painter MJ.Nelson's essentials of paediatrics.4th ed.Philadelphia:WB Saunders:2002.Neurology;p.767-820.

Bhandar A.Bhandari V.Pitfalls,problems,and progress in bronchopulmonary dysplasia.Paediatrics 2009:123:1562-1573.

Biggar W.Duchenne muscular dystrophy.Pediatr Rev 2006:27:83-88.

r-i

L J

Activate Windows

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P101 Paediatrics Toronto Notes 2023

Blake KD.Prasad C. CHARGE syndrome. Orphanet.J Bale Dis 2006:1:34.

Blanks.Brady M.Buerk E,etal.Male circumcision.Paediatrics 2012:130|3):e756-85.

Boak A.Ellon*Marshal1.Mann BE.et aL Drag use among Ontario students.1977*2019:detailed findings from the Ontario Student Drug Use and Health Survey (OSOUHS).2020.Toronto. OH:Centre for Addiction and

Mental Health.

Canadian cystic fibrosis patient data registry report.Canadian Cystic Fibrosis Foundation.2017.

Canadian Medical Association Journal.Canada:Canada Medical Association.Vol.173.No.6 suppl.

Canadian Task force on Preventive Health Care.Becommendations on screening (or developmental delay.CMAJ. 2016 May 17;188|8|:579*87.

Canadian Task Force on Preventive Health Care.Becommendations for growth monitoring,and prevention and management of overweight and obesity in children and youth in primary care.CMAJ 2015;187|6):41l421.

Chan ES. Cummings C. Dietary exposures and allergy prevention in high risk infants.PaedialiChild Health 2013;18(10):545*549.

Chudley AE. Conry J, Cook Jt.elal.Fetalalcohol spectrum disorder:Canadian guidelines(or diagnosis. CMAJ 2005;172|6 Suppl):S1*21.

Cohen P. Bogol AD. Deal Cl.et al.Consensus statement on the diagnosis and treatmentof children with idiopathic short stature.JClinEndocrinol Melab 2008:93:4210.

Cole $2.lanham JS. Failure lo thrive:an update. Am Earn Physician 20H:83(7|:829 34

Corrigan J.Bomeau F.Hemolytic-uremic syndrome. Pedialr Rev 2001:22:365*369.

Critch JH.Nutrition lor healthy term infants,birth to six months:an overview.Paediati Child Health 2013:18|4):206-207.

D'Augusline S.Flosi T.Tarascon Paediatric outpatient pocketbook.1st ed.California:Taiascon Publishing:2008.

Dabelea D. Rewers A.Stafford JM.etal.Trends in the prevalence of ketoacidosis at diabetes diagnosis:the SEARCH for diabetes in youth study.Pediatrics 2014;133(4):e938- e945.

OajaniAS.Ayoub E,Bierman FZ.etal.Buidelinesfor the diagnosis of rheumatic fever:Jones criteria.1992 update.JAMA1992:268(15):2069*2073.

Dietitians of Canada:Canadian Paediatric Society:College of Family Physicians of Canada:Community Health Nurses of Canada.Seeker D.Promoting optimal monitoring of child growth in Canada:using the new WHO

growth charts.Can J Diet Pract Res 2010:71(1):e1-3.

Denny L.Coles S.Blitz B.Fetal alcoholsyndrome and fetal alcohol spectrum disorders.American family physician.2017 0ct15:96(8):515 *22.

Deshpande P.Salcedo B,Haq C. Common sleep disorders in children.Am Fam Physician. 2022;105|2):168*1)6.

Diabetes Canada ClinicalPractice Guidelines f ipert Committee. Diabetes Canada 2018 ClinicalPractice Guidelines lor thePrevention and Management of Diabetes inCanada. Can J Diabetes. 2018:42(Suppl1|:S1*

S32S

Oipthand A.Friedman J. Bismllla Z. elal.Ihe Hospital for Sick Children handbook of Paediatrics.11th ed. loronlo:Elsevier Canada: 2009.

Divcn SC,lutheiIT. A practical primary care approach to hematuiia in children.Pedialr Nephrol 2000:14:65*72.

