Clerkship Ready: Pediatrics

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”)
      1. Causes
      2. Clinical presentation
      3. Treatment
   4. Foreign body in ear
   5. 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

Links:

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

About the Speaker:

Host: Chris Stadnick, MD – Chris Stadnick, MD is a board-certified pediatrician at Metropolitan Pediatrics in Portland, Oregon. He earned his MD from the University of Tennessee Health Science Center and completed his pediatric residency at the University of Virginia.

Clerkship Ready: Pediatrics is a podcast aimed at medical students doing their clinical clerkship in Pediatrics. The views expressed are the speakers' own and do not constitute medical advice.

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 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

Links:

https://doi.org/10.1001/jamanetworkopen.2021

About the Speaker:

Host: Cindy Christian, MD – Cindy Christian, MD holds the Anthony A. Latini endowed Chair in the Prevention of Child Abuse and Neglect at Children's Hospital of Philadelphia. She is a Professor of Pediatrics at UPenn's Perelman School of Medicine and an internationally recognized expert in child maltreatment.

Clerkship Ready: Pediatrics is a podcast aimed at medical students doing their clinical clerkship in Pediatrics. The views expressed are the speakers' own and do not constitute medical advice.

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/

Links:

https://www.cdc.gov/reproductivehealth/contraception/pdf/summary-chart-us-medical-eligibility-criteria_508tagged.pdf

About the Speaker:

Host: Rebecca Hu, MD – Rebecca Hu, MD is a pediatrician at Signature Healthcare in Brockton, Massachusetts. She completed her pediatric residency at the University of Virginia, where she served as a chief resident with interests in adolescent health and developmental-behavioral pediatrics.

Clerkship Ready: Pediatrics is a podcast aimed at medical students doing their clinical clerkship in Pediatrics. The views expressed are the speakers' own and do not constitute medical advice.

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://agesandstages.com/products-pricing/asq3/
• Modified Checklist for Autism in Toddlers (MCHAT): https://www.mchatscreen.com/

Links:

https://www.cdc.gov/ncbddd/actearly/milestones/index.html

About the Speaker:

Host: Rachel Moon, MD – Rachel Moon, MD is the Harrison Distinguished Professor of Pediatrics at UVA Health Children's. She is an internationally recognized researcher in sudden unexpected infant death and chairs the AAP Task Force on SIDS. She is also the Chief of General Pediatrics at UVA.

Clerkship Ready: Pediatrics is a podcast aimed at medical students doing their clinical clerkship in Pediatrics. The views expressed are the speakers' own and do not constitute medical advice.

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

Links:

https://downloads.aap.org/AAP/PDF/Seminars_in_Fetal_Neonatal_Medicine.pdf

About the Speaker:

Host: Joanna Parga-Belinkie, MD – Joanna Parga-Belinkie, MD is an Associate Professor of Clinical Pediatrics in Neonatology at the University of Pennsylvania and Attending Physician at Children's Hospital of Philadelphia (CHOP).

Clerkship Ready: Pediatrics is a podcast aimed at medical students doing their clinical clerkship in Pediatrics. The views expressed are the speakers' own and do not constitute medical advice.

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

Links:

https://www.uwmedicine.org/sites/stevie/files/2019-11/sodbp_vanderbilt_scoringinstructions.pdf

About the Speaker:

Host: Lauren Ferguson, MD – Lauren Ferguson, MD is an Assistant Professor of Pediatrics at the University of Utah. She graduated from Virginia Tech Carilion School of Medicine and completed her residency and chief year at UVA, with clinical interests in newborn medicine, breastfeeding, mental health, and ADHD management.

Clerkship Ready: Pediatrics is a podcast aimed at medical students doing their clinical clerkship in Pediatrics. The views expressed are the speakers' own and do not constitute medical advice.

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:
    • Growth curves
    • Assessing liver size: percussion vs scratch test
    • Neurologic exam
• Review of laboratory and imaging work up for a jaundiced infant
• Brief discussion on management of unconjugated hyperbilirubinemia etiologies
  • Feeding
  • Phototherapy
  • Review of neurotoxicity risk factors
• Brief discussion on management of conjugated hyperbilirubinemia, specifically biliary atresia
  • Early referral to Pediatric Gastroenterology
  • Kasai portoenterostomy
  • Liver transplant
  • Maximizing nutrition

Resources/Links:

• Kemper, A. R., Newman, T. B., Slaughter, J. L., Maisels, M. J., Watchko, J. F., Downs, S. M., ... & Russell, T. L. (2022). Clinical practice guideline revision: management of hyperbilirubinemia in the newborn infant 35 or more weeks of gestation. Pediatrics, 150(3).
• Pan, D. H., & Rivas, Y. (2017). Jaundice: newborn to age 2 months. Pediatrics in Review, 38(11), 499-510.
• Chou, J. PediTools. AAP 2022 Hyperbilirubinemia management guidelines. https://peditools.org/bili2022/. Published 2012. Updated 2023. Accessed Aug 18, 2023.

Links:

https://peditools.org/bili2022/

About the Speaker:

Host: Ashlee Commeree, MD – Ashlee Commeree, MD is a pediatric critical care medicine physician at the University of Utah in Salt Lake City. She completed her pediatric residency at the University of Virginia before pursuing fellowship training in pediatric critical care.

Clerkship Ready: Pediatrics is a podcast aimed at medical students doing their clinical clerkship in Pediatrics. The views expressed are the speakers' own and do not constitute medical advice.

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)

Links:

https://publications.aap.org/pediatrics/article/142/6/e20183083/37529/Clinical-Practice-Guideline-Maintenance?autologincheck=redirected

About the Speaker:

Host: Lisa Hainstock, MD – Lisa Hainstock, MD is an Associate Professor of Pediatrics and Director of the Pediatric Residency Program at UVA Health. She is board-certified in hospital medicine and general pediatrics with interests in children with medical complexity and medical education.

Clerkship Ready: Pediatrics is a podcast aimed at medical students doing their clinical clerkship in Pediatrics. The views expressed are the speakers' own and do not constitute medical advice.

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
  

Links:

https://newbornweight.org/

About the Speaker:

Host: Emily Fronk – Emily Fronk is a former UVA School of Medicine student who has published research on virtual reality in pediatrics and pain management in pediatric patients.

Clerkship Ready: Pediatrics is a podcast aimed at medical students doing their clinical clerkship in Pediatrics. The views expressed are the speakers' own and do not constitute medical advice.

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
  

Links:

https://newbornweight.org/

About the Speaker:

Host: Emily Fronk – Emily Fronk is a former UVA School of Medicine student who has published research on virtual reality in pediatrics and pain management in pediatric patients.

Clerkship Ready: Pediatrics is a podcast aimed at medical students doing their clinical clerkship in Pediatrics. The views expressed are the speakers' own and do not constitute medical advice.