Clerkship Ready: Pediatrics

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)

Links:

https://www.aap.org/en/learning/neonatal-resuscitation-program/

About the Speaker:

Host: Jolene "Jody" Carlton, DNP, APRN, CPNP-PC/AC, RNC-NIC, EMT-B – Jolene "Jody" Carlton, DNP, APRN is a Pediatric Nurse Practitioner affiliated with UVA Health University Medical Center in Charlottesville. She holds multiple certifications including CPNP-PC/AC and RNC-NIC.

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.

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

Links:

https://doi.org/10.1176/appi.books.9780890424865

About the Speaker:

Host: Sam Baldazo, MD – Sam Baldazo, MD completed his pediatric residency at UVA, where he was involved with the wellness committee and process improvement initiatives. He is currently a Hospice and Palliative Care Fellow.

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.

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

Links:

https://publications.aap.org/redbook?autologincheck=redirected

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.

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

Links:

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

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.

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:

–         “Addressing Low Health Literacy and Limited English Proficiency,” American Academy of Pediatrics: https://www.aap.org/en/practice-management/providing-patient--and-family-centered-care/addressing-low-health-literacy-and-limited-english-proficiency/

–         “Guidelines for Use of Medical Interpreter Services,” Association of American Medical Colleges: https://www.aamc.org/media/24801/download

–         “Appropriate Use of Medical Interpreters,” American Academy of Family Physicians: https://www.aafp.org/pubs/afp/issues/2014/1001/p476.html

–         “Working effectively with an interpreter,” U.S. Department of Health and Human Services Office of Minority Health: https://thinkculturalhealth.hhs.gov/assets/pdfs/resource-library/working-effectively-with-interpreter.pdf

Links:

https://www.aap.org/en/practice-management/providing-patient--and-family-centered-care/addressing-low-health-literacy-and-limited-english-proficiency/

About the Speaker:

Host: Irène Mathieu, MD, MPH, FAAP – Irène Mathieu, MD, MPH, FAAP is an Associate Professor of Pediatrics at UVA and core faculty at the Center for Health Humanities & Ethics. She is a primary care pediatrician, award-winning poet with four published collections, and a Fulbright Fellow who completed her residency at 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.

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? https://safetosleep.nichd.nih.gov/reduce-risk/back-sleeping

Links:

https://publications.aap.org/pediatrics/article/150/1/e2022057990/188304/Sleep-Related-Infant-Deaths-Updated-2022?autologincheck=redirected

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.

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

Links:

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

About the Speaker:

Host: Jennifer Louis-Jacques, MD, MPH – Jennifer Louis-Jacques, MD, MPH is an Associate Professor of Pediatrics specializing in Adolescent Medicine at UVA Health. She trained at Columbia/NYU and completed her fellowship at Boston Children's Hospital, with special interests in eating disorders and menstrual disorders.

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.

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

Links:

https://batesvisualguide.com/

About the Speaker:

Host: Shakun Gupta, MD – Shakun Gupta, MD is an Associate Professor of Pediatrics and Associate Clerkship Director at the University of Virginia. She completed her residency at Lurie Children's Hospital/Northwestern and joined UVA in 2014, where she practices general pediatrics and pediatric hospital medicine.

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.

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. Shared decision making
   2. Common side effects are a sign that vaccines are working
   3. Treatment of fever
7. How to handle vaccine hesitancy
   1. Recommend the vaccines
   2. Ask if they have questions that you can answer
   3. Provide reputable resources
   4. Helping older children with their anxiety about being vaccinated

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

Links:

http://www.cdc.gov/vaccines

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.

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

About the Speaker:

Host: Krista Roncone, MD – Krista Roncone, MD, FAAP completed her pediatric residency at the University of Virginia. She is a board-certified pediatrician with interests in humanitarian assistance, global health, 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.