Dorothy IM;Canadian Paediatric Society.Infectious Diseases and Immunization Committee.Immunization olthe immunocompromised child: Key principles.Paediatr Child Health 2018.23(3):203-205

Dosman CF.Andrews D.Goulden KJ.Evidence-based milestone ages as a framewoik lor developmental surveillance.Paediatr Chid Health 2012;17|10|:561 568.

Ducharme FM.Dell SD,Radhaknshnan D.etal.Diagnosis andmanagement of asthma in preschoolers: a Canadian Thoracic Society and Canadian Paediatric Society position paper.Paediatr Child Health

2015:20(7):353 371.

Eichenwald EC.COMMITTEE ON FETUS AND HEWB0RN.Cummings JJ.et al.Oragnosisand Management of Gastroesophageal Reflux inPreterm Infants.Pediatrics July 2018:142 (1):e20181061

Fine A,Nizet V.Mandl K.Large-scale validation of the Centor and Mdsaac scores to predict group A streptococcal pharyngitis.Arch Intern Med 2012:172:847-852.

Foisy M,Ali S.Geist R,et al.The Cochranelibrary and the treatment of chronic abdominal pain in children and adolescents:an overview of reviews.Evid-Based Child Health 2011:6:1027-1043.

Forgie S.Zhanel G. Robinson J.CPS Infectious Diseases and Immunization Committee.Management of acute otitis media - a summary.Paediatr ChildHealth 2009:14(7):457-464.

Ford 6.LaFranchi SH.Screening for congenital hypothyroidism: a worldwide view of strategies.Best Pract Res Clin Endocrinol Melab 2014:28:175-187.

Ford-Jones EL.Kellner JO.“Cheap torches'

:an acronym for congenital and perinatal infections.Pediatr Infect Dis J1995;14|7):638*639.

Fortanier AC. Venekamp BP. Boonacker CW.Pneumococcal coniugatc vaccines for preventing acute otitis media in children Cochrane DB Syst Rev 2019;5|5):CD001480.

Fox DA.Islam N.Sutherland J,et al.Type 1diabetes incidence and prevalence trends

a cohort of Canadian children and youth.Pediati Diabetes 2018:19:501*505.

Fox A.Brown 1.Walsh J.et al. An update to the milk allergy In primary caie guideline. Clm Tiansl Allergy 2019:9:40.

Friedman JN. Risk of acute hyponatremia inhospitalized children and youth receiving maintenance Intiavcnousllulds.Paediatr ChildHealth 2013:18(21:102104.

Gadomski AM.Brower M. Bronchodilators for bronchiolitis. Cochrane DB Syst Rev 2010:12:CD001266.

Ganzl.Sinus tachycardia.Rose BD (editor).Waltham: UploDate.2012.

Garrison MM. Christakis DA.Harvey E.etal.Systemic corticosteroids in infant bronchiolitis:a meta-analysis.Paediatrics 2000:105:e44.

Gomella TL.Cunningham MD.Eyal FG.etaL Neonatology:management,procedures,on-cadproblems,diseases and drugs.5th ed.New York:McGraw-Hill;2004.Assessment of gestational age;21-28.491-496.

559-562.

Greer FR.Sicherer SH,Burks AW.etal.Effects of nutritional interventions on the development of atopic disease in infants and children:the role of maternal dietary restriction,breastfeeding,liming of introduction of

complementary foods,and hydrolyzed formulas.Paediatrics 2008:129:183-191.

Gurnani M.Birken C. Hamilton J.Childhoodobesity:causes,consequences,and management.Pediatr Clin N Am 2015:62|4):821 840.

Hirtz D.Ashwal S. Berg A. et al.Practice parameter:evaluation of a fust nonfebrile seuure inchildren. Report of the quality standards subcommittee of the AmericanEpilepsy Academy olNeurology.The Child

Neurology Society,and The American Epilepsy Society.Neurology 2000;55|5):616 623.

Hogg RJ. Porlman RJ. Milliner 0,etal. Evaluation and management of proteinuria and nephiotic syndrome in children: recommendations from a paediatric nephrology panel established at the National Kidney

Foundation Conference on proteinuria,albuminuria,risk assessment,detection and elimination (PARADE).Paediatrics 2000:105(6):1242 1249.

