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1.14 Common Clinical Diagnoses and Conditions: Fluid and Electrolyte Management
Introduction
A greater understanding of pediatric fluid therapy is one of the most important advances of pediatric medicine and a cornerstone of current inpatient pediatric practice. Despite the use of rotavirus vaccine, gastroenteritis and dehydration with electrolyte abnormalities remains among the top 10 admission diagnoses nationwide, with annual hospitalization rates of 3 to 5 per 1000 U.S. children under 5 years of age. Although the majority of previously healthy hospitalized children can compensate for errors in calculations of fluid therapy, mistakes – even in healthy children admitted for minor illnesses – can have devastating outcomes. Patients with underlying disease processes are at even greater risk for adverse outcomes, if fluids and electrolytes are not meticulously managed. Pediatric hospitalists should be experts at managing frequently encountered fluid and electrolyte abnormalities.
Knowledge
Pediatric hospitalists should be able to:
- Discuss the physiology of fluid and electrolyte homeostasis and the changes that occur with growth and development.
- Discuss maintenance fluid calculations for water and electrolyte homeostasis based on body surface area or the Holliday Segar method, considering alterations in the renin-angiotensin system and vasopressin levels in hospitalized children which predispose them to hyponatremia.
- Describe the methods used for calculation of excessive fluid losses due to gastrointestinal, respiratory, renal, or skin abnormalities and identify the best fluid replacement type for each.
- Describe common errors in clinical estimations of dehydration and fluid and electrolyte requirements.
- Explain the rationale, indications, and contraindications for oral rehydration, including the correct glucose and electrolyte composition and technique for administration.
- Discuss the benefits of and barriers to intravenous (IV) versus enteral methods for fluid and electrolyte repletion and the indications, benefits, and barriers for each.
- Review the indications for administering a parenteral fluid bolus for resuscitation and explain the rationale for the use of isotonic fluids for rehydration.
- Discuss the benefits and risks of repeated lab testing and intravenous access placement, including cost, pain, effect on clinical management, the family/caregivers’ perceptions, staff time, and others.
- Compare and contrast true hyponatremia with pseudohyponatremia and give examples of conditions in which these exist.
- List differential diagnoses for hyponatremia and hypernatremia.
- Summarize the management of hyponatremia and hypernatremia, attending to duration of corrective therapy and potential complications during correction.
- Distinguish between hyperkalemia and pseudohyperkalemia and give examples of the conditions in which these exist.
- List differential diagnoses for hypokalemia and hyperkalemia.
- Distinguish hypocalcemia from pseudohypocalcemia and give examples of the conditions in which these exist.
- Discuss the etiology and sequelae of hypomagnesemia and secondary hypomagnesemia.
- Discuss the interaction of fluid and electrolytes with acid/base balance.
- Describe common acid/base disturbances that accompany frequently encountered causes of fluid deficit and give examples of exacerbating issues including underlying co-morbidity and use of over-the-counter medications.
Skills
Pediatric hospitalists should be able to:
- Calculate maintenance fluid and electrolyte requirements for hospitalized infants and children.
- Adjust maintenance fluids for increased insensible losses and ongoing fluid and electrolyte needs.
- Estimate the degree of dehydration for children of various ages based upon clinical symptoms and signs.
- Identify common presenting signs and symptoms associated with an excess or deficit of common electrolytes and glucose in infants and children.
- Correctly estimate osmolar disturbance by interpreting electrolyte, glucose, and blood urea nitrogen results.
- Calculate and administer an isotonic fluid bolus correctly when indicated.
- Obtain IV or intraosseous access in moderate to severely dehydrated patients.
- Assess the success of fluid resuscitation by interpreting clinical changes and laboratory values.
- Calculate and administer maintenance and deficit fluid replacement for isotonic, hypertonic, and hypotonic dehydration.
- Interpret urine and serum electrolytes and osmolality, as well as fluid status (hypo-, hyper-, or isovolemic), to determine the etiology for hyponatremia or hypernatremia.
- Correct hyponatremia using appropriate replacement or restriction of fluids, sodium chloride, and medications depending upon the diagnosis.
- Correct hypernatremia using an appropriate electrolyte composition and rate of fluid replacement, as well as medications depending upon the diagnosis.
- Correct hypoglycemia using an appropriate replacement solution.
- Interpret EKG findings in the context of specific electrolyte abnormalities.
- Prescribe electrolyte replacement therapy and institute proper monitoring for arrhythmias.
- Correct symptomatic hyperkalemia using a combination of therapies to stabilize cardiac conduction, redistribute potassium to the intracellular space, and remove it from the body.
- Consult pediatric subspecialists appropriately to expedite the diagnosis and management of serious electrolyte disorders and transfer to a higher level of care when indicated.
Attitudes
Pediatric hospitalists should be able to:
- Recognize the benefits of oral rehydration and advocate for its use when indicated and clinically appropriate.
- Realize the importance of collaboration with subspecialty and primary care providers to ensure coordinated follow up for patients with persistent fluid and electrolyte disturbances at discharge.
- Consider cost-effectiveness, pain, and patient safety when creating plans for the treatment of fluid deficits.
Systems Organization and Improvement
In order to improve efficiency and quality within their organizations, pediatric hospitalists should:
- Work collaboratively with others such as surgeons, intensivists, and advanced practice nurses to establish institutional protocols for attainment of venous access.
- Lead, coordinate, or participate in plans to develop institutional policies to safely monitor and administer fluids and electrolytes.
- Lead, coordinate, or participate in developing guidelines for the treatment of fluid and electrolyte abnormalities in the hospital and community.
1. Meyers RS. Pediatric fluid and electrolyte therapy. J Pediatr Pharmacol Ther. 2009;14(4):204–211. https://doi.org/ 10.5863/1551-6776-14.4.204.
2. Santillanes G, Rose E. Evaluation and management of dehydration in children. Emerg Med Clin North Am. 2018;36(2):259-273. https://doi.org/10.1016/j.emc.2017.12.004.
Introduction
A greater understanding of pediatric fluid therapy is one of the most important advances of pediatric medicine and a cornerstone of current inpatient pediatric practice. Despite the use of rotavirus vaccine, gastroenteritis and dehydration with electrolyte abnormalities remains among the top 10 admission diagnoses nationwide, with annual hospitalization rates of 3 to 5 per 1000 U.S. children under 5 years of age. Although the majority of previously healthy hospitalized children can compensate for errors in calculations of fluid therapy, mistakes – even in healthy children admitted for minor illnesses – can have devastating outcomes. Patients with underlying disease processes are at even greater risk for adverse outcomes, if fluids and electrolytes are not meticulously managed. Pediatric hospitalists should be experts at managing frequently encountered fluid and electrolyte abnormalities.
Knowledge
Pediatric hospitalists should be able to:
- Discuss the physiology of fluid and electrolyte homeostasis and the changes that occur with growth and development.
- Discuss maintenance fluid calculations for water and electrolyte homeostasis based on body surface area or the Holliday Segar method, considering alterations in the renin-angiotensin system and vasopressin levels in hospitalized children which predispose them to hyponatremia.
- Describe the methods used for calculation of excessive fluid losses due to gastrointestinal, respiratory, renal, or skin abnormalities and identify the best fluid replacement type for each.
- Describe common errors in clinical estimations of dehydration and fluid and electrolyte requirements.
- Explain the rationale, indications, and contraindications for oral rehydration, including the correct glucose and electrolyte composition and technique for administration.
- Discuss the benefits of and barriers to intravenous (IV) versus enteral methods for fluid and electrolyte repletion and the indications, benefits, and barriers for each.
- Review the indications for administering a parenteral fluid bolus for resuscitation and explain the rationale for the use of isotonic fluids for rehydration.
- Discuss the benefits and risks of repeated lab testing and intravenous access placement, including cost, pain, effect on clinical management, the family/caregivers’ perceptions, staff time, and others.
- Compare and contrast true hyponatremia with pseudohyponatremia and give examples of conditions in which these exist.
- List differential diagnoses for hyponatremia and hypernatremia.
- Summarize the management of hyponatremia and hypernatremia, attending to duration of corrective therapy and potential complications during correction.
- Distinguish between hyperkalemia and pseudohyperkalemia and give examples of the conditions in which these exist.
- List differential diagnoses for hypokalemia and hyperkalemia.
- Distinguish hypocalcemia from pseudohypocalcemia and give examples of the conditions in which these exist.
- Discuss the etiology and sequelae of hypomagnesemia and secondary hypomagnesemia.
- Discuss the interaction of fluid and electrolytes with acid/base balance.
- Describe common acid/base disturbances that accompany frequently encountered causes of fluid deficit and give examples of exacerbating issues including underlying co-morbidity and use of over-the-counter medications.
Skills
Pediatric hospitalists should be able to:
- Calculate maintenance fluid and electrolyte requirements for hospitalized infants and children.
- Adjust maintenance fluids for increased insensible losses and ongoing fluid and electrolyte needs.
- Estimate the degree of dehydration for children of various ages based upon clinical symptoms and signs.
- Identify common presenting signs and symptoms associated with an excess or deficit of common electrolytes and glucose in infants and children.
- Correctly estimate osmolar disturbance by interpreting electrolyte, glucose, and blood urea nitrogen results.
- Calculate and administer an isotonic fluid bolus correctly when indicated.
- Obtain IV or intraosseous access in moderate to severely dehydrated patients.
- Assess the success of fluid resuscitation by interpreting clinical changes and laboratory values.
- Calculate and administer maintenance and deficit fluid replacement for isotonic, hypertonic, and hypotonic dehydration.
- Interpret urine and serum electrolytes and osmolality, as well as fluid status (hypo-, hyper-, or isovolemic), to determine the etiology for hyponatremia or hypernatremia.
- Correct hyponatremia using appropriate replacement or restriction of fluids, sodium chloride, and medications depending upon the diagnosis.
- Correct hypernatremia using an appropriate electrolyte composition and rate of fluid replacement, as well as medications depending upon the diagnosis.
- Correct hypoglycemia using an appropriate replacement solution.
- Interpret EKG findings in the context of specific electrolyte abnormalities.
- Prescribe electrolyte replacement therapy and institute proper monitoring for arrhythmias.
- Correct symptomatic hyperkalemia using a combination of therapies to stabilize cardiac conduction, redistribute potassium to the intracellular space, and remove it from the body.
- Consult pediatric subspecialists appropriately to expedite the diagnosis and management of serious electrolyte disorders and transfer to a higher level of care when indicated.
Attitudes
Pediatric hospitalists should be able to:
- Recognize the benefits of oral rehydration and advocate for its use when indicated and clinically appropriate.
- Realize the importance of collaboration with subspecialty and primary care providers to ensure coordinated follow up for patients with persistent fluid and electrolyte disturbances at discharge.
- Consider cost-effectiveness, pain, and patient safety when creating plans for the treatment of fluid deficits.
Systems Organization and Improvement
In order to improve efficiency and quality within their organizations, pediatric hospitalists should:
- Work collaboratively with others such as surgeons, intensivists, and advanced practice nurses to establish institutional protocols for attainment of venous access.
- Lead, coordinate, or participate in plans to develop institutional policies to safely monitor and administer fluids and electrolytes.
- Lead, coordinate, or participate in developing guidelines for the treatment of fluid and electrolyte abnormalities in the hospital and community.
Introduction
A greater understanding of pediatric fluid therapy is one of the most important advances of pediatric medicine and a cornerstone of current inpatient pediatric practice. Despite the use of rotavirus vaccine, gastroenteritis and dehydration with electrolyte abnormalities remains among the top 10 admission diagnoses nationwide, with annual hospitalization rates of 3 to 5 per 1000 U.S. children under 5 years of age. Although the majority of previously healthy hospitalized children can compensate for errors in calculations of fluid therapy, mistakes – even in healthy children admitted for minor illnesses – can have devastating outcomes. Patients with underlying disease processes are at even greater risk for adverse outcomes, if fluids and electrolytes are not meticulously managed. Pediatric hospitalists should be experts at managing frequently encountered fluid and electrolyte abnormalities.
Knowledge
Pediatric hospitalists should be able to:
- Discuss the physiology of fluid and electrolyte homeostasis and the changes that occur with growth and development.
- Discuss maintenance fluid calculations for water and electrolyte homeostasis based on body surface area or the Holliday Segar method, considering alterations in the renin-angiotensin system and vasopressin levels in hospitalized children which predispose them to hyponatremia.
- Describe the methods used for calculation of excessive fluid losses due to gastrointestinal, respiratory, renal, or skin abnormalities and identify the best fluid replacement type for each.
- Describe common errors in clinical estimations of dehydration and fluid and electrolyte requirements.
- Explain the rationale, indications, and contraindications for oral rehydration, including the correct glucose and electrolyte composition and technique for administration.
- Discuss the benefits of and barriers to intravenous (IV) versus enteral methods for fluid and electrolyte repletion and the indications, benefits, and barriers for each.
- Review the indications for administering a parenteral fluid bolus for resuscitation and explain the rationale for the use of isotonic fluids for rehydration.
- Discuss the benefits and risks of repeated lab testing and intravenous access placement, including cost, pain, effect on clinical management, the family/caregivers’ perceptions, staff time, and others.
- Compare and contrast true hyponatremia with pseudohyponatremia and give examples of conditions in which these exist.
- List differential diagnoses for hyponatremia and hypernatremia.
- Summarize the management of hyponatremia and hypernatremia, attending to duration of corrective therapy and potential complications during correction.
- Distinguish between hyperkalemia and pseudohyperkalemia and give examples of the conditions in which these exist.
- List differential diagnoses for hypokalemia and hyperkalemia.
- Distinguish hypocalcemia from pseudohypocalcemia and give examples of the conditions in which these exist.
- Discuss the etiology and sequelae of hypomagnesemia and secondary hypomagnesemia.
- Discuss the interaction of fluid and electrolytes with acid/base balance.
- Describe common acid/base disturbances that accompany frequently encountered causes of fluid deficit and give examples of exacerbating issues including underlying co-morbidity and use of over-the-counter medications.
Skills
Pediatric hospitalists should be able to:
- Calculate maintenance fluid and electrolyte requirements for hospitalized infants and children.
- Adjust maintenance fluids for increased insensible losses and ongoing fluid and electrolyte needs.
- Estimate the degree of dehydration for children of various ages based upon clinical symptoms and signs.
- Identify common presenting signs and symptoms associated with an excess or deficit of common electrolytes and glucose in infants and children.
- Correctly estimate osmolar disturbance by interpreting electrolyte, glucose, and blood urea nitrogen results.
- Calculate and administer an isotonic fluid bolus correctly when indicated.
- Obtain IV or intraosseous access in moderate to severely dehydrated patients.
- Assess the success of fluid resuscitation by interpreting clinical changes and laboratory values.
- Calculate and administer maintenance and deficit fluid replacement for isotonic, hypertonic, and hypotonic dehydration.
- Interpret urine and serum electrolytes and osmolality, as well as fluid status (hypo-, hyper-, or isovolemic), to determine the etiology for hyponatremia or hypernatremia.
- Correct hyponatremia using appropriate replacement or restriction of fluids, sodium chloride, and medications depending upon the diagnosis.
- Correct hypernatremia using an appropriate electrolyte composition and rate of fluid replacement, as well as medications depending upon the diagnosis.
- Correct hypoglycemia using an appropriate replacement solution.
- Interpret EKG findings in the context of specific electrolyte abnormalities.
- Prescribe electrolyte replacement therapy and institute proper monitoring for arrhythmias.
- Correct symptomatic hyperkalemia using a combination of therapies to stabilize cardiac conduction, redistribute potassium to the intracellular space, and remove it from the body.
- Consult pediatric subspecialists appropriately to expedite the diagnosis and management of serious electrolyte disorders and transfer to a higher level of care when indicated.
Attitudes
Pediatric hospitalists should be able to:
- Recognize the benefits of oral rehydration and advocate for its use when indicated and clinically appropriate.
- Realize the importance of collaboration with subspecialty and primary care providers to ensure coordinated follow up for patients with persistent fluid and electrolyte disturbances at discharge.
- Consider cost-effectiveness, pain, and patient safety when creating plans for the treatment of fluid deficits.
Systems Organization and Improvement
In order to improve efficiency and quality within their organizations, pediatric hospitalists should:
- Work collaboratively with others such as surgeons, intensivists, and advanced practice nurses to establish institutional protocols for attainment of venous access.
- Lead, coordinate, or participate in plans to develop institutional policies to safely monitor and administer fluids and electrolytes.
- Lead, coordinate, or participate in developing guidelines for the treatment of fluid and electrolyte abnormalities in the hospital and community.
1. Meyers RS. Pediatric fluid and electrolyte therapy. J Pediatr Pharmacol Ther. 2009;14(4):204–211. https://doi.org/ 10.5863/1551-6776-14.4.204.
2. Santillanes G, Rose E. Evaluation and management of dehydration in children. Emerg Med Clin North Am. 2018;36(2):259-273. https://doi.org/10.1016/j.emc.2017.12.004.
1. Meyers RS. Pediatric fluid and electrolyte therapy. J Pediatr Pharmacol Ther. 2009;14(4):204–211. https://doi.org/ 10.5863/1551-6776-14.4.204.
2. Santillanes G, Rose E. Evaluation and management of dehydration in children. Emerg Med Clin North Am. 2018;36(2):259-273. https://doi.org/10.1016/j.emc.2017.12.004.
1.13 Common Clinical Diagnoses and Conditions: Fever of Unknown Origin
Introduction
Fever is the most common presenting complaint in the pediatric outpatient and emergency room setting. In most cases, the etiology of acute fever is readily discernable. In contrast, fever of unknown origin (FUO) is typically defined as fever of 38.3° C (101° F) or greater for 14 days duration (range 8-21 days) with no apparent cause after a thorough history, physical examination, and initial laboratory evaluation. The differential diagnosis of FUO is very broad. Infection is the most common cause of prolonged fever; other major etiologic categories include malignancy, rheumatologic conditions, inflammatory bowel disease, drug fever, and miscellaneous causes. When children require hospitalization for prolonged fever with concern for FUO, pediatric hospitalists should develop a thoughtful, stepwise, and cost-effective approach to diagnosis and management.
Knowledge
Pediatric hospitalists should be able to:
- Discuss the pathophysiologic mechanisms that result in fever.
- List the different methods available for obtaining a temperature and explain common errors associated with each.
- Differentiate FUO from disorders known to present with serial or prolonged fevers.
- Describe the differential diagnosis of FUO for children of varying chronological and developmental ages and state the relative prevalence of each etiologic category.
- Identify the common infectious causes of FUO, particularly as they differ by geographic region.
- Describe the key features of the history, including details of the fever pattern and course of illness, immunization status, travel and exposure history, and family history.
- Discuss areas of specific focus when performing the physical examination, including those related to occult infection and/or underlying single or multiple organ-system pathology, such as skin and eye findings, lymph nodes, sinuses, liver and spleen size, bone and joint exam, neurologic exam, and neurobehavioral state.
- Describe the indications for and goals of hospitalization, including the role of close observation without treatment and daily physical examination.
- List common initial laboratory tests for FUO, recognizing the utility, sensitivity, and specificity of diagnostic tests, as well as local availability and processing times.
- Summarize the diagnostic value of advanced testing (such as bone scan, bone marrow aspiration/biopsy, repeated blood cultures with fever, and others) when initial testing and observation is non-diagnostic.
- Recognize indications for subspecialty consultation, such as infectious disease, rheumatology, hematology/oncology, and others.
- Discuss the benefits, risks, and potential complications of empiric antibiotic treatment.
- Compare and contrast the mechanisms of action and modifying effect on systemic symptoms of antipyretics versus anti-inflammatory agents, noting common side effects.
- Discuss reasons for patient transfer to a referral center in cases requiring pediatric-specific services not available at the local facility.
- Explain goals for hospital discharge, including specific measures of clinical stability and a post-discharge care plan for safe transition.
Skills
Pediatric hospitalists should be able to:
- Obtain a thorough fever history, including method obtained, duration, height, pattern, associated signs and symptoms.
