Clerkship Ready: Pediatrics

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Asthma is a common chronic disease of childhood that affects 1 in 12 children in the United States. It can range from mild respiratory symptoms to life threatening respiratory failure, with a range of treatment options in-between from the primary care setting to the pediatric ICU. In this episode, we will discuss the underlying pathophysiology, diagnosis, evaluation, and management of patients with asthma, along with some useful clinical pearls to help you take care of these patients!

Cause of asthma
Genetics: “Atopic triad” of asthma, atopic dermatitis or eczema, and allergic rhinitis
Prenatal and childhood environmental factors: maternal smoking and allergen exposure
Pathophysiology and diagnosis
AAP definition: “episodic and reversible airway constriction and inflammation in response to infection, environmental allergens, and irritants. It is a complex, multifactorial, and immune-mediated process that presents with various clinical phenotypes.”
Airway hyperreactivity leads to inflammation of bronchi, increased mucus production, bronchial smooth muscle contraction
Key elements of the history – recurrent episodes of cough, wheeze, difficulty breathing, nighttime symptoms, consistent trigger, atopic personal or family history, improvement with asthma treatment.
Identification of triggers is important. Common triggers include respiratory infections, mold or pet dander, pollen, intense crying or laughing, exercise, pollution, and cold air.
Children from minority and lower-income backgrounds experience an increased asthma burden, likely closely tied to a complex interaction of factors such as decreased access to healthcare, increased rates of obesity, and poor air quality in the areas in which they live.
Classification of asthma: determined by the frequency and severity of symptoms when they are not receiving preventative treatment.
New 2022 guidelines for asthma treatment
Albuterol or other beta 2 agonist as needed for symptoms - relaxes bronchial smooth muscles
Daily controller medication (usually inhaled steroid) if symptoms more than twice weekly - inhaled steroid decreases inflammation
Inhaled steroid + long-acting beta 2 agonist combination inhaler preferred for those >5 years
Asthma action plan should be given to every patient
Treatment of acute asthma attack
Quick assessment and stabilization of patient is important
Treat acute symptoms first, then address chronic control of asthma
Albuterol or ipratropium-albuterol, systemic steroids are generally first lines of treatment
Supplemental oxygen as needed
Other options for medications: magnesium, terbutaline, theophylline, epinephrine
Frequent reassessment is needed

Resources:

Global Initiative for Asthma, Pocket Guide for Asthma Management and Prevention for Adults, Adolescents and Children 6-11 Years. Updated 2023. https://ginasthma.org/wp-content/uploads/2023/07/GINA-2023-Pocket-Guide-WMS.pdf

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In this episode, we discuss lead toxicity and lead screening. We will talk about what lead is, what happens when a child is exposed to lead, what to ask parents about if you’re worried about lead exposure, how to screen for lead toxicity, and what to do if your patient has an elevated lead level.

Sources of lead exposure
Ingestion of contaminated food or water
Ingestion or breathing in of lead dust
Other sources: lead-acid batteries, ammunition, lead-based pigments and paints, stained glass, lead crystal glasses, ceramic glazes, jewelry, toys
For families from other cultures, think about ceramic glazes, traditional cosmetics, traditional medicines
Government policies to decrease lead exposure
Unleaded gasoline
Lead-free paint
Lead-free solder in food cans
Lead-free water pipes
Why young children are at risk for lead toxicity
Hand-to-mouth behavior
Increased absorption of lead
Developing nervous system is vulnerable
Calcium or iron deficiency increase absorption of lead
Effects of lead toxicity in children can be seen at levels as low as 3.5 µg/dL
Growth and development delays
Lower IQ
Learning and behavior problems
Hearing and speech problems
School underperformance
At higher levels, you may see
Irritability
Loss of appetite, weight loss, fatigue
Abdominal pain, vomiting, and/or constipation
Anemia
Pica
Seizures, coma, death
Universal lead screening at 1 and 2 years
Screening questionnaires are not very sensitive or specific
Blood lead test
Capillary – get results quickly, but can be falsely elevated
Venous – results more accurate, but may take some time to come back
Management of elevated lead level
Repeat it if it was a capillary sample
Review results with family
Ask about potential exposures – may need to contact health department, landlord, or independent certified lead inspector to test home for lead
Assess risk factors for iron or calcium deficiency
Ask about developmental milestones – may need to refer to early intervention services
Consider abdominal xray if history of pica
For levels >45, may need chelation therapy

Resources/Links:

CDC, Childhood Lead Poisoning Prevention, https://www.cdc.gov/nceh/lead/default.htm
AAP policy statement. Prevention of Childhood Lead Toxicity, Pediatrics 2016: 138(1):e20161493. https://publications.aap.org/pediatrics/article/138/1/e20161493/52600/Prevention-of-Childhood-Lead-Toxicity
Mona Hanna-Attisha, What the Eyes Don't See: A Story of Crisis, Resistance, and Hope in an American City, 2018. https://www.amazon.com/What-Eyes-Dont-See-Resistance/dp/0399590838

What the Eyes Don't See: A Story of Crisis, Resistance, and Hope in an American City

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In this episode of Clerkship Ready – Pediatrics Dr. Jared Barkes, a Child Neurology resident at The University of Virginia, will be walking you through how to complete the neurologic exam! Throughout the episode he will cover in detail the different parts of a formal neuro exam while also providing useful tips for remembering commonly tested facts, reviewing specific examples of abnormal findings and common neurologic conditions, and offering helpful advice for completing a neuro exam on a pediatric patient. After listening to this podcast you will have all the tools necessary to shine on your first day of your neurology clerkship!

