Pediatric Component, Year 2

ACE: Year 2 - Pediatric Component

Introduction

The pediatric component of ACE: Year 2 focuses on the impact of disease and its treatment on the developing human and recognition of common health problems. The pediatric component aims to teach the core of pediatric knowledge, skills and attitudes basic to the development of a competent general physician.

The pediatric component of ACE: Year 2 introduces the student to a unique, complex and challenging field of medicine. It emphasizes those aspects of general pediatrics important for all medical students and will provide a foundation for those students who elect to further study the health care of infants, children and adolescents.

When confronted with a particular constellation of signs and symptoms you will begin to develop a list of differential diagnoses that best explain the abnormal findings. You will begin to rank your presumptive diagnoses from the most likely explanation of your patient's problems to the least likely and act on them accordingly. Finally, through your growing understanding of the pathophysiology of disease processes you will begin to prescribe therapies to restore your patient to health. These goals will be achieved through your readings and interacting with ill children encountered in the primary care pediatric preceptor's office. Medical facts are important and you will need to develop a good fund of medical knowledge to be a competent physician. However, more importantly during your clinical experiences try to focus on the approach your clinical mentors use to sort through the patient's complaints and physical findings to develop a set of differential diagnoses. Notice how they use laboratory tests to narrow down their differential diagnoses and confirm their primary diagnosis and eliminate others. Observe how knowledge of the pathophysiology of the disease process guides the choice of the therapeutic regimen. Try to develop your own differential diagnoses based on your history and physical examination of patients. Think about what laboratory tests would help confirm or rule out some of your diagnoses. What therapy would you recommend? Discuss your thought process with your mentor and notice how experience may alter the approach to a given patient. Observation and practice are key for the acquisition of clinical skills. Attendance at all assigned clinical sites is therefore mandatory.

Required Text and Readings

Berkowitz CD, ed. Pediatrics: A Primary Care Approach, 2nd ed. Philadelphia, WB Saunders; 2000.

Chapter 6: Principles of Pediatric Therapeutics
Chapter 19: Well Child Care for Children with Trisomy 21
Chapter 21: Needs of Children with Physical and Sensory Disabilities
Chapter 33. Enuresis

Chapter 34: Encopresis

Chapter 35: Fever and Bacteremia
Chapter 36: Febrile Seizures
Chapter 37: Respiratory Distress
Chapter 38: Stridor and Croup
Chapter 40: Syncope
Chapter 49: Approach to the Dysmorphic Child

Chapter 51: Common Oral Lesions
Chapter 52: Otitis Media

Chapter 53: Hearing Impairment
Chapter 54: Sore Throat

Chapter 55: Nosebleeds

Chapter 56: Strabismus

Chapter 57: Infections of the Eye

Chapter 59: Neck Masses
Chapter 60: Allergic Disease
Chapter 61: Wheezing and Asthma
Chapter 62: Cough
Chapter 63: Anemia
Chapter 65: Lymphadenopathy
Chapter 66: Heart Murmurs
Chapter 70: Hypertension
Chapter 72: Hematuria
Chapter 73: Proteinuria
Chapter 74: Urinary Tract Infectionsa

Chapter 75: Vaginitis

Chapter 76: Sexually Transmitted Diseases

Chapter 77: Menstrual Disorders

Chapter 79: Developmental Hip Dysplasia

Chapter 80: Rotational Problems of the Lower Extremities: In-toeing and Out-toeing
Chapter 81: Angular Deformities of the Lower Extremity: Bow Legs

Chapter 82: Orthopedic Injuries and Growing Pains
Chapter 84: Evaluation of Limp
Chapter 86: Vomiting

Chapter 87: Gastroesophageal Reflux

Chapter 88: Gastrointestinal Bleeding
Chapter 89: Diarrhea
Chapter 90: Constipation
Chapter 91: Abdominal pain
Chapter 95: Headaches