- Obtain a complete medical history, including signs and symptoms, immunization status, travel history, exposure history (such as animals, tick bites, consumption of raw foods or contaminated water, sick contacts, and others), and family history.
- Perform a comprehensive physical examination, assessing for manifestations of infection and/or underlying single or multiple organ system pathology.
- Access and comprehensively review all relevant prior records.
- Perform careful reassessments daily and as needed, note changes in clinical status and test results, and respond with appropriate actions.
- Interpret basic tests and identify abnormal findings that require further testing or consultation with a subspecialist.
- Engage consultants (such as infectious disease physicians, rheumatologists, and others) efficiently and appropriately when indicated.
- Perform a cost-effective, sequential, evidence-based evaluation, avoiding unnecessary repeat testing.
- Demonstrate the ability to order laboratory studies with appropriate detail to ensure specimens are correctly collected, stored, handled, and processed.
- Determine when to continue inpatient versus outpatient diagnostic evaluation, considering factors including persistence of fever and pending test results.
- Formulate appropriate treatment plans for the presumptive or confirmed diagnosis when indicated.
- Create an effective discharge plan, including specific expectations for home observation of fever and other symptoms.
- Coordinate care with the primary care provider and subspecialists if indicated, arranging an appropriate transition plan for hospital discharge.
Attitudes
Pediatric hospitalists should be able to:
- Recognize the importance of effective collaboration with the primary care provider and consultants regarding the evaluation and treatment conducted in and out of the hospital, along with discharge and follow up needs.
- Acknowledge the significant stress placed on the family/caregivers when the diagnosis is unclear and multiple healthcare providers are involved in care, assist the family through periods of uncertainty, and mobilize other family support resources.
- Realize responsibility for educating patients and the family/caregivers regarding the importance of observation and the need for a thoughtful, stepwise approach to the diagnosis and potential treatment plan.
Systems Organization and Improvement
In order to improve efficiency and quality within their organizations, pediatric hospitalists should:
- Lead, coordinate, or participate in multidisciplinary initiatives to develop and implement evidence-based clinical guidelines to effectively use hospital resources, promote a targeted stepwise clinical approach, and improve quality of care for children with FUO.
1. Chien YL, Huang FL, Huang CM, Chen PY. Clinical approach to fever of unknown origin in children. J Microbiol Immunol Infect. 2015;50(6):893-898. https://doi.org/10.1016/j.jmii.2015.08.007.
2. Tolan RW Jr. Fever of unknown origin: a diagnostic approach to this vexing problem. Clin Pediatr (Phila) 2010;49:207-213. https://doi.org/0.1177/0009922809347799.
3. Chusid MJ. Fever of Unknown Origin in Childhood. Pediatr Clin North Am. 2017; 64:205-230. https://doi.org/10.1016/j.pcl.2016.08.014.
Introduction
Fever is the most common presenting complaint in the pediatric outpatient and emergency room setting. In most cases, the etiology of acute fever is readily discernable. In contrast, fever of unknown origin (FUO) is typically defined as fever of 38.3° C (101° F) or greater for 14 days duration (range 8-21 days) with no apparent cause after a thorough history, physical examination, and initial laboratory evaluation. The differential diagnosis of FUO is very broad. Infection is the most common cause of prolonged fever; other major etiologic categories include malignancy, rheumatologic conditions, inflammatory bowel disease, drug fever, and miscellaneous causes. When children require hospitalization for prolonged fever with concern for FUO, pediatric hospitalists should develop a thoughtful, stepwise, and cost-effective approach to diagnosis and management.
Knowledge
Pediatric hospitalists should be able to:
- Discuss the pathophysiologic mechanisms that result in fever.
- List the different methods available for obtaining a temperature and explain common errors associated with each.
- Differentiate FUO from disorders known to present with serial or prolonged fevers.
- Describe the differential diagnosis of FUO for children of varying chronological and developmental ages and state the relative prevalence of each etiologic category.
- Identify the common infectious causes of FUO, particularly as they differ by geographic region.
- Describe the key features of the history, including details of the fever pattern and course of illness, immunization status, travel and exposure history, and family history.
- Discuss areas of specific focus when performing the physical examination, including those related to occult infection and/or underlying single or multiple organ-system pathology, such as skin and eye findings, lymph nodes, sinuses, liver and spleen size, bone and joint exam, neurologic exam, and neurobehavioral state.
- Describe the indications for and goals of hospitalization, including the role of close observation without treatment and daily physical examination.
- List common initial laboratory tests for FUO, recognizing the utility, sensitivity, and specificity of diagnostic tests, as well as local availability and processing times.
- Summarize the diagnostic value of advanced testing (such as bone scan, bone marrow aspiration/biopsy, repeated blood cultures with fever, and others) when initial testing and observation is non-diagnostic.
- Recognize indications for subspecialty consultation, such as infectious disease, rheumatology, hematology/oncology, and others.
- Discuss the benefits, risks, and potential complications of empiric antibiotic treatment.
- Compare and contrast the mechanisms of action and modifying effect on systemic symptoms of antipyretics versus anti-inflammatory agents, noting common side effects.
- Discuss reasons for patient transfer to a referral center in cases requiring pediatric-specific services not available at the local facility.
- Explain goals for hospital discharge, including specific measures of clinical stability and a post-discharge care plan for safe transition.
Skills
Pediatric hospitalists should be able to:
- Obtain a thorough fever history, including method obtained, duration, height, pattern, associated signs and symptoms.
- Obtain a complete medical history, including signs and symptoms, immunization status, travel history, exposure history (such as animals, tick bites, consumption of raw foods or contaminated water, sick contacts, and others), and family history.
- Perform a comprehensive physical examination, assessing for manifestations of infection and/or underlying single or multiple organ system pathology.
- Access and comprehensively review all relevant prior records.
- Perform careful reassessments daily and as needed, note changes in clinical status and test results, and respond with appropriate actions.
- Interpret basic tests and identify abnormal findings that require further testing or consultation with a subspecialist.
- Engage consultants (such as infectious disease physicians, rheumatologists, and others) efficiently and appropriately when indicated.
- Perform a cost-effective, sequential, evidence-based evaluation, avoiding unnecessary repeat testing.
- Demonstrate the ability to order laboratory studies with appropriate detail to ensure specimens are correctly collected, stored, handled, and processed.
- Determine when to continue inpatient versus outpatient diagnostic evaluation, considering factors including persistence of fever and pending test results.
- Formulate appropriate treatment plans for the presumptive or confirmed diagnosis when indicated.
- Create an effective discharge plan, including specific expectations for home observation of fever and other symptoms.
- Coordinate care with the primary care provider and subspecialists if indicated, arranging an appropriate transition plan for hospital discharge.
Attitudes
Pediatric hospitalists should be able to:
- Recognize the importance of effective collaboration with the primary care provider and consultants regarding the evaluation and treatment conducted in and out of the hospital, along with discharge and follow up needs.
- Acknowledge the significant stress placed on the family/caregivers when the diagnosis is unclear and multiple healthcare providers are involved in care, assist the family through periods of uncertainty, and mobilize other family support resources.
- Realize responsibility for educating patients and the family/caregivers regarding the importance of observation and the need for a thoughtful, stepwise approach to the diagnosis and potential treatment plan.
Systems Organization and Improvement
In order to improve efficiency and quality within their organizations, pediatric hospitalists should:
- Lead, coordinate, or participate in multidisciplinary initiatives to develop and implement evidence-based clinical guidelines to effectively use hospital resources, promote a targeted stepwise clinical approach, and improve quality of care for children with FUO.
Introduction
Fever is the most common presenting complaint in the pediatric outpatient and emergency room setting. In most cases, the etiology of acute fever is readily discernable. In contrast, fever of unknown origin (FUO) is typically defined as fever of 38.3° C (101° F) or greater for 14 days duration (range 8-21 days) with no apparent cause after a thorough history, physical examination, and initial laboratory evaluation. The differential diagnosis of FUO is very broad. Infection is the most common cause of prolonged fever; other major etiologic categories include malignancy, rheumatologic conditions, inflammatory bowel disease, drug fever, and miscellaneous causes. When children require hospitalization for prolonged fever with concern for FUO, pediatric hospitalists should develop a thoughtful, stepwise, and cost-effective approach to diagnosis and management.
Knowledge
Pediatric hospitalists should be able to:
- Discuss the pathophysiologic mechanisms that result in fever.
- List the different methods available for obtaining a temperature and explain common errors associated with each.
- Differentiate FUO from disorders known to present with serial or prolonged fevers.
- Describe the differential diagnosis of FUO for children of varying chronological and developmental ages and state the relative prevalence of each etiologic category.
- Identify the common infectious causes of FUO, particularly as they differ by geographic region.
- Describe the key features of the history, including details of the fever pattern and course of illness, immunization status, travel and exposure history, and family history.
- Discuss areas of specific focus when performing the physical examination, including those related to occult infection and/or underlying single or multiple organ-system pathology, such as skin and eye findings, lymph nodes, sinuses, liver and spleen size, bone and joint exam, neurologic exam, and neurobehavioral state.
- Describe the indications for and goals of hospitalization, including the role of close observation without treatment and daily physical examination.
- List common initial laboratory tests for FUO, recognizing the utility, sensitivity, and specificity of diagnostic tests, as well as local availability and processing times.
- Summarize the diagnostic value of advanced testing (such as bone scan, bone marrow aspiration/biopsy, repeated blood cultures with fever, and others) when initial testing and observation is non-diagnostic.
- Recognize indications for subspecialty consultation, such as infectious disease, rheumatology, hematology/oncology, and others.
- Discuss the benefits, risks, and potential complications of empiric antibiotic treatment.
- Compare and contrast the mechanisms of action and modifying effect on systemic symptoms of antipyretics versus anti-inflammatory agents, noting common side effects.
- Discuss reasons for patient transfer to a referral center in cases requiring pediatric-specific services not available at the local facility.
- Explain goals for hospital discharge, including specific measures of clinical stability and a post-discharge care plan for safe transition.
Skills
Pediatric hospitalists should be able to:
- Obtain a thorough fever history, including method obtained, duration, height, pattern, associated signs and symptoms.
- Obtain a complete medical history, including signs and symptoms, immunization status, travel history, exposure history (such as animals, tick bites, consumption of raw foods or contaminated water, sick contacts, and others), and family history.
- Perform a comprehensive physical examination, assessing for manifestations of infection and/or underlying single or multiple organ system pathology.
- Access and comprehensively review all relevant prior records.
- Perform careful reassessments daily and as needed, note changes in clinical status and test results, and respond with appropriate actions.
- Interpret basic tests and identify abnormal findings that require further testing or consultation with a subspecialist.
- Engage consultants (such as infectious disease physicians, rheumatologists, and others) efficiently and appropriately when indicated.
- Perform a cost-effective, sequential, evidence-based evaluation, avoiding unnecessary repeat testing.
- Demonstrate the ability to order laboratory studies with appropriate detail to ensure specimens are correctly collected, stored, handled, and processed.
- Determine when to continue inpatient versus outpatient diagnostic evaluation, considering factors including persistence of fever and pending test results.
- Formulate appropriate treatment plans for the presumptive or confirmed diagnosis when indicated.
- Create an effective discharge plan, including specific expectations for home observation of fever and other symptoms.
- Coordinate care with the primary care provider and subspecialists if indicated, arranging an appropriate transition plan for hospital discharge.
Attitudes
Pediatric hospitalists should be able to:
- Recognize the importance of effective collaboration with the primary care provider and consultants regarding the evaluation and treatment conducted in and out of the hospital, along with discharge and follow up needs.
- Acknowledge the significant stress placed on the family/caregivers when the diagnosis is unclear and multiple healthcare providers are involved in care, assist the family through periods of uncertainty, and mobilize other family support resources.
- Realize responsibility for educating patients and the family/caregivers regarding the importance of observation and the need for a thoughtful, stepwise approach to the diagnosis and potential treatment plan.
Systems Organization and Improvement
In order to improve efficiency and quality within their organizations, pediatric hospitalists should:
- Lead, coordinate, or participate in multidisciplinary initiatives to develop and implement evidence-based clinical guidelines to effectively use hospital resources, promote a targeted stepwise clinical approach, and improve quality of care for children with FUO.
1. Chien YL, Huang FL, Huang CM, Chen PY. Clinical approach to fever of unknown origin in children. J Microbiol Immunol Infect. 2015;50(6):893-898. https://doi.org/10.1016/j.jmii.2015.08.007.
2. Tolan RW Jr. Fever of unknown origin: a diagnostic approach to this vexing problem. Clin Pediatr (Phila) 2010;49:207-213. https://doi.org/0.1177/0009922809347799.
3. Chusid MJ. Fever of Unknown Origin in Childhood. Pediatr Clin North Am. 2017; 64:205-230. https://doi.org/10.1016/j.pcl.2016.08.014.
1. Chien YL, Huang FL, Huang CM, Chen PY. Clinical approach to fever of unknown origin in children. J Microbiol Immunol Infect. 2015;50(6):893-898. https://doi.org/10.1016/j.jmii.2015.08.007.
2. Tolan RW Jr. Fever of unknown origin: a diagnostic approach to this vexing problem. Clin Pediatr (Phila) 2010;49:207-213. https://doi.org/0.1177/0009922809347799.
3. Chusid MJ. Fever of Unknown Origin in Childhood. Pediatr Clin North Am. 2017; 64:205-230. https://doi.org/10.1016/j.pcl.2016.08.014.
1.12 Common Clinical Diagnoses and Conditions: Failure to Thrive
Introduction
Failure to thrive (FTT), also known as weight faltering, is a descriptive term that refers to a child with relative undernutrition and subsequent inadequate growth over time, when compared to other children of similar age, gender, and ethnicity. Several definitions have been proposed based on abnormal anthropometric criteria, but none is uniformly accepted. The etiology of FTT is often multifactorial and results from a complex interplay between psychosocial, behavioral, and physiological factors. Ultimately, this interaction leads to inadequate caloric intake (in the setting of normal or excessive metabolic demands), inadequate absorption of calories, impaired utilization of absorbed calories, or a combination of these. FTT is often successfully managed in the outpatient setting. However, hospitalization may be necessary for very complex situations, when a child’s safety is in question, or when outpatient management has not been successful. FTT accounts for up to 5% of all pediatric hospitalizations, with a growing proportion of these occurring in children with medical complexity. Pediatric hospitalists should use evidence-based approaches to guide evaluation and management, provide leadership for multidisciplinary teams, and coordinate care to optimize outcomes.
Knowledge
Pediatric hospitalists should be able to:
- Describe the differential diagnosis of FTT for children of varying chronological and developmental ages, recognizing that most children with FTT do not have an underlying medical disorder.
- Explain why infants and toddlers are at greater risk for FTT than older children.
- Describe the association between FTT and child abuse and neglect.
- Describe normal growth patterns for children and the sequential effect of undernutrition on weight velocity, height velocity, and head growth.
- Describe the key historical or physical examination findings that may indicate a psychosocial, behavioral, or physiological factor contributing to poor growth.
- Describe the relationship between food insecurity and FTT, including the indirect contributions of increased family stress, parental depression, and a chaotic family environment.
- Explain indications for admission to the hospital and state criteria for determining the appropriate level of care.
- Describe the goals of hospitalization including stabilization, diagnosis, treatment, observation, and education.
- Discuss the importance of observation of feeding behaviors and recording of nutritional intake over time in the evaluation of FTT.
- Describe the role of targeted diagnostic testing in the evaluation of FTT, recognizing that routine screening tests are not beneficial in most cases.
- Discuss the indications for consultation with a pediatric speech or occupational therapist, nutritionist, gastroenterologist, or another specialist.
- Discuss the need for catch-up calories in FTT, as well as the methods by which to achieve adequate caloric supplementation.
- Define refeeding syndrome and describe methods that lead to its early detection and prevention.
- Discuss potential sequelae of FTT (such as behavioral or developmental abnormalities, increased susceptibility to infections, and others) and list the risk factors associated with each.
- List the risk factors for FTT-readmissions after the index hospitalization, such as increased age on admission and medical complexity.
Skills
Pediatric hospitalists should be able to:
- Stabilize patients presenting with metabolic abnormalities, cardiopulmonary compromise, or other urgent problems as a result of dehydration, malnutrition, or an abnormal pathophysiological state.
- Obtain a thorough patient history, including a detailed social, family, dietary, and feeding history, attending to markers of abnormal behavioral, psychosocial factors, and food insecurity.
- Perform a directed physical examination, including careful measurement of anthropometric data, attending to findings that may indicate an underlying medical or genetic condition, developmental abnormality, or child abuse and neglect.
- Utilize standardized growth charts to identify isolated growth abnormalities and to assess the growth pattern over time.
- Directly observe and correctly interpret a feeding session, with attention paid to feeding behavior and the child-caregiver interactions.
- Assess the level of evidence and risk/benefit ratio for an expanded diagnostic evaluation.
- Calculate caloric needs and adjust feeding regimens to maximize weight gain while avoiding gastrointestinal compromise.
- Engage and coordinate care with subspecialists and support services (such as speech and/or occupational therapy, nutrition, social services, and others), both during the hospitalization and upon discharge, when indicated.
Attitudes
Pediatric hospitalists should be able to:
- Appreciate the impact of food insecurity and other social determinants of health on the development of FTT.
- Consider the concerns of the family/caregivers when obtaining a history, developing a diagnostic approach, and offering anticipatory guidance and management options.
- Realize responsibility for providing support and education to the family/caregivers on FTT, with specific focus on the patient-specific underlying diagnoses and family/caregivers’ social situation.
- Recognize the importance of communicating effectively with the family/caregivers and healthcare providers regarding findings and care plans.
- Exemplify collaborative practice with the primary care provider, specialists, and support services as indicated to ensure coordinated longitudinal care for children with FTT.
Systems Organization and Improvement
In order to improve efficiency and quality within their organizations, pediatric hospitalists should:
- Work with healthcare providers and community leaders to develop a system for effective and safe transitions of care from the inpatient to outpatient healthcare providers, preserving the multidisciplinary nature of the care team when appropriate.
- Lead, coordinate, or participate in institutional and community efforts to identify food insecurity and connect children and the family/caregivers to government and other available resources.
- Advocate at the local, state, or national level in support of government and other programs that address food insecurity among children and the family/caregivers.
- Lead, coordinate, or participate in efforts to develop evidence-based guidelines for the evaluation and management of FTT in the hospital.
1. Homan GJ. Failure to thrive: a practical guide. Am Fam Physician. 2016;94(4):295-299.
2. Puls HT, Hall M, Bettenhausen J, et al. Failure to thrive hospitalizations and risk factors for readmission to children’s hospitals. Hosp Pediatr. 2016;6(8):468-475. https://doi.org/10.1542/hpeds.2015-0248.
Introduction
Failure to thrive (FTT), also known as weight faltering, is a descriptive term that refers to a child with relative undernutrition and subsequent inadequate growth over time, when compared to other children of similar age, gender, and ethnicity. Several definitions have been proposed based on abnormal anthropometric criteria, but none is uniformly accepted. The etiology of FTT is often multifactorial and results from a complex interplay between psychosocial, behavioral, and physiological factors. Ultimately, this interaction leads to inadequate caloric intake (in the setting of normal or excessive metabolic demands), inadequate absorption of calories, impaired utilization of absorbed calories, or a combination of these. FTT is often successfully managed in the outpatient setting. However, hospitalization may be necessary for very complex situations, when a child’s safety is in question, or when outpatient management has not been successful. FTT accounts for up to 5% of all pediatric hospitalizations, with a growing proportion of these occurring in children with medical complexity. Pediatric hospitalists should use evidence-based approaches to guide evaluation and management, provide leadership for multidisciplinary teams, and coordinate care to optimize outcomes.
Knowledge
Pediatric hospitalists should be able to:
- Describe the differential diagnosis of FTT for children of varying chronological and developmental ages, recognizing that most children with FTT do not have an underlying medical disorder.
- Explain why infants and toddlers are at greater risk for FTT than older children.
- Describe the association between FTT and child abuse and neglect.
- Describe normal growth patterns for children and the sequential effect of undernutrition on weight velocity, height velocity, and head growth.
