Episodes
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Sepsis is a clinical syndrome in which an infection leads to an inflammatory response throughout the body that rapidly progresses to organ dysfunction or even death. Worldwide, neonatal sepsis affects 2,202 infants per 100,000 live births, and has a mortality rate of >11%. In the United States, early onset sepsis affects 50 in 100,000 live births, with a mortality rate of about 3%. So it’s a big problem that we don’t want to miss. In this episode, we will define neonatal sepsis, talk about the presentation of sepsis, what a sepsis workup entails, how to make the diagnosis and treatment of neonatal sepsis.
Defining Neonatal Sepsis Early Onset SepsisLate Onset SepsisNeonatal Early Onset Sepsis Calculator - https://neonatalsepsiscalculator.kaiserpermanente.org/Presentation of Illness and Physical Exam PathogenesisGroup B StrepScreening and prophylaxis E coliStrep viridansKlebsiellaEnterococcusListeria HSV Screening and prophylaxis Types of InfectionBacteremia PneumoniaMeningitis Work up CBC with differential Blood CultureUrinalysis and Urine CultureCerebrospinal Fluid culture Chest X-Ray Surface swabs of mucous membranes -
Iron deficiency is the most common nutritional deficiency that occurs in children in United States. Iron plays a vital role in cellular function in all organ systems. Today, we will be reviewing what you need to know before you first see a patient with possible iron deficiency. We will discuss why iron is so important, when and why iron deficiency occurs, screening, diagnosis, and treatment for iron deficiency.
Importance of Iron Iron and Hemoglobin Iron and NeurodevelopmentIron and the Immune SystemWhat happens in iron deficiencyReasons that children are at high risk for iron deficiency Rapid Growth . Insufficient dietary intake and limited absorption Increased losses Peaks of IncidenceOther risk factors for iron deficiency.Preterm infants Children who suffer from neuro-motor disorders as they often have nutritional deficiency related to swallowing impairmentG.I. diseases that cause malabsorption, Diseases predisposing them to bleeding.Lead toxicity. Screening for IDAHistory: Asking about prematurity, low birth weight, exclusive breastfeeding beyond 4 months of age, weaning to whole milk without addition of iron rich foods, feeding problems, and any past medical conditions. Exposure to lead (i.e. age/ condition of home, recent renovations, a parent who has occupational exposure, concerns about drinking water). Any possible symptoms of anemia, such as fatigue, breath holding spells, picaPhysical exam: pallor. Lab testing.Treatment for iron deficiency Oral iron: daily dose of 3 to 6 mg per kilogram of elemental iron divided into three doses is adequate.Give iron supplemen -
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Ear pain is one of the most common chief complaints pediatricians encounter in the outpatient setting and there are quite a few things you need to consider to make a thoughtful diagnosis, assessment, and plan. In this episode, we will discuss the differential diagnosis of ear pain in children, physical exam findings that will help you make a diagnosis, and treatment for the most common causes of ear pain.
Ear anatomyOuter ear, tympanic membrane (TM), middle ear, inner earEustacian tube in children is smaller in diameter and angled more horizontally than in adults. This makes it more difficult to drain fluid behind the middle ear and why kids are more prone to get ear infections when they get a cold than adults are. The adenoids also are thought to play a role in fluid collection and buildup. Taking a history for patient with chief complaint of ear painHow old is this child? Have they had a fever? Are there any other viral symptoms such as cough, runny nose, or sore throat? Has the child been swimming recently? Has the child put anything in their ears? Has there been any ear drainage or changes in hearing? Ear examinationMake sure that the child’s head is as still as possible How to use the otoscopeWhat to look for: Color of the TM. Fluid behind the TM Is the TM bulging or not bulgingLight reflex of the TMEar canalAcute otitis mediaInfectious causes - bacteria (especially Strep pneumonia, H influenzae, and Moraxella catarrhalis), virusesTreatmentAntibiotics vs. &ldq -
Child abuse, which is sometimes called non-accidental trauma, is a public health problem with life-long health consequences for survivors and their families. In this episode, we will review what you need to know before you encounter your first patient who may have or has been abused. We will focus on physical and sexual abuse of children.