Chapter 97: Acne
Chapter 99: Diaper Dermatitis
Chapter 100: Papulosquamous Eruptions
Chapter 101: Maculopapular Rashes
Chapter 102: Vesicular Exanthems
Chapter 103: Attention Deficit/Hyperactivity Disorder
Chapter 104: Physical Abuse
Chapter 105: Child Sexual abuse
Chapter 106: Failure to thrive

Chapter 108: Substance Abuse
Chapter 109: Eating Disorders
Chapter 110: Childhood Obesity

Chapter 111: Divorce

Chapter 112: Violence

Chapter 113: Adolescent Depression and Suicide
Chapter 114: Cancer in Children
Chapter 117: Diabetes Mellitus
Chapter 118: Chronic Lung Disease
Chapter 122: Seizures and Epilepsy

Evaluation

Evaluation for the pediatric component of ACE: Year 2 will depend on

1. The preceptor's assessment of the student's :

a) knowledge of common pediatric illnesses and the student's approach to the evaluation and management of common pediatric disorders.

b) skill in obtaining an appropriate focused pediatric history and performing an appropriate focused pediatric physical exam.

c) professionalism in attitude and interactions with patients, their families, and all staff.

2. Assessment of the student's knowledge of clinical pediatrics on the ACE exams.

Goals

The goals of the pediatric component of ACE: Year 2 are to foster:

1. Acquisition of basic knowledge of growth and development (physical, physiologic and psychosocial) and of its clinical application from birth through adolescence
2. Development of communication skills that will facilitate the clinical interaction with children, adolescents and their families and thus ensure that complete, accurate data are obtained
   
3. Development of competency in the physical examination of infants, children and adolescents
   
4. Acquisition of the knowledge necessary for the diagnosis and initial management of common acute and chronic illnesses
   
5. Development of clinical problem-solving skills
   
6. An understanding of the influence of family, community and society on the child in health and disease
7. Development of the attitudes and professional behaviors appropriate for clinical practice
   
8. An understanding of the approach of pediatricians to the health care of children and adolescents
9. Required Text and Readings:

Learning Objectives

Professional Conduct and Attitudes

Rationale

Professional conduct is complex and difficult to define, but is at the core of a physician's daily activities. Knowledge, diagnostic skills and problem solving abilities are necessary, but not sufficient to guarantee successful clinical interactions. The physician also must have well developed interpersonal skills that facilitate communication and must demonstrate attitudes, behaviors and beliefs that promote the patient's best interest. In particular, the physician who provides medical care to infants, children, and adolescents must remember that the patient and the clinical interaction will change continuously under the influence of growth and development. How the physician communicates can have a lasting effect in how the parents handle situations and communicate with the physician. The evolving family structure also will influence the physician's interaction with both the patient and the family. Lastly, the physician must have a commitment to lifelong learning to ensure that the medical care provided to patients is the most appropriate, effective treatment available.

Prerequisites

Well developed data gathering skills and knowledge of ethical principles are essential foundations for the student. Important personal characteristics include, but are not limited to caring, compassion, empathy, enthusiasm, adaptability, flexibility, patience, gentleness, cultural sensitivity, tolerance of difference, willingness to listen and explain, personal honesty, respect for privacy and confidentiality, commitment to work and dedication to learning.

Such concepts can be learned to some degree in the abstract, but will be acquired most effectively through contact with physician role models. Ethical principles, likewise, while learned in the abstract, must be applied clinically; the importance of role models cannot be overemphasized.

Learning Objectives

The attitudes, beliefs and behaviors central to the professional conduct of all physicians will be enhanced by a student's experience in pediatrics. Specific issues during clinical pediatrics are highlighted here. However, interaction with children and adolescents (and their families) during the pediatric component will require students to develop their own attitudes, beliefs, ethical and legal concepts and professional conduct.