Hospital lot Sick Children. ClInca!Practice Guidelines: fluid and electrolyte administration In children.2011.

Hoyme HE.Kalberg W0.Elliot AJ.et al.Updated criteria lor diagnosing fetal alcohol spectrum disorders.Paediatrics 2016:138(2):C201S4256.

Jaffe AC.Failure to thrive:currentdinical concepts.Pediati Rev 2011:32|3|:100.

Jainl.Eaton DC.Physiology of fetal lung fluid clearance and the effect of labor.Semin Perinatot 2006:30(1):34-43.

JanusJ.Moerschel SK.Evaluation of anemia in children.Am Fam Physician 2010:81:1462-1471.

Jefferies AL.Management term infants at increased risk for early onset bacterialsepsis.Paediatr Child Health 2017;22{4):223-228.

Jeffrey NC;Canadian Paediatric Society.Nutrition and Gastroenterology Committee.Nutrition for healthy term infants,six to 24 months:An overview.Paediatr Child Health 2014:19(10):547-49

Joseph J.Zorc ZK.A cyanotic infant:true blue or otherwise? Pediatr Ann 2001:30(10):597- 601.

Kirshner BS. Black 00.Nelson's essentials of paediatrics.3rd ed.Philadelphia:W8 Saunders:1998.Thegastrointestinal tract,p.419-458.

Klein DA.Emerick JE,Sylvester JE.et al.Disorders of puberty:an approach to diagnosis and management.American family physician.2017;96|9|:S90-9.

Klemola T.Vanto T,Juntunen Backman K.etal.Allergy to soy formula and to extensively hydrolyzed whey formula ininfants with cows'milk allergy:a prospective,randomized study with a follow-up to the age o(2

years. J Pediatr 2002:140:219 *224.

Klrcgman RM. Maicdantc K.Jenson HB.el al. Nelson essentials of paediatrics.5th ed.Philadelphia:Elsevier Saunders:2006.

Knight JR. Shrici LA. Braverider ID. etal. A new brief screen for adolescent substance abuse. Arch Pcdrat Adol Med 1999:153(61:591*596.

lambcrli LM.Ashral S.Walker Cl.et al.A systematic review of Ihe effect olrotavirus vaccination on diarrhea outcomes among children younger than 5 yeais.Pediatr Infect Dis J 2016:35(9) 992 998

Lau E.2010*2011Drug handhookand formulary.Toronto:Hospital for Sick Children DepartmentolPharmacy, 2009.

leduc D.Woods S. Temperature measurement

paediatrics.Canadian Paediatrics Society Position Statement.Posted:2000 Jan1.Updated: 2015 Oct 15 [cited 2021Mar 30[.

lenhard MJ.Reeves GO. Continuous subcutaneous insulininfusion:a comprehensive review of insulin pump therapy.ArchInt Med 2001;161:2293-3000.

levy RG.Cooper PH,Giri P.Ketogenicdiet and other dietary treatments for epilepsy.Cochrane DB Syst Rev 2012:3:CD001903.

Lewis D.Ashwal S.Hershey A.et al.American Academy of Neurology.Practice parameter:pharmacological treatment of migraine headache inchildren and adolescents.Neurology 2004;63:2215-2224.

Lewis 0W.AshawalS,Dahl G,etal.Reportof the Ouality Standards subcommitteeof IheAmerican Academyof Neurology and the Practice Committee of the Child Neurology Society.Practice parameter:evaluation of

children and adolescents with recurrent headaches.Neurology 2002;59:490-498.

Long D.Precocious puberty.Pediati Rev 20t5:36:319.

Lougheed MD.lemiere C.Dell SD.et al.Canadian Thoracic Society Asthma Management Continuum: 2010 consensus summary for children sii yr of age and over,and adults.Can Respir J 2010:17:15-24.

MacDonald NE,Dcsal S. Gcrslein 8.Working with vaccine-hesitant parents:An update.Paediatr Child Health 2018:23(8):56I

-S62.

