Clerkship Ready: Pediatrics (MedReady)

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 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

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 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.

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

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

Next follow up ap...

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:

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

During visit:

1. Introduce yourself; ask how they would like to be addressed
2. Review structure of visit, including genital exam and interviewing adolescent alone; importance of confidentiality
3. Direct questions to adolescent as much as possible
4. Concerns from adolescent/parent or from prior visits that require follow up or updates
5. 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. 
6. Nutrition: number of meals/snacks, dairy intake 
7. Sleep: nighttime and naps
8. Screen time: duration, type(s)
9. Dental: frequency of brushing, last seen by dentist
10. Menstrual history: Age of menarche, frequency, length of periods, heaviness of flow, symptoms associated with menses
11. Review medications, allergies, growth chart, vaccines
12. Confidential interview: any additional questions or concerns; Home, Drugs and substance use; Emotions, eating, and depression; Sexuality; Safety

Physical exam

1. Head to toe
2. Discuss acne
3. Need chaperone for breast and genital exam

Preparation for oral presentation 

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.

1. Before the Rotation
   1.  Reach out to your team..
   2. Understand what first day expectations are. 
   3. Peruse the patient list.
   4. Identify what study materials and resources will help you excel.
   5. Come ready to learn and have fun! 
2. How to Pre-round

1. Collect information on previous day and overnight events - includes talking with resident or night team, reading all notes from day prior
2. Review all vitals from past day
3. Review and calculate “Ins and Outs”
4. Review all labs
5. Check to see what medications, including PRN meds, your patient got
6. Introduce yourself to patient and family - get their input on how patient is doing 
7. Collect your thoughts, interpret your data, and formulate your assessment and plan for your presentation and note

1. How to Present a Patient on the inpatient wards service
   1. Begin with one liner
   2. Subjective: interval and overnight events
   3. Any patient or caregiver concern or question noted when you prerounded
   4. Ins and Outs
   5. Vital signs
   6. Head-to-toe physical exam
   7. Labs, microbiology, and radiology
   8. Assessment one-liner
   9. Plan
2. How to be an effective team member
   1. Touch base with a resident to run through your assessment and plan. 
   2. Show initiative
   3. Be honest and direct
   4. On rounds, listen to all patient presentations, not just your own
   5. Follow up on tasks for your patients (and other patients on the team) and make sure they are carried through
   6. Revisit your patients to keep them updated
   7. Write notes and ask for feedback on your notes

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.

1. List of pediatric vaccines
2. How vaccines work
   1. Harmless piece of the pathogen that is enough to create immune response
   2. Explaining how vaccines work to parents
      1. Emphasis on protecting the community, not just one person
      2. Analogy of vaccine being like a software update
      3. Analogy of vaccine being like a flame retardant that stops a fire from spreading
      4. Analogy of vaccine being like an insecticide that stops bugs from spreading
3. Types of vaccines
   1. Live, attenuated vaccines – cannot be given to patients with immunocompromise
   2. Vaccines without live, attenuated pathogen – includes mRNA vaccines
   3. RSV vaccines
      1. Vaccine for older adults and pregnant adults
      2. Monoclonal antibody for infants
4. What you need to do before the visit
   1. Review the vaccine record
   2. Review the medical record for vaccine contraindications
5. What you should review with families before ordering the vaccines (including precautions and contraindications)
   1. Current or recent illness
   2. Allergies
   3. Problems with vaccines in the past
   4. Chronic disease
   5. History of intussusception, seizures, neurological problems
   6. History of blood transfusion, immunoglobulin or antiviral medications
   7. Pregnancy
6. Anticipatory guidance about vaccines
   1. Common side effects are a sign that vaccines are working
   2. Treatment of fever
7. How to handle vaccine...

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.

1. How to examine a baby/infant
2. How to examine a toddler/preschool aged child
3. Focused information on the ear exam/otoscopy
4. How to examine a school aged child/teen
5. Engaging older children in your exam
6. Focused information on the genitourinary exam 
7. Presenting your physical exam during oral presentation

Resources/Links:

1. Bates' Guide to Physical Examination and History Taking by Lynn Bickley (your pediatric clinics will generally have a copy)

2. 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:

1. 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
2. Won’t my baby choke if they spit up when placed on their back to sleep?

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.

1.   Definitions
2.   Interpretation vs translation
3.   Modes of interpretation
4.   When do I need an interpreter?

III.           Who should not serve as an interpreter?

1.   Non-certified team members
2.   Patient’s non-certified friends or community members
3.   Patient’s family members
4.   Getting started
5.   Verify preferred language
6.   Positions in the room
7.   Introductions, including of the interpreter and recording interpreter’s information
8.   Conducting the visit
9.   How long to speak before awaiting interpretation
10.   During the physical exam
11.   Teach-back method via interpreter
12.   Trouble-shooting
13.   When the patient declines interpreter services
14.   When you think the interpreter is misinterpreting
15.   When you have technical difficulties or ambient noise

VII.         At the end of the encounter

1.   Translating written patient materials
2.   Considering variable written and medical literacies
3.   Next steps and follow-up care

VIII.        After the visit

1.   Documentation of your use of interpreter services
2.   Verification of preferred language

Resources:

–...