1. The patient constantly changes as growth and development proceed, and the family, likewise, develops and changes as the child grows and as subsequent children are born. The patient's ability to participate in the clinical interaction progresses, as do his or her knowledge, experience and concerns. The adolescent presents specific challenges, including such issues as privacy, risk-taking behaviors, confidentiality and personal involvement with health. The role of parents in the clinical interaction and their knowledge, experience and concerns also change. Students must work to adapt their clinical approach, as appropriate to the developmental stage of the child or adolescent and family.
   
2. Cultural, ethnic and socioeconomic factors also affect personal and family traits and behaviors, with varying effects on child rearing practices. Recognition of and respect for difference are important. The student must still be alert for the child or adolescent at risk in different family environments, given that the physician's primary obligation is to promote the best interest of the patient.
   
3. Acute and chronic illness and disability test the physician's clinical and interpersonal skills. The student must learn how to communicate clearly and sensitively. In such situations the health care team plays an important role and the student must learn to work within a team, treating each member of the team with courtesy and respect and recognizing the contributions of each to the clinical interaction.
   
4. There are unique ethical issues in pediatrics. The student must have a firm foundation in basic ethical principles and must develop an appreciation of the ethical challenges specific to clinical interactions with children, adolescents and their families.
   
5. At the core of the physician's professional conduct are attitudes, skills and knowledge that evolve as the individual's experiences grow. Intellectual curiosity, initiative and willingness to assume responsibility for the continued development of clinical skills are crucial for the lifelong learning demanded by a career in medicine.
   
   

Competencies

1. Demonstrate the professional conduct necessary for a successful clinical interaction
   
2. Demonstrate tolerance of parent and family differences in attitudes, behaviors and lifestyles, but recognize when a child or adolescent is at risk and know when and how to intervene. Provide examples that demonstrate how child-rearing practices differ across cultural and ethnic groups and in socioeconomic situations.
   
3. Explain in general terms how to conduct an interview and physical exam of an adolescent with his or her parent. In addition, outline how the results of the examination and any diagnostic tests should be discussed with the adolescent and parent.
   
4. Discuss how to relate news of a serious acute or chronic illness or a congenital abnormality to parents. How would your discussion differ with the child or the adolescent?
   
5. Demonstrate intellectual curiosity, initiative, responsibility, and reliability
   

Pediatric Skills

Rationale

There are five general skill areas introduced and reinforced during the pediatric clerkship:

1. conducting an interview
   
2. performing a physical exam
   
3. communicating information
   
4. identifying and solving clinical problems
   
5. developing an initial diagnosis and therapeutic plan.
   
   

These are fundamental competencies and will be taught in some form during all the second year clinical experiences. Aspects of these skills that are unique to pediatrics are identified here. The development of competent clinical skills requires both practice and supervision with feedback.

Prerequisites

1. Basic knowledge of the general history and physical examination, including an understanding of different styles of questions used in the medical interview, such as open-ended, directed, follow-up, and summary questions
   
2. Elementary knowledge of growth and development
   
3. Basic clinical organization and problem solving skills
   

Learning Objectives

1. Interviewing
   1. Patient interviews occur in a variety of clinical settings, including: initial history for a hospital admission or first ambulatory visit, health maintenance visit, acute care visit, interim visit for a child with an acute or chronic health condition. The student should develop an awareness that in conducting a medical interview in a variety of settings, it is sometimes appropriate to obtain a complete medical history, while at other times a more limited, focused or interval history is appropriate.
      
   2. Obtain a medical history from a second party (usually the parent), as well as from the patient, noting the increased reliability of obtaining information directly from the patient as the patient matures. The student must be aware of issues of appropriate privacy at all ages and confidentiality in older children and adolescents.
      