Long term health consequences of child abuseWhy identification of child abuse is difficultIt is often difficult to distinguish an accidental injury from a non-accidental injuryA caregiver who has abused a child rarely confesses to harming the childChild may be brought to medical care by unsuspecting parentIt is emotionally difficult for us to confront parents when there are concerns for abuseMandated reporting of child abusePotential clues that a child may have been physically abusedMedical record reviewHistoryPhysical examDifferential diagnosis of physical abuseLabs and other tests that you may getThe role of the child protection team and child protective servicesPotential clues that a child may have been sexually abusedHistoryPhysical examLab testingMedical documentationResources/Links:
Christian CW; Committee on Child Abuse and Neglect, American Academy of Pediatrics. The evaluation of suspected child physical abuse. Pediatrics. 2015 May;135(5):e1337-54. doi: 10.1542/peds.2015-0356.Pierce MC, Kaczor K, Lorenz DJ, Bertocci G, Fingarson AK, Makorof K, Berger RP, Bennett B, Magana J, Staley S, Ramaiah V, Fortin K, Currie M, Herman BE, Herr S, Hymel KP, Jenny C, Sheehan K, Zuckerbraun N, Hickey S, Meyers G, Leventhal JM (2021) Validation of a clinical decision rule to predict abuse in young children based on bruising characteristics. JAMA Netw Open 4(4):e215832. -
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 contraindicationsPhysiology of hormonal optionsEfficacy of pregnancy preventionPatient considerations and concernsEmergency contraceptionMythsResources/links:
CDC MEC: https://www.cdc.gov/reproductivehealth/contraception/pdf/summary-chart-us-medical-eligibility-criteria_508tagged.pdfACOG contraception chart: https://www.acog.org/womens-health/infographics/effectiveness-of-birth-control-methodshttps://www.reproductiveaccess.org/https://www.bedsider.org/ -
In today’s episode, we are talking about normal child development. We will talk about why this is important and how you will be evaluating children’s development. We will go over major milestones in the 4 developmental domains: movement/physical development – or gross and fine motor, language/communication, cognitive, and social/emotional. We will go over some common cases. Finally, we will briefly discuss what you should do if you suspect developmental delay. Why it is important to learn about developmental delay.
Why it is important to learn about developmentDevelopmental surveillance versus developmental screening versus diagnosis of developmental issuesDevelopmental domains/categories:Expressive languageReceptive languageGross motor: this is how you use all of your big muscles Fine motor: hand/eye coordination Social/emotional: how children interact with others and show emotion. 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.Cognitive: how children learn new things and solve problemsMovement/Physical Development: how children use their bodies. Learning milestonesLearn the schedule for well child visitsWatch children at different ages to see what they can do. Gross motor milestones: 1 year goal is to be able to walk independently.Fine motor milestones: 1 year goal is to be able to put food into one’s mouthLanguage and communication milestones: 1 year goal is to be able to say a few wordsSocial 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. CasesWhat if there is developmental delayResources/Links:
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Neonatal hypoglycemia is a common and often transient issue for newborns during a period of transition from intrauterine to extrauterine life. Many infants with hypoglycemia are screened for it and treated for it in the nursery, and a handful will require NICU admissions. This podcast will help you understand these things about neonatal hypoglycemia:
Why we worry What causes itWhich infants are most at riskHow to treat it and who needs the NICUResources/Links:
https://downloads.aap.org/AAP/PDF/Seminars_in_Fetal_Neonatal_Medicine.pdfhttps://publications.aap.org/hospitalpediatrics/article/11/6/595/180015/Practice-Variations-in-Diagnosis-and-Treatment-ofhttps://publications.aap.org/aapnews/news/25073/Myriad-unknowns-regarding-neonatal-hypoglycemia?autologincheck=redirected -
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 typesPreparing for your first visitInitial evaluation of ADHD vs. med checkReviewing prior visitsDuring an initial visit:Evaluating historical features Behaviors at home, behaviors at schoolCommon misconceptions about ADHDSurrounding factors and comorbidities/misdiagnosisPhysical ExamImportant features of the examObserving the child’s behaviorRole of the VanderbiltScoring a VanderbiltTreatmentMedication vs. non-pharmacologic interventionsOverview of different medicationsStimulantsNonstimulantsChoosing a medicationFamily historyComorbiditiesTitrating medicationsFollow-up visitsSymptoms to look forResources/Links:
Vanderbilt Scoring: https://www.uwmedicine.org/sites/stevie/files/2019-11/sodbp_vanderbilt_scoringinstructions.pdfParent Training in Behavior Management for ADHD: https://www.cdc.gov/ncbddd/adhd/behavior-therapy.htmlDosing guidelines when switching from one stimulant to another in the treatment of attention deficit hyperactivity disorder in children and adolescents: https://www.uptodate.com/contents/image?imageKey=PEDS%2F61007
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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 hyperbilirubinemiaJaundice is the yellowing of skin, sclerae, and mucous membranes caused by hyperbilirubinemiaHyperbilirubinemia can be further separated into unconjugated or conjugated forms, which allows us to further differentiate etiologyReview of bilirubin breakdown pathway, to include enterohepatic circulationUnconjugated hyperbilirubinemia etiologies:Excessive or increased production of bilirubinCephalohematomasHemolysis: ABO and Rh incompatibilities; Red Blood Cell (RBC) membrane or enzyme defects, RBC oxidative stress (secondary to sepsis, asphyxia, and acidosis)Decreased clearance of bilirubinBreast milk jaundicePrematurityHypothyroidismGilbert SyndromeCrigler-Najjar SyndromeSuboptimal Intake JaundiceMedicationsCombination of bothPhysiologic jaundiceConjugated hyperbilirubinemia etiologies:Always pathologicBiliary atresiaBriefly mentioned the vast range of other etiologies: infectious, genetic, metabolic, and anatomicKey elements of history and physical examination for a jaundiced infantHistory:OnsetFeeding patterns (what, how much/often, quality of feeding) -
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.