Introduction
What is the neuro exam?
Review of the “Map” of the neuro system
- Cortex, Brainstem, Spinal Cord, Motor neuron
How to complete a neuro exam and what to look for!
General Assessment
Mental Status
Language
Cranial Nerves
Strength
Sensation
Coordination
Reflexes
Special consideration for pediatrics
Closing

Resources/Links:

“NeuroLogic Exam”, A complete in-depth guide of the neuro exam complete with references and videos produced by Dr. Paul D. Larsen, M.D. and Suzanne S. Stensaas, Ph.D. at The University of Utah. (https://neurologicexam.med.utah.edu/adult/html/home_exam.html).
“PediNeurologic Exam” A guide of the neuro exam for children produced by Dr. Paul D. Larsen, M.D. and Suzanne S. Stensaas, Ph.D. at The University of Utah (https://neurologicexam.med.utah.edu/pediatric/html/home_exam.html)
Medical Student Resources from the American Academy of Neurology (https://www.aan.com/tools-resources/medical-student-educational-resources).

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Sepsis is a clinical syndrome in which an infection leads to an inflammatory response throughout the body that rapidly progresses to organ dysfunction or even death. Worldwide, neonatal sepsis affects 2,202 infants per 100,000 live births, and has a mortality rate of >11%. In the United States, early onset sepsis affects 50 in 100,000 live births, with a mortality rate of about 3%. So it’s a big problem that we don’t want to miss. In this episode, we will define neonatal sepsis, talk about the presentation of sepsis, what a sepsis workup entails, how to make the diagnosis and treatment of neonatal sepsis.

Defining Neonatal Sepsis
Early Onset Sepsis
Late Onset Sepsis
Neonatal Early Onset Sepsis Calculator - https://neonatalsepsiscalculator.kaiserpermanente.org/
Presentation of Illness and Physical Exam
Pathogenesis
Group B Strep
Screening and prophylaxis
E coli
Strep viridans
Klebsiella
Enterococcus
Listeria
HSV
Screening and prophylaxis
Types of Infection
Bacteremia
Pneumonia
Meningitis
Work up
CBC with differential
Blood Culture
Urinalysis and Urine Culture
Cerebrospinal Fluid culture
Chest X-Ray
Surface swabs of mucous membranes
Antimicrobial coverage
Evaluation and Treatment of a Well Appearing Febrile Infant 8-60 days old
https://doi.org/10.1542/peds.2021-052228
8-21 days
22-28 days
29-60 days

References:

Neonatal Early Onset Sepsis Calculator - https://neonatalsepsiscalculator.kaiserpermanente.org/
AAP Guidelines for Evaluation and Treatment of a Well Appearing Febrile Infant 8-60 days old: https://doi.org/10.1542/peds.2021-052228

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Iron deficiency is the most common nutritional deficiency that occurs in children in United States. Iron plays a vital role in cellular function in all organ systems. Today, we will be reviewing what you need to know before you first see a patient with possible iron deficiency. We will discuss why iron is so important, when and why iron deficiency occurs, screening, diagnosis, and treatment for iron deficiency.

Importance of Iron
Iron and Hemoglobin
Iron and Neurodevelopment
Iron and the Immune System
What happens in iron deficiency
Reasons that children are at high risk for iron deficiency
Rapid Growth .
Insufficient dietary intake and limited absorption
Increased losses
Peaks of Incidence
Other risk factors for iron deficiency.
Preterm infants
Children who suffer from neuro-motor disorders as they often have nutritional deficiency related to swallowing impairment
G.I. diseases that cause malabsorption,
Diseases predisposing them to bleeding.
Lead toxicity.
Screening for IDA
History: Asking about prematurity, low birth weight, exclusive breastfeeding beyond 4 months of age, weaning to whole milk without addition of iron rich foods, feeding problems, and any past medical conditions.
Exposure to lead (i.e. age/ condition of home, recent renovations, a parent who has occupational exposure, concerns about drinking water).
Any possible symptoms of anemia, such as fatigue, breath holding spells, pica
Physical exam: pallor.
Lab testing.
Treatment for iron deficiency
Oral iron: daily dose of 3 to 6 mg per kilogram of elemental iron divided into three doses is adequate.
Give iron supplements with juice - increases iron absorption through the action of ascorbic acid! Juices that are high in ascorbic acid include orange and apple juice.
Supplements should be continued for a minimum of three months to reestablish iron stores. After completion of treatment, reassessment of iron status
In addition to iron supplementation, the other aspect of treatment is encouraging dietary intake of iron rich foods (meat and fish, cereals, legumes, vegetables, soy, eggs)
Follow up