   3. Obtain a relevant history that is unique to pediatrics in addition to the standard medical history.
      
   4. Modify the medical history depending on the age of the child, with particular attention given to the following age groups: neonate, infant, toddler/preschool-aged child, school aged child, adolescence.
   5. Past History
      1. Neonatal history, including: birth weight and approximate gestational age maternal complications, such as extent of prenatal care, infections, exposure to drugs, alcohol or medications, problems in the newborn period, such as prematurity, respiratory distress, jaundice and infections
         
      2. Immunizations
         
      3. Development, noting the importance of assessing developmental milestones in evaluating the health of the child
         
      4. Diet, noting the importance of assessing the amount, type, and method of infant feeding
   6. Family History:
      1. Number and ages of siblings; consanguinity, known genetic disorders, early childhood deaths, cardiovascular disease, depression and alcohol abuse.
   7. Social History
      1. Assessment of the home environment, school and peer relationships
   8. Review of Systems
      1. The relevant items are limited, but expand as the patient's age increases.
2. Physical Examination
   1. Establish rapport with children of various ages in order to perform the physical examination.
      
   2. Recognize that the age of the child influences the areas included in the exam, as well as the order of the examination, and the approach to the patient.
      
   3. Recognize the important role of observation as a method of obtaining data in the assessment of the child.
      
   4. Perform a complete physical examinations on an infant, child and adolescent, including the observation and documentation of normal physical findings.
      
   5. Demonstrate the appropriate use of the limited or focused examination, particularly in the ambulatory setting.
      
   6. Use developmental assessment as part of the physical examination for all ages.
      
   7. Observe how normal behaviors, such as stranger anxiety, affect the ability of the examiner to perform the examination, and develop strategies for improving rapport.
      
   8. Identify the physical changes of puberty and be able to conduct Tanner staging.
      
   9. Observe and demonstrate physical exam findings unique to the pediatric age group, and understand how findings have different clinical significance depending on the age of the child. Some examples are:

Appearance:

a) Recognize signs of acute illness in an infant, toddler and child by evaluating skin color, respiration, hydration, mental status, cry and social interaction
b) Recognize the importance of observing the psychosocial condition of the child, including behavior, development, body habitus (height, weight, body fat), relationship to parent and examiner, and general condition.

Vital signs

a) Measure heart rate, respiratory rate, blood pressure and temperature in an infant and child, demonstrating knowledge of the appropriate sized blood pressure cuff, interval to count respirations, and normal variation in temperature depending on the route of measurement (oral, rectal, axillary or tympanic)
b) Understand that normal values of heart rate, respiratory rate and blood pressure change with age
c) Recognize the importance of assessing vital signs in the evaluation of acute illness.

Measurements

a) Accurately measure height, weight and head circumference
b) Plot the data on an appropriate growth chart
c) Understand the normal relationships between height, weight and head circumference
d) Recognize the usefulness of longitudinal data

HEENT

a) Identify the anterior and posterior fontanels and assess them for fullness or turgor
b) Recognize the need for careful observation of the head size and shape, symmetry, facial features, ear size and hair whorls as part of the examination for dysmorphic features
c) Recognize the red reflex and strabismus
d) Assess hydration of the mucous membranes
e) Examine the tympanic membranes using pneumatic otoscopy

Neck

a) Palpate lymph nodes, know what anatomic areas they drain
b) Know that lymph nodes are more prominent during childhood
c) Recognize and demonstrate maneuvers that test for nuchal rigidity

Chest

a) Recognize how the rate and pattern of respirations change with age, and that abdominal respirations are normal in infants
b) Observe the rate and effort of breathing as a measure of respiratory distress
c) Recognize stridor, wheezing and rales and be able to distinguish between inspiratory and expiratory obstruction
d) Interpret less serious respiratory sounds such as transmitted upper airway sounds

Cardiovascular

a) Palpate pulses in the upper and lower extremities
b) Auscultate the heart for rhythm, rate, quality of the heart sounds and murmurs

Abdomen

a) Understand that the liver edge, spleen tip and kidneys may be palpable in the normal newborn
b) Examine the umbilical cord for signs of infection
c) Examine the abdomen for distention, tenderness, rebound and mass lesions in an infant or young child with lethargy, irritability or signs of acute illness, noting the inability of the patient to communicate symptoms of abdominal complaints
d) Be able to do a rectal examination and recognize when it is indicated