- Describe the key historical or physical examination findings that may indicate a psychosocial, behavioral, or physiological factor contributing to poor growth.
- Describe the relationship between food insecurity and FTT, including the indirect contributions of increased family stress, parental depression, and a chaotic family environment.
- Explain indications for admission to the hospital and state criteria for determining the appropriate level of care.
- Describe the goals of hospitalization including stabilization, diagnosis, treatment, observation, and education.
- Discuss the importance of observation of feeding behaviors and recording of nutritional intake over time in the evaluation of FTT.
- Describe the role of targeted diagnostic testing in the evaluation of FTT, recognizing that routine screening tests are not beneficial in most cases.
- Discuss the indications for consultation with a pediatric speech or occupational therapist, nutritionist, gastroenterologist, or another specialist.
- Discuss the need for catch-up calories in FTT, as well as the methods by which to achieve adequate caloric supplementation.
- Define refeeding syndrome and describe methods that lead to its early detection and prevention.
- Discuss potential sequelae of FTT (such as behavioral or developmental abnormalities, increased susceptibility to infections, and others) and list the risk factors associated with each.
- List the risk factors for FTT-readmissions after the index hospitalization, such as increased age on admission and medical complexity.
Skills
Pediatric hospitalists should be able to:
- Stabilize patients presenting with metabolic abnormalities, cardiopulmonary compromise, or other urgent problems as a result of dehydration, malnutrition, or an abnormal pathophysiological state.
- Obtain a thorough patient history, including a detailed social, family, dietary, and feeding history, attending to markers of abnormal behavioral, psychosocial factors, and food insecurity.
- Perform a directed physical examination, including careful measurement of anthropometric data, attending to findings that may indicate an underlying medical or genetic condition, developmental abnormality, or child abuse and neglect.
- Utilize standardized growth charts to identify isolated growth abnormalities and to assess the growth pattern over time.
- Directly observe and correctly interpret a feeding session, with attention paid to feeding behavior and the child-caregiver interactions.
- Assess the level of evidence and risk/benefit ratio for an expanded diagnostic evaluation.
- Calculate caloric needs and adjust feeding regimens to maximize weight gain while avoiding gastrointestinal compromise.
- Engage and coordinate care with subspecialists and support services (such as speech and/or occupational therapy, nutrition, social services, and others), both during the hospitalization and upon discharge, when indicated.
Attitudes
Pediatric hospitalists should be able to:
- Appreciate the impact of food insecurity and other social determinants of health on the development of FTT.
- Consider the concerns of the family/caregivers when obtaining a history, developing a diagnostic approach, and offering anticipatory guidance and management options.
- Realize responsibility for providing support and education to the family/caregivers on FTT, with specific focus on the patient-specific underlying diagnoses and family/caregivers’ social situation.
- Recognize the importance of communicating effectively with the family/caregivers and healthcare providers regarding findings and care plans.
- Exemplify collaborative practice with the primary care provider, specialists, and support services as indicated to ensure coordinated longitudinal care for children with FTT.
Systems Organization and Improvement
In order to improve efficiency and quality within their organizations, pediatric hospitalists should:
- Work with healthcare providers and community leaders to develop a system for effective and safe transitions of care from the inpatient to outpatient healthcare providers, preserving the multidisciplinary nature of the care team when appropriate.
- Lead, coordinate, or participate in institutional and community efforts to identify food insecurity and connect children and the family/caregivers to government and other available resources.
- Advocate at the local, state, or national level in support of government and other programs that address food insecurity among children and the family/caregivers.
- Lead, coordinate, or participate in efforts to develop evidence-based guidelines for the evaluation and management of FTT in the hospital.
Introduction
Failure to thrive (FTT), also known as weight faltering, is a descriptive term that refers to a child with relative undernutrition and subsequent inadequate growth over time, when compared to other children of similar age, gender, and ethnicity. Several definitions have been proposed based on abnormal anthropometric criteria, but none is uniformly accepted. The etiology of FTT is often multifactorial and results from a complex interplay between psychosocial, behavioral, and physiological factors. Ultimately, this interaction leads to inadequate caloric intake (in the setting of normal or excessive metabolic demands), inadequate absorption of calories, impaired utilization of absorbed calories, or a combination of these. FTT is often successfully managed in the outpatient setting. However, hospitalization may be necessary for very complex situations, when a child’s safety is in question, or when outpatient management has not been successful. FTT accounts for up to 5% of all pediatric hospitalizations, with a growing proportion of these occurring in children with medical complexity. Pediatric hospitalists should use evidence-based approaches to guide evaluation and management, provide leadership for multidisciplinary teams, and coordinate care to optimize outcomes.
Knowledge
Pediatric hospitalists should be able to:
- Describe the differential diagnosis of FTT for children of varying chronological and developmental ages, recognizing that most children with FTT do not have an underlying medical disorder.
- Explain why infants and toddlers are at greater risk for FTT than older children.
- Describe the association between FTT and child abuse and neglect.
- Describe normal growth patterns for children and the sequential effect of undernutrition on weight velocity, height velocity, and head growth.
- Describe the key historical or physical examination findings that may indicate a psychosocial, behavioral, or physiological factor contributing to poor growth.
- Describe the relationship between food insecurity and FTT, including the indirect contributions of increased family stress, parental depression, and a chaotic family environment.
- Explain indications for admission to the hospital and state criteria for determining the appropriate level of care.
- Describe the goals of hospitalization including stabilization, diagnosis, treatment, observation, and education.
- Discuss the importance of observation of feeding behaviors and recording of nutritional intake over time in the evaluation of FTT.
- Describe the role of targeted diagnostic testing in the evaluation of FTT, recognizing that routine screening tests are not beneficial in most cases.
- Discuss the indications for consultation with a pediatric speech or occupational therapist, nutritionist, gastroenterologist, or another specialist.
- Discuss the need for catch-up calories in FTT, as well as the methods by which to achieve adequate caloric supplementation.
- Define refeeding syndrome and describe methods that lead to its early detection and prevention.
- Discuss potential sequelae of FTT (such as behavioral or developmental abnormalities, increased susceptibility to infections, and others) and list the risk factors associated with each.
- List the risk factors for FTT-readmissions after the index hospitalization, such as increased age on admission and medical complexity.
Skills
Pediatric hospitalists should be able to:
- Stabilize patients presenting with metabolic abnormalities, cardiopulmonary compromise, or other urgent problems as a result of dehydration, malnutrition, or an abnormal pathophysiological state.
- Obtain a thorough patient history, including a detailed social, family, dietary, and feeding history, attending to markers of abnormal behavioral, psychosocial factors, and food insecurity.
- Perform a directed physical examination, including careful measurement of anthropometric data, attending to findings that may indicate an underlying medical or genetic condition, developmental abnormality, or child abuse and neglect.
- Utilize standardized growth charts to identify isolated growth abnormalities and to assess the growth pattern over time.
- Directly observe and correctly interpret a feeding session, with attention paid to feeding behavior and the child-caregiver interactions.
- Assess the level of evidence and risk/benefit ratio for an expanded diagnostic evaluation.
- Calculate caloric needs and adjust feeding regimens to maximize weight gain while avoiding gastrointestinal compromise.
- Engage and coordinate care with subspecialists and support services (such as speech and/or occupational therapy, nutrition, social services, and others), both during the hospitalization and upon discharge, when indicated.
Attitudes
Pediatric hospitalists should be able to:
- Appreciate the impact of food insecurity and other social determinants of health on the development of FTT.
- Consider the concerns of the family/caregivers when obtaining a history, developing a diagnostic approach, and offering anticipatory guidance and management options.
- Realize responsibility for providing support and education to the family/caregivers on FTT, with specific focus on the patient-specific underlying diagnoses and family/caregivers’ social situation.
- Recognize the importance of communicating effectively with the family/caregivers and healthcare providers regarding findings and care plans.
- Exemplify collaborative practice with the primary care provider, specialists, and support services as indicated to ensure coordinated longitudinal care for children with FTT.
Systems Organization and Improvement
In order to improve efficiency and quality within their organizations, pediatric hospitalists should:
- Work with healthcare providers and community leaders to develop a system for effective and safe transitions of care from the inpatient to outpatient healthcare providers, preserving the multidisciplinary nature of the care team when appropriate.
- Lead, coordinate, or participate in institutional and community efforts to identify food insecurity and connect children and the family/caregivers to government and other available resources.
- Advocate at the local, state, or national level in support of government and other programs that address food insecurity among children and the family/caregivers.
- Lead, coordinate, or participate in efforts to develop evidence-based guidelines for the evaluation and management of FTT in the hospital.
1. Homan GJ. Failure to thrive: a practical guide. Am Fam Physician. 2016;94(4):295-299.
2. Puls HT, Hall M, Bettenhausen J, et al. Failure to thrive hospitalizations and risk factors for readmission to children’s hospitals. Hosp Pediatr. 2016;6(8):468-475. https://doi.org/10.1542/hpeds.2015-0248.
1. Homan GJ. Failure to thrive: a practical guide. Am Fam Physician. 2016;94(4):295-299.
2. Puls HT, Hall M, Bettenhausen J, et al. Failure to thrive hospitalizations and risk factors for readmission to children’s hospitals. Hosp Pediatr. 2016;6(8):468-475. https://doi.org/10.1542/hpeds.2015-0248.
1.11 Common Clinical Diagnoses and Conditions: Diabetes Mellitus
Introduction
Diabetes mellitus, a disorder of glucose homeostasis, is increasing in incidence and prevalence in pediatrics. Although there has been a significant rise in the incidence of type 2 diabetes, particularly among adolescents in high-risk ethnic groups, type 1 diabetes is still the most common form of diabetes in the pediatric and adolescent populations. The increase in obesity in the general population and the propensity of adolescents with type 2 diabetes to develop ketosis has resulted in phenotypic overlap in the pediatric patient presenting with a new diagnosis. In addition to the medical complications associated with these chronic conditions, both forms of diabetes have profound social and emotional impacts on the child. Pediatric hospitalists frequently encounter both children with new-onset diabetes and children previously diagnosed who may require hospitalization because of a diabetes related complication, an unrelated condition, or an elective procedure. Pediatric hospitalists are often positioned to provide both immediate care for children with diabetes as well as to coordinate care across multiple specialties when indicated.
Knowledge
Pediatric hospitalists should be able to:
- Compare and contrast the epidemiology and pathophysiology of type 1 and type 2 diabetes, attending to differences in family history, impairment of glucose regulation, and occurrence of ketoacidosis.
- Discuss the potential short and long-term complications of poor glucose control, including end-organ damage, and describe methods to assess for these complications.
- Describe common comorbidities and polyendocrinopathies associated with type 1 and type 2 diabetes.
- Describe the role of obesity in metabolic syndrome and type 2 diabetes.
- List other common causes of hyperglycemia, such as stress, drug, or steroid-induced hyperglycemia and indicate when insulin administration is needed.
- Explain the critical role of glucose homeostasis for patients admitted for reasons unrelated to their diagnosis of diabetes.
- List and interpret the laboratory tests, including islet autoantibodies and hemoglobin A1c, used to classify diabetes type and assess glycemic control.
- List the type and appropriate timing of screening tests for complications and co-morbidities of both type 1 and type 2 diabetes.
- Describe the different formulations of insulin and the different systems for insulin delivery and glucose monitoring.
- Describe the expected patterns of post-prandial glucose excursion in patients with diabetes and identify when a change in management is needed based on these patterns.
- Compare and contrast the role of nutrition in the management of type 1 versus type 2 diabetes.
- Review the principles of carbohydrate counting.
- Compare and contrast glucose monitoring, dietary recommendations, insulin dosing, and glucose targets between populations (such as type 1, type 2, cystic fibrosis related diabetes, and others).
- Define diabetic ketoacidosis (DKA) and describe its initial management, attending to fluid delivery, electrolyte and acid-base monitoring, mental status assessments, and appropriate patient placement based on local context.
- Discuss potential complications that may result from treatment of diabetes and DKA, including hypoglycemia and electrolyte imbalances.
- Summarize the approach toward management and education after stabilization of DKA.
- Describe criteria for hospital discharge, including specific measures of clinical improvement, education for patients and the family/caregivers, and establishment of a coordinated longitudinal care plan.
Skills
Pediatric hospitalists should be able to:
- Diagnose diabetes and its complications by efficiently performing a history and physical examination, determining if the patient meets diagnostic criteria.
- Identify and treat underlying causes of increased insulin demand that may lead to DKA in the patient with known diabetes.
- Order appropriate diagnostic testing for patients with new onset diabetes, diabetes exacerbations, or secondary causes of hyperglycemia.
- Order insulin doses and delivery systems (such as intravenous infusion, subcutaneous injection, and others) and other classes of drugs used in the treatment of diabetes.
- Identify and manage both hyperglycemia and hypoglycemia with attention to complications that may arise during treatment.
- Identify changes in clinical status related to severe acidosis and fluid and electrolyte disturbances and promptly initiate appropriate actions, including transfer to a higher level of care when indicated.
- Obtain prompt consultation with an endocrinologist or other subspecialist as appropriate.
- Utilize available support services, such as a certified diabetes educator, social worker, child life specialist, registered dietitian, and others, to ensure a comprehensive approach to management.
- Coordinate care and education for patients and the family/caregivers with other healthcare providers.
- Coordinate care with subspecialists and the primary care provider and arrange an appropriate transition plan for hospital discharge.
Attitudes
Pediatric hospitalists should be able to:
- Realize the importance of effective communication and culturally responsive care when creating a diabetes management plan, maintaining awareness of the unique needs of various groups.
- Recognize that acute and chronic psychosocial factors that impact the ability of patients and the family/caregivers to manage diabetes appropriately.
- Recognize the importance of the multidisciplinary team approach in the management of diabetes in children, including involvement of the primary care provider, endocrinologist, diabetes educator, dietitian, social worker, psychologist, child life specialist, and school representative.
- Acknowledge the value of collaboration with subspecialists and the primary care provider to ensure coordinated longitudinal care for children with diabetes.
- Maintain awareness of local populations and their risk factors for diabetes.
Systems Organization and Improvement
In order to improve efficiency and quality within their organizations, pediatric hospitalists should:
- Lead, coordinate, or participate in the development and implementation of cost-effective, safe, evidence-based care pathways to standardize the evaluation and management for hospitalized children with diabetes.
- Work with hospital administration, hospital staff, subspecialists, and community organizations to effect system-wide processes to improve the transition of care from hospital to the ambulatory setting.
- Lead, coordinate, or participate in system-wide processes within the hospital to promote therapeutic safety and vigilance in the use of hypoglycemic agents.
- Lead, coordinate, or participate in educational events to promote awareness of and familiarity with national guidelines for management strategies, new therapeutic and pharmacologic agents, and the use of medical devices to improve and monitor glucose homeostasis.
1. American Diabetes Association. Children and Adolescents: Standards of Medical Care in Diabetes - 2019. Diabetes Care.2019;42(Supplement 1):S148-S164. https://doi.org/10.2337/dc19-S013.
2. Rosenbloom AL. The management of diabetic ketoacidosis in children. Diabetes Ther. 2010;1(2):103-120. https://doi.org/10.1007/s13300-010-0008-2.
Introduction
Diabetes mellitus, a disorder of glucose homeostasis, is increasing in incidence and prevalence in pediatrics. Although there has been a significant rise in the incidence of type 2 diabetes, particularly among adolescents in high-risk ethnic groups, type 1 diabetes is still the most common form of diabetes in the pediatric and adolescent populations. The increase in obesity in the general population and the propensity of adolescents with type 2 diabetes to develop ketosis has resulted in phenotypic overlap in the pediatric patient presenting with a new diagnosis. In addition to the medical complications associated with these chronic conditions, both forms of diabetes have profound social and emotional impacts on the child. Pediatric hospitalists frequently encounter both children with new-onset diabetes and children previously diagnosed who may require hospitalization because of a diabetes related complication, an unrelated condition, or an elective procedure. Pediatric hospitalists are often positioned to provide both immediate care for children with diabetes as well as to coordinate care across multiple specialties when indicated.
Knowledge
Pediatric hospitalists should be able to:
- Compare and contrast the epidemiology and pathophysiology of type 1 and type 2 diabetes, attending to differences in family history, impairment of glucose regulation, and occurrence of ketoacidosis.
- Discuss the potential short and long-term complications of poor glucose control, including end-organ damage, and describe methods to assess for these complications.
- Describe common comorbidities and polyendocrinopathies associated with type 1 and type 2 diabetes.
- Describe the role of obesity in metabolic syndrome and type 2 diabetes.
- List other common causes of hyperglycemia, such as stress, drug, or steroid-induced hyperglycemia and indicate when insulin administration is needed.
- Explain the critical role of glucose homeostasis for patients admitted for reasons unrelated to their diagnosis of diabetes.
- List and interpret the laboratory tests, including islet autoantibodies and hemoglobin A1c, used to classify diabetes type and assess glycemic control.
- List the type and appropriate timing of screening tests for complications and co-morbidities of both type 1 and type 2 diabetes.
- Describe the different formulations of insulin and the different systems for insulin delivery and glucose monitoring.
- Describe the expected patterns of post-prandial glucose excursion in patients with diabetes and identify when a change in management is needed based on these patterns.
- Compare and contrast the role of nutrition in the management of type 1 versus type 2 diabetes.
- Review the principles of carbohydrate counting.
- Compare and contrast glucose monitoring, dietary recommendations, insulin dosing, and glucose targets between populations (such as type 1, type 2, cystic fibrosis related diabetes, and others).
- Define diabetic ketoacidosis (DKA) and describe its initial management, attending to fluid delivery, electrolyte and acid-base monitoring, mental status assessments, and appropriate patient placement based on local context.
- Discuss potential complications that may result from treatment of diabetes and DKA, including hypoglycemia and electrolyte imbalances.
- Summarize the approach toward management and education after stabilization of DKA.
- Describe criteria for hospital discharge, including specific measures of clinical improvement, education for patients and the family/caregivers, and establishment of a coordinated longitudinal care plan.
Skills
Pediatric hospitalists should be able to:
- Diagnose diabetes and its complications by efficiently performing a history and physical examination, determining if the patient meets diagnostic criteria.
- Identify and treat underlying causes of increased insulin demand that may lead to DKA in the patient with known diabetes.
- Order appropriate diagnostic testing for patients with new onset diabetes, diabetes exacerbations, or secondary causes of hyperglycemia.
- Order insulin doses and delivery systems (such as intravenous infusion, subcutaneous injection, and others) and other classes of drugs used in the treatment of diabetes.
- Identify and manage both hyperglycemia and hypoglycemia with attention to complications that may arise during treatment.
- Identify changes in clinical status related to severe acidosis and fluid and electrolyte disturbances and promptly initiate appropriate actions, including transfer to a higher level of care when indicated.
- Obtain prompt consultation with an endocrinologist or other subspecialist as appropriate.
- Utilize available support services, such as a certified diabetes educator, social worker, child life specialist, registered dietitian, and others, to ensure a comprehensive approach to management.
- Coordinate care and education for patients and the family/caregivers with other healthcare providers.
- Coordinate care with subspecialists and the primary care provider and arrange an appropriate transition plan for hospital discharge.
Attitudes
Pediatric hospitalists should be able to:
- Realize the importance of effective communication and culturally responsive care when creating a diabetes management plan, maintaining awareness of the unique needs of various groups.
- Recognize that acute and chronic psychosocial factors that impact the ability of patients and the family/caregivers to manage diabetes appropriately.
- Recognize the importance of the multidisciplinary team approach in the management of diabetes in children, including involvement of the primary care provider, endocrinologist, diabetes educator, dietitian, social worker, psychologist, child life specialist, and school representative.
- Acknowledge the value of collaboration with subspecialists and the primary care provider to ensure coordinated longitudinal care for children with diabetes.
- Maintain awareness of local populations and their risk factors for diabetes.
Systems Organization and Improvement
In order to improve efficiency and quality within their organizations, pediatric hospitalists should:
- Lead, coordinate, or participate in the development and implementation of cost-effective, safe, evidence-based care pathways to standardize the evaluation and management for hospitalized children with diabetes.