Mandcville K.Chicn M. Willyerd FA,et al. Intussusception:clinical presentations andimaging characteristics. Pedialr Emcrg Caie 2012:28:842*844,

McCann Crosby B. Ambiguous genitalia:cvakialion and management in the newborn.NcoRcvicws 2016;17:c144 e(53.

McGahren ED.Wilson WG.Paediatrics recall. 3rd ed. Baltimore:lipprncotl Williams A Wilkins,2008.

MeinzenDerr J,PoindexleiB. Wrage L.elal.Role of human milk in extremely low birth weight infants'risk of necrotizing enterocolitis or death. J Pcrinatol 2009:29:57*62.

Michael RS.Toilet training.Pediatr Rev 1999:20(7):240-246.

Mmich11.Sleeper LA,Atz AM.etal.Oelayed diagnosis of Kawasaki disease:whatare the risk factors? Pediatrics 2007:120(6):e1434*1440.

Moeschler JB,Shevell M.Comprehensive evaluation of the childwith intellectual disabilrtyor global developmental delays.Pediatrics 2014:134(3):e903-18.

Moon RT.Fu L.Sudden infant death syndrome:an update.Pediatr Rev 2012;33(7):314-320.

Muir A.Precocious puberty.Pediatr Rev 2006:27:373-380.

Myers Tfi.McNeil MM,Hg CS.etal.Adverse events following quadrivalent meningococcal CRM -conjugate vaccine (Menveor ) reported lo the Vaccine Adverse Event ReportingSystem (VAERS),2010-2015.Vaccine

2017;35(14):1758-1763.

Harvey et al. The screening and management of newborns at risk for low blood glucose.Paediatr Child Health.2019;24(8):536.

National Advisory Committee on Immunization. Canadian Immunization Guide [Internet). Ottawa:Public Health Agency ol Canada:[updated 2021Mai 26:cited 2021Apr 28'

.Available fiom: https:77www.canada.ca/en/

publichcaltWscrvicc5/eanadian *immunizalion* guide.html.

National Heart,lung, and Blood Institute (Bethesda.Maryland). Task force on blood pressure control in children: reportof the second task force on blood pressure control inchildren. Pediatrics 1987:79:1*2.

Neveus1.Fonseca E. Fianco l.et al. Management and treatment of nocturnal enuresis anupdalcd standardization document from theInternational Children's Continence Society.J Pediatr Urol 2020:16(l):10 19.

Newburger JW.lakahashi M.Gerber MA.et al.Diagnosis,treatment,and long termmanagement olKawasaki disease:a statement for health professionals from the Committee on Rheumatic Fever.Endocarditisand

Kawasaki Disease,Council on Cardiovasculai Disease in IheYoung.American Heait Association.Circulation 2004:110:2747*2771.

r n

L J

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Pi02 Paediatrics Toronto Notes 2023

Ng 1, loewy AD. Guidelineslor vitamin K prophylaxis in newborns. Paedialt Child Health 2018:23:394 - 397.

Nicholson JF. Nelson's essentials ol pediatrics. 4th ed. Philadelphia: WB Saunders. 2002. Inborn errois ol metabolism, p.153-178.

Niermcycr S.Kallwinhcl J. Van Receipts P.etal. International guidelineslor neonatal resuscitation: an excerpt (torn the guidelines 2000 for cardiopulmonary resuscitation and emergency cardiovascular care:

international consensus on science. Pediatrics 2000:106:120.

Olson JC. Nelson's essentials of paediatrics. 3rd ed. Philadelphia: WB Saunders:1908. Rheumatic diseases ol childhood, p.290- 314.

Oitir- Alvarez 0. Mikrogianakisft. Canadian Paediatric Society Acute CareCommittee. Managing the paediatric patient with an acute asthma exacerbation. Paediatr Child Health 2012:17(51:251-255.

Palmer!MR. Dunkel l. Delayed puberty. NFJM 2012: 366|5):445 453.

Panagiotou l, Rourke U, Rourke JI, et al. Evidence - based wel- baby care. Part 2:education and advice section of the next generation of the Routke Baby Record.Can Fam Physician 1998; 44:568 - 572.

Panagiotopoutos C. Riddell MC.Sellers EAC. Canadian Diabetes Association 2013 Clinical Practice Guidelines for the Prevention and Management ol Diabetes in Canada:type 2 diabetes in children and adolescents.