Resources/Links:

Baker RD, Greer FR, et al. Clinical Report – Diagnosis and Prevention of Iron Deficiency and Iron-Deficiency Anemia in Infants and Young Children (0-3 years of age). Pediatrics. 2010; 126(5). www.pediatrics.org/cgi/doi/10.1542/peds.2010-2576
Özdemir N. Iron deficiency anemia from diagnosis to treatment in children. Turk Pediatri Ars. 2015 Mar 1;50(1):11-9. doi: 10.5152/tpa.2015.2337. PMID: 26078692; PMCID: PMC4462328.
Lozoff B, Beard J, Connor J, Barbara F, Georgieff M, Schallert T. Long-lasting neural and behavioral effects of iron deficiency in infancy. Nutr Rev. 2006 May;64(5 Pt 2):S34-43; discussion S72-91. doi: 10.1301/nr.2006.may.s34-s43. PMID: 16770951; PMCID: PMC1540447.
Yadav, D., Chandra, J. Iron Deficiency: Beyond Anemia. Indian J Pediatr 78, 65–72 (2011). https://doi.org/10.1007/s12098-010-0129-7

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Ear pain is one of the most common chief complaints pediatricians encounter in the outpatient setting and there are quite a few things you need to consider to make a thoughtful diagnosis, assessment, and plan. In this episode, we will discuss the differential diagnosis of ear pain in children, physical exam findings that will help you make a diagnosis, and treatment for the most common causes of ear pain.

Ear anatomy
Outer ear, tympanic membrane (TM), middle ear, inner ear
Eustacian tube in children is smaller in diameter and angled more horizontally than in adults. This makes it more difficult to drain fluid behind the middle ear and why kids are more prone to get ear infections when they get a cold than adults are.
The adenoids also are thought to play a role in fluid collection and buildup.
Taking a history for patient with chief complaint of ear pain
How old is this child?
Have they had a fever?
Are there any other viral symptoms such as cough, runny nose, or sore throat?
Has the child been swimming recently?
Has the child put anything in their ears?
Has there been any ear drainage or changes in hearing?
Ear examination
Make sure that the child’s head is as still as possible
How to use the otoscope
What to look for:
Color of the TM.
Fluid behind the TM
Is the TM bulging or not bulging
Light reflex of the TM
Ear canal
Acute otitis media
Infectious causes - bacteria (especially Strep pneumonia, H influenzae, and Moraxella catarrhalis), viruses
Treatment
Antibiotics vs. “watch and wait approach”
Criteria for using antibiotics
Antibiotic options
Indications for tympanostomy tubes
Acute otitis externa (“Swimmer’s ear”)
Causes
Clinical presentation
Treatment
Foreign body in ear
Mastoiditis

Resources and Links:

Anatomy and Ear Tubes/Adenoidectomy

https://www.texaschildrens.org/departments/ear-nose-and-throat-otolaryngology/conditions-we-treat/dysfunction-eustachian-tube#:~:text=Eustachian%20tubes%20in%20children%20are,cause%20pain%20for%20the%20child.

https://www.childrensmn.org/educationmaterials/childrensmn/article/18784/adenoidectomy-and-ear-tubes/#:~:text=The%20adenoid%20is%20located%20next,is%20for%20recurrent%20nasal%20infections

https://www.ncbi.nlm.nih.gov/books/NBK570549/#:~:text=The%20middle%20ear%20consists%20of,the%20transmission%20of%20sound%20waves.

https://www.ncbi.nlm.nih.gov/books/NBK551658/#:~:text=The%20inner%20ear%20is%20located,labyrinth%2C%20separated%20only%20by%20perilymph.

https://www.hopkinsmedicine.org/health/treatment-tests-and-therapies/ear-tube-insertion

https://www.chop.edu/news/health-tip/3-signs-your-child-may-need-ear-tubes

Otitis Externa

https://publications.aap.org/pediatricsinreview/article/34/3/143/34784/Otitis-Externa

https://www.aafp.org/pubs/afp/issues/2001/0301/p927.html

https://www.aafp.org/pubs/afp/issues/2006/1101/p1510.html

AAP Otitis Media Guidelines:

https://publications.aap.org/pediatrics/article/131/3/e964/30912/The-Diagnosis-and-Management-of-Acute-Otitis-Media

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Child abuse, which is sometimes called non-accidental trauma, is a public health problem with life-long health consequences for survivors and their families. In this episode, we will review what you need to know before you encounter your first patient who may have or has been abused. We will focus on physical and sexual abuse of children.