- Work with hospital administration, hospital staff, subspecialists, and community organizations to effect system-wide processes to improve the transition of care from hospital to the ambulatory setting.
- Lead, coordinate, or participate in system-wide processes within the hospital to promote therapeutic safety and vigilance in the use of hypoglycemic agents.
- Lead, coordinate, or participate in educational events to promote awareness of and familiarity with national guidelines for management strategies, new therapeutic and pharmacologic agents, and the use of medical devices to improve and monitor glucose homeostasis.
Introduction
Diabetes mellitus, a disorder of glucose homeostasis, is increasing in incidence and prevalence in pediatrics. Although there has been a significant rise in the incidence of type 2 diabetes, particularly among adolescents in high-risk ethnic groups, type 1 diabetes is still the most common form of diabetes in the pediatric and adolescent populations. The increase in obesity in the general population and the propensity of adolescents with type 2 diabetes to develop ketosis has resulted in phenotypic overlap in the pediatric patient presenting with a new diagnosis. In addition to the medical complications associated with these chronic conditions, both forms of diabetes have profound social and emotional impacts on the child. Pediatric hospitalists frequently encounter both children with new-onset diabetes and children previously diagnosed who may require hospitalization because of a diabetes related complication, an unrelated condition, or an elective procedure. Pediatric hospitalists are often positioned to provide both immediate care for children with diabetes as well as to coordinate care across multiple specialties when indicated.
Knowledge
Pediatric hospitalists should be able to:
- Compare and contrast the epidemiology and pathophysiology of type 1 and type 2 diabetes, attending to differences in family history, impairment of glucose regulation, and occurrence of ketoacidosis.
- Discuss the potential short and long-term complications of poor glucose control, including end-organ damage, and describe methods to assess for these complications.
- Describe common comorbidities and polyendocrinopathies associated with type 1 and type 2 diabetes.
- Describe the role of obesity in metabolic syndrome and type 2 diabetes.
- List other common causes of hyperglycemia, such as stress, drug, or steroid-induced hyperglycemia and indicate when insulin administration is needed.
- Explain the critical role of glucose homeostasis for patients admitted for reasons unrelated to their diagnosis of diabetes.
- List and interpret the laboratory tests, including islet autoantibodies and hemoglobin A1c, used to classify diabetes type and assess glycemic control.
- List the type and appropriate timing of screening tests for complications and co-morbidities of both type 1 and type 2 diabetes.
- Describe the different formulations of insulin and the different systems for insulin delivery and glucose monitoring.
- Describe the expected patterns of post-prandial glucose excursion in patients with diabetes and identify when a change in management is needed based on these patterns.
- Compare and contrast the role of nutrition in the management of type 1 versus type 2 diabetes.
- Review the principles of carbohydrate counting.
- Compare and contrast glucose monitoring, dietary recommendations, insulin dosing, and glucose targets between populations (such as type 1, type 2, cystic fibrosis related diabetes, and others).
- Define diabetic ketoacidosis (DKA) and describe its initial management, attending to fluid delivery, electrolyte and acid-base monitoring, mental status assessments, and appropriate patient placement based on local context.
- Discuss potential complications that may result from treatment of diabetes and DKA, including hypoglycemia and electrolyte imbalances.
- Summarize the approach toward management and education after stabilization of DKA.
- Describe criteria for hospital discharge, including specific measures of clinical improvement, education for patients and the family/caregivers, and establishment of a coordinated longitudinal care plan.
Skills
Pediatric hospitalists should be able to:
- Diagnose diabetes and its complications by efficiently performing a history and physical examination, determining if the patient meets diagnostic criteria.
- Identify and treat underlying causes of increased insulin demand that may lead to DKA in the patient with known diabetes.
- Order appropriate diagnostic testing for patients with new onset diabetes, diabetes exacerbations, or secondary causes of hyperglycemia.
- Order insulin doses and delivery systems (such as intravenous infusion, subcutaneous injection, and others) and other classes of drugs used in the treatment of diabetes.
- Identify and manage both hyperglycemia and hypoglycemia with attention to complications that may arise during treatment.
- Identify changes in clinical status related to severe acidosis and fluid and electrolyte disturbances and promptly initiate appropriate actions, including transfer to a higher level of care when indicated.
- Obtain prompt consultation with an endocrinologist or other subspecialist as appropriate.
- Utilize available support services, such as a certified diabetes educator, social worker, child life specialist, registered dietitian, and others, to ensure a comprehensive approach to management.
- Coordinate care and education for patients and the family/caregivers with other healthcare providers.
- Coordinate care with subspecialists and the primary care provider and arrange an appropriate transition plan for hospital discharge.
Attitudes
Pediatric hospitalists should be able to:
- Realize the importance of effective communication and culturally responsive care when creating a diabetes management plan, maintaining awareness of the unique needs of various groups.
- Recognize that acute and chronic psychosocial factors that impact the ability of patients and the family/caregivers to manage diabetes appropriately.
- Recognize the importance of the multidisciplinary team approach in the management of diabetes in children, including involvement of the primary care provider, endocrinologist, diabetes educator, dietitian, social worker, psychologist, child life specialist, and school representative.
- Acknowledge the value of collaboration with subspecialists and the primary care provider to ensure coordinated longitudinal care for children with diabetes.
- Maintain awareness of local populations and their risk factors for diabetes.
Systems Organization and Improvement
In order to improve efficiency and quality within their organizations, pediatric hospitalists should:
- Lead, coordinate, or participate in the development and implementation of cost-effective, safe, evidence-based care pathways to standardize the evaluation and management for hospitalized children with diabetes.
- Work with hospital administration, hospital staff, subspecialists, and community organizations to effect system-wide processes to improve the transition of care from hospital to the ambulatory setting.
- Lead, coordinate, or participate in system-wide processes within the hospital to promote therapeutic safety and vigilance in the use of hypoglycemic agents.
- Lead, coordinate, or participate in educational events to promote awareness of and familiarity with national guidelines for management strategies, new therapeutic and pharmacologic agents, and the use of medical devices to improve and monitor glucose homeostasis.
1. American Diabetes Association. Children and Adolescents: Standards of Medical Care in Diabetes - 2019. Diabetes Care.2019;42(Supplement 1):S148-S164. https://doi.org/10.2337/dc19-S013.
2. Rosenbloom AL. The management of diabetic ketoacidosis in children. Diabetes Ther. 2010;1(2):103-120. https://doi.org/10.1007/s13300-010-0008-2.
1. American Diabetes Association. Children and Adolescents: Standards of Medical Care in Diabetes - 2019. Diabetes Care.2019;42(Supplement 1):S148-S164. https://doi.org/10.2337/dc19-S013.
2. Rosenbloom AL. The management of diabetic ketoacidosis in children. Diabetes Ther. 2010;1(2):103-120. https://doi.org/10.1007/s13300-010-0008-2.
1.10 Common Clinical Diagnoses and Conditions: Constipation
Introduction
Constipation is a common pediatric problem, accounting for 3% of all outpatient visits and up to 0.5% of all pediatric hospital admissions. While constipation affects many children, only a very small minority have an organic cause for their symptoms. The great majority have functional constipation, also termed idiopathic constipation or functional fecal retention. Pediatric hospitalists frequently care for children admitted for fecal impaction or encounter constipation as a comorbidity during other admissions. Therefore, pediatric hospitalists must be knowledgeable about the differential diagnosis of organic and functional causes of constipation. In addition, they must be adept at the implementation of evidence-based approaches for relieving stool burden and providing education for patients and caregivers.
Knowledge
Pediatric hospitalists should be able to:
- Discuss the self-perpetuating nature of constipation, the physiologic changes related to colonic volume and defecation signaling, and the pathophysiology of encopresis and soiling.
- Discuss the elements of the history which are pertinent; including family history, stooling history, age at which first stool was passed, current stooling pattern, diet history, prior test results, previous treatments and response, and related behaviors such as withholding, stooling avoidance, and others.
- Describe the elements of the physical exam that would help confirm or contradict the diagnosis of constipation.
- Describe common factors that might lead to functional or non-organic constipation, including cognitive disabilities, toilet/school bathroom phobia, poor toilet training experiences, sexual abuse, low fiber diet, dehydration, underfeeding, and inattentiveness to internal stooling signals.
- Compare and contrast key historical and physical exam findings for uncommon but important medical causes of constipation (such as hypothyroidism, hypercalcemia, hypokalemia, cystic fibrosis, diabetes, cerebral palsy, Hirschsprung disease, and others), including the key features that would distinguish them from a diagnosis of functional constipation.
- Discuss the pathophysiology of the development of constipation in the post-operative setting, including preventative strategies and medical management.
- Identify common medications that can lead to constipation, including opioids, antacids, anticholinergics, antidepressants, and sympathomimetics.
- Describe common inpatient medical conditions that can lead to secondary constipation, such as inactivity or immobility, poor oral intake, sedation, ileus from other gastrointestinal disorders, and others.
- Discuss the inpatient treatment options for acute stool impaction and symptomatic constipation, as well as options for outpatient management strategies (such as therapies available, side effects, timing of periodic monitoring, duration of therapy, and others).
- Describe the admission criteria for fecal impaction and circumstances that should trigger consultation with a gastroenterologist or pediatric surgeon.
Skills
Pediatric hospitalists should be able to:
- Diagnose and differentiate functional and organic constipation by performing a careful history and exam.
- Identify signs and symptoms of developing stool retention as a secondary problem during hospitalization and effectively respond with an appropriate treatment plan.
- Select appropriate diagnostic studies to evaluate functional or organic causes of constipation when suspected and correctly interpret results.
- Prescribe and manage disimpaction and/or whole bowel clean out regimens, accounting for potential complications of therapy (such as fluid and electrolyte shifts and others), designation of an appropriate endpoint, and discharge criteria.
- Engage consultants (such as registered dieticians, gastroenterology, psychology, and others) efficiently when indicated.
- Create a discharge maintenance therapy regimen and follow-up plan, including education of the patient and the family/caregivers.
Attitudes
Pediatric hospitalists should be able to:
- Realize responsibility and long-term importance of promoting communication with patients and caregivers about the causes of constipation and the goals and duration of therapy.
- Reflect on the psychological implications inherent in the diagnosis of constipation including the impact of parental frustration, toileting expectations, frequent soiling, and the non-volitional nature of the disorder.
- Acknowledge and provide support for patients and caregivers on common pitfalls in the treatment of chronic constipation.
Systems Organization and Improvement
In order to improve efficiency and quality within their organizations, pediatric hospitalists should:
- Lead, coordinate, or participate in the development and implementation of evidence-based and cost-effective clinical guidelines to improve the quality of care for inpatient management of constipation and whole bowel clean out.
- Collaborate with subspecialty consultants, including surgeons and gastroenterologists, to improve the care and management of complex patients with constipation.
- Coordinate the care of professional staff (including primary care providers and subspecialists) to ensure communication about, enhance adherence to, and provide education to patients and the family/caregivers regarding ongoing treatment regimens.
1. Evaluation and treatment of functional constipation in infants and children: Evidence-based recommendations from ESPGHAN-NASPGHAN. J Pediatr Gastro Nutr. 2014;58(2):258-274. https://doi.org/10.1097/MPG.0000000000000266.
Introduction
Constipation is a common pediatric problem, accounting for 3% of all outpatient visits and up to 0.5% of all pediatric hospital admissions. While constipation affects many children, only a very small minority have an organic cause for their symptoms. The great majority have functional constipation, also termed idiopathic constipation or functional fecal retention. Pediatric hospitalists frequently care for children admitted for fecal impaction or encounter constipation as a comorbidity during other admissions. Therefore, pediatric hospitalists must be knowledgeable about the differential diagnosis of organic and functional causes of constipation. In addition, they must be adept at the implementation of evidence-based approaches for relieving stool burden and providing education for patients and caregivers.
Knowledge
Pediatric hospitalists should be able to:
- Discuss the self-perpetuating nature of constipation, the physiologic changes related to colonic volume and defecation signaling, and the pathophysiology of encopresis and soiling.
- Discuss the elements of the history which are pertinent; including family history, stooling history, age at which first stool was passed, current stooling pattern, diet history, prior test results, previous treatments and response, and related behaviors such as withholding, stooling avoidance, and others.
- Describe the elements of the physical exam that would help confirm or contradict the diagnosis of constipation.
- Describe common factors that might lead to functional or non-organic constipation, including cognitive disabilities, toilet/school bathroom phobia, poor toilet training experiences, sexual abuse, low fiber diet, dehydration, underfeeding, and inattentiveness to internal stooling signals.
- Compare and contrast key historical and physical exam findings for uncommon but important medical causes of constipation (such as hypothyroidism, hypercalcemia, hypokalemia, cystic fibrosis, diabetes, cerebral palsy, Hirschsprung disease, and others), including the key features that would distinguish them from a diagnosis of functional constipation.
- Discuss the pathophysiology of the development of constipation in the post-operative setting, including preventative strategies and medical management.
- Identify common medications that can lead to constipation, including opioids, antacids, anticholinergics, antidepressants, and sympathomimetics.
- Describe common inpatient medical conditions that can lead to secondary constipation, such as inactivity or immobility, poor oral intake, sedation, ileus from other gastrointestinal disorders, and others.
- Discuss the inpatient treatment options for acute stool impaction and symptomatic constipation, as well as options for outpatient management strategies (such as therapies available, side effects, timing of periodic monitoring, duration of therapy, and others).
- Describe the admission criteria for fecal impaction and circumstances that should trigger consultation with a gastroenterologist or pediatric surgeon.
Skills
Pediatric hospitalists should be able to:
- Diagnose and differentiate functional and organic constipation by performing a careful history and exam.
- Identify signs and symptoms of developing stool retention as a secondary problem during hospitalization and effectively respond with an appropriate treatment plan.
- Select appropriate diagnostic studies to evaluate functional or organic causes of constipation when suspected and correctly interpret results.
- Prescribe and manage disimpaction and/or whole bowel clean out regimens, accounting for potential complications of therapy (such as fluid and electrolyte shifts and others), designation of an appropriate endpoint, and discharge criteria.
- Engage consultants (such as registered dieticians, gastroenterology, psychology, and others) efficiently when indicated.
- Create a discharge maintenance therapy regimen and follow-up plan, including education of the patient and the family/caregivers.
Attitudes
Pediatric hospitalists should be able to:
- Realize responsibility and long-term importance of promoting communication with patients and caregivers about the causes of constipation and the goals and duration of therapy.
- Reflect on the psychological implications inherent in the diagnosis of constipation including the impact of parental frustration, toileting expectations, frequent soiling, and the non-volitional nature of the disorder.
- Acknowledge and provide support for patients and caregivers on common pitfalls in the treatment of chronic constipation.
Systems Organization and Improvement
In order to improve efficiency and quality within their organizations, pediatric hospitalists should:
- Lead, coordinate, or participate in the development and implementation of evidence-based and cost-effective clinical guidelines to improve the quality of care for inpatient management of constipation and whole bowel clean out.
- Collaborate with subspecialty consultants, including surgeons and gastroenterologists, to improve the care and management of complex patients with constipation.
- Coordinate the care of professional staff (including primary care providers and subspecialists) to ensure communication about, enhance adherence to, and provide education to patients and the family/caregivers regarding ongoing treatment regimens.
Introduction
Constipation is a common pediatric problem, accounting for 3% of all outpatient visits and up to 0.5% of all pediatric hospital admissions. While constipation affects many children, only a very small minority have an organic cause for their symptoms. The great majority have functional constipation, also termed idiopathic constipation or functional fecal retention. Pediatric hospitalists frequently care for children admitted for fecal impaction or encounter constipation as a comorbidity during other admissions. Therefore, pediatric hospitalists must be knowledgeable about the differential diagnosis of organic and functional causes of constipation. In addition, they must be adept at the implementation of evidence-based approaches for relieving stool burden and providing education for patients and caregivers.
Knowledge
Pediatric hospitalists should be able to:
- Discuss the self-perpetuating nature of constipation, the physiologic changes related to colonic volume and defecation signaling, and the pathophysiology of encopresis and soiling.
- Discuss the elements of the history which are pertinent; including family history, stooling history, age at which first stool was passed, current stooling pattern, diet history, prior test results, previous treatments and response, and related behaviors such as withholding, stooling avoidance, and others.
- Describe the elements of the physical exam that would help confirm or contradict the diagnosis of constipation.
- Describe common factors that might lead to functional or non-organic constipation, including cognitive disabilities, toilet/school bathroom phobia, poor toilet training experiences, sexual abuse, low fiber diet, dehydration, underfeeding, and inattentiveness to internal stooling signals.
- Compare and contrast key historical and physical exam findings for uncommon but important medical causes of constipation (such as hypothyroidism, hypercalcemia, hypokalemia, cystic fibrosis, diabetes, cerebral palsy, Hirschsprung disease, and others), including the key features that would distinguish them from a diagnosis of functional constipation.
- Discuss the pathophysiology of the development of constipation in the post-operative setting, including preventative strategies and medical management.
- Identify common medications that can lead to constipation, including opioids, antacids, anticholinergics, antidepressants, and sympathomimetics.
- Describe common inpatient medical conditions that can lead to secondary constipation, such as inactivity or immobility, poor oral intake, sedation, ileus from other gastrointestinal disorders, and others.
- Discuss the inpatient treatment options for acute stool impaction and symptomatic constipation, as well as options for outpatient management strategies (such as therapies available, side effects, timing of periodic monitoring, duration of therapy, and others).
- Describe the admission criteria for fecal impaction and circumstances that should trigger consultation with a gastroenterologist or pediatric surgeon.
Skills
Pediatric hospitalists should be able to:
- Diagnose and differentiate functional and organic constipation by performing a careful history and exam.
- Identify signs and symptoms of developing stool retention as a secondary problem during hospitalization and effectively respond with an appropriate treatment plan.
- Select appropriate diagnostic studies to evaluate functional or organic causes of constipation when suspected and correctly interpret results.
- Prescribe and manage disimpaction and/or whole bowel clean out regimens, accounting for potential complications of therapy (such as fluid and electrolyte shifts and others), designation of an appropriate endpoint, and discharge criteria.
- Engage consultants (such as registered dieticians, gastroenterology, psychology, and others) efficiently when indicated.
- Create a discharge maintenance therapy regimen and follow-up plan, including education of the patient and the family/caregivers.
Attitudes
Pediatric hospitalists should be able to:
- Realize responsibility and long-term importance of promoting communication with patients and caregivers about the causes of constipation and the goals and duration of therapy.
- Reflect on the psychological implications inherent in the diagnosis of constipation including the impact of parental frustration, toileting expectations, frequent soiling, and the non-volitional nature of the disorder.
- Acknowledge and provide support for patients and caregivers on common pitfalls in the treatment of chronic constipation.
Systems Organization and Improvement
In order to improve efficiency and quality within their organizations, pediatric hospitalists should:
- Lead, coordinate, or participate in the development and implementation of evidence-based and cost-effective clinical guidelines to improve the quality of care for inpatient management of constipation and whole bowel clean out.
- Collaborate with subspecialty consultants, including surgeons and gastroenterologists, to improve the care and management of complex patients with constipation.
- Coordinate the care of professional staff (including primary care providers and subspecialists) to ensure communication about, enhance adherence to, and provide education to patients and the family/caregivers regarding ongoing treatment regimens.
1. Evaluation and treatment of functional constipation in infants and children: Evidence-based recommendations from ESPGHAN-NASPGHAN. J Pediatr Gastro Nutr. 2014;58(2):258-274. https://doi.org/10.1097/MPG.0000000000000266.
1. Evaluation and treatment of functional constipation in infants and children: Evidence-based recommendations from ESPGHAN-NASPGHAN. J Pediatr Gastro Nutr. 2014;58(2):258-274. https://doi.org/10.1097/MPG.0000000000000266.