IntroductionDefinition of maintenance fluid needsImportant considerations about maintenance fluidsDiscussion regarding which fluids to order for different patient populations and at what rate to administerRole of ADH in hospitalized patientsHow to order a fluid bolus—amount, composition, and rate administeredAssessing your patient with dehydration utilizing physical exam findings, vital signs, and other objective data such as weightCase scenarios: Identification and management of hyperkalemia and hypokalemiaCase #1- 12-year old with hyperkalemia following infection with influenzaCase #2- 2-year old child with history of neglect and malnutritionAdditional clinical pearls including the association between albumin and calcium, acidosis/alkalosis and potassium levelsResources/Links:
Clinical Practice Guideline: Maintenance Intravenous Fluids in Children | Pediatrics | American Academy of Pediatrics (aap.org)
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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 productionLatchingNewborn stomach volumesHow to know if baby is getting enough milkWhat to do if baby isn’t getting enough milkManual expression and pumpingBreastfeeding complicationsResources/Links:
Bella Breastfeeding Curriculum on Open Pediatrics (free): www.openpediatrics.orgVirginia Department of Health/Breastfeeding Education Consortium Online Course (free for those who live or work in Virginia): https://bfconsortium.orgAmerican 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-practiceAAP 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-statesNEWT Curve: https://newbornweight.orgUpToDate “Initiation of Breastfeeding”: https://www.uptodate.com/contents/initiation-of-breastfeeding
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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 comfortableBenefits of breastfeeding for mom and babyContraindications to breastfeedingApproaching conversations about breastfeeding with familiesThe process of lactogenesis (milk production)Resources/Links:
Bella Breastfeeding Curriculum on Open Pediatrics (free): www.openpediatrics.orgVirginia Department of Health/Breastfeeding Education Consortium Online Course (free for those who live or work in Virginia): https://bfconsortium.orgAmerican 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-practiceAAP 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-statesNEWT Curve: https://newbornweight.orgUpToDate “Initiation of Breastfeeding”: https://www.uptodate.com/contents/initiation-of-breastfeeding
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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 pageDifferences 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 warmerDelayed 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 warmerNeonatal Resuscitation
NRP guidelines from American Academy of PediatricsPertinent Physical Exam at delivery
Importance of full, efficient exam in delivery roomNeed for Higher Level Intervention: Neonatal Intensive Care
Reasons for calling for NICU: high-risk delivery teamResources/Links:
Neonatal Resuscitation Program (NRP)/American Academy of PediatricsNeonatal Resuscitation Program (aap.org)
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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 disordersResources/Links:
The American Psychiatric Association Practice Guideline for the Treatment of Patients with Eating Disorders, 2023, https://doi.org/10.1176/appi.books.9780890424865.Laurie L. Hornberger, Margo A. Lane, THE COMMITTEE ON ADOLESCENCE, Laurie L. Hornberger, Margo Lane, Cora C. Breuner, Elizabeth M. Alderman, Laura K. Grubb, Makia Powers, Krishna Kumari Upadhya, Stephenie B. Wallace, Laurie L. Hornberger, Margo Lane, MD FRCPC, Meredith Loveless, Seema Menon, Lauren Zapata, Liwei Hua, Karen Smith, James Baumberger; Identification and Management of Eating Disorders in Children and Adolescents. Pediatrics January 2021; 147 (1): e2020040279. 10.1542/peds.2020-040279
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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 treatBecause we often treat empirically, we need to know organisms that typically case this typical infectionNarrow-spectrum antibiotics if possibleAnatomy of the infectionFor fever in first 4-6 weeks, think about organisms that infant was exposed to during pregnancy and deliveryFor respiratory infections, think about organisms that live in the respiratory tractAbnormal anatomyImmunization status of child may change your differential diagnosisDrug allergiesLook in medical record and ask patient and family about allergiesConsider cross-reactivity of antibioticsGeographic location: resistance patternsIndividual circumstancesChronic diseasesEnvironmental exposuresResources/Links:
Up to date: uptodate.com
American Academy of Pediatrics Red Book: https://publications.aap.org/redbook?autologincheck=redirected
Sanford Guide to Antimicrobial therapy: https://www.sanfordguide.com/products/print-guides/?gad=1&gclid=CjwKCAjwtuOlBhBREiwA7agf1oWtsyBrx0OFaHxpG2ZpDTXYukd1JGs5R_ZpRWrECT_v0bqhboN15hoCijIQAvD_BwE
American Academy of Pediatrics clinical practice guideline: The Diagnosis and Management of Acute Otitis Media. 2013. https://publications.aap.org/pediatrics/article/131/3/e964/30912/The-Diagnosis-and-Management-of-Acute-Otitis-Media
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Prescribing medicines in pediatrics is different than prescribing medicines for adults. In this episode, we discuss what you need to know before prescribing medications for the pediatric population, including calculating dose for the child’s weight, choosing IV vs PO medications, and other considerations.