Long term health consequences of child abuse
Why identification of child abuse is difficult
It is often difficult to distinguish an accidental injury from a non-accidental injury
A caregiver who has abused a child rarely confesses to harming the child
Child may be brought to medical care by unsuspecting parent
It is emotionally difficult for us to confront parents when there are concerns for abuse
Mandated reporting of child abuse
Potential clues that a child may have been physically abused
Medical record review
History
Physical exam
Differential diagnosis of physical abuse
Labs and other tests that you may get
The role of the child protection team and child protective services
Potential clues that a child may have been sexually abused
History
Physical exam
Lab testing
Medical documentation

Resources/Links:

Christian CW; Committee on Child Abuse and Neglect, American Academy of Pediatrics. The evaluation of suspected child physical abuse. Pediatrics. 2015 May;135(5):e1337-54. doi: 10.1542/peds.2015-0356.
Pierce MC, Kaczor K, Lorenz DJ, Bertocci G, Fingarson AK, Makorof K, Berger RP, Bennett B, Magana J, Staley S, Ramaiah V, Fortin K, Currie M, Herman BE, Herr S, Hymel KP, Jenny C, Sheehan K, Zuckerbraun N, Hickey S, Meyers G, Leventhal JM (2021) Validation of a clinical decision rule to predict abuse in young children based on bruising characteristics. JAMA Netw Open 4(4):e215832. https://doi.org/10.1001/jamanetworkopen.2021. 5832. Erratum in: JAMA Netw Open. 2021 Sep 1;4(9):e2130136. PMID: 33852003; PMCID: PMC8047759
Smith T, Chauvin-Kimoff L, Baird B, Ornstein A. The medical evaluation of prepubertal children with suspected sexual abuse. Paediatr Child Health. 2020 Apr;25(3):180-194. doi: 10.1093/pch/pxaa019. Epub 2020 Apr 10. PMID: 32296280; PMCID: PMC7147698

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Discussing menses and pregnancy prevention is an important part of preventative care and reproductive health. Patients and parents come in with a wide range of preconceptions and understanding. It can be daunting to counsel about the many types of contraception to come to a shared decision about what is best for the patient. This podcast will review the following about contraception:

Medical contraindications
Physiology of hormonal options
Efficacy of pregnancy prevention
Patient considerations and concerns
Emergency contraception
Myths

Resources/links:

CDC MEC: https://www.cdc.gov/reproductivehealth/contraception/pdf/summary-chart-us-medical-eligibility-criteria_508tagged.pdf
ACOG contraception chart: https://www.acog.org/womens-health/infographics/effectiveness-of-birth-control-methods
https://www.reproductiveaccess.org/
https://www.bedsider.org/

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In today’s episode, we are talking about normal child development. We will talk about why this is important and how you will be evaluating children’s development. We will go over major milestones in the 4 developmental domains: movement/physical development – or gross and fine motor, language/communication, cognitive, and social/emotional. We will go over some common cases. Finally, we will briefly discuss what you should do if you suspect developmental delay. Why it is important to learn about developmental delay.

Why it is important to learn about development
Developmental surveillance versus developmental screening versus diagnosis of developmental issues
Developmental domains/categories:
1. Expressive language
2. Receptive language
3. Gross motor: this is how you use all of your big muscles
4. Fine motor: hand/eye coordination
5. Social/emotional: how children interact with others and show emotion.
6. Language/Communication: how children express their needs and share what they are thinking, as well as understand what is said to them. Hearing is important for language/communication development.
7. Cognitive: how children learn new things and solve problems
8. Movement/Physical Development: how children use their bodies.
Learning milestones
Learn the schedule for well child visits
Watch children at different ages to see what they can do.
Gross motor milestones: 1 year goal is to be able to walk independently.
Fine motor milestones: 1 year goal is to be able to put food into one’s mouth
Language and communication milestones: 1 year goal is to be able to say a few words
Social and emotional milestones: 1 year goal is to recognize that people are individuals that they can interact withOK, so those are some of the major milestones. Now, let’s go through a few common case scenarios that have some specific teaching points.
Cases
What if there is developmental delay

Resources/Links:

CDC’s Developmental Milestones: https://www.cdc.gov/ncbddd/actearly/milestones/index.html
Ages and Stages developmental screening tool: https://agesandstages.com/products-pricing/asq3/
Modified Checklist for Autism in Toddlers (MCHAT): https://www.mchatscreen.com/

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Neonatal hypoglycemia is a common and often transient issue for newborns during a period of transition from intrauterine to extrauterine life. Many infants with hypoglycemia are screened for it and treated for it in the nursery, and a handful will require NICU admissions. This podcast will help you understand these things about neonatal hypoglycemia:

Why we worry
What causes it
Which infants are most at risk
How to treat it and who needs the NICU

Resources/Links:

https://downloads.aap.org/AAP/PDF/Seminars_in_Fetal_Neonatal_Medicine.pdf
https://publications.aap.org/hospitalpediatrics/article/11/6/595/180015/Practice-Variations-in-Diagnosis-and-Treatment-of
https://publications.aap.org/aapnews/news/25073/Myriad-unknowns-regarding-neonatal-hypoglycemia?autologincheck=redirected

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Attention deficit-hyperactivity disorder (ADHD) is one of the most common neurodevelopmental disorders in children. In this episode, we will discuss ADHD, including the different types, evaluation, management, and follow up.

