How to Survive the Pediatric Clerkship

How to Survive (and Shine!) on your 3rd Year Pediatrics Clerkship

All pediatrics clerkships are structured differently, but in general, you should be prepared to work with children in both the inpatient and outpatient settings. Some programs also have dedicated time in the newborn nursery. All of the tips you have learned on other clerkships - such as taking ownership of your patients and reading up on your patients - still apply. These guidelines focus on aspects of medicine that are unique to pediatrics to help you excel with the kids!

Well Baby Nursery

Every child that is born in the hospital must be examined by a pediatrician. Some practices have their own providers come to the hospital where a baby is born; other hospitals have a hospitalist pediatrician who examines all babies. Regardless, as a medical student, you will examine babies (often at mom's bedside, since most hospitals have babies at the bedside now to increase breastfeeding rates and parental-baby bonding during the first few days of life) and may be responsible for providing parents with advice before they bring their new baby home for the first time. This may sound like an important job to leave to the medical student, but once you start talking to new parents, you will be surprised by how much information you have to share with them.

Newborn exam - think head to toe

  • HEENT
    • Head
      • Caput succedaneum (edema, crosses suture lines) v. Cephalohematoma (hemorrhages, limted by suture lines)
      • Fontanelles
    • Eyes - Red Reflex
    • Mouth - intact palate? suck reflex?
    • Ears - normal external shape and location? tags or pits?
    • Neck - make sure clavicles are intact (fractures can occur during delivery of large neonates)
    • Heart - murmur? femoral pulses?
    • Lungs
    • Abdomen
    • Hips - Ortolani and Barlow maneuvers
    • GU
      • Descended testes?
      • Patent anus?
    • Skin - some common, benign findings:
      • Mongolian spots(at birth) - hyperpigmented spots on back and buttocks
      • Jaundice (>24 hrs) - assess where baby is yellow (often described by how far it descends from head to toe); if baby is jaundice at <24 hrs of life, this is pathologic and needs to be investigated further
    • Reflexes
      • Moro
      • Hand grasp
      • Rooting
  • Anticipatory guidance
  • Feeds
  • Breastfeeding is best for baby's health but be sure to respect each family's feeding decisions
  • Aim for at least 8 feeds/24hrs
  • Sleep
  • Always put baby on their back to sleep.
  • Make sure every baby will have its own crib at home. It is dangerous for baby to ever sleep in parents' bed!
  • Fevers
  • Always call your pediatrician if baby is running a temperature of greater than 100.4F (38.0C)
  • Always take baby's temperature rectally for most accurate results

Outpatient
In the outpatient world, you will see a broad spectrum of kids and conditions.

Newborn/Well Baby

  1. The first few newborn visits are similar to your nursery experience
  2. Everyone gets a head to toe newborn exam
  3. We trend newborns weights very closely
    • Newborns typically lose 10% of their birth weight in the first few days of life and we expect them to be back at their birth weight by 7 days of life
  4. Always follow up on feeding/sleeping/crying
  5. Pay attention to their vaccine schedule (they get a lot in those first 6 months)
  6. Reinforce anticipatory guidance from nursery

Well Child: Modify Everything Base On Age!

  • General Tips
    • Always start by engaging with the child - you will gain both the child and parent's trust!
    • Include child in questions when age appropriate
    • ALWAYS look at the growth curve!!
  • Key History Components
    • Developmental milestones - think walking?  talking?  potty training?
    • Diet - balanced? drinks (water, milk, juice)?
    • Daycare/School - academic performance and behavior
    • Safety - car seats? seat belts and helmets? guns? smoking in