We are excited to see so many of you join our spring FMEP courses. Several of you have requested we continue to post more practice SAMPs, so here you go!

Just a reminder… pay attention to the questions. Here are our general tips one more time:

1. Pay attention to the questions. Look carefully at how many items you are being asked to list. If the question asks for five items, you will not get more marks if you list eight items; the examiner will look at the first five and allocate marks only for the first five answers – so be careful. On a SAMP, if it is not clearly stated how many items you should list, look at the amount of points/marks being allocated for the question to get an idea of how many answers the examiner may be anticipating you write down.

2. Do not write lengthy answers. Most questions can be answered in 10 words or less!

3. Be specific when writing down investigations (hemoglobin instead of CBC; CT abdomen instead of CT).

4. Remember that trade names and generic names are both acceptable when writing down medications.

5. For more helpful tips, you can refer to CCFP’s SAMP instructions by clicking here.

SAMP

Janet is a 32 year old G1P1, who delivered her newborn baby 4 weeks ago. The baby has had excellent weight gain since birth and she has been exclusively breastfeeding. She is here for the 1-month follow-up and has a number of questions. (10 points)

1. She went to the pharmacy but forgot the amount of vitamin D she should give to her baby. For infants who are exclusively breastfed, what is the recommended vitamin d supplementation? (1 point)

• • Vitamin D 400 IU from birth until solid food and/or cow’s milk is introduced

2. At times, the baby has difficulty with the latch. What are two ways to optimize the latch and improve success with breastfeeding? (2 points)

• • Latch: ensure the latch is asymmetric whereby the areola is more visible above the baby’s top lip
  • Positioning: baby’s ears, shoulders, and hips are aligned during breastfeeding
  • Nose should be in the sniffing position and open
  • Nipple should point towards baby’s upper lip or nostril
  • Remember on your exam- you have the whole team at your disposal! Refer to the lactation consultant when you need. Helpful link and videos: How To: Asymmetrical Latch Breastfeeding | Lactation-911

3. She reports a tender nodule in her breast with some erythema. You examine her and her right breast has mild erythema and is tender to palpate. She is otherwise well. How would you manage? (1 point)

• • Warm and cool compresses, massage, rest, hydration, NSAIDs (if no contraindication). If there is no improvement within 24 hours, start cloxacillin, cephalexin or erythromycin. If there is any concern for MRSA, consider clindamycin. Ensure you have close follow-up and advise your patient to go to the ER if she develops any systemic symptoms (e.g., fevers, chills, etc.).

4. She reports plaques on the baby’s tongue. You try to remove them with a tongue depressor but are unable to do so. How would you manage? (1 point)

• • Treat for candida. You can treat with Nystatin Infant drops (100,000–200,000 units PO QID for 2 weeks (after feeds). An alternative option is clotrimazole or miconazole cream to be applied to mom after every feed for 2 weeks.

5. What are three contraindications to breastfeeding? (3 points)

• • Infants with inborn errors of metabolism
  • Classic galactosemia (here you can use galactose-free human milk substitute)
  • Maple syrup urine disease (here you can use milk substitute free of leucine, isoleucine, and valine)
  • Phenylketonuria (use phenylalanine-free human milk substitute; some breastfeeding possible with careful monitoring)

6. She asks about her contraceptive options while breastfeeding. What two options could you offer? (2 points)

• • Progestin-only pill
  • IUD (both copper and progesterone IUDs)
  • Combined OCP can be considered 4-6 weeks postpartum, once breastfeeding is well established

Helpful Resources:
1) Breastfeeding Challenges and Newborn Nutrition, Feb 2021, Practice Based Small Group Learning Program. www.fmpe.org.
2) https://www.jogc.com/article/S1701-2163(16)39786-9/pdf
3) https://cdn.dal.ca/content/dam/dalhousie/pdf/faculty/medicine/departments/core-units/cpd/academic-detailing/ADS_2015_Contraception_Workbook.pdf
4) https://www.gacguidelines.ca/site/GAC_Guidelines/assets/pdf/CONT05_-_Contraception_Summary_Mar_12_08.pdf