General definition of ADHD and its types
Preparing for your first visit
Initial evaluation of ADHD vs. med check
Reviewing prior visits
During an initial visit:
- Evaluating historical features
  - Behaviors at home, behaviors at school
  - Common misconceptions about ADHD
  - Surrounding factors and comorbidities/misdiagnosis
- Physical Exam
  - Important features of the exam
  - Observing the child’s behavior
- Role of the Vanderbilt
  - Scoring a Vanderbilt
Treatment
- Medication vs. non-pharmacologic interventions
  - Overview of different medications
    - Stimulants
    - Nonstimulants
  - Choosing a medication
    - Family history
    - Comorbidities
- Titrating medications
Follow-up visits
- Symptoms to look for

Resources/Links:

Vanderbilt Scoring: https://www.uwmedicine.org/sites/stevie/files/2019-11/sodbp_vanderbilt_scoringinstructions.pdf
Parent Training in Behavior Management for ADHD: https://www.cdc.gov/ncbddd/adhd/behavior-therapy.html

Dosing guidelines when switching from one stimulant to another in the treatment of attention deficit hyperactivity disorder in children and adolescents: https://www.uptodate.com/contents/image?imageKey=PEDS%2F61007

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Introduction to jaundice and hyperbilirubinemia
Jaundice is the yellowing of skin, sclerae, and mucous membranes caused by hyperbilirubinemia
Hyperbilirubinemia can be further separated into unconjugated or conjugated forms, which allows us to further differentiate etiology
Review of bilirubin breakdown pathway, to include enterohepatic circulation
Unconjugated hyperbilirubinemia etiologies:
Excessive or increased production of bilirubin
Cephalohematomas
Hemolysis: ABO and Rh incompatibilities; Red Blood Cell (RBC) membrane or enzyme defects, RBC oxidative stress (secondary to sepsis, asphyxia, and acidosis)
Decreased clearance of bilirubin
Breast milk jaundice
Prematurity
Hypothyroidism
Gilbert Syndrome
Crigler-Najjar Syndrome
Suboptimal Intake Jaundice
Medications
Combination of both
Physiologic jaundice
Conjugated hyperbilirubinemia etiologies:
Always pathologic
Biliary atresia
Briefly mentioned the vast range of other etiologies: infectious, genetic, metabolic, and anatomic
Key elements of history and physical examination for a jaundiced infant
History:
Onset
Feeding patterns (what, how much/often, quality of feeding)
Urine and stool diapers
Prenatal history
Delivery history
Family history

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Introduction
Definition of maintenance fluid needs
Important considerations about maintenance fluids
Discussion regarding which fluids to order for different patient populations and at what rate to administer
Role of ADH in hospitalized patients
How to order a fluid bolus—amount, composition, and rate administered
Assessing your patient with dehydration utilizing physical exam findings, vital signs, and other objective data such as weight
Case scenarios: Identification and management of hyperkalemia and hypokalemia
Case #1- 12-year old with hyperkalemia following infection with influenza
Case #2- 2-year old child with history of neglect and malnutrition
Additional clinical pearls including the association between albumin and calcium, acidosis/alkalosis and potassium levels

Resources/Links:

Clinical Practice Guideline: Maintenance Intravenous Fluids in Children | Pediatrics | American Academy of Pediatrics (aap.org)

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Strategies to improve milk production
Latching
Newborn stomach volumes
How to know if baby is getting enough milk
What to do if baby isn’t getting enough milk
Manual expression and pumping
Breastfeeding complications

Resources/Links:

Bella Breastfeeding Curriculum on Open Pediatrics (free): www.openpediatrics.org
Virginia Department of Health/Breastfeeding Education Consortium Online Course (free for those who live or work in Virginia): https://bfconsortium.org
American Academy of Pediatrics Residency Breastfeeding Curriculum: https://www.aap.org/en/learning/breastfeeding-curriculum/
ACOG Statement on Optimizing Support for Breastfeeding: https://www.acog.org/clinical/clinical-guidance/committee-opinion/articles/2018/10/optimizing-support-for-breastfeeding-as-part-of-obstetric-practice
AAP Policy Statement: Breastfeeding and the Use of Human Milk, 2022: https://publications.aap.org/journal-blogs/blog/20699/Welcome-to-the-AAP-s-2022-Policy-on-Breastfeeding?autologincheck=redirected#
US Breastfeeding Guidelines for Mothers with HIV: https://clinicalinfo.hiv.gov/en/guidelines/perinatal/infant-feeding-individuals-hiv-united-states
NEWT Curve: https://newbornweight.org
UpToDate “Initiation of Breastfeeding”: https://www.uptodate.com/contents/initiation-of-breastfeeding

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Making families feel comfortable
Benefits of breastfeeding for mom and baby
Contraindications to breastfeeding
Approaching conversations about breastfeeding with families
The process of lactogenesis (milk production)

Resources/Links:

Bella Breastfeeding Curriculum on Open Pediatrics (free): www.openpediatrics.org
Virginia Department of Health/Breastfeeding Education Consortium Online Course (free for those who live or work in Virginia): https://bfconsortium.org
American Academy of Pediatrics Residency Breastfeeding Curriculum: https://www.aap.org/en/learning/breastfeeding-curriculum/
ACOG Statement on Optimizing Support for Breastfeeding: https://www.acog.org/clinical/clinical-guidance/committee-opinion/articles/2018/10/optimizing-support-for-breastfeeding-as-part-of-obstetric-practice
AAP Policy Statement: Breastfeeding and the Use of Human Milk, 2022: https://publications.aap.org/journal-blogs/blog/20699/Welcome-to-the-AAP-s-2022-Policy-on-Breastfeeding?autologincheck=redirected#
US Breastfeeding Guidelines for Mothers with HIV: https://clinicalinfo.hiv.gov/en/guidelines/perinatal/infant-feeding-individuals-hiv-united-states
NEWT Curve: https://newbornweight.org
UpToDate “Initiation of Breastfeeding”: https://www.uptodate.com/contents/initiation-of-breastfeeding

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Newborn deliveries: Low Risk

Low-risk delivery team members
What constitutes a low-risk delivery page

Differences in Operating Room (OR) versus labor room deliveries

Differences in attending delivery in the delivery room versus the operating room
Operating room attire
Importance of Apgar (timer button) on radiant warmer

Delayed Cord clamping

Delayed cord clamping: When this happens and the importance
Why it matters if umbilical cord is clamped before 1 minute and infant brought to the radiant warmer

Neonatal Resuscitation

NRP guidelines from American Academy of Pediatrics

Pertinent Physical Exam at delivery

Importance of full, efficient exam in delivery room

Need for Higher Level Intervention: Neonatal Intensive Care

Reasons for calling for NICU: high-risk delivery team

Resources/Links:

Neonatal Resuscitation Program (NRP)/American Academy of Pediatrics

Neonatal Resuscitation Program (aap.org)

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How to identify an eating disorder
What to do if you suspect an eating disorder
How to manage eating disorder patients in the outpatient setting or in the hospital
Strategies and tips for talking to teens with eating disorders

Resources/Links:

The American Psychiatric Association Practice Guideline for the Treatment of Patients with Eating Disorders, 2023, https://doi.org/10.1176/appi.books.9780890424865.

Laurie L. Hornberger, Margo A. Lane, THE COMMITTEE ON ADOLESCENCE, Laurie L. Hornberger, Margo Lane, Cora C. Breuner, Elizabeth M. Alderman, Laura K. Grubb, Makia Powers, Krishna Kumari Upadhya, Stephenie B. Wallace, Laurie L. Hornberger, Margo Lane, MD FRCPC, Meredith Loveless, Seema Menon, Lauren Zapata, Liwei Hua, Karen Smith, James Baumberger; Identification and Management of Eating Disorders in Children and Adolescents. Pediatrics January 2021; 147 (1): e2020040279. 10.1542/peds.2020-040279

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Know what organisms you want to treat
Because we often treat empirically, we need to know organisms that typically case this typical infection
Narrow-spectrum antibiotics if possible
Anatomy of the infection
For fever in first 4-6 weeks, think about organisms that infant was exposed to during pregnancy and delivery
For respiratory infections, think about organisms that live in the respiratory tract
Abnormal anatomy
Immunization status of child may change your differential diagnosis
Drug allergies
Look in medical record and ask patient and family about allergies
Consider cross-reactivity of antibiotics
Geographic location: resistance patterns
Individual circumstances
Chronic diseases
Environmental exposures

Resources/Links:

Up to date: uptodate.com

American Academy of Pediatrics Red Book: https://publications.aap.org/redbook?autologincheck=redirected

Sanford Guide to Antimicrobial therapy: https://www.sanfordguide.com/products/print-guides/?gad=1&gclid=CjwKCAjwtuOlBhBREiwA7agf1oWtsyBrx0OFaHxpG2ZpDTXYukd1JGs5R_ZpRWrECT_v0bqhboN15hoCijIQAvD_BwE

American Academy of Pediatrics clinical practice guideline: The Diagnosis and Management of Acute Otitis Media. 2013. https://publications.aap.org/pediatrics/article/131/3/e964/30912/The-Diagnosis-and-Management-of-Acute-Otitis-Media

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1) References to look up pediatric drug doses and frequencies.

2) Calculating weight-based doses

3) Maximum daily doses

4) Different formulations of medications

5) Prescribing oral medicines

Pills vs Liquid
Consider taste
Use the most concentrated suspension
Use milliliters instead of spoonfuls

6) What if the medicine is not available in liquid form

7) Options if oral medications are not easily available in liquid form.

8) Medicine dosing frequency – use the least frequent option

9) Acetaminophen and Ibuprofen

Resources/Links:

Up to date: uptodate.com

Harriet Lane Handbook: https://evolve.elsevier.com/cs/product/9780323876988?role=student

Lexi-Comp: https://apps.apple.com/ca/app/lexicomp/id313401238

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Definitions
Interpretation vs translation
Modes of interpretation
When do I need an interpreter?