Can J Diabetes 2013:37(suppl 1):S163- S167.

Parashette KR.Crollie J. Vomiting. Pediatr in Rev 2013:34(7):307-3I9.

Pearce JM.Sills RH . Childhood leukemia. Pediatr Rev 2005:26:96-102.

Provan D. Stasi R , Newland AC, et al. International consensus report on the investigation and management of primary immune thrombocytopenia.Blood 2010:115:168-186.

Publicly funded immunization schedules for Ontario. Augusl 2011.

Purugganan O.Intellectual disabilities.Pediatr Rev 2018:39:299-309.

Rastogi MV. LaFranchi SN.Congenital hypothyroidism.OrphanetJ Rare Dis 2010:5:11.

Rimrodt SL, Lipkin PH. Learning disabilities and school failure.Pediatr Rev 2011:32|8):315-324.

Robinson JL, Finlay JC. Lang ME.etal. Urinary tract infection in infants and children: Diagnosis and management. Paediatr Child Health.2014:19(6|:315-319.

Rosa -Olivares J, Porro A, Rodriguez-Varela M.et al.Otitis Media:To Treat.To Refer.To Do Nothing: A Review for the Practitioner.Pediatrics in Review.2015:36(11):481.

Rose SR, Vogiatzi MG.Copeland KC.A general paediatric approach to evaluating a short child.Pediatr Rev 2005:26|11|:410-420.

Rowan Legg A.Canadian Paediatric Society.Community Paediatrics Committee. Managing functional constipation in children. Paediatr Child Health 2011:16(10):661-665.

Rowan- Legg A. Canadian Paediatric Society.Community Paediatrics Committee. Oral health care tor children: a call for action. Paediatr Child Health 2013:18(1):37-43.

Schneeweiss S.LalaniA. Hospital for Sick Children handbook of paediatric emergency medicine. Sudbury:Jones and Bartlett; 2008.

Scott R 6. Recurrent abdominal pain during childhood.CanFam Physician 1994:40:539-547.

Scruggs K . Johnson MI. Paediatrics 5-minute reviews.Current Clinical Strategies Publishing. 2001- 2002.

SEER Cancer Statistics Review. National Cancer Institute.Bcthesda. MD.Available at: http:/7seer.cancer.govJfaststats 7selections.php?40utput (Accessed on April 28.2021).

SegeIGB. Anemia. Pediatr in Rev 1988:10:77-88.

Shalini P. Management ol obstructive sleep apnea in children:UploOate. 2021

Shane AL, Mody RK. Crump JA, et al. Practice guidelines loi the diagnosisand management of infectious diarrhea.Clin Infect Dis 2017:65:1963 1973.

Shields M. Measured obesity: ovciwcight Canadian children and adolescents. Nutrition findingsfrom the Canadian Community Health Survey.Statistics Canada. 2005.

Silbcibach M , Hannon D. Presentation of congenital heart disease in the neonate and young infant, Pediatr Rev 2007;28|4|:123-13t

Silversides CK . Kicss M , Beauchesnc L.el al. Canadian Cardiovascular Society 2009Consensus Conference on the management of adults with congenital heart disease:outflow tract obstruction, coarctation ol the

aorta, tetralogy of Fallot. Ebstein anomaly and Marfan'ssyndrome.Can J Cardiol 2010:26(3):c80-97.

Silvcrstein J. Kilgensmilh G.Copeland K.et al.Care of children and adolescents with type1diabetes: a statement of the American Diabetes Association.Diabetes Care 2005:28:186- 208.

Singh RK.Singh TP. Etiology and diagnosis of heart failure in infants and children. Rose BD (editor). Waltham: UpToDate.2013.

Sorokan SI. Finlay JC.Jefferies AL:Canadian Paediatric Society.Fetus and Newborn Committee. Infectious Diseases and Immunization Committee. Newborn male circumcision . Paediatr Child Health 2015;20|6|:311- 20.