1) References to look up pediatric drug doses and frequencies.
2) Calculating weight-based doses
3) Maximum daily doses
4) Different formulations of medications
5) Prescribing oral medicines
Pills vs Liquid Consider taste Use the most concentrated suspension Use milliliters instead of spoonfuls6) What if the medicine is not available in liquid form
7) Options if oral medications are not easily available in liquid form.
8) Medicine dosing frequency – use the least frequent option
9) Acetaminophen and Ibuprofen
Resources/Links:
Up to date: uptodate.com
Harriet Lane Handbook: https://evolve.elsevier.com/cs/product/9780323876988?role=student
Lexi-Comp: https://apps.apple.com/ca/app/lexicomp/id313401238
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Many of our patients and their families are not proficient in English, and it's important to be able to communicate effectively with them. In this episode, you’ll learn about how to work with an interpreter during encounters with patients who are not proficient in English. We’ll discuss dos and don’ts, common challenges, and tips for interacting with interpreters and families.
Definitions Interpretation vs translation Modes of interpretation When do I need an interpreter?III. Who should not serve as an interpreter?
Non-certified team members Patient’s non-certified friends or community members Patient’s family members Getting started Verify preferred language Positions in the room Introductions, including of the interpreter and recording interpreter’s information Conducting the visit How long to speak before awaiting interpretation During the physical exam Teach-back method via interpreter Trouble-shooting When the patient declines interpreter services When you think the interpreter is misinterpreting When you have technical difficulties or ambient noiseVII. At the end of the encounter
Translating written patient materials Considering variable written and medical literacies Next steps and follow-up careVIII. After the visit
Documentation of your use of int -
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 environmentsAsking about sleep practicesABCs of safe sleep: Alone, Back, CribSafe sleep recommendations:
Infants should be on their backsInfants should sleep on a firm, flat, noninclined sleep surfaceThere 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 timeParents 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 birthInfants should be fully immunized.Commercial sleep products are only safe if they are consistent with safe sleep recommendationsTummy timeReferences:
Moon RY, Carlin RF, Hand I, American Academy of Pediatrics Task Force on Sudden Infant Death Syndrome and the Committee on Fetus and Newborn. Sleep-Related Infant Deaths: Updated 2022 Recommendations for Reducing Infant Deaths in the Sleep Environment. Pediatrics. 2022 Jul 1; 150(1):e2022057990. https://publications.aap.org/pediatri -
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 importantConfidentiality5 Ps Framework PartnersPracticesProtection of STIsPast history of STIsPregnancy IntentionSTI Screening and TreatmentHIV screening algorithmReferences:
5 Ps Framework:
https://www.cdc.gov/std/treatment/SexualHistory.htmSTI Screening and Treatment:
https://www.cdc.gov/std/treatment-guidelines/provider-resources.htm#MobileApphttps://www.cdc.gov/std/treatment-guidelines/default.htmHIV screening algorithm:
https://stacks.cdc.gov/view/cdc/50872 -
Today, we will be reviewing what you need to know to examine your pediatric patients. Examining children is a bit of an art form and is often unfamiliar to clerkship students who may have a varied degree of experience being around children, may never have worked with children and may not have been exposed to pediatric patients in the pre-clinical years. In this episode, we discuss tips and tricks to get the exam you need on your pediatric patient with as little crying as possible.
How to examine a baby/infantHow to examine a toddler/preschool aged childFocused information on the ear exam/otoscopyHow to examine a school aged child/teenEngaging older children in your examFocused information on the genitourinary exam Presenting your physical exam during oral presentation
Resources/Links:Bates' Guide to Physical Examination and History Taking by Lynn Bickley (your pediatric clinics will generally have a copy)
https://batesvisualguide.com
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