Genitalia

a) Recognize the appearance of normal male and female genitalia in the newborn
b) Recognize abnormalities, including cryptorchidism, hypospadias, testicular mass in the male
c) Be able to examine the external genitalia of a female patient
d) Recognize the need for privacy at all ages

Extremities

a) Examine the hips of a newborn for dysplasia
b) Recognize arthritis
c) Evaluate gait and limp

Back

a) Know how to test for scoliosis.

b) Neurologic examination

c) Elicit primitive reflexes
d) Assess tone, gait, strength and reflexes, recognizing the importance of symmetry
e) Assess developmental milestones
f) Recognize that much of the neurologic examination of infants and children is accomplished through observation alone

Skin

a) Recognize jaundice, petechiae, purpura, common birth marks (such as nevus flammeus and Mongolian spots), vesicles, urticaria and common rashes, such as erythema toxicum, impetigo, eczema, diaper dermatitis and viral exanthems
b) Recognize common skin findings associated with child abuse
c) Assess skin turgor

Communication Skills

a) Communication with the patient and/or family

b) Establish rapport with the patient and family
c) Identify the primary concerns of the patient and/or family
d) Recognize the triangular relationship between physician, patient and parent and be able to communicate information to both the patient and parent, making sure both understand the diagnosis and treatment plan and have the opportunity to ask questions; be aware that the relationship changes with increasing age of the child.
e) Provide anticipatory guidance during health maintenance visits, including the newborn nursery visit
f) Recognize the important role of patient education in management of acute and chronic illnesses

Written communication skills

a) Write a complete summary of the history and physical examination in a timely manner which is suitable to place in the patient's chart
b) Outline the different formats for documenting the history and physical examination which may be used in different clinical settings
c) Write a prescription (see Therapeutics section)

Oral communication skills

a) Present a complete, well-organized summary of the findings of the patient's history and physical examination, modifying the presentation to fit the situation
b) Communicate effectively with other health care workers, including consultants, nurses and social workers
c) Explain the thought process that led to the diagnostic and therapeutic plan
d) Use precise descriptions of physical findings and avoid vague terms and jargon, such as "clear" and "WNL"

Clinical Problem-Solving Skills

a) Develop a complete problem list and a differential diagnosis for each problem; combine problems where appropriate to develop a differential diagnosis for the patient's unique combination of symptoms
b) Use knowledge of key signs and symptoms and the frequency and prevalence of diseases at different ages when developing a differential diagnosis
c) Formulate an initial diagnostic and therapeutic plan, considering the cost, risks, benefits and limitations of laboratory tests, imaging studies, medications, consultations, hospitalization, and more conservative measures such as observation
d) Interpret the results of commonly ordered laboratory tests, such as the CBC, urinalysis, and serum electrolytes, and recognize that the normal values of some tests may vary with the age of the patient
e) Use the pediatric literature to research the diagnosis and management of clinical problems
f) Develop critical thinking skills and the ability to use scientific evidence in making clinical decisions
g) Recognize that physicians work in collaboration with other care providers in both the medical center and the community, including the schools, public health department, social service agencies and child protective services

Competencies

1. Evaluate patients from infancy through adolescence in a variety of clinical settings, establishing rapport with the patient and family in order to obtain a complete history and physical examination
   
2. Prepare a complete written summary of the history and physical and orally present the case in a focused and chronological manner
   
3. Identify clinical problems and outline an initial diagnostic and therapeutic plan
   
4. Know when hospitalization and diagnostic tests are indicated
   
5. Select the diagnostic tests which are most likely to be useful and be aware of their costs and limitations
   
6. Effectively communicate information about the diagnosis and treatment to the patient and caregiver
   
7. Obtain up-dated information relevant to the diagnosis and treatment of the patient, performing a literature search and critical review of the literature
   

Growth

Rationale

Growth is the defining feature of childhood. Genetic and environmental factors influence the rate of growth and the final stature and body habitus the child attains. Regular monitoring of growth provides the clinician with one of the best indicators of the underlying health of the child.