Special Writing Groupofthe Committee. Rheumatic fever, endocarditis, and Kawasaki disease ofthecouncilon cardiovascular disease in the young of the Ameiican Heart Association.Guidelines for the diagnosis of

rheumatic fever -Jones criteria.1992 update.JAMA 1992:268:2069.

Speiser PW.Arlt W.Auchus RJ, et al.Congenital adrenal hyperplasia due to steroid 21- hydroxylase deficiency:an endocrine society clinical practice guideline.J Clin Endocr Metab 2018:103(11) 4043 4083.

Standards of medical care in diabetes- 2020 (American Diabetes Association). Diabetes Care.2020:43:S163-S182.

Strahm B, Malkin D.Hereditary cancer predisposition in children:genetic basis and clinical implications.IntJ Cancer 200G;119(9):2001-2006.

Styne DM.Glaser NS. Nelson's essentia Is of paediatrics.4th ed.Philadelphia:WB Saunders:2002.Chapter 17. Endocrinology; p 711-766.

Summary of recommendations from the Canadian Asthma Consensus Guidelines.2003 and Canadian Paediatric Asthma Consensus Guidelines.2003(updated December 2004) CMAJ 2005:173(suppl):S1-56.

TenembaumS.Disseminated encephalomyelitisin children.Clin Neurol Neurosur 2008:110(9|:928-938.

Clin Neurol Neurosur 2008;110|9|428-938.

Teri LT.Shea P.Infantile colic:Manageme ntand outcome:UpToDate.2021.

Tiwari T. Murphy TV.Moran J,et al.Recommended antimicrobial agentsfor the treatment and postexposure prophylaxis of pertussis:2005 C0C guidelines.MMWR Recomm Rep 2005:54(RR-14|:1-16.

Vaughan VC. Bchrman RE. Nelson textbook of paediatrics.

Vick GW.Bezold LI. Classification of alrial septal defects(ASDs),and clinical features and diagnosis of isolated ASOs in children.Rose 80 (editor).Waltham:UpToDate.2014.

Virbalas J.Smith L. Upper airway obstruction.Pediatr Rev 2015:36)2):62-73.doi:10.1542 /pit.36-2- 62

Vissers IE, van Ravenswaaij CM.Admiraal R.et at. Mutations in a new member of the chiomodomain gene family cause CHARGE syndrome. Nat Genet 2004:36|9):95S-957.

Walsh PR.Johnson S. Treatment and management of children with haemolytic uraemic syndiome. Arch Dis Child 2018:103:285-291.

Waid MGK. Ornstein A. Nice A. etal.The medical assessment of bruising in suspected child maltreatment cases: a clinical perspective. Paediatr Child Health 2013:18(8)434 438.

Whcrrctt D. Hunt C. Mitchell 8. et al. Canadian Oiabetes Association 2013 Clinical Practice Guidelinesfor the Prevention and Management ol Diabetes in Canada:type1diabetes in children and adolescents. Can J

Diabetes 2013:37(suppl 1):SI53 5162.

WHO Multicentie Growth Reference Study Gioup. WHO Child Growth Standards based on lengthfheight. wclghtand age. Ada Paediatr 2006:Suppl 450:76 85.

Wormscr GP. Datlwyler RJ.Shapiro ED. et al. The clinical assessment, tiealmcnt. and prevention of Lyme disease, human granulocytic anaplasmosis. and babesiosis: clinical practice guidelines by the Infectious

Diseases Society of America. Clm Infect Da 200643:1089.

Wubbel L. McCracken 0. McCracken GH Jr.Management bacterial meningitis.Pediatr Rev 1998:19|3|:78 84.

Zaripov IN. Midglcy A. Christmas SE. etal.Juvenile idiopathic arthritis:liom aetiopathogenesisto therapeutic approaches. Pediatr Rheumatol 2021:19.135. hltps://doi.org/10.1186/s12969-021-00G 29 8

Zclla GC. Israel EJ.Chronic diarrhea in children.Pediatr Rev 2012:33:2017-218.

Zorc JJ. Kiddoo DA.Shaw KN. Diagnosis and management of paediatric urinary trad infections.Clin Microbiol Rev 2005:18(2)417 422.

