Clerkship Ready: Pediatrics

Pediatrics is different from any other rotation that you will do. Children are not just small adults. There is a huge range of ages and developmental stages. This episode will provide you with some general tips and tricks for all clerkships in general and the Pediatrics clerkship specifically, and essential resources that will help you to succeed in your clerkship. 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 t

This episode will prepare you to see well newborn babies in the newborn nursery on day 1. We will talk about the typical newborn stay, the information you need to gather to successfully give oral presentations on your patients, the newborn physical exam, and the tests and procedures commonly performed on all newborns. Nursery orientation: family expectations and goals of the healthcare team, expected length of stay History  Maternal History: Gs and Ps Prenatal Care: prenatal labs and ultrasounds Past Medical History & medications Social situation/support Baby History: Gestational Age Delivery type and why, resuscitation efforts and complications Growth parameters The complete newborn exam: head to toe During the newborn stay: Ins and Outs Medications and vaccines Routine screening labs and tests Parental discharge education  Discharge criteria and follow up

This episode will prepare you for your first well child visit. In primary care, about half of a pediatrician's time will be spent in well child visits. We will talk about what you need to review before you walk into the patient's room, the elements of the history (diet, sleep, elimination, development, etc.) that you need to ask about in well child visits, tips to approaching the physical exam in children, and anticipatory guidance. Finally, we will provide an example of an oral presentation for a well child visit.  

In Pediatric Gastroenterology (or GI) clinic, you will see patients with a host of gastrointestinal, pancreatic, liver, and nutrition issues. This episode will discuss specific questions that you will want to cover in your history and the elements of a complete GI exam - which is a lot more than just an abdominal exam! Peds GI clinic covers a host of gastrointestinal, pancreatic, liver and nutrition issues -3yr fellowship after peds residency  Before Clinic  Review what types of patients you will be seeing. It may be a mix of lots of issues, or just a liver transplant clinic. This will tell you what type of prep you should do (conditions to read up on, medications to review, etc) before the day of clinic. On the day of clinic, review expectations with the attending, fellow or resident physician. Do they want you to see patient independently and write notes, just shadow or somewhere inbetween. Review what questions they always want asked, what exams you should do alone vs with your whole team. Setting expectations before you start will set you up for success!  Questions: Pain, the PQRST mnemonic is helpful to better understand the pain Provoked the pain Quality of the pain Radiating Severity  Specific questions to ask in Peds GI:  Does pain wakes the patient at night?  how much school or other activities the Patient has missed because of symptoms?  Does defecation or passage of gas alleviates pain?  Any specific dietary changes already tried? Poop! understand the: Quality of the stool Size and caliber of the bowel movement (Use Bristol stool scale) GERD vs EoE   A complete GI exam– a lot more than the abdomen!

This episode describes how to prepare for a newborn’s first outpatient visit after they have been 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. 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

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 parent/caregiver and their health provider. There are thus specific ways in which the adolescent well visit differs from well visits for younger children. We will discuss how you can approach these visits, how to handle patient confidentiality, and how to ask those sensitive questions. 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 breas

In this episode, we discuss how to best prepare for your time on the inpatient wards, including how to prepare before the rotation, how to pre-round, how to present a patient, and how to be an effective team member. 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

Providing vaccines is one of the most important health promotion activities that we do. However, it involves much more than just putting in the orders for the various vaccines. In this podcast episode, we will briefly review how vaccines work, the 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), and anticipatory guidance about vaccines. We will also talk a little bit about how to handle vaccine hesitancy. 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  

Today, we will be reviewing what you need to know to examine your pediatric patients. Examining children is a bit of an art form and is often unfamiliar to clerkship students who may have a varied degree of experience being around children, may never have worked with children and may not have been exposed to pediatric patients in the pre-clinical years. In this episode, we discuss tips and tricks to get the exam you need on your pediatric patient with as little crying as possible. 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

The sexual history is an important part of the adolescent visit. In this episode, we will discuss the importance of the sexual history and how to handle patient confidentiality. We will introduce the 5Ps framework for the sexual history. We will also brieflyy discuss screening for sexually transmitted infections (STIs), including human immunodeficiency virus (HIV). 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

Following safe sleep guidelines is the best way to protect a baby from dying suddenly and unexpectedly from sudden infant death syndrome (SIDS), accidental suffocation or strangulation, and deaths with unknown cause. Today we’re going to talk about what you need to know before you talk to a family about what safe sleep looks like for their infant. We’re going to talk about the importance of safe sleep habits, the AAP safe sleep recommendations, guidelines for infant sleep products, and tummy time. 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/pediatri

Many of our patients and their families are not proficient in English, and it's important to be able to communicate effectively with them.  In this episode, you’ll learn about how to work with an interpreter during encounters with patients who are not proficient in English. We’ll discuss dos and don’ts, common challenges, and tips for interacting with interpreters and families.   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 int

Prescribing medicines in pediatrics is different than prescribing medicines for adults. In this episode, we discuss what you need to know before prescribing medications for the pediatric population, including calculating dose for the child’s weight, choosing IV vs PO medications, and other considerations. 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  

Antibiotic selection can be complicated. In this episode, we discuss how you should approach choosing the appropriate antibiotic for your pediatric patient. There are multiple considerations, including: What organisms do you want to treat? What does anatomy have to do with antibiotic selection? You also have to think about individual circumstances, such as immunzation status, chronic disease, drug allergies, and environmental exposures. 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  

Today, we’ll be discussing how to evaluate and work up a patient with a suspected eating disorder. We’ll use a general case for an adolescent with an eating disorder to examine the different aspects of care you should be thinking about, from lab work to admission criteria and what to do once the diagnosis is made. 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

Today we will talk about what to expect before attending your first delivery as part of the pediatrics team while on the Newborn rotation. Each delivery is different and what is needed for each infant at the delivery can be different depending on the status of the infant at birth. In this episode, we will focus on the lower risk deliveries that you are most likely to attend during your newborn rotation, and what you can expect once the baby is born. 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)

This episode describes what you need to know before your first time working with a breastfeeding parent. This will include topics such as how to ensure families feel comfortable, benefits of and contraindications to breastfeeding, how to approach conversations about breastfeeding, and the science behind lactation or milk production. 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

This episode is a follow-up to “Before Your First Time Working with a Breastfeeding Mother”. We’ll be reviewing additional details about breastfeeding that can help you to answer some of the most common questions that come up for families. We will discuss strategies to improve milk production, newborn stomach volumes, how to know if baby is getting enough milk, what to do if baby isn’t getting enough milk, and breastfeeding complications. 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

Many of the pediatric inpatients you care for will need intravenous fluids and electrolytes. This episode describes what you need to know before you order fluids or electrolyte replacement for your patient. We will discuss maintenance fluid needs and talk more in depth about what fluids to order and at what rate. We will also talk about managing patients with dehydration and how to replete fluids. Then we will discuss a few cases where we will work through some more common electrolyte derangements and discuss how to manage them. We will end with additional clinical pearls that will be helpful during your time on the inpatient pediatric service. 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)

In this episode, we discuss things you’ll need to know and think about before seeing an infant with jaundice. We will focus on infants from birth to 2 months of age. We will discuss the pathophysiology of hyperbilirubinemia, the difference between unconjugated and conjugated hyperbilirubinemia, the differential diagnosis, key elements of the history and physical exam, laboratory and imaging workup, and management. 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)