Learning Objectives

1. Explain the use of growth charts in the longitudinal evaluation of height, weight and head circumference.
   
2. Recognize abnormalities of growth which warrant further evaluation, such as crossing lines on a growth chart, discrepancies between height, weight and head circumference, short stature, failure to thrive, obesity, microcephaly and macrocephaly.
   
3. Identify intrauterine factors which affect growth of the fetus.
   
4. Recognize normal variants of growth, such as familial short stature and constitutional delay.

Competencies

1. Accurately measure height, weight and head circumference and plot the data on an appropriate chart.
   
2. Include an assessment of growth in the patient work-up.
   
3. Identify abnormal growth patterns and explain the initial assessment.
   
4. Outline the initial evaluation of a child with failure to thrive.
   
5. Identify by history, growth pattern and physical findings, the child with hypothyroidism and growth hormone deficiency.

Medical Genetics and Congenital Malformations

Rationale

A physician should be able to distinguish between genetic and non-genetic congenital disorders, as well as recognize genetic diseases presenting later in childhood. A genetic disorder, a condition caused by abnormal genes or chromosomes, should be contrasted with a congenital malformation, one that is apparent at birth and not known to be related to any specific genetic abnormality. Genetic abnormalities may produce congenital malformations, metabolic disturbances, specific organ dysfunction and abnormalities of sexual differentiation. Growth and development may be adversely affected by both genetic disorders and congenital malformations.

Learning Objectives

1. Discuss common physical exam findings and implications associated with the diagnosis of:
   1. Chromosomal abnormalities (e.g. Trisomy 21, Prader-Willi syndrome)
      
   2. Sex Chromosome abnormalities (e.g. Turner syndrome, Klinefelter syndrome, Fragile X syndrome)
      
   3. Other genetic disorders (e.g. Cystic Fibrosis, Sickle Cell Disease)
      
   4. Congenital malformations (e.g. spina bifida, VATER and CHARGE association).
2. Discuss the effects of teratogenic agents including: alcohol, phenytoin, maternal tobacco smoking, illicit drug use.
   
3. Be able to categorize congenital anomalies as: malformation, deformation, disruption. Understand the patterns of multiple congenital anomalies: syndrome, sequence anomaly, association.
   
4. Collect relevant information, including history and physical exam, to evaluate a genetic disorder or congenital defect.
   
5. Construct a family pedigree.

Competencies

1. Gather basic data from history/physical exam.
   
2. Consider useful laboratory tests when evaluating a child with a possible common genetic disorder or a congenital malformation.

Common Pediatric Illnesses

Rationale

A patient's illness comes to the physician's attention as a clinical problem. The problem may be a complaint (e.g. headache) or a complex of symptoms and signs (e.g. fever, rash and sore throat) that prompts the physician visit; or the problem may be identified as a finding on physical examination or from the results of laboratory tests or imaging studies. The physician must solve the problems posed by the patient using information obtained from the history, the physical examination and, when appropriate, laboratory tests and/or imaging studies. In the problem-solving process, the physician develops a problem list that includes differential diagnoses for each of the problems identified. The diagnostic process demands knowledge of disease etiology, pathophysiology and epidemiology and of the patient's gender, ethnicity, environment and prior health status. Commonly occurring illnesses will be the first considered, but other, less common disorders may need to be included in the evaluation of the problem.

Learning Objectives

1. Using the table of common signs and symptoms, develop a differential diagnosis considering the clinical conditions listed.
   
2. List differentiating factors that help distinguish between the possible diagnoses.
   
3. Identify, in addition, for each of the Common Conditions on table 2 (middle column):
   1. Etiology and/or pathophysiology,
      
   2. Natural history of the disease
   3. Presenting signs and symptoms.
   4. Initial laboratory test and/or imaging studies indicated for diagnosis.
   5. Plan for initial management.
      