Web-Based Resources

Paediatrics(Internet!.New York City (NY ):Medscape:c1994 2020[cited 2021Apr 28],Available from:https://www.medscape.com/paediatries.

http:77www.icondata.com/healLh/pedbase.

http://www.cda-adc.ca.

http://www.aboutkidshealth.ca.

http://www.healthychildren.org.

http:/ /www.publichealth.gc.ca.

http://www.cps.ca.

https://www.amboss.com/

https://www.merckmanuals.com

www.uptodate.com.

Gandy A.Paediatric Database (PEOBASE) Homepage [Internet'

. London (OH):Alan Gandy;1995 Nov 15 [updated 2003 Oct 7: cited 2021 Apr 28'

.Available from: htlps://web.archive.org/web/20040203153554i

'http://

www.icondata.com/health/pedbase/.

Canadian Dental Association [Internet'. Ottawa (ON):Canadian Dental Association: c2020 [cited 2021 Api 28|. Available from:http://www.cda -adc.ca.

AboutKidsHcallh [Internet]. Toronto (ON ):The Hospital for Sick Children:c2020 "cited 2021 Apr 28|. Available from: http://www.aboutkidshealth.ca.

HeatlhyChildien.org [Internet;. Itasca (II): American Academy of Paediatrics:c2020 [cited 2021Apr 28]. Available from: http://www.heallhychildien.org.

Public Health Agency ol Canada|lnlernet|. Ottawa (ON): Government of Canada 'Gouverncmcnt du Canada;[updated 2021 Apr 12: cited 2021 Apr 28[. Available from: http://www.puhlicheallh.gc.ca.

A home for paediatricians. A voice for children and youth. [Internet) Ottawa (ON):Canadian Paediatric Society: c2020 (cited 2021 Apr 28]. Available liom: https:/ /www.cps.ca/cn/. Wolters Kluwer. Evidence -Based Clinical Decision Support at the Point of Caic [Internet]. Waltham (MA): UploOate Inc ; c2020 [cited 2021Apr 28|.Available from: https://www.uplodale.com.

Onlano Ministry ol Health and long- term Care [Internet' Ontario:Ontario Ministry of Health and long- Tcim Care; c 2009 2020 Ontario's routine immumzolion schedule; [cited 2021 Apr 28]. [about 15 screens).

Available from: http://www . hcaHh.gov.on .ca/en/public/programs/immvnization /static/ lmmunization tool.Mini

Schedule of well- child visits [Internet].Cps.ca.[cited 2022 May 16]. Available from: htlps://caringforkids.cps.ca /handouls/pregnancy-and - babies/schedule of well child visits

Child developmentand milestones [ Internet]. Amhoss.com.[cited 2022 May 16].Available from: https://wwtw.iiinboss.com/us/lcnawledge/Child development and milestones/

Merckmanuals.com.[cited 2022 May 16'

. Available from: https: / www.merckmanuals.tom/cn - ca/professlonal/pedialiies/behaviotal- conceins-and - problems- in -childien/bieath- holding-spells

Merckmanuals.com.[cited 2022 May 16'

.Available from:

https://www.merckmanuals.com/en'ca /professionaljpediatricsi,

congenital-cardiovascular-anomalies/patent- ductus- arteriosus- pda ?query'patent'o20duclus%20arleriosus +

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Palliative Medicine

Manu Sharina and Christine VVu,chapter editors

Ming Li and Dorrin Zarrin Khat, associate editors

Vijithan Sugumar, KBM editor

Dr. Risa Bordman, Dr. Adam Rapoport, and Dr. Donna Spaner, staff editors

Acronyms

Palliative Approach to Care.

Palliative Care

Pain andSymptom Management

Assessment Tools

Care of the Dying Patient.

Psychosocial and Spiritual Needs.

End-of-LifeDecision Making.

Types of Discussions

Communication

Approach to Communicating Bad News

Collaboration.

Suffering

Self-Care.

Paediatric Palliative Care

Assessment Tools.