III. Who should not serve as an interpreter?

Non-certified team members
Patient’s non-certified friends or community members
Patient’s family members
Getting started
Verify preferred language
Positions in the room
Introductions, including of the interpreter and recording interpreter’s information
Conducting the visit
How long to speak before awaiting interpretation
During the physical exam
Teach-back method via interpreter
Trouble-shooting
When the patient declines interpreter services
When you think the interpreter is misinterpreting
When you have technical difficulties or ambient noise

VII. At the end of the encounter

Translating written patient materials
Considering variable written and medical literacies
Next steps and follow-up care

VIII. After the visit

Documentation of your use of interpreter services
Verification of preferred language

Resources:

– “A

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Why do we talk about safe sleep for infants?
What causes infants to die suddenly and unexpectedly?
Goals of safe sleep recommendations are to increase infant arousability and decrease asphyxiating environments
Asking about sleep practices
ABCs of safe sleep: Alone, Back, Crib

Safe sleep recommendations:

Infants should be on their backs
Infants should sleep on a firm, flat, noninclined sleep surface
There should be no bedding, such as pillows, blankets, bumper pads, stuffed toys, or fur-like materials in the infant’s sleep area.
The infant should be breastfed as much and for as long as possible.
The infant should sleep in the parents’ room, close to the parent’s bed but on a separate surface designed for infants, ideally for at least the first 6 months of life.
Couches, sofas, and padded armchairs are extremely dangerous places for infants to sleep.
Offer a pacifier at sleep time
Parents should stay smoke-free during pregnancy and after the infant is born.
Parents should avoid alcohol, marijuana, opioids, and illicit drug use during pregnancy and after birth
Infants should be fully immunized.
Commercial sleep products are only safe if they are consistent with safe sleep recommendations
Tummy time

References:

Moon RY, Carlin RF, Hand I, American Academy of Pediatrics Task Force on Sudden Infant Death Syndrome and the Committee on Fetus and Newborn. Sleep-Related Infant Deaths: Updated 2022 Recommendations for Reducing Infant Deaths in the Sleep Environment. Pediatrics. 2022 Jul 1; 150(1):e2022057990. https://publications.aap.org/pediatrics/article/150/1/e2022057990/188304/Sleep-Related-Infant-Deaths-Updated-2022?autologincheck=redirected
Won’t my baby choke if they spit up when placed on their back to sleep? https://safetosleep.nichd.nih.gov/reduce-risk/back-sleeping

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Sexual History - why it is important
Confidentiality
5 Ps Framework
Partners
Practices
Protection of STIs
Past history of STIs
Pregnancy Intention
STI Screening and Treatment
HIV screening algorithm

References:

5 Ps Framework:

https://www.cdc.gov/std/treatment/SexualHistory.htm

STI Screening and Treatment:

https://www.cdc.gov/std/treatment-guidelines/provider-resources.htm#MobileApp
https://www.cdc.gov/std/treatment-guidelines/default.htm

HIV screening algorithm:

https://stacks.cdc.gov/view/cdc/50872

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How to examine a baby/infant
How to examine a toddler/preschool aged child
Focused information on the ear exam/otoscopy
How to examine a school aged child/teen
Engaging older children in your exam
Focused information on the genitourinary exam
Presenting your physical exam during oral presentation

Resources/Links:

Bates' Guide to Physical Examination and History Taking by Lynn Bickley (your pediatric clinics will generally have a copy)
https://batesvisualguide.com

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List of pediatric vaccines
How vaccines work
Types of vaccines
What you need to do before the visit
What you should review with families before ordering the vaccines (including precautions and contraindications)
Anticipatory guidance about vaccines
How to handle vaccine hesitancy

REFERENCES/LINKS:

www.cdc.gov/vaccines

AAP Child and Adolescent Immunization Schedule by Age: https://publications.aap.org/redbook/pages/Immunization-Schedules?autologincheck=redirected

O’Shea P, John J, et al. Reframing the Conversation about Child and Adolescent Vaccines, January 2023, Frameworks Institute. https://www.frameworksinstitute.org/wp-content/uploads/2023/01/reframing-the-conversation-about-child-and-adolescent-vaccinations_Jan272023.pdf

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Before the Rotation
Reach out to your team..
Understand what first day expectations are.
Peruse the patient list.
Identify what study materials and resources will help you excel.
Come ready to learn and have fun!
How to Pre-round
Collect information on previous day and overnight events - includes talking with resident or night team, reading all notes from day prior
Review all vitals from past day
Review and calculate “Ins and Outs”
Review all labs
Check to see what medications, including PRN meds, your patient got
Introduce yourself to patient and family - get their input on how patient is doing
Collect your thoughts, interpret your data, and formulate your assessment and plan for your presentation and note
How to Present a Patient on the inpatient wards service
Begin with one liner
Subjective: interval and overnight events
Any patient or caregiver concern or question noted when you prerounded
Ins and Outs
Vital signs
Head-to-toe physical exam
Labs, microbiology, and radiology
Assessment one-liner
Plan
How to be an effective team member
Touch base with a resident to run through your assessment and plan.
Show initiative
Be honest and direct
On rounds, listen to all patient presentations, not just your own
Follow

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The goal of the adolescent well visit is to empower the adolescent in starting to take ownership of their health with the support of their provider and caregiver.