   6. Identify also for each of the Significant Other Conditions in Table 2 (right hand column):
      
      1. Etiology and/or pathophysiology
         
      2. Presenting signs and symptoms
         
      3. Initial laboratory test and/or imaging studies indicated for diagnosis

Competencies

1. Develop a diagnostic approach to any of the clinical problems listed in the Tables 2 and 3 below.
2. Explain how the physical manifestations and the evaluation and management of many pediatric illnesses vary with the age of the patient. Give specific examples.
3. Discuss in some detail the appropriate uses of these diagnostic tests: Chest x-ray, lumbar puncture and CSF examination, EEG, craniospinal CT and MR imaging, echocardiogram.
4. Discuss the characteristics of the patient and of the illness that must be considered when making the decision to manage the patient in the outpatient setting or to admit to hospital.

Management of Chronic Illness

Rationale

General physicians are involved in the day to day care of children with chronic disease, solely or in conjunction with subspecialty physicians. Children are more prone to rapid changes in their health status, as the various diagnoses are exacerbated by viral illness, hydration status and rapid growth periods. Chronic illness presents the affected child and their families with many challenges, both in terms of direct effects of their illness and the impact of the illness or it's treatment may have on all aspects of the child and their families lives. Providing information to the patient and family, encouraging the older patient to contribute to the decision making process are important aspects to the care of the patient with chronic disease. Emotional support during times of crisis is a significant part of the physician-patient relationship.

Learning Objectives

1. Describe the impact a chronic illness such as cancer, sickle cell disease, asthma, or cystic fibrosis has on growth and development.
   
2. Recognize common psychological complications of chronic illness. Identify the factors that contribute to family stress and disruption within the family of a chronically ill child.
   
3. Explain how the impact of chronic illness for the patient and family changes as the child matures through adolescence.
   
4. Discuss factors such as schedule, frequency of follow up, etc. that affect the compliance with treatment regimens.
   
5. Describe the management plan for the following chronic illnesses/disorders in children: allergic rhinitis, asthma, sickle cell disease, seizure disorder, insulin dependent diabetes mellitus, cystic fibrosis, hemophilia, childhood malignancies.
   
6. The student will recognize the clinical signs and symptoms of the common complications of the listed chronic diseases.
   
7. The student will understand the rationale behind common anticipatory guidance issues relative to the common chronic illnesses listed.
   
8. Explain the role of multi-disciplinary teams in the treatment of chronic illness in children.
   
9. Recognize the financial and social costs.
   
10. Identify the social support services available.

Competencies

1. Perform an initial history and physical examination on a new patient who presents with a chronic illness. Include assessment of growth and pubertal development.
   
2. Take an interval history and problem focused exam on a patient seen in follow up for their chronic disease.
   
3. Interact effectively with other members of a multi-disciplinary team caring for the child with a chronic illness.
4. Outline the basic management for a child who presents with the following chronic disease: allergic rhinitis, chronic urticaria, asthma, sickle cell disease, seizure disorder, insulin dependent diabetes mellitus, cystic fibrosis, hemophilia, childhood malignancies.
   
5. Provide anticipatory guidance to the family of a child with one of the above chronic diseases, alerting them to the clinical symptoms that would signal complication from the disease or it's treatment.

Therapeutics

Rationale

Informed use of medications and therapeutic agents is essential, especially in pediatrics. Appropriate and successful treatment requires choice of the correct medication, appropriate dose, and both a dosage form and regimen that will maximize compliance. The pharmacokinetics of medications changes under the influence of growth and physiologic maturation. In addition, both the therapeutic and the adverse effects of medications vary as the child grows and matures. Child behavior and psychomotor development influence the form of medication dispensed and the expectation for compliance.