1.09 Common Clinical Diagnoses and Conditions: Central Nervous System Infections
Introduction
Central nervous system (CNS) infections in children can cause significant morbidity and mortality and require prompt diagnosis and management. CNS infections include meningitis, encephalitis, infections of CNS implanted devices, parameningeal infections, spinal epidural abscesses, and others. The common infectious pathogens and predisposing risk factors vary by infection type, as do the overall severity of illness and the expected outcome. Likewise, the type and severity of infection dictates the choice of pharmacological and other therapeutic agents. To optimize outcomes, management often requires coordination of care with subspecialists, including infectious disease physicians, neurologists, neurosurgeons, and others. Pediatric hospitalists are uniquely equipped to provide both coordinated acute care and develop an integrated transition plan for post-discharge care and placement.
Knowledge
Pediatric hospitalists should be able to:
- Discuss the most common etiologic agents of different CNS infections for children of varying chronological ages and predisposing factors.
- Discuss the common presenting signs and symptoms of CNS infections, including those features that differentiate meningitis, encephalitis, parameningeal infections (including brain abscess, subdural empyema, and intracranial epidural abscess), and spinal epidural abscess, considering variation in presentation by chronological age.
- Discuss how the presence of comorbid conditions, such as immunocompromised status, implanted CNS devices, developmental delay, and others, may impact or alter some elements of the history and physical examination.
- Discuss the impact of cerebrospinal fluid (CSF) shunts on risk for CNS infection, particularly in the first month following shunt placement, as well as the indications for shunt tap, shunt externalization, and/or removal.
- Review alternative diagnoses that may mimic the presentation of CNS infection, such as autoimmune diseases involving the CNS, stroke, toxidromes, psychiatric disorders, neoplastic syndromes, and others.
- List predisposing conditions for parameningeal infections, including sinusitis, otitis media, mastoiditis, and orbital cellulitis.
- Discuss appropriate microbiologic, virologic, and serologic tests utilized to establish a diagnosis, including the use of indirect sampling from rectal or nasopharyngeal sites.
- Discuss the risks, benefits, indications, and contraindications for lumbar puncture.
- Compare and contrast CSF analysis values found in bacterial, viral, fungal, parasitic, and aseptic meningitis, encephalitis, and parameningeal infections.
- Explain the indications for imaging of children with meningitis, encephalitis, ventricular infections, and parameningeal infections, stating the modality of choice for each diagnosis.
- Compare and contrast the value of computed tomography versus magnetic resonance for diagnostic imaging of CNS infections of the head, neck, and spine, attending to sedation needs, local availability, radiation exposure, and contrast versus non-contrast images.
- Discuss initial antimicrobial therapy for CNS infections, and how this varies by age, site of infection, presence of CSF shunt, CNS drug penetration, and regional microbial drug resistance patterns.
- Describe the most common acute complications of CNS infections, including fluid and electrolyte imbalance, seizures, and increased intracranial pressure.
- Explain patient characteristics that indicate a requirement for higher level of care and/or monitoring for children with CNS infection.
- Discuss the prognosis and long-term sequelae of different CNS infections.
- Describe criteria, including specific measures of clinical stability, which must be met before discharging or transferring patients with CNS infections.
Skills
Pediatric hospitalists should be able to:
- Elicit a thorough medical history, with emphasis on elements that may distinguish between types of CNS infections.
- Perform a thorough physical examination, to elicit key features of various types of CNS infections, such as mental status changes and focal versus global neurological findings.
- Perform a lumbar puncture as indicated or coordinate lumbar puncture with appropriate subspecialists when assistance is required.
- Initiate an empiric antimicrobial regimen based on patient history, underlying comorbid conditions, and initial diagnostic testing.
- Tailor antibiotic regimens and duration of therapy based on microbiologic culture and sensitivity data, as well as the patient’s clinical condition and underlying comorbidities.
- Adhere consistently to proper infection control practices.
- Perform frequent careful reassessments, note changes in clinical status, manage acute complications, and identify indications for transfer to a higher level of care.
- Engage and coordinate consultants, such as neurologists, neurosurgeons, infectious diseases specialists, rehabilitation therapists, and others when indicated, including those whose support is required by the presence of neurological sequelae.
- Coordinate care with subspecialists and the primary care provider to arrange an appropriate transition plan for hospital discharge inclusive of therapies, school needs, and psychosocial support.
Attitudes
Pediatric hospitalists should be able to:
- Realize responsibility for sensitive and clear communications with the family/caregivers regarding diagnosis, treatment plans, and potential neurologic sequelae, engaging consultants as appropriate.
- Recognize the importance of collaboration with subspecialists and the primary care provider to ensure coordinated longitudinal care for children with CNS infections.
Systems Organization and Improvement
In order to improve efficiency and quality within their organizations, pediatric hospitalists should:
- Lead, coordinate, or participate in the development and implementation of cost-effective, safe, evidence-based care pathways to standardize the evaluation and management for hospitalized children with CNS infections.
- Advocate and work with hospital and community leaders to assure that proper services are available for children requiring short and long-term support services.
1. Tunkel AR, Glaser CA, Bloch KC, et al. The management of encephalitis: clinical practice guidelines by the Infectious Diseases Society of America. Clin Infect Dis. 2008;47(3):303-327. https://doi.org/10.1086/589747.
2. Harrison C. Focal Suppurative Infections of the Nervous System. In: Long SS, Prober CG, Fischer M, eds. Principles and Practice of Pediatric Infectious Diseases. 5th ed. Philadelphia, PA: Elsevier, 2017:329-340.
Introduction
Central nervous system (CNS) infections in children can cause significant morbidity and mortality and require prompt diagnosis and management. CNS infections include meningitis, encephalitis, infections of CNS implanted devices, parameningeal infections, spinal epidural abscesses, and others. The common infectious pathogens and predisposing risk factors vary by infection type, as do the overall severity of illness and the expected outcome. Likewise, the type and severity of infection dictates the choice of pharmacological and other therapeutic agents. To optimize outcomes, management often requires coordination of care with subspecialists, including infectious disease physicians, neurologists, neurosurgeons, and others. Pediatric hospitalists are uniquely equipped to provide both coordinated acute care and develop an integrated transition plan for post-discharge care and placement.
Knowledge
Pediatric hospitalists should be able to:
- Discuss the most common etiologic agents of different CNS infections for children of varying chronological ages and predisposing factors.
- Discuss the common presenting signs and symptoms of CNS infections, including those features that differentiate meningitis, encephalitis, parameningeal infections (including brain abscess, subdural empyema, and intracranial epidural abscess), and spinal epidural abscess, considering variation in presentation by chronological age.
- Discuss how the presence of comorbid conditions, such as immunocompromised status, implanted CNS devices, developmental delay, and others, may impact or alter some elements of the history and physical examination.
- Discuss the impact of cerebrospinal fluid (CSF) shunts on risk for CNS infection, particularly in the first month following shunt placement, as well as the indications for shunt tap, shunt externalization, and/or removal.
- Review alternative diagnoses that may mimic the presentation of CNS infection, such as autoimmune diseases involving the CNS, stroke, toxidromes, psychiatric disorders, neoplastic syndromes, and others.
- List predisposing conditions for parameningeal infections, including sinusitis, otitis media, mastoiditis, and orbital cellulitis.
- Discuss appropriate microbiologic, virologic, and serologic tests utilized to establish a diagnosis, including the use of indirect sampling from rectal or nasopharyngeal sites.
- Discuss the risks, benefits, indications, and contraindications for lumbar puncture.
- Compare and contrast CSF analysis values found in bacterial, viral, fungal, parasitic, and aseptic meningitis, encephalitis, and parameningeal infections.
- Explain the indications for imaging of children with meningitis, encephalitis, ventricular infections, and parameningeal infections, stating the modality of choice for each diagnosis.
- Compare and contrast the value of computed tomography versus magnetic resonance for diagnostic imaging of CNS infections of the head, neck, and spine, attending to sedation needs, local availability, radiation exposure, and contrast versus non-contrast images.
- Discuss initial antimicrobial therapy for CNS infections, and how this varies by age, site of infection, presence of CSF shunt, CNS drug penetration, and regional microbial drug resistance patterns.
- Describe the most common acute complications of CNS infections, including fluid and electrolyte imbalance, seizures, and increased intracranial pressure.
- Explain patient characteristics that indicate a requirement for higher level of care and/or monitoring for children with CNS infection.
- Discuss the prognosis and long-term sequelae of different CNS infections.
- Describe criteria, including specific measures of clinical stability, which must be met before discharging or transferring patients with CNS infections.
Skills
Pediatric hospitalists should be able to:
- Elicit a thorough medical history, with emphasis on elements that may distinguish between types of CNS infections.
- Perform a thorough physical examination, to elicit key features of various types of CNS infections, such as mental status changes and focal versus global neurological findings.
- Perform a lumbar puncture as indicated or coordinate lumbar puncture with appropriate subspecialists when assistance is required.
- Initiate an empiric antimicrobial regimen based on patient history, underlying comorbid conditions, and initial diagnostic testing.
- Tailor antibiotic regimens and duration of therapy based on microbiologic culture and sensitivity data, as well as the patient’s clinical condition and underlying comorbidities.
- Adhere consistently to proper infection control practices.
- Perform frequent careful reassessments, note changes in clinical status, manage acute complications, and identify indications for transfer to a higher level of care.
- Engage and coordinate consultants, such as neurologists, neurosurgeons, infectious diseases specialists, rehabilitation therapists, and others when indicated, including those whose support is required by the presence of neurological sequelae.
- Coordinate care with subspecialists and the primary care provider to arrange an appropriate transition plan for hospital discharge inclusive of therapies, school needs, and psychosocial support.
Attitudes
Pediatric hospitalists should be able to:
- Realize responsibility for sensitive and clear communications with the family/caregivers regarding diagnosis, treatment plans, and potential neurologic sequelae, engaging consultants as appropriate.
- Recognize the importance of collaboration with subspecialists and the primary care provider to ensure coordinated longitudinal care for children with CNS infections.
Systems Organization and Improvement
In order to improve efficiency and quality within their organizations, pediatric hospitalists should:
- Lead, coordinate, or participate in the development and implementation of cost-effective, safe, evidence-based care pathways to standardize the evaluation and management for hospitalized children with CNS infections.
- Advocate and work with hospital and community leaders to assure that proper services are available for children requiring short and long-term support services.
Introduction
Central nervous system (CNS) infections in children can cause significant morbidity and mortality and require prompt diagnosis and management. CNS infections include meningitis, encephalitis, infections of CNS implanted devices, parameningeal infections, spinal epidural abscesses, and others. The common infectious pathogens and predisposing risk factors vary by infection type, as do the overall severity of illness and the expected outcome. Likewise, the type and severity of infection dictates the choice of pharmacological and other therapeutic agents. To optimize outcomes, management often requires coordination of care with subspecialists, including infectious disease physicians, neurologists, neurosurgeons, and others. Pediatric hospitalists are uniquely equipped to provide both coordinated acute care and develop an integrated transition plan for post-discharge care and placement.
Knowledge
Pediatric hospitalists should be able to:
- Discuss the most common etiologic agents of different CNS infections for children of varying chronological ages and predisposing factors.
- Discuss the common presenting signs and symptoms of CNS infections, including those features that differentiate meningitis, encephalitis, parameningeal infections (including brain abscess, subdural empyema, and intracranial epidural abscess), and spinal epidural abscess, considering variation in presentation by chronological age.
- Discuss how the presence of comorbid conditions, such as immunocompromised status, implanted CNS devices, developmental delay, and others, may impact or alter some elements of the history and physical examination.
- Discuss the impact of cerebrospinal fluid (CSF) shunts on risk for CNS infection, particularly in the first month following shunt placement, as well as the indications for shunt tap, shunt externalization, and/or removal.
- Review alternative diagnoses that may mimic the presentation of CNS infection, such as autoimmune diseases involving the CNS, stroke, toxidromes, psychiatric disorders, neoplastic syndromes, and others.
- List predisposing conditions for parameningeal infections, including sinusitis, otitis media, mastoiditis, and orbital cellulitis.
- Discuss appropriate microbiologic, virologic, and serologic tests utilized to establish a diagnosis, including the use of indirect sampling from rectal or nasopharyngeal sites.
- Discuss the risks, benefits, indications, and contraindications for lumbar puncture.
- Compare and contrast CSF analysis values found in bacterial, viral, fungal, parasitic, and aseptic meningitis, encephalitis, and parameningeal infections.
- Explain the indications for imaging of children with meningitis, encephalitis, ventricular infections, and parameningeal infections, stating the modality of choice for each diagnosis.
- Compare and contrast the value of computed tomography versus magnetic resonance for diagnostic imaging of CNS infections of the head, neck, and spine, attending to sedation needs, local availability, radiation exposure, and contrast versus non-contrast images.
- Discuss initial antimicrobial therapy for CNS infections, and how this varies by age, site of infection, presence of CSF shunt, CNS drug penetration, and regional microbial drug resistance patterns.
- Describe the most common acute complications of CNS infections, including fluid and electrolyte imbalance, seizures, and increased intracranial pressure.
- Explain patient characteristics that indicate a requirement for higher level of care and/or monitoring for children with CNS infection.
- Discuss the prognosis and long-term sequelae of different CNS infections.
- Describe criteria, including specific measures of clinical stability, which must be met before discharging or transferring patients with CNS infections.
Skills
Pediatric hospitalists should be able to:
- Elicit a thorough medical history, with emphasis on elements that may distinguish between types of CNS infections.
- Perform a thorough physical examination, to elicit key features of various types of CNS infections, such as mental status changes and focal versus global neurological findings.
- Perform a lumbar puncture as indicated or coordinate lumbar puncture with appropriate subspecialists when assistance is required.
- Initiate an empiric antimicrobial regimen based on patient history, underlying comorbid conditions, and initial diagnostic testing.
- Tailor antibiotic regimens and duration of therapy based on microbiologic culture and sensitivity data, as well as the patient’s clinical condition and underlying comorbidities.
- Adhere consistently to proper infection control practices.
- Perform frequent careful reassessments, note changes in clinical status, manage acute complications, and identify indications for transfer to a higher level of care.
- Engage and coordinate consultants, such as neurologists, neurosurgeons, infectious diseases specialists, rehabilitation therapists, and others when indicated, including those whose support is required by the presence of neurological sequelae.
- Coordinate care with subspecialists and the primary care provider to arrange an appropriate transition plan for hospital discharge inclusive of therapies, school needs, and psychosocial support.
Attitudes
Pediatric hospitalists should be able to:
- Realize responsibility for sensitive and clear communications with the family/caregivers regarding diagnosis, treatment plans, and potential neurologic sequelae, engaging consultants as appropriate.
- Recognize the importance of collaboration with subspecialists and the primary care provider to ensure coordinated longitudinal care for children with CNS infections.
Systems Organization and Improvement
In order to improve efficiency and quality within their organizations, pediatric hospitalists should:
- Lead, coordinate, or participate in the development and implementation of cost-effective, safe, evidence-based care pathways to standardize the evaluation and management for hospitalized children with CNS infections.
- Advocate and work with hospital and community leaders to assure that proper services are available for children requiring short and long-term support services.
1. Tunkel AR, Glaser CA, Bloch KC, et al. The management of encephalitis: clinical practice guidelines by the Infectious Diseases Society of America. Clin Infect Dis. 2008;47(3):303-327. https://doi.org/10.1086/589747.
2. Harrison C. Focal Suppurative Infections of the Nervous System. In: Long SS, Prober CG, Fischer M, eds. Principles and Practice of Pediatric Infectious Diseases. 5th ed. Philadelphia, PA: Elsevier, 2017:329-340.
1. Tunkel AR, Glaser CA, Bloch KC, et al. The management of encephalitis: clinical practice guidelines by the Infectious Diseases Society of America. Clin Infect Dis. 2008;47(3):303-327. https://doi.org/10.1086/589747.
2. Harrison C. Focal Suppurative Infections of the Nervous System. In: Long SS, Prober CG, Fischer M, eds. Principles and Practice of Pediatric Infectious Diseases. 5th ed. Philadelphia, PA: Elsevier, 2017:329-340.
1.08 Common Clinical Diagnoses and Conditions: Bronchiolitis
Introduction
Bronchiolitis is the most common viral lower respiratory illness in young children and infants. It is responsible for hundreds of thousands of outpatient and emergency department visits and more than 100,000 hospitalizations per year, accounting for more than $1.7 billion in hospital charges annually. The most commonly identified etiology of bronchiolitis is respiratory syncytial virus (RSV), however bronchiolitis may be caused by many other viruses, including rhinovirus, human metapneumovirus, parainfluenza, adenovirus, and influenza. With hospital care provided for these patients in a variety of settings, the potential for significant variation in practices exists despite guidelines published by the American Academy of Pediatrics. Pediatric hospitalists should render evidence-based care that minimizes harm, improves outcomes, and avoids unnecessary testing, hospitalization, and treatments.
Knowledge
Pediatric hospitalists should be able to:
- Compare and contrast the epidemiology and pathogenesis of bronchiolitis with asthma.
- Describe the typical clinical signs of viral bronchiolitis (such as wheezing, rales, tachypnea, acute respiratory distress, hypoxia, cough, apnea, nasal obstruction, and others) and explain the ways in which presentations may vary.
- Discuss alternate diagnoses that may mimic bronchiolitis, such as pneumonia, congestive heart failure, previously undiagnosed cyanotic or non-cyanotic congenital heart disease, sepsis, aspiration, and others.
- Describe risk factors that predispose infants and children to severe illness or complications of bronchiolitis, including prematurity, heart disease, pulmonary disease, immunodeficiency, neuromuscular disease, and environmental smoke exposure.
- Explain indications for hospital admission and cite discharge criteria.
- Discuss indications for diagnostic testing, including viral testing and chest radiographs.
- Discuss risks of serious bacterial infection and initial diagnostic evaluations for febrile infants of various ages presenting with bronchiolitis, attending to ages less than 30 days, 31-60 days, and others.
- Explain the indications and contraindications for RSV immunoprophylaxis.
- Summarize the evidence for the use of specific therapies in the treatment of routine bronchiolitis, including beta-agonists, hypertonic saline, and steroids.
- Discuss the evidence regarding use of supportive measures, including suctioning (such as nasal-pharyngeal, oral, and others), chest physiotherapy, positioning, enteral versus intravenous fluids and nutrition, supplemental oxygen, and others.
- Define the benefits, limitations, and potential harms associated with use of various non-invasive monitoring modalities, including cardiorespiratory, oxygen saturation, and capnography.
- Discuss management strategies for patients with worsening respiratory status, including use of various oxygen delivery systems and advanced respiratory support (including heated high flow nasal cannula, forms of non-invasive ventilation, and endotracheal intubation and mechanical ventilation).
Skills
Pediatric hospitalists should be able to:
- Diagnose bronchiolitis by efficiently performing an accurate history and physical examination, determining if key features of the disease are present.
- Assess clinical signs of respiratory distress and identify impending respiratory failure.
- Identify the indications for escalating level of care, transferring to a tertiary care center, and initiation of ventilatory support.
- Assess nutrition and hydration status and choose appropriate methods to maintain adequate hydration and nutrition, with promotion of breastfeeding when appropriate.
- Order appropriate monitoring (type and frequency) and correctly interpret monitor data.
- Perform reassessments daily and as needed, note changes in clinical status, and respond with appropriate actions, including discontinuation of ineffective or unnecessary therapies and monitoring.
- Utilize standardized respiratory scores to objectively assess and document response to interventions.
- Implement appropriate oxygen weaning strategies, including the use of appropriate oxygen saturation parameters.
- Adhere to proper infection control measures and educate the family/caregivers in the importance of hand washing and minimizing environmental exposure in the prevention of infection.
- Communicate with the family/caregivers about the etiology and natural history of bronchiolitis, interpretation of clinical findings, care plans, and supportive care.
- Deliver efficient care by proactively creating a discharge plan that can be expediently activated when appropriate.
- Coordinate care with the primary care provider and other services as indicated, to arrange an appropriate transition plan for hospital discharge.
Attitudes
Pediatric hospitalists should be able to:
- Acknowledge the importance of discussing the role of supportive care and the limited evidence for other interventions with the family/caregivers.