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

1.   Pills vs Liquid
2.   Consider taste
3.   Use the most concentrated suspension
4.   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

1. Case #1- 12-year old with hyperkalemia following infection with influenza
2. 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)
    • Urine and stool diapers
    • Prenatal history
    • Delivery history
    • Family history
  • Physical exam:<...

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

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

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.

1. Why it is important to learn about development
2. Developmental surveillance versus developmental screening versus diagnosis of developmental issues
3. 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. 
4. Learning milestones
   1. Learn the schedule for well child visits
   2. Watch children at different ages to see what they can do. 
5. Gross motor milestones: 1 year goal is to be able to walk independently.
6. Fine motor milestones: 1 year goal is to be able to put food into one’s mouth
7. Language and communication milestones: 1 year goal is to be able to say a few words
8. 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. 
9. Cases
10. 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://agesandstag...

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/

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. 

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

Resources/Links:

1. 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.
2. 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
3. Smith T, Chauvin-Kimoff L, Baird B, Ornstein A. The medical evaluation of prepubertal children with s...

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. 

1. Ear anatomy
   1. Outer ear, tympanic membrane (TM), middle ear, inner ear
   2. 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. 
   3. The adenoids also are thought to play a role in fluid collection and buildup. 
2. Taking a history for patient with chief complaint of ear pain
   1. How old is this child? 
   2. Have they had a fever? 
   3. Are there any other viral symptoms such as cough, runny nose, or  sore throat? 
   4. Has the child been swimming recently? 
   5. Has the child put anything in their ears? 
   6. Has there been any ear drainage or changes in hearing? 
3. Ear examination
   1. Make sure that the child’s head is as still as possible 
   2. How to use the otoscope
   3. What to look for: 
      1. Color of the TM. 
      2. Fluid behind the TM 
      3. Is the TM bulging or not bulging
      4. Light reflex of the TM
      5. Ear canal
4. Acute otitis media
   1. Infectious causes - bacteria (especially Strep pneumonia, H influenzae, and Moraxella catarrhalis), viruses
   2. Treatment
      1. Antibiotics vs. “watch and wait approach”
      2. Criteria for using antibiotics
      3. Antibiotic options
      4. Indications for tympanostomy tubes
   3. Acute otitis externa (“Swimmer’s ear”)

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.

1. Importance of Iron 
   1. Iron and Hemoglobin 
   2. Iron and Neurodevelopment
   3. Iron and the Immune System
2. What happens in iron deficiency
3. Reasons that children are at high risk for iron deficiency 
   1. Rapid Growth . 
   2. Insufficient dietary intake and limited absorption 
   3. Increased losses 
4. Peaks of Incidence
5. Other risk factors for iron deficiency.
   1. Preterm infants 
   2. Children who suffer from neuro-motor disorders as they often have nutritional deficiency related to swallowing impairment
   3. G.I. diseases that cause malabsorption, 
   4. Diseases predisposing them to bleeding.
   5. Lead toxicity. 
6. Screening for IDA
   1. 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. 
   2. Exposure to lead (i.e. age/ condition of home, recent renovations, a parent who has occupational exposure, concerns about drinking water). 
   3. Any possible symptoms of anemia, such as fatigue, breath holding spells, pica
   4. Physical exam: pallor. 
   5. Lab testing.
7. Treatment for iron deficiency 
   1. Oral iron: daily dose of 3 to 6 mg per kilogram of elemental iron divided into three doses is adequate.
   2. 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.
   3. Supplements should be continued for a minimum of three months to reestablish iron stores. After completion of treatment, reassessment of iron status 
   4. In addition to iron supplementation, the other aspect...

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.

1. Defining Neonatal Sepsis 
   1. Early Onset Sepsis
   2. Late Onset Sepsis
2. Neonatal Early Onset Sepsis Calculator - https://neonatalsepsiscalculator.kaiserpermanente.org/
3. Presentation of Illness and Physical Exam 
4. Pathogenesis
   1. Group B Strep
      1. Screening and prophylaxis 
   2. E coli
   3. Strep viridans
   4. Klebsiella
   5. Enterococcus
   6. Listeria 
   7. HSV 
      1. Screening and prophylaxis 
5. Types of Infection
   1. Bacteremia 
   2. Pneumonia
   3. Meningitis 
6. Work up 
   1. CBC with differential 
   2. Blood Culture
   3. Urinalysis and Urine Culture
   4. Cerebrospinal Fluid culture 
   5. Chest X-Ray 
   6. Surface swabs of mucous membranes 
7. Antimicrobial coverage
8. Evaluation and Treatment of a Well Appearing Febrile Infant 8-60 days old
   1. https://doi.org/10.1542/peds.2021-052228
   2. 8-21 days <...