Before visit:

Review normal psychosocial development of adolescence
Review sexual maturity rating (SMR) (previously referred to as Tanner Staging) of adolescence
Review past medical history, medications, vaccines, labs, prior concerns from previous visits, and their last well visit if available.
Vital signs (including BP), height weight, BMI.
Any screening questionnaires (e.g., PHQ-9A)

During visit:

Introduce yourself; ask how they would like to be addressed
Review structure of visit, including genital exam and interviewing adolescent alone; importance of confidentiality
Direct questions to adolescent as much as possible
Concerns from adolescent/parent or from prior visits that require follow up or updates
Psychosocial screening: HEADSS (home, education/employment, activities, drugs, sexuality, suicide/depression/self-image, and safety) or SSHADESS (strength, school, home, activities, drugs/substance use, emotions/eating/depression, sexuality, and safety). NOTE: Some of this will be done during confidential interview.
Nutrition: number of meals/snacks, dairy intake
Sleep: nighttime and naps
Screen time: duration, type(s)
Dental: frequency of brushing, last seen by dentist
Menstrual history: Age of menarche, frequency, length of periods, heaviness of flow, symptoms associated with menses
Review medications, allergies, growth chart, vaccines
Confidential interview: any additional questions or concerns; Home, Drugs and substance use; Emotions, eating, and depression; Sexuality; Safety

Physical exam

Head to toe
Discuss acne
Need chaperone for breast and genital exam

Preparation for oral presentation

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Show Notes/Description

This episode describes how to prepare for a newborn’s first outpatient visit after being discharged from the birth hospital, including the information that you need to obtain from the medical record before the visit, the topics you need to discuss during the visit, and how to approach the physical examination in a newborn.

Title: Before Your First Newborn Follow up Visit

Host: Augustin Casals,MD Pediatrics Resident, University of Virginia.

Show Outline:

Introduction

Socio-emotional state of parents

Before the visit, you should review

Prenatal history
Delivery history, gestational age
Physical exam at time of birth
Preventative treatments
Course in newborn nursery or NICU
Type of feeding
Concerns for infection
Bilirubin
Screening tests

Newborn visit

Parental questions and concerns
Feeding history and any problems with feeding
Elimination
Sleep and safe sleep
Social history and parental support system
Review of systems – irritability, fever, rashes.

Normal newborn vital signs

Infant growth parameters and weight trajectory

Physical exam

General
Head size and shape
Eyes – pupil shape, red light reflex, scleral icterus
Cardiovascular – murmurs, capillary refill
Respiratory
Abdominal
Genitourinary – testicles, hernias/hydroceles, circumcision, vaginal discharge
Musculoskeletal- clavicles, hip
Skin – jaundice, birthmarks, sacral dimples
Neurological: tone, reflexes

Anticipatory guidance

Fever
Safe sleep
Prevention of shaken baby syndrome
Postpartum depression
Appropriate feeding

Next follow up appointment depends on weight, bilirubin level

Resources/Links:

https://peditools.org/bili2022/ - resource for management of hyperbilirubinemia

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Essential Resources Podcasts:

Clerkship Ready-Pediatrics
Charting Pediatrics - Weekly podcast with lots of bread-and-butter pediatrics discussed.
Pediatrics on Call - The most recent research and the newest policy updates from the American Academy of Pediatrics.

Books:

Red Book (also an app for AAP members) - the definitive source for pediatric infectious diseases.
Harriet Lane Handbook (also an app) - has drug doses, commonly used charts, and algorithms.

Websites:

Peditools for bilirubin
Uptodate
CDC website is a great source for vaccine guidelines

Apps:

PedsScripts App: specifically to work on illness scripts

General Tips and Tricks:

Be Proactive
Know what the expectations are.
Become familiar with the electronic medical record system.
Be Self-sufficient, but ask for help when appropriate.
Know when you should come in to round, who to pre-round on, and where to meet. Pair up with an intern to pre-round.
Ask for feedback.

Pediatric-specific Tips and Tricks:

Pediatrics is different from any other rotation.
Huge range of ages and developmental stages.
At every age, children act differently - and you need to adjust appropriately.
If you can, get as much of the history from the child, but you will likely need to supplement that with history from the parent or guardian.
When you do your physical exam on younger children, have to adjust the order of exam
Vital signs change with age. Look up or ask about what is a normal vital sign in the age you are seeing.
Check weight, length/height and/or head circumference and report both percentiles and trends.
If an infant has been born prematurely, correct growth and development for gestational age.
Fluids and medication are dosed per kilogram.
Family-centered rounds are a unique, important part of pediatrics. The goal is to get both the team and family up to date on the patient’s diagnosis and overall course, and to formulate a plan for the day together with the family.
Brief summary and plan outside of the patient room.
Invite family to participate.
Conversational language with no medical jargon.
Be concise and clear.

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Clerkship Ready: Pediatrics: Recent Episodes

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