Symptom Management

Landmark Palliative Medicine Trial*

...,

References

PM2

PM4

PM5

PM6

PM7

PM8

PM9

PM11

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Acronyms

ADLs activities of daily living

AND allow natural death

CPR cardiopulmonary resuscitation EOl

do not resuscitate

end-of'life

DNR SDM substitute decision maker

Palliative Approach to Care

Palliative Care

Definition

• an approach that seeks to improve the quality of life of patients and their familiesfacing a lifethreatening illness, through the prevention and relief of suffering

• applicable at any time during a life-limiting illness, and may be delivered in conjunction with lifeprolonging or curative intervention

• palliative approach to care is not just for EOL

Urd-a-t Pal. abve Care Trials table lor more

rforaat M osthe stdy by Iemel elsi.. 2010 which

d ea Is toe oe -eta o< esrly palliative tare lor patients

wtt aetaststc npa

-irnall-cell lung cancer.

Survivorship

See Lerda-r Pal adveCare Trials table Tor more

“j

—etc- oo tie ENABLE II trial,which details the

e fetrf a oarsog-led intervention on quality of life

(Oot|.spoton intecsityr. mood, and resource ose io

Detectsnth advanced gastrointestinal tract,lung,

geoitoo- nary tract,or breast cancer.

Cure Rehabilitation

Disease

Management

Palliative

Care Pain & Symptom Management

Hospice

Paliative Care Unit

End-of-life care

Control

Bereavement See lisdaut Pel stiveCan Trials table lor more

i-fonabci oistudy by Back et al., 2007 which

d eta Is“e eftcacy of communication skills framing

To-gweg bad news aid discussing transitionsto

oakatveca-e.

Figure1.Palliative care enhanced model

Cocrtesy of Dr.Philippa Hawley

Palliative Care Assessment

• comprehensive and includes physical, psychosocial, and spiritual domains of care

• complete medical history -includes determining the patient’s knowledge of their illness and their

goals of care

• physical symptom assessment- patient'

s opinion of severity is the gold standard, and may be

measured using assessment toolssuch asthe Edmonton Symptom Assessment System (ESAS)

• functional status assessment

- ability to perform ADLs, measured using toolssuch as the Palliative

Performance Scale (PPS)

• psychosocialsymptom assessment- anxiety,depression,family/caregiver distress, and cultural/

financial status

• spiritual assessment-religious beliefs, values, coping mechanisms, and distress

• medication review -limit polypharmacy

Pain and Symptom Management

Assessment Tools

• Edmonton Symptom Assessment System (ESAS):a tool used to screen for common symptoms

seen in palliative care. Patients/caregivers are asked to rate the intensity of symptoms front 0 to 10

on a numeric rating scale where 0 representsthe absence of the symptom and 10 represents the worst

severity of the symptom. Assesses:pain, tiredness, nausea, depression, anxiety,drowsiness, appetite,

well-being,shortness of breath, and “other problems"

associated with specific conditionssuch as

pruritusin liver disease and cough in lung disease, lhe ESAS provides a measure ofsymptom burden

and allows for tracking the efficacy'of interventions over time

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Alberta Health

|Services

Affix patient label witin this box

Edmonton Symptom Assessment System

Revised (ESAS-r)

Please circle the nnmber that best describes how you leel NOW:

No Pain 0 2 3 4 S 6 7 89 10 Worst poss>blc pain

No Tiredness

ffirednsss.fact of irngrl

0 2 3 4 9 6 7 89 10 Worst possible bredness

No Drowsiness

tDms'

.niss- fttlepsleepy)

D 2 3 4 5 8 7 8 9 10 Worst possible drowsiness

No Nausea 0 2 3 4 9 8 7 8 9 10 Worst possible nausea

No lack ot Appetite 2 3 4 9 6 7 8 9 10 Worst possible lack of appetite

2 3 4 S 6 7 8 9 10 Worst possible shortness of breath

No Shortness olBreath 0

No Depression

IDipms.cn -M«jSlil

0 2 3 4 S 6 7 8 9 10 Worst possible depression

No Anxiety

|4iu»ly.f«lnp wrvoutj

0 2 3 4 9 0 7 8 9 10 Worst possible anxiety

Best Wellbeing

Wellbeing - bo*

yenfee)oteiall

0 2 3 4 S 6 7 8 9 10 Worst possible wellbeing

No 0 2 3 4 9 6 7 8 9 10 Worst possible

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