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).

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. 

1. Sources of lead exposure 
   1. Ingestion of contaminated food or water
   2. Ingestion or breathing in of lead dust
   3. Other sources: lead-acid batteries, ammunition, lead-based pigments and paints, stained glass, lead crystal glasses, ceramic glazes, jewelry, toys
   4. For families from other cultures, think about ceramic glazes, traditional cosmetics, traditional medicines
2. Government policies to decrease lead exposure
   1. Unleaded gasoline
   2. Lead-free paint
   3. Lead-free solder in food cans
   4. Lead-free water pipes
3. Why young children are at risk for lead toxicity
   1. Hand-to-mouth behavior
   2. Increased absorption of lead
   3. Developing nervous system is vulnerable
   4. Calcium or iron deficiency increase absorption of lead
4. Effects of lead toxicity in children can be seen at levels as low as 3.5 µg/dL
   1. Growth and development delays
   2. Lower IQ
   3. Learning and behavior problems
   4. Hearing and speech problems
   5. School underperformance
   6. At higher levels, you may see
      1. Irritability
      2. Loss of appetite, weight loss, fatigue
      3. Abdominal pain, vomiting, and/or constipation
      4. Anemia
      5. Pica
      6. Seizures, coma, death
5. Universal lead screening at 1 and 2 years
   1. Screening questionnaires are not very sensitive or specific 
   2. Blood lead test 
      1. Capillary – get results quickly, but can be falsely elevated

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!

1. Cause of asthma
   1. Genetics: “Atopic triad” of asthma, atopic dermatitis or eczema, and allergic rhinitis 
   2. Prenatal and childhood environmental factors: maternal smoking and allergen exposure 
2. Pathophysiology and diagnosis 
   1. 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.”
   2. Airway hyperreactivity leads to inflammation of bronchi, increased mucus production, bronchial smooth muscle contraction
   3. 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.
   4. Identification of triggers is important. Common triggers include respiratory infections, mold or pet dander, pollen, intense crying or laughing, exercise, pollution, and cold air. 
   5. 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.
3. Classification of asthma: determined by the frequency and severity of symptoms when they are not receiving preventative treatment.
4. New 2022 guidelines for asthma treatment
   1. Albuterol or other beta 2 agonist as needed for symptoms - relaxes bronchial smooth muscles
   2. Daily controller medication (usually inhaled steroid) if symptoms more than twice weekly - inhaled steroid decreases inflammation
   3. Inhaled steroid + long-acting beta 2 agonist combination inhaler preferred for those >5 years
   4. Asthma action plan should be given to every patient
5. Treatment of acute asthma attack
   1. Quick assessment and stabilization of patient is important
   2. Treat acute symptoms first, then address chronic control of asthma
   3. Albuterol or ipratropium-albuterol, systemic steroids are generally first lines of treatment

Listen along as we dive into the many causes of sore throat. Learn about the common causes such as allergies and viral illnesses while also what to do when a child with epiglottitis comes in.  We will cover CENTOR criteria as well and when you should think about Group A strep testing.

Common Causes

• Viral Presentation
  • HSV
  • Mononucleosis
• Allergic Presentation
• Group A Strep 
  • CENTOR Criteria

Emergency Causes

• Peritonsillar Abscess
• Retropharyngeal Abscess
• Epiglottitis

Wrap Up & Conclusion

Resources/Links:

https://www.chop.edu/conditions-diseases/throat-anatomy-and-physiology 

https://www.mdcalc.com/calc/104/centor-score-modified-mcisaac-strep-pharyngitis 

References

1. Aluma Chovel-Sella, Amir Ben Tov, Einat Lahav, Orna Mor, Hagit Rudich, Gideon Paret, Shimon Reif; Incidence of Rash After Amoxicillin Treatment in Children With Infectious Mononucleosis. Pediatrics May 2013; 131 (5): e1424–e1427. 10.1542/peds.2012-1575
2. Becker JA, Smith JA. Return to play after infectious mononucleosis. Sports Health. 2014 May;6(3):232-8. doi: 10.1177/1941738114521984. PMID: 24790693; PMCID: PMC4000473.
3. Chowdhury MDS, Koziatek CA, Rajnik M. Acute Rheumatic Fever. [Updated 2023 Aug 2]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2024 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK594238/
4. Esposito, S.; De Guido, C.; Pappalardo, M.; Laudisio, S.; Meccariello, G.; Capoferri, G.; Rahman, S.; Vicini, C.; Principi, N. Retropharyngeal, Parapharyngeal and Peritonsillar Abscesses. Children 2022,9,618. https://doi.org/ 10.3390/children9050618 
5. Martin JM. The Mysterie...