Learning Objectives

1. Describe the ways that physical and physiologic growth change the pharmacokinetics of commonly used medications in pediatrics. Specifically address drug absorption, distribution, metabolism and elimination.
   
2. Recognize drugs that are contraindicated or must be used with extreme caution in specific pediatric populations.
   
3. Summarize the factors that affect drug excretion into breast milk.
   
4. Be cognizant of the importance of patient education in ensuring compliance with prescribed treatment regimens.
   
5. Understand the appropriate use, possible side effects and complications of the following common medications in the outpatient setting, including when it is NOT appropriate to treat with a medication:
   1. analgesics / antipyretics
      
   2. antibiotics
      
   3. bronchodilators
      
   4. corticosteroids
      
   5. cough and cold preparations
      
   6. ophthalmic preparations
      
   7. otic preparations
      
   8. vitamin / mineral supplements.

Competencies

1. Demonstrate the ability to write a prescription.
   
2. Explain how a drug dose is calculated for infants and prepubertal children.
   
3. List the most common generic types of medications used for management of the following uncomplicated conditions:
   
   1. otitis media
      
   2. wheezing
      
   3. conjunctivitis
      
   4. allergic rhinitis
      
   5. urinary tract infection
      
   6. impetigo
      
   7. eczema
      
   8. fever
      
   9. streptococcal pharyngitis
      
   10. acne
       

Child Abuse (Physical and Sexual)

Rationale

Abuse of children and adolescents is part of the spectrum of family dysfunction and results in injury and death to millions of children each year in the United States. Abuse causes physical, sexual and/or emotional trauma or may occur in the form of neglect when caregivers fail to provide basic physical, emotional or medical needs. Medical professionals are required by law in all 50 states to protect children and adolescents by identifying abuse and by reporting it to child protective services. Students must understand the varying presentations of abuse and must recognize the physical, emotional and social factors that put a child at risk for abuse. Students must know when to consider abuse in the differential diagnosis of child or adolescent health problems and must further understand the legal obligation they will eventually have as mandatory reporters of abuse.

Learning Objectives

1. List the physical and behavioral signs of physical abuse, sexual abuse and neglect.
   
2. List the risk factors for domestic violence and child abuse.
   
3. Describe the specific types or patterns of injury that suggest physical abuse.
   
4. Name some of the physical and behavioral signs of sexual abuse in children.
5. List the family, social and environmental history items that are important when considering possible abuse.
   
6. Summarize the physical findings expected in an infant who has been subjected to abuse by shaking (i.e. the shaken baby syndrome).

Competencies

1. Know the types of questions to ask in assessment of a child for non-accidental injuries and child abuse.
   
2. Summarize the ethical responsibilities to identify and report child abuse and the obligation placed on reporters by community or state.
   

Child Advocacy

Rationale

Pediatrics encompasses children's health as well as threats to children's health. Habits adopted during childhood have broad implications throughout life, and practicing preventive pediatrics is important to all physicians caring for children. Although most children in this country enjoy good health, medical as well as social problems can adversely impact a child's well-being. Children in low-income or dysfunctional families have a higher incidence of disease and have less access to well-child and acute illness care than their more affluent counterparts. Pediatricians have a variety of roles in child heath. In addition to patient care they serve as advocates for individual children and families. At the local level they function as consultants to schools and health care agencies. Their efforts at legislative change have improved car safety, lowered the incidence of aspirin ingestion and helped bring about funding of health care for children. Internationally, pediatricians have been active in a broad range of issues as well.

Learning Objectives

1. Recognize that children are frequently unable to advocate for themselves in a variety of institutional and policy making settings and physicians need to advocate for them.
2. Identify specific issues where child advocacy by physicians has resulted in improvements in child health.

Competencies

1. Identify the ways that practicing physicians can advocate for children.
   
2. Describe the types of problems that benefit more from a community approach rather than an individual patient approach.

Table 2: Common Symptoms/Acute Illnesses

Table 3: Significant Clinical Signs

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