- Exemplify a proactive, engaged attitude regarding proper isolation measures, including hand washing to prevent spread of the etiologic agent in the hospital.
- Realize responsibility for explaining the relationship between bronchiolitis and risk of future wheezing when educating the family/caregivers regarding this diagnosis.
Systems Organization and Improvement
In order to improve efficiency and quality within their organizations, pediatric hospitalists should:
- Collaborate with hospital infection control practitioners to prevent nosocomial infection related to bronchiolitis.
- Partner with community services to educate the public on respiratory infection preventive strategies.
- Lead, coordinate, or participate in multidisciplinary initiatives (including nursing, respiratory therapy, emergency department physicians, primary care physicians, intensivists, and other specialists) to develop, implement, and assess quality outcomes of evidence-based clinical guidelines for the care of children with bronchiolitis.
- Collaborate with intensivists, respiratory therapists, and nurses to mutually develop and implement evidence-based criteria for use of non-invasive respiratory support therapies such as supplemental oxygen, heated high-flow nasal cannula, and others.
1. Ralston WL, Lieberthal AS, Meissner HC. Clinical Practice Guideline: The Diagnosis, Management, and Prevention of Bronchiolitis. Pediatrics. 2014; 134(5): e1474-1502. https://pediatrics.aappublications.org/content/134/5/e1474.long. Accessed August 28, 2019.
2. National Institute for Health and Care Excellence. Bronchiolitis: diagnosis and management of bronchiolitis in children. Clinical Guideline NG 9. June 2015. https://www.nice.org.uk/guidance/ng9. Accessed August 25, 2019.
Introduction
Bronchiolitis is the most common viral lower respiratory illness in young children and infants. It is responsible for hundreds of thousands of outpatient and emergency department visits and more than 100,000 hospitalizations per year, accounting for more than $1.7 billion in hospital charges annually. The most commonly identified etiology of bronchiolitis is respiratory syncytial virus (RSV), however bronchiolitis may be caused by many other viruses, including rhinovirus, human metapneumovirus, parainfluenza, adenovirus, and influenza. With hospital care provided for these patients in a variety of settings, the potential for significant variation in practices exists despite guidelines published by the American Academy of Pediatrics. Pediatric hospitalists should render evidence-based care that minimizes harm, improves outcomes, and avoids unnecessary testing, hospitalization, and treatments.
Knowledge
Pediatric hospitalists should be able to:
- Compare and contrast the epidemiology and pathogenesis of bronchiolitis with asthma.
- Describe the typical clinical signs of viral bronchiolitis (such as wheezing, rales, tachypnea, acute respiratory distress, hypoxia, cough, apnea, nasal obstruction, and others) and explain the ways in which presentations may vary.
- Discuss alternate diagnoses that may mimic bronchiolitis, such as pneumonia, congestive heart failure, previously undiagnosed cyanotic or non-cyanotic congenital heart disease, sepsis, aspiration, and others.
- Describe risk factors that predispose infants and children to severe illness or complications of bronchiolitis, including prematurity, heart disease, pulmonary disease, immunodeficiency, neuromuscular disease, and environmental smoke exposure.
- Explain indications for hospital admission and cite discharge criteria.
- Discuss indications for diagnostic testing, including viral testing and chest radiographs.
- Discuss risks of serious bacterial infection and initial diagnostic evaluations for febrile infants of various ages presenting with bronchiolitis, attending to ages less than 30 days, 31-60 days, and others.
- Explain the indications and contraindications for RSV immunoprophylaxis.
- Summarize the evidence for the use of specific therapies in the treatment of routine bronchiolitis, including beta-agonists, hypertonic saline, and steroids.
- Discuss the evidence regarding use of supportive measures, including suctioning (such as nasal-pharyngeal, oral, and others), chest physiotherapy, positioning, enteral versus intravenous fluids and nutrition, supplemental oxygen, and others.
- Define the benefits, limitations, and potential harms associated with use of various non-invasive monitoring modalities, including cardiorespiratory, oxygen saturation, and capnography.
- Discuss management strategies for patients with worsening respiratory status, including use of various oxygen delivery systems and advanced respiratory support (including heated high flow nasal cannula, forms of non-invasive ventilation, and endotracheal intubation and mechanical ventilation).
Skills
Pediatric hospitalists should be able to:
- Diagnose bronchiolitis by efficiently performing an accurate history and physical examination, determining if key features of the disease are present.
- Assess clinical signs of respiratory distress and identify impending respiratory failure.
- Identify the indications for escalating level of care, transferring to a tertiary care center, and initiation of ventilatory support.
- Assess nutrition and hydration status and choose appropriate methods to maintain adequate hydration and nutrition, with promotion of breastfeeding when appropriate.
- Order appropriate monitoring (type and frequency) and correctly interpret monitor data.
- Perform reassessments daily and as needed, note changes in clinical status, and respond with appropriate actions, including discontinuation of ineffective or unnecessary therapies and monitoring.
- Utilize standardized respiratory scores to objectively assess and document response to interventions.
- Implement appropriate oxygen weaning strategies, including the use of appropriate oxygen saturation parameters.
- Adhere to proper infection control measures and educate the family/caregivers in the importance of hand washing and minimizing environmental exposure in the prevention of infection.
- Communicate with the family/caregivers about the etiology and natural history of bronchiolitis, interpretation of clinical findings, care plans, and supportive care.
- Deliver efficient care by proactively creating a discharge plan that can be expediently activated when appropriate.
- Coordinate care with the primary care provider and other services as indicated, to arrange an appropriate transition plan for hospital discharge.
Attitudes
Pediatric hospitalists should be able to:
- Acknowledge the importance of discussing the role of supportive care and the limited evidence for other interventions with the family/caregivers.
- Exemplify a proactive, engaged attitude regarding proper isolation measures, including hand washing to prevent spread of the etiologic agent in the hospital.
- Realize responsibility for explaining the relationship between bronchiolitis and risk of future wheezing when educating the family/caregivers regarding this diagnosis.
Systems Organization and Improvement
In order to improve efficiency and quality within their organizations, pediatric hospitalists should:
- Collaborate with hospital infection control practitioners to prevent nosocomial infection related to bronchiolitis.
- Partner with community services to educate the public on respiratory infection preventive strategies.
- Lead, coordinate, or participate in multidisciplinary initiatives (including nursing, respiratory therapy, emergency department physicians, primary care physicians, intensivists, and other specialists) to develop, implement, and assess quality outcomes of evidence-based clinical guidelines for the care of children with bronchiolitis.
- Collaborate with intensivists, respiratory therapists, and nurses to mutually develop and implement evidence-based criteria for use of non-invasive respiratory support therapies such as supplemental oxygen, heated high-flow nasal cannula, and others.
Introduction
Bronchiolitis is the most common viral lower respiratory illness in young children and infants. It is responsible for hundreds of thousands of outpatient and emergency department visits and more than 100,000 hospitalizations per year, accounting for more than $1.7 billion in hospital charges annually. The most commonly identified etiology of bronchiolitis is respiratory syncytial virus (RSV), however bronchiolitis may be caused by many other viruses, including rhinovirus, human metapneumovirus, parainfluenza, adenovirus, and influenza. With hospital care provided for these patients in a variety of settings, the potential for significant variation in practices exists despite guidelines published by the American Academy of Pediatrics. Pediatric hospitalists should render evidence-based care that minimizes harm, improves outcomes, and avoids unnecessary testing, hospitalization, and treatments.
Knowledge
Pediatric hospitalists should be able to:
- Compare and contrast the epidemiology and pathogenesis of bronchiolitis with asthma.
- Describe the typical clinical signs of viral bronchiolitis (such as wheezing, rales, tachypnea, acute respiratory distress, hypoxia, cough, apnea, nasal obstruction, and others) and explain the ways in which presentations may vary.
- Discuss alternate diagnoses that may mimic bronchiolitis, such as pneumonia, congestive heart failure, previously undiagnosed cyanotic or non-cyanotic congenital heart disease, sepsis, aspiration, and others.
- Describe risk factors that predispose infants and children to severe illness or complications of bronchiolitis, including prematurity, heart disease, pulmonary disease, immunodeficiency, neuromuscular disease, and environmental smoke exposure.
- Explain indications for hospital admission and cite discharge criteria.
- Discuss indications for diagnostic testing, including viral testing and chest radiographs.
- Discuss risks of serious bacterial infection and initial diagnostic evaluations for febrile infants of various ages presenting with bronchiolitis, attending to ages less than 30 days, 31-60 days, and others.
- Explain the indications and contraindications for RSV immunoprophylaxis.
- Summarize the evidence for the use of specific therapies in the treatment of routine bronchiolitis, including beta-agonists, hypertonic saline, and steroids.
- Discuss the evidence regarding use of supportive measures, including suctioning (such as nasal-pharyngeal, oral, and others), chest physiotherapy, positioning, enteral versus intravenous fluids and nutrition, supplemental oxygen, and others.
- Define the benefits, limitations, and potential harms associated with use of various non-invasive monitoring modalities, including cardiorespiratory, oxygen saturation, and capnography.
- Discuss management strategies for patients with worsening respiratory status, including use of various oxygen delivery systems and advanced respiratory support (including heated high flow nasal cannula, forms of non-invasive ventilation, and endotracheal intubation and mechanical ventilation).
Skills
Pediatric hospitalists should be able to:
- Diagnose bronchiolitis by efficiently performing an accurate history and physical examination, determining if key features of the disease are present.
- Assess clinical signs of respiratory distress and identify impending respiratory failure.
- Identify the indications for escalating level of care, transferring to a tertiary care center, and initiation of ventilatory support.
- Assess nutrition and hydration status and choose appropriate methods to maintain adequate hydration and nutrition, with promotion of breastfeeding when appropriate.
- Order appropriate monitoring (type and frequency) and correctly interpret monitor data.
- Perform reassessments daily and as needed, note changes in clinical status, and respond with appropriate actions, including discontinuation of ineffective or unnecessary therapies and monitoring.
- Utilize standardized respiratory scores to objectively assess and document response to interventions.
- Implement appropriate oxygen weaning strategies, including the use of appropriate oxygen saturation parameters.
- Adhere to proper infection control measures and educate the family/caregivers in the importance of hand washing and minimizing environmental exposure in the prevention of infection.
- Communicate with the family/caregivers about the etiology and natural history of bronchiolitis, interpretation of clinical findings, care plans, and supportive care.
- Deliver efficient care by proactively creating a discharge plan that can be expediently activated when appropriate.
- Coordinate care with the primary care provider and other services as indicated, to arrange an appropriate transition plan for hospital discharge.
Attitudes
Pediatric hospitalists should be able to:
- Acknowledge the importance of discussing the role of supportive care and the limited evidence for other interventions with the family/caregivers.
- Exemplify a proactive, engaged attitude regarding proper isolation measures, including hand washing to prevent spread of the etiologic agent in the hospital.
- Realize responsibility for explaining the relationship between bronchiolitis and risk of future wheezing when educating the family/caregivers regarding this diagnosis.
Systems Organization and Improvement
In order to improve efficiency and quality within their organizations, pediatric hospitalists should:
- Collaborate with hospital infection control practitioners to prevent nosocomial infection related to bronchiolitis.
- Partner with community services to educate the public on respiratory infection preventive strategies.
- Lead, coordinate, or participate in multidisciplinary initiatives (including nursing, respiratory therapy, emergency department physicians, primary care physicians, intensivists, and other specialists) to develop, implement, and assess quality outcomes of evidence-based clinical guidelines for the care of children with bronchiolitis.
- Collaborate with intensivists, respiratory therapists, and nurses to mutually develop and implement evidence-based criteria for use of non-invasive respiratory support therapies such as supplemental oxygen, heated high-flow nasal cannula, and others.
1. Ralston WL, Lieberthal AS, Meissner HC. Clinical Practice Guideline: The Diagnosis, Management, and Prevention of Bronchiolitis. Pediatrics. 2014; 134(5): e1474-1502. https://pediatrics.aappublications.org/content/134/5/e1474.long. Accessed August 28, 2019.
2. National Institute for Health and Care Excellence. Bronchiolitis: diagnosis and management of bronchiolitis in children. Clinical Guideline NG 9. June 2015. https://www.nice.org.uk/guidance/ng9. Accessed August 25, 2019.
1. Ralston WL, Lieberthal AS, Meissner HC. Clinical Practice Guideline: The Diagnosis, Management, and Prevention of Bronchiolitis. Pediatrics. 2014; 134(5): e1474-1502. https://pediatrics.aappublications.org/content/134/5/e1474.long. Accessed August 28, 2019.
2. National Institute for Health and Care Excellence. Bronchiolitis: diagnosis and management of bronchiolitis in children. Clinical Guideline NG 9. June 2015. https://www.nice.org.uk/guidance/ng9. Accessed August 25, 2019.
1.07 Common Clinical Diagnoses and Conditions: Brief Resolved Unexplained Event
Introduction
A Brief Resolved Unexplained Event (BRUE) is defined as an event occurring in an infant younger than 1 year during which the observer reports a sudden, brief, and now resolved episode which includes one or more of the following: cyanosis or pallor; absent, decreased, or irregular breathing; marked change in tone (hyper- or hypotonia); and altered level of responsiveness, and after a thorough history and physical examination an explanation is unable to be identified. BRUE is a more specific term that replaces the previously used term Apparent Life-Threatening Event (ALTE). Patients experiencing a BRUE are categorized into lower- and higher-risk groups based on event and patient characteristics. While patients in the lower-risk group generally do not require hospitalization, those in the higher-risk group may benefit from admission for observation of events and/or completion of a targeted evaluation. Given that a BRUE can be caused by a wide variety of disorders, most self-limiting and non-life threatening, pediatric hospitalists are uniquely positioned to lead a step-wise and systematic evaluation, involving testing and subspecialists as indicated.
Knowledge
Pediatric hospitalists should be able to:
- Describe the symptoms and signs that define a BRUE and compare and contrast the criteria for lower-risk and higher-risk categorization.
- Compare and contrast the differences between Sudden Infant Death Syndrome (SIDS) and BRUE, clarifying that they are unrelated entities.
- Discuss key diagnoses and their associated historical or physical exam findings, that should be considered when evaluating a child diagnosed with a BRUE, such as oral dysphagia, gastroesophageal reflux, seizure, apnea of prematurity, infection (including sepsis, meningitis, pertussis, and bronchiolitis), toxin exposure, cardiac dysfunction, obstructive apnea, inborn errors of metabolism, central hypoventilation syndrome, hydrocephalus, child abuse, and others.
- Discuss types of child abuse (including neglect, poisoning, medical child abuse, and abusive head trauma) presenting as a BRUE and history and physical examination findings that should increase suspicion for this etiology.
- Discuss the indication for and goals of hospitalization (including monitoring, diagnosis, treatment, reassurance, and education), as well as potential risks (including increased anxiety of the family/caregivers, false positive testing, and nosocomial infections).
- Discuss the role of diagnostic testing in the evaluation of children presenting with BRUE and the clinical factors that may warrant additional management.
- Describe indications for subspecialty consultation for evaluation and treatment of children diagnosed with BRUE.
- Describe criteria and care coordination steps that must be met before discharge of patients with BRUE.
Skills
Pediatric hospitalists should be able to:
- Communicate effectively with the referring provider about the role of and criteria for hospitalization, emphasizing principles of evidenced-based medicine and high value care.
- Obtain an accurate patient history and perform a thorough physical examination, eliciting features to fully characterize the event.
- Categorize the event as a lower- or higher-risk BRUE.
- Critically assess the level of evidence and risk/benefit ratio for the evaluation and management of lower-risk patients with BRUE.
- Interpret diagnostic tests (such as laboratory tests, chest x-rays, and electrocardiograms) and identify abnormal findings that require further testing or consultation.
- Order appropriate monitoring and correctly interpret monitor data.
- Perform careful reassessments daily and as needed, note changes in clinical status and test results, and respond with appropriate actions.
- Engage consultants and support staff (such as subspecialists, feeding specialists, and social workers) efficiently when indicated.
- Communicate effectively with the family/caregivers and healthcare providers regarding findings and care plans, with special focus on aligning recommendations with current literature, especially as it relates to the usefulness of home monitoring.
- Coordinate care with the primary care provider and other providers to arrange an appropriate transition plan for hospital discharge.
Attitudes
Pediatric hospitalists should be able to:
- Realize responsibility for effective communication with the family/caregivers and healthcare providers regarding findings and care plans.
- Realize the importance of clarifying that SIDS and BRUE are different entities, addressing common confusion among the family/caregivers, hospital staff, and learners.
- Realize the impact of a BRUE on the family/caregivers and the implications for discharge planning and follow-up.
- Exemplify professional behavior when addressing issues related to anxiety of the family/caregivers, home safety, and social determinants of health.
Systems Organization and Improvement
In order to improve efficiency and quality within their organizations, pediatric hospitalists should:
- Lead, coordinate, or participate in multidisciplinary initiatives to develop and implement evidence-based clinical guidelines to improve quality of care for infants with BRUE.
1. Tieder JS, Bonkowsky JL, Etzel RA, et al. Brief resolved unexplained events (formerly apparent life-threatening events) and evaluation of lower-risk infants. Pediatrics. 2016;137(5):e20160590. https://www.ncbi.nlm.nih.gov/pubmed/27244835 . Accessed August 28, 2019.
2. Merritt JL 2nd, Quinonez RA, Bonkowsky JL, et al. A framework for evaluation of the higher-risk infant after a brief resolved unexplained event. Pediatrics. 2019;144(2): e20184101. https://pediatrics.aappublications.org/content/144/2/e20184101 Accessed August 28, 2019.
Introduction
A Brief Resolved Unexplained Event (BRUE) is defined as an event occurring in an infant younger than 1 year during which the observer reports a sudden, brief, and now resolved episode which includes one or more of the following: cyanosis or pallor; absent, decreased, or irregular breathing; marked change in tone (hyper- or hypotonia); and altered level of responsiveness, and after a thorough history and physical examination an explanation is unable to be identified. BRUE is a more specific term that replaces the previously used term Apparent Life-Threatening Event (ALTE). Patients experiencing a BRUE are categorized into lower- and higher-risk groups based on event and patient characteristics. While patients in the lower-risk group generally do not require hospitalization, those in the higher-risk group may benefit from admission for observation of events and/or completion of a targeted evaluation. Given that a BRUE can be caused by a wide variety of disorders, most self-limiting and non-life threatening, pediatric hospitalists are uniquely positioned to lead a step-wise and systematic evaluation, involving testing and subspecialists as indicated.
Knowledge
Pediatric hospitalists should be able to:
- Describe the symptoms and signs that define a BRUE and compare and contrast the criteria for lower-risk and higher-risk categorization.
- Compare and contrast the differences between Sudden Infant Death Syndrome (SIDS) and BRUE, clarifying that they are unrelated entities.
- Discuss key diagnoses and their associated historical or physical exam findings, that should be considered when evaluating a child diagnosed with a BRUE, such as oral dysphagia, gastroesophageal reflux, seizure, apnea of prematurity, infection (including sepsis, meningitis, pertussis, and bronchiolitis), toxin exposure, cardiac dysfunction, obstructive apnea, inborn errors of metabolism, central hypoventilation syndrome, hydrocephalus, child abuse, and others.
- Discuss types of child abuse (including neglect, poisoning, medical child abuse, and abusive head trauma) presenting as a BRUE and history and physical examination findings that should increase suspicion for this etiology.
- Discuss the indication for and goals of hospitalization (including monitoring, diagnosis, treatment, reassurance, and education), as well as potential risks (including increased anxiety of the family/caregivers, false positive testing, and nosocomial infections).
- Discuss the role of diagnostic testing in the evaluation of children presenting with BRUE and the clinical factors that may warrant additional management.
- Describe indications for subspecialty consultation for evaluation and treatment of children diagnosed with BRUE.
- Describe criteria and care coordination steps that must be met before discharge of patients with BRUE.
Skills
Pediatric hospitalists should be able to:
- Communicate effectively with the referring provider about the role of and criteria for hospitalization, emphasizing principles of evidenced-based medicine and high value care.
- Obtain an accurate patient history and perform a thorough physical examination, eliciting features to fully characterize the event.
- Categorize the event as a lower- or higher-risk BRUE.
- Critically assess the level of evidence and risk/benefit ratio for the evaluation and management of lower-risk patients with BRUE.
- Interpret diagnostic tests (such as laboratory tests, chest x-rays, and electrocardiograms) and identify abnormal findings that require further testing or consultation.
- Order appropriate monitoring and correctly interpret monitor data.
- Perform careful reassessments daily and as needed, note changes in clinical status and test results, and respond with appropriate actions.
- Engage consultants and support staff (such as subspecialists, feeding specialists, and social workers) efficiently when indicated.
- Communicate effectively with the family/caregivers and healthcare providers regarding findings and care plans, with special focus on aligning recommendations with current literature, especially as it relates to the usefulness of home monitoring.
- Coordinate care with the primary care provider and other providers to arrange an appropriate transition plan for hospital discharge.
Attitudes
Pediatric hospitalists should be able to:
- Realize responsibility for effective communication with the family/caregivers and healthcare providers regarding findings and care plans.
- Realize the importance of clarifying that SIDS and BRUE are different entities, addressing common confusion among the family/caregivers, hospital staff, and learners.
- Realize the impact of a BRUE on the family/caregivers and the implications for discharge planning and follow-up.
- Exemplify professional behavior when addressing issues related to anxiety of the family/caregivers, home safety, and social determinants of health.
Systems Organization and Improvement
In order to improve efficiency and quality within their organizations, pediatric hospitalists should:
- Lead, coordinate, or participate in multidisciplinary initiatives to develop and implement evidence-based clinical guidelines to improve quality of care for infants with BRUE.
Introduction
A Brief Resolved Unexplained Event (BRUE) is defined as an event occurring in an infant younger than 1 year during which the observer reports a sudden, brief, and now resolved episode which includes one or more of the following: cyanosis or pallor; absent, decreased, or irregular breathing; marked change in tone (hyper- or hypotonia); and altered level of responsiveness, and after a thorough history and physical examination an explanation is unable to be identified. BRUE is a more specific term that replaces the previously used term Apparent Life-Threatening Event (ALTE). Patients experiencing a BRUE are categorized into lower- and higher-risk groups based on event and patient characteristics. While patients in the lower-risk group generally do not require hospitalization, those in the higher-risk group may benefit from admission for observation of events and/or completion of a targeted evaluation. Given that a BRUE can be caused by a wide variety of disorders, most self-limiting and non-life threatening, pediatric hospitalists are uniquely positioned to lead a step-wise and systematic evaluation, involving testing and subspecialists as indicated.
Knowledge
Pediatric hospitalists should be able to:
- Describe the symptoms and signs that define a BRUE and compare and contrast the criteria for lower-risk and higher-risk categorization.
- Compare and contrast the differences between Sudden Infant Death Syndrome (SIDS) and BRUE, clarifying that they are unrelated entities.
- Discuss key diagnoses and their associated historical or physical exam findings, that should be considered when evaluating a child diagnosed with a BRUE, such as oral dysphagia, gastroesophageal reflux, seizure, apnea of prematurity, infection (including sepsis, meningitis, pertussis, and bronchiolitis), toxin exposure, cardiac dysfunction, obstructive apnea, inborn errors of metabolism, central hypoventilation syndrome, hydrocephalus, child abuse, and others.
- Discuss types of child abuse (including neglect, poisoning, medical child abuse, and abusive head trauma) presenting as a BRUE and history and physical examination findings that should increase suspicion for this etiology.
- Discuss the indication for and goals of hospitalization (including monitoring, diagnosis, treatment, reassurance, and education), as well as potential risks (including increased anxiety of the family/caregivers, false positive testing, and nosocomial infections).
- Discuss the role of diagnostic testing in the evaluation of children presenting with BRUE and the clinical factors that may warrant additional management.
- Describe indications for subspecialty consultation for evaluation and treatment of children diagnosed with BRUE.
- Describe criteria and care coordination steps that must be met before discharge of patients with BRUE.
Skills
Pediatric hospitalists should be able to:
- Communicate effectively with the referring provider about the role of and criteria for hospitalization, emphasizing principles of evidenced-based medicine and high value care.
- Obtain an accurate patient history and perform a thorough physical examination, eliciting features to fully characterize the event.
- Categorize the event as a lower- or higher-risk BRUE.
- Critically assess the level of evidence and risk/benefit ratio for the evaluation and management of lower-risk patients with BRUE.
- Interpret diagnostic tests (such as laboratory tests, chest x-rays, and electrocardiograms) and identify abnormal findings that require further testing or consultation.
- Order appropriate monitoring and correctly interpret monitor data.
- Perform careful reassessments daily and as needed, note changes in clinical status and test results, and respond with appropriate actions.
- Engage consultants and support staff (such as subspecialists, feeding specialists, and social workers) efficiently when indicated.
- Communicate effectively with the family/caregivers and healthcare providers regarding findings and care plans, with special focus on aligning recommendations with current literature, especially as it relates to the usefulness of home monitoring.
- Coordinate care with the primary care provider and other providers to arrange an appropriate transition plan for hospital discharge.
Attitudes
Pediatric hospitalists should be able to:
- Realize responsibility for effective communication with the family/caregivers and healthcare providers regarding findings and care plans.
- Realize the importance of clarifying that SIDS and BRUE are different entities, addressing common confusion among the family/caregivers, hospital staff, and learners.
- Realize the impact of a BRUE on the family/caregivers and the implications for discharge planning and follow-up.
- Exemplify professional behavior when addressing issues related to anxiety of the family/caregivers, home safety, and social determinants of health.
Systems Organization and Improvement
In order to improve efficiency and quality within their organizations, pediatric hospitalists should:
- Lead, coordinate, or participate in multidisciplinary initiatives to develop and implement evidence-based clinical guidelines to improve quality of care for infants with BRUE.
1. Tieder JS, Bonkowsky JL, Etzel RA, et al. Brief resolved unexplained events (formerly apparent life-threatening events) and evaluation of lower-risk infants. Pediatrics. 2016;137(5):e20160590. https://www.ncbi.nlm.nih.gov/pubmed/27244835 . Accessed August 28, 2019.
2. Merritt JL 2nd, Quinonez RA, Bonkowsky JL, et al. A framework for evaluation of the higher-risk infant after a brief resolved unexplained event. Pediatrics. 2019;144(2): e20184101. https://pediatrics.aappublications.org/content/144/2/e20184101 Accessed August 28, 2019.
1. Tieder JS, Bonkowsky JL, Etzel RA, et al. Brief resolved unexplained events (formerly apparent life-threatening events) and evaluation of lower-risk infants. Pediatrics. 2016;137(5):e20160590. https://www.ncbi.nlm.nih.gov/pubmed/27244835 . Accessed August 28, 2019.
2. Merritt JL 2nd, Quinonez RA, Bonkowsky JL, et al. A framework for evaluation of the higher-risk infant after a brief resolved unexplained event. Pediatrics. 2019;144(2): e20184101. https://pediatrics.aappublications.org/content/144/2/e20184101 Accessed August 28, 2019.
1.06 Common Clinical Diagnoses and Conditions: Bone and Joint Infections
Introduction
Osteomyelitis is a pyogenic infection of the bone or periosteum, whereas septic arthritis is an infection of the joint space. In children, these most commonly result from hematogenous spread. Osteomyelitis may also result from extension of contiguous skin or muscle infection. Septic arthritis may also result from either contiguous bone infection or direct inoculation of bacteria into the joint from penetrating trauma, intra-articular injection, or other causes. Either site of infection may represent a medical emergency in children. Bone and joint infections are commonly caused by Staphylococcus aureus, Streptococcus species, Kingella kingae, and Salmonella species. They most commonly occur in children <5 years of age. Males are nearly twice as likely to be affected as females. Prompt recognition and appropriate treatment are essential to reduce the risk of significant complications, including permanent bone or cartilage destruction with life-long disability. Pediatric hospitalists should render evidence-based care that minimizes harm, improves outcomes, and avoids use of unnecessary procedures and treatments.
Knowledge
Pediatric hospitalists should be able to:
- Discuss the differential diagnosis of common presenting signs and symptoms of bone and joint infections, including swollen joint, limp, and pain or limited movement of the affected bone or joint.
- Explain the pathophysiology of bone and joint infections.
- Compare and contrast the different clinical presentations of bone and joint infections between children of varying chronological ages.
- Explain risk factors for bone and joint infections, including sickle cell disease.
- Identify indications for admission to the hospital and goals for therapy while hospitalized for children with suspected osteomyelitis and septic arthritis.
- Classify the most likely pathogens based on age, underlying risk factors, and exposures and list appropriate antimicrobial agents for each.
- State relative local antimicrobial resistance rates for the most common organisms and explain the importance of these in prescribing therapy.
- Describe the relative advantages, disadvantages, and local availability of commonly used laboratory tests (such as C-reactive protein, blood cultures, bone aspirate, and others) and radiologic modalities (such as plain film, computed tomography, bone scan, magnetic resonance imaging, and others) in the evaluation of bone and joint infections.
- Identify risk factors for poor outcomes, including leg length discrepancy or chronic infection.
- Describe a comprehensive approach to pain management in children with bone and joint infections, including the roles of child life, occupational therapy, the pain service, and others according to local context.
- Discuss the relative advantages and disadvantages of intravenous versus oral antibiotic administration at discharge and identify the rare circumstances in which intravenous antibiotic therapy may be preferred.
- Define the role of the orthopedic surgeon and infectious diseases subspecialists in consultation, co-management, and follow-up care.
- Discuss criteria for patient transfer to a referral center in cases requiring pediatric-specific services not available at the local facility.
- Describe criteria, including specific measures of clinical improvement, antimicrobial treatment plan, and post-discharge management plan, which must be met before discharging patients with bone and joint infections.
Skills
Pediatric hospitalists should be able to:
- Diagnose osteomyelitis or septic arthritis by efficiently performing an accurate history and physical examination.
- Develop a cost-effective approach to diagnostic evaluation for children suspected of having a bone or joint infection, including laboratory and radiographic testing.
- Interpret laboratory and radiographic studies commonly ordered to assess for bone and joint infections.
- Manage pain effectively for children with bone and joint infections.
- Engage consultants (such as orthopedic surgeons, infectious disease specialists, physical therapists, and others) in a timely and effective manner when indicated.
- Access and arrange for pediatric home care services as appropriate.
- Coordinate care with subspecialists and the primary care provider and arrange an appropriate transition plan for hospital discharge.
Attitudes
Pediatric hospitalists should be able to:
- Acknowledge the need for effective communication with patients, the family/caregivers, and healthcare providers regarding findings and care plans.
- Collaborate with subspecialists and the primary care provider to ensure coordinated, longitudinal care for children with bone and joint infections.
Systems Organization and Improvement
In order to improve efficiency and quality within their organizations, pediatric hospitalists should:
- Lead, coordinate, or participate in the development and implementation of cost-effective, safe, evidence-based care pathways to standardize the evaluation and management for hospitalized children with bone and joint infections.
- Work with hospital administration to build a multidisciplinary team that can provide high value care to children with bone and joint infections, including nursing, social work, physical therapy, pharmacy, and care coordinators.
- Assist in creating systems to evaluate and improve pain management for children hospitalized with bone and joint infections.
- Lead, coordinate, or participate in efforts to increase pediatric-specific community health care resources that allow for an efficient transition to outpatient therapy and management after inpatient goals are achieved.
1. Keren R, Shah SS, Srivastava R, et al. Comparative effectiveness of intravenous vs. oral antibiotics for postdischarge treatment of acute osteomyelitis in children. JAMA Pediatr. 2015;169(2):120-128. https://doi.org/10.1001/jamapediatrics.2014.2822.
Introduction
Osteomyelitis is a pyogenic infection of the bone or periosteum, whereas septic arthritis is an infection of the joint space. In children, these most commonly result from hematogenous spread. Osteomyelitis may also result from extension of contiguous skin or muscle infection. Septic arthritis may also result from either contiguous bone infection or direct inoculation of bacteria into the joint from penetrating trauma, intra-articular injection, or other causes. Either site of infection may represent a medical emergency in children. Bone and joint infections are commonly caused by Staphylococcus aureus, Streptococcus species, Kingella kingae, and Salmonella species. They most commonly occur in children <5 years of age. Males are nearly twice as likely to be affected as females. Prompt recognition and appropriate treatment are essential to reduce the risk of significant complications, including permanent bone or cartilage destruction with life-long disability. Pediatric hospitalists should render evidence-based care that minimizes harm, improves outcomes, and avoids use of unnecessary procedures and treatments.
Knowledge
Pediatric hospitalists should be able to:
- Discuss the differential diagnosis of common presenting signs and symptoms of bone and joint infections, including swollen joint, limp, and pain or limited movement of the affected bone or joint.
- Explain the pathophysiology of bone and joint infections.
- Compare and contrast the different clinical presentations of bone and joint infections between children of varying chronological ages.
- Explain risk factors for bone and joint infections, including sickle cell disease.
- Identify indications for admission to the hospital and goals for therapy while hospitalized for children with suspected osteomyelitis and septic arthritis.
- Classify the most likely pathogens based on age, underlying risk factors, and exposures and list appropriate antimicrobial agents for each.
- State relative local antimicrobial resistance rates for the most common organisms and explain the importance of these in prescribing therapy.
- Describe the relative advantages, disadvantages, and local availability of commonly used laboratory tests (such as C-reactive protein, blood cultures, bone aspirate, and others) and radiologic modalities (such as plain film, computed tomography, bone scan, magnetic resonance imaging, and others) in the evaluation of bone and joint infections.
- Identify risk factors for poor outcomes, including leg length discrepancy or chronic infection.
- Describe a comprehensive approach to pain management in children with bone and joint infections, including the roles of child life, occupational therapy, the pain service, and others according to local context.
- Discuss the relative advantages and disadvantages of intravenous versus oral antibiotic administration at discharge and identify the rare circumstances in which intravenous antibiotic therapy may be preferred.
- Define the role of the orthopedic surgeon and infectious diseases subspecialists in consultation, co-management, and follow-up care.
- Discuss criteria for patient transfer to a referral center in cases requiring pediatric-specific services not available at the local facility.
- Describe criteria, including specific measures of clinical improvement, antimicrobial treatment plan, and post-discharge management plan, which must be met before discharging patients with bone and joint infections.
Skills
Pediatric hospitalists should be able to:
- Diagnose osteomyelitis or septic arthritis by efficiently performing an accurate history and physical examination.
- Develop a cost-effective approach to diagnostic evaluation for children suspected of having a bone or joint infection, including laboratory and radiographic testing.
- Interpret laboratory and radiographic studies commonly ordered to assess for bone and joint infections.
- Manage pain effectively for children with bone and joint infections.
- Engage consultants (such as orthopedic surgeons, infectious disease specialists, physical therapists, and others) in a timely and effective manner when indicated.
- Access and arrange for pediatric home care services as appropriate.
- Coordinate care with subspecialists and the primary care provider and arrange an appropriate transition plan for hospital discharge.
Attitudes
Pediatric hospitalists should be able to:
- Acknowledge the need for effective communication with patients, the family/caregivers, and healthcare providers regarding findings and care plans.
- Collaborate with subspecialists and the primary care provider to ensure coordinated, longitudinal care for children with bone and joint infections.
Systems Organization and Improvement
In order to improve efficiency and quality within their organizations, pediatric hospitalists should:
- Lead, coordinate, or participate in the development and implementation of cost-effective, safe, evidence-based care pathways to standardize the evaluation and management for hospitalized children with bone and joint infections.
- Work with hospital administration to build a multidisciplinary team that can provide high value care to children with bone and joint infections, including nursing, social work, physical therapy, pharmacy, and care coordinators.
- Assist in creating systems to evaluate and improve pain management for children hospitalized with bone and joint infections.
- Lead, coordinate, or participate in efforts to increase pediatric-specific community health care resources that allow for an efficient transition to outpatient therapy and management after inpatient goals are achieved.
Introduction
Osteomyelitis is a pyogenic infection of the bone or periosteum, whereas septic arthritis is an infection of the joint space. In children, these most commonly result from hematogenous spread. Osteomyelitis may also result from extension of contiguous skin or muscle infection. Septic arthritis may also result from either contiguous bone infection or direct inoculation of bacteria into the joint from penetrating trauma, intra-articular injection, or other causes. Either site of infection may represent a medical emergency in children. Bone and joint infections are commonly caused by Staphylococcus aureus, Streptococcus species, Kingella kingae, and Salmonella species. They most commonly occur in children <5 years of age. Males are nearly twice as likely to be affected as females. Prompt recognition and appropriate treatment are essential to reduce the risk of significant complications, including permanent bone or cartilage destruction with life-long disability. Pediatric hospitalists should render evidence-based care that minimizes harm, improves outcomes, and avoids use of unnecessary procedures and treatments.
Knowledge
Pediatric hospitalists should be able to:
- Discuss the differential diagnosis of common presenting signs and symptoms of bone and joint infections, including swollen joint, limp, and pain or limited movement of the affected bone or joint.
- Explain the pathophysiology of bone and joint infections.
- Compare and contrast the different clinical presentations of bone and joint infections between children of varying chronological ages.
- Explain risk factors for bone and joint infections, including sickle cell disease.
- Identify indications for admission to the hospital and goals for therapy while hospitalized for children with suspected osteomyelitis and septic arthritis.
- Classify the most likely pathogens based on age, underlying risk factors, and exposures and list appropriate antimicrobial agents for each.
- State relative local antimicrobial resistance rates for the most common organisms and explain the importance of these in prescribing therapy.
- Describe the relative advantages, disadvantages, and local availability of commonly used laboratory tests (such as C-reactive protein, blood cultures, bone aspirate, and others) and radiologic modalities (such as plain film, computed tomography, bone scan, magnetic resonance imaging, and others) in the evaluation of bone and joint infections.
- Identify risk factors for poor outcomes, including leg length discrepancy or chronic infection.
- Describe a comprehensive approach to pain management in children with bone and joint infections, including the roles of child life, occupational therapy, the pain service, and others according to local context.
- Discuss the relative advantages and disadvantages of intravenous versus oral antibiotic administration at discharge and identify the rare circumstances in which intravenous antibiotic therapy may be preferred.
- Define the role of the orthopedic surgeon and infectious diseases subspecialists in consultation, co-management, and follow-up care.
- Discuss criteria for patient transfer to a referral center in cases requiring pediatric-specific services not available at the local facility.
- Describe criteria, including specific measures of clinical improvement, antimicrobial treatment plan, and post-discharge management plan, which must be met before discharging patients with bone and joint infections.
Skills
Pediatric hospitalists should be able to:
- Diagnose osteomyelitis or septic arthritis by efficiently performing an accurate history and physical examination.
- Develop a cost-effective approach to diagnostic evaluation for children suspected of having a bone or joint infection, including laboratory and radiographic testing.
- Interpret laboratory and radiographic studies commonly ordered to assess for bone and joint infections.
- Manage pain effectively for children with bone and joint infections.
- Engage consultants (such as orthopedic surgeons, infectious disease specialists, physical therapists, and others) in a timely and effective manner when indicated.
- Access and arrange for pediatric home care services as appropriate.
- Coordinate care with subspecialists and the primary care provider and arrange an appropriate transition plan for hospital discharge.
Attitudes
Pediatric hospitalists should be able to:
- Acknowledge the need for effective communication with patients, the family/caregivers, and healthcare providers regarding findings and care plans.
- Collaborate with subspecialists and the primary care provider to ensure coordinated, longitudinal care for children with bone and joint infections.
Systems Organization and Improvement
In order to improve efficiency and quality within their organizations, pediatric hospitalists should:
- Lead, coordinate, or participate in the development and implementation of cost-effective, safe, evidence-based care pathways to standardize the evaluation and management for hospitalized children with bone and joint infections.
- Work with hospital administration to build a multidisciplinary team that can provide high value care to children with bone and joint infections, including nursing, social work, physical therapy, pharmacy, and care coordinators.
- Assist in creating systems to evaluate and improve pain management for children hospitalized with bone and joint infections.
- Lead, coordinate, or participate in efforts to increase pediatric-specific community health care resources that allow for an efficient transition to outpatient therapy and management after inpatient goals are achieved.
1. Keren R, Shah SS, Srivastava R, et al. Comparative effectiveness of intravenous vs. oral antibiotics for postdischarge treatment of acute osteomyelitis in children. JAMA Pediatr. 2015;169(2):120-128. https://doi.org/10.1001/jamapediatrics.2014.2822.
1. Keren R, Shah SS, Srivastava R, et al. Comparative effectiveness of intravenous vs. oral antibiotics for postdischarge treatment of acute osteomyelitis in children. JAMA Pediatr. 2015;169(2):120-128. https://doi.org/10.1001/jamapediatrics.2014.2822.
1.05 Common Clinical Diagnoses and Conditions: Asthma
Introduction
Asthma is one of the most common, non-communicable, chronic childhood diseases. It is a leading cause of healthcare utilization resulting in a significant number of primary care visits, emergency room visits, and hospitalizations. It has direct impact on patient quality of life with a heavy financial burden to individuals and society. The prevalence of asthma continues to rise and is not equally distributed throughout the population, differing by sex, race, socioeconomic level, and geographic location. The Department of Health and Human Services (DHHS) recognizes the weight of asthma disease on our society, having directed the National Institute of Health to create evidence-based guidelines for asthma care. Additionally, the DHHS continues to recognize asthma as a key element of the Healthy People 2020 initiative with several specific health objectives related directly to inpatient management. Due to the chronic nature of this disease, pediatric hospitalists should not only treat acute exacerbations resulting in status asthmaticus, but also create or reaffirm long-term management plans.
Knowledge
Pediatric hospitalists should be able to:
- Discuss the pathophysiology of asthma addressing both bronchoconstrictive and inflammatory components, and state how each impact pharmacologic treatment choices.
- Compare and contrast the pathophysiology of asthma with other common small airway illnesses in children, such as bronchiolitis, viral pneumonia with bronchospasm, or chronic lung disease.
- Describe disparities in asthma prevalence by sex, race, socioeconomic level, and geographic location.
- Discuss the role psychosocial factors (such as housing, parental mental health, financial status, lack of health insurance, and others) play in the risk for exposure to allergens, non-compliance to medical regimens, and access to health care.
- List the differential diagnosis of wheezing for various age groups and delineate the defining features leading to a diagnosis of asthma.
- Define asthma groups by symptom severity and frequency based on current classification guidelines.
- Discuss the impact of risk factors, exacerbating factors, and chronic comorbidities on morbidity, treatment, and prognosis.
- List common asthma triggers and explain the importance of trigger avoidance and environmental controls in minimizing the frequency and severity of asthma exacerbations.
- State the basic pharmacology, safety profile, and potential adverse effects of commonly used medications, including bronchodilators, leukotriene modifiers, inhaled or systemic corticosteroids, and magnesium sulfate
- Compare and contrast indications for the use of high dose bronchodilator therapy via multiple meter dose inhaler or continuous nebulized albuterol.
- Describe the different formulations of systemic corticosteroids commonly used for treatment of acute asthma exacerbation and the indications for each.
- Describe the utility of alternate therapies such as magnesium sulfate for acute refractory asthma.
- Cite the common complications of asthma or asthma treatment, including pneumothorax, atelectasis, lobar collapse, respiratory failure, poor cardiac output, dysrhythmias, and others.
- Describe the utility of using asthma management plans to both monitor and treat asthma via early symptom recognition, pulmonary function testing (spirometry and/or peak flow), and proper use of controller and reliever medications.
- Discuss the goals of asthma management, including the maintenance of normal activity levels (including physical activity, uninterrupted sleep, and school attendance) and pulmonary function; the prevention of chronic symptoms, recurrent exacerbations, and hospitalizations; and the provision of optimal pharmacotherapy, while minimizing adverse events.
- List specific indications for referral to an asthma subspecialist.
Skills
Pediatric hospitalists should be able to:
- Diagnose and correctly classify asthma by efficiently performing an accurate history and physical examination.
- Assess clinical findings to determine the need for hospitalization and the appropriate level of care.
- Direct an evidence-based treatment plan for status asthmaticus.
- Identify and respond to side effects associated with asthma medications.
- Order and interpret objective measures of pulmonary function, including peak flow monitoring and spirometry.
- Order and interpret results of basic diagnostic tools, such as chest radiograph, blood gas, and others as indicated.
- Order appropriate monitoring and correctly interpret monitor data.
- Provide supplemental oxygen therapy and advanced airway management as necessary.
- Recognize signs and symptoms of serious complications of asthma, including pneumothorax or impending respiratory failure.
- Facilitate an effective transfer to a tertiary care center or intensive care setting when appropriate.
- Assess disease severity and modify the daily medication regimen based upon accurate assessment of changes in disease state, both for inpatient management and transition to home.
- Assess psychosocial factors that may impact care plans and provide appropriate interventions, including support, education, and referral to available resources.
- Initiate asthma education for patients and the family/caregivers as soon after admission as possible, as appropriate for the clinical context.
- Create a discharge plan that can be expediently activated when appropriate.
- Coordinate care with the primary care provider with a plan inclusive of discharge medications, home instructions, and follow-up plans.
- Complete a written asthma action plan and use it to educate patients and the family/caregivers on trigger avoidance, medication adherence, and disease control.
Attitudes
Pediatric hospitalists should be able to:
- Reinforce the role and responsibility of patients and the family/caregivers regarding self-care, recognition of symptoms, and disease management.
- Realize responsibility for effective communication with patients, the family/caregivers, and healthcare providers regarding care plans.
- Engage in a multi-disciplinary approach to the prevention, diagnosis, and treatment of asthma, involving when appropriate, social workers or case managers, respiratory therapists, and subspecialists.
- Collaborate with primary care providers and subspecialists to ensure coordinated longitudinal care for children with asthma.
Systems Organization and Improvement
In order to improve efficiency and quality within their organizations, pediatric hospitalists should:
- Lead, coordinate, or participate in local and national initiatives to further the development and implementation of evidence-based clinical guidelines to promote effective resource utilization and improve quality of care for hospitalized children with asthma.
- Work with hospital administrators to implement and utilize performance feedback and quality improvement measures to assess outcomes of instituted guidelines for the management of inpatient asthma.
- Collaborate with primary care providers, subspecialists, social workers, and case managers to ensure a smooth transition to the outpatient setting, and to minimize the need for readmission.
1. U.S. Department of Health and Human Services, National Institutes of Health. Expert Panel Report 3: Guidelines for the Diagnosis and Management of Asthma (EPR-3). 2007 Edition. http://www.nhlbi.nih.gov/health-pro/guidelines/current/asthma-guidelines. Accessed August 22, 2019.
2. Jones BP, Fleming GM, Otillio JK, Asokan I, Arnold DH. Pediatric acute asthma exacerbations: Evaluation and management from emergency department to intensive care unit. J Asthma. 2016;53(6):607-617. https://doi.org/10.3109/02770903.2015.1067323.
3. Saglani S, Fleming L, Sonnappa S, and Bush A. Advances in the aetiology, management, and prevention of acute asthma attacks in children. Lancet Child Adol Health. 2019;3(5):354-364. https://doi.org/10.1016/S2352-4642(19)30025-2.
Introduction
Asthma is one of the most common, non-communicable, chronic childhood diseases. It is a leading cause of healthcare utilization resulting in a significant number of primary care visits, emergency room visits, and hospitalizations. It has direct impact on patient quality of life with a heavy financial burden to individuals and society. The prevalence of asthma continues to rise and is not equally distributed throughout the population, differing by sex, race, socioeconomic level, and geographic location. The Department of Health and Human Services (DHHS) recognizes the weight of asthma disease on our society, having directed the National Institute of Health to create evidence-based guidelines for asthma care. Additionally, the DHHS continues to recognize asthma as a key element of the Healthy People 2020 initiative with several specific health objectives related directly to inpatient management. Due to the chronic nature of this disease, pediatric hospitalists should not only treat acute exacerbations resulting in status asthmaticus, but also create or reaffirm long-term management plans.
Knowledge
Pediatric hospitalists should be able to:
- Discuss the pathophysiology of asthma addressing both bronchoconstrictive and inflammatory components, and state how each impact pharmacologic treatment choices.
- Compare and contrast the pathophysiology of asthma with other common small airway illnesses in children, such as bronchiolitis, viral pneumonia with bronchospasm, or chronic lung disease.
- Describe disparities in asthma prevalence by sex, race, socioeconomic level, and geographic location.
- Discuss the role psychosocial factors (such as housing, parental mental health, financial status, lack of health insurance, and others) play in the risk for exposure to allergens, non-compliance to medical regimens, and access to health care.
- List the differential diagnosis of wheezing for various age groups and delineate the defining features leading to a diagnosis of asthma.
- Define asthma groups by symptom severity and frequency based on current classification guidelines.
- Discuss the impact of risk factors, exacerbating factors, and chronic comorbidities on morbidity, treatment, and prognosis.
- List common asthma triggers and explain the importance of trigger avoidance and environmental controls in minimizing the frequency and severity of asthma exacerbations.
- State the basic pharmacology, safety profile, and potential adverse effects of commonly used medications, including bronchodilators, leukotriene modifiers, inhaled or systemic corticosteroids, and magnesium sulfate
- Compare and contrast indications for the use of high dose bronchodilator therapy via multiple meter dose inhaler or continuous nebulized albuterol.
- Describe the different formulations of systemic corticosteroids commonly used for treatment of acute asthma exacerbation and the indications for each.
- Describe the utility of alternate therapies such as magnesium sulfate for acute refractory asthma.
- Cite the common complications of asthma or asthma treatment, including pneumothorax, atelectasis, lobar collapse, respiratory failure, poor cardiac output, dysrhythmias, and others.
- Describe the utility of using asthma management plans to both monitor and treat asthma via early symptom recognition, pulmonary function testing (spirometry and/or peak flow), and proper use of controller and reliever medications.
- Discuss the goals of asthma management, including the maintenance of normal activity levels (including physical activity, uninterrupted sleep, and school attendance) and pulmonary function; the prevention of chronic symptoms, recurrent exacerbations, and hospitalizations; and the provision of optimal pharmacotherapy, while minimizing adverse events.
- List specific indications for referral to an asthma subspecialist.
Skills
Pediatric hospitalists should be able to:
- Diagnose and correctly classify asthma by efficiently performing an accurate history and physical examination.
- Assess clinical findings to determine the need for hospitalization and the appropriate level of care.
- Direct an evidence-based treatment plan for status asthmaticus.
- Identify and respond to side effects associated with asthma medications.
- Order and interpret objective measures of pulmonary function, including peak flow monitoring and spirometry.
- Order and interpret results of basic diagnostic tools, such as chest radiograph, blood gas, and others as indicated.
- Order appropriate monitoring and correctly interpret monitor data.
- Provide supplemental oxygen therapy and advanced airway management as necessary.
- Recognize signs and symptoms of serious complications of asthma, including pneumothorax or impending respiratory failure.
- Facilitate an effective transfer to a tertiary care center or intensive care setting when appropriate.
- Assess disease severity and modify the daily medication regimen based upon accurate assessment of changes in disease state, both for inpatient management and transition to home.
- Assess psychosocial factors that may impact care plans and provide appropriate interventions, including support, education, and referral to available resources.
- Initiate asthma education for patients and the family/caregivers as soon after admission as possible, as appropriate for the clinical context.
- Create a discharge plan that can be expediently activated when appropriate.
- Coordinate care with the primary care provider with a plan inclusive of discharge medications, home instructions, and follow-up plans.
- Complete a written asthma action plan and use it to educate patients and the family/caregivers on trigger avoidance, medication adherence, and disease control.
Attitudes
Pediatric hospitalists should be able to:
- Reinforce the role and responsibility of patients and the family/caregivers regarding self-care, recognition of symptoms, and disease management.
- Realize responsibility for effective communication with patients, the family/caregivers, and healthcare providers regarding care plans.
- Engage in a multi-disciplinary approach to the prevention, diagnosis, and treatment of asthma, involving when appropriate, social workers or case managers, respiratory therapists, and subspecialists.
- Collaborate with primary care providers and subspecialists to ensure coordinated longitudinal care for children with asthma.
Systems Organization and Improvement
In order to improve efficiency and quality within their organizations, pediatric hospitalists should:
- Lead, coordinate, or participate in local and national initiatives to further the development and implementation of evidence-based clinical guidelines to promote effective resource utilization and improve quality of care for hospitalized children with asthma.
- Work with hospital administrators to implement and utilize performance feedback and quality improvement measures to assess outcomes of instituted guidelines for the management of inpatient asthma.
- Collaborate with primary care providers, subspecialists, social workers, and case managers to ensure a smooth transition to the outpatient setting, and to minimize the need for readmission.
Introduction
Asthma is one of the most common, non-communicable, chronic childhood diseases. It is a leading cause of healthcare utilization resulting in a significant number of primary care visits, emergency room visits, and hospitalizations. It has direct impact on patient quality of life with a heavy financial burden to individuals and society. The prevalence of asthma continues to rise and is not equally distributed throughout the population, differing by sex, race, socioeconomic level, and geographic location. The Department of Health and Human Services (DHHS) recognizes the weight of asthma disease on our society, having directed the National Institute of Health to create evidence-based guidelines for asthma care. Additionally, the DHHS continues to recognize asthma as a key element of the Healthy People 2020 initiative with several specific health objectives related directly to inpatient management. Due to the chronic nature of this disease, pediatric hospitalists should not only treat acute exacerbations resulting in status asthmaticus, but also create or reaffirm long-term management plans.
Knowledge
Pediatric hospitalists should be able to:
- Discuss the pathophysiology of asthma addressing both bronchoconstrictive and inflammatory components, and state how each impact pharmacologic treatment choices.
- Compare and contrast the pathophysiology of asthma with other common small airway illnesses in children, such as bronchiolitis, viral pneumonia with bronchospasm, or chronic lung disease.
- Describe disparities in asthma prevalence by sex, race, socioeconomic level, and geographic location.
- Discuss the role psychosocial factors (such as housing, parental mental health, financial status, lack of health insurance, and others) play in the risk for exposure to allergens, non-compliance to medical regimens, and access to health care.
- List the differential diagnosis of wheezing for various age groups and delineate the defining features leading to a diagnosis of asthma.
- Define asthma groups by symptom severity and frequency based on current classification guidelines.
- Discuss the impact of risk factors, exacerbating factors, and chronic comorbidities on morbidity, treatment, and prognosis.
- List common asthma triggers and explain the importance of trigger avoidance and environmental controls in minimizing the frequency and severity of asthma exacerbations.
- State the basic pharmacology, safety profile, and potential adverse effects of commonly used medications, including bronchodilators, leukotriene modifiers, inhaled or systemic corticosteroids, and magnesium sulfate
- Compare and contrast indications for the use of high dose bronchodilator therapy via multiple meter dose inhaler or continuous nebulized albuterol.
- Describe the different formulations of systemic corticosteroids commonly used for treatment of acute asthma exacerbation and the indications for each.
- Describe the utility of alternate therapies such as magnesium sulfate for acute refractory asthma.
- Cite the common complications of asthma or asthma treatment, including pneumothorax, atelectasis, lobar collapse, respiratory failure, poor cardiac output, dysrhythmias, and others.
- Describe the utility of using asthma management plans to both monitor and treat asthma via early symptom recognition, pulmonary function testing (spirometry and/or peak flow), and proper use of controller and reliever medications.
- Discuss the goals of asthma management, including the maintenance of normal activity levels (including physical activity, uninterrupted sleep, and school attendance) and pulmonary function; the prevention of chronic symptoms, recurrent exacerbations, and hospitalizations; and the provision of optimal pharmacotherapy, while minimizing adverse events.
- List specific indications for referral to an asthma subspecialist.
Skills
Pediatric hospitalists should be able to:
- Diagnose and correctly classify asthma by efficiently performing an accurate history and physical examination.
- Assess clinical findings to determine the need for hospitalization and the appropriate level of care.
- Direct an evidence-based treatment plan for status asthmaticus.
- Identify and respond to side effects associated with asthma medications.
- Order and interpret objective measures of pulmonary function, including peak flow monitoring and spirometry.
- Order and interpret results of basic diagnostic tools, such as chest radiograph, blood gas, and others as indicated.
- Order appropriate monitoring and correctly interpret monitor data.
- Provide supplemental oxygen therapy and advanced airway management as necessary.
- Recognize signs and symptoms of serious complications of asthma, including pneumothorax or impending respiratory failure.
- Facilitate an effective transfer to a tertiary care center or intensive care setting when appropriate.
- Assess disease severity and modify the daily medication regimen based upon accurate assessment of changes in disease state, both for inpatient management and transition to home.
- Assess psychosocial factors that may impact care plans and provide appropriate interventions, including support, education, and referral to available resources.
- Initiate asthma education for patients and the family/caregivers as soon after admission as possible, as appropriate for the clinical context.
- Create a discharge plan that can be expediently activated when appropriate.
- Coordinate care with the primary care provider with a plan inclusive of discharge medications, home instructions, and follow-up plans.
- Complete a written asthma action plan and use it to educate patients and the family/caregivers on trigger avoidance, medication adherence, and disease control.
Attitudes
Pediatric hospitalists should be able to:
- Reinforce the role and responsibility of patients and the family/caregivers regarding self-care, recognition of symptoms, and disease management.
- Realize responsibility for effective communication with patients, the family/caregivers, and healthcare providers regarding care plans.
- Engage in a multi-disciplinary approach to the prevention, diagnosis, and treatment of asthma, involving when appropriate, social workers or case managers, respiratory therapists, and subspecialists.
- Collaborate with primary care providers and subspecialists to ensure coordinated longitudinal care for children with asthma.
Systems Organization and Improvement
In order to improve efficiency and quality within their organizations, pediatric hospitalists should:
- Lead, coordinate, or participate in local and national initiatives to further the development and implementation of evidence-based clinical guidelines to promote effective resource utilization and improve quality of care for hospitalized children with asthma.
- Work with hospital administrators to implement and utilize performance feedback and quality improvement measures to assess outcomes of instituted guidelines for the management of inpatient asthma.
- Collaborate with primary care providers, subspecialists, social workers, and case managers to ensure a smooth transition to the outpatient setting, and to minimize the need for readmission.
1. U.S. Department of Health and Human Services, National Institutes of Health. Expert Panel Report 3: Guidelines for the Diagnosis and Management of Asthma (EPR-3). 2007 Edition. http://www.nhlbi.nih.gov/health-pro/guidelines/current/asthma-guidelines. Accessed August 22, 2019.
2. Jones BP, Fleming GM, Otillio JK, Asokan I, Arnold DH. Pediatric acute asthma exacerbations: Evaluation and management from emergency department to intensive care unit. J Asthma. 2016;53(6):607-617. https://doi.org/10.3109/02770903.2015.1067323.
3. Saglani S, Fleming L, Sonnappa S, and Bush A. Advances in the aetiology, management, and prevention of acute asthma attacks in children. Lancet Child Adol Health. 2019;3(5):354-364. https://doi.org/10.1016/S2352-4642(19)30025-2.
1. U.S. Department of Health and Human Services, National Institutes of Health. Expert Panel Report 3: Guidelines for the Diagnosis and Management of Asthma (EPR-3). 2007 Edition. http://www.nhlbi.nih.gov/health-pro/guidelines/current/asthma-guidelines. Accessed August 22, 2019.
2. Jones BP, Fleming GM, Otillio JK, Asokan I, Arnold DH. Pediatric acute asthma exacerbations: Evaluation and management from emergency department to intensive care unit. J Asthma. 2016;53(6):607-617. https://doi.org/10.3109/02770903.2015.1067323.
3. Saglani S, Fleming L, Sonnappa S, and Bush A. Advances in the aetiology, management, and prevention of acute asthma attacks in children. Lancet Child Adol Health. 2019;3(5):354-364. https://doi.org/10.1016/S2352-4642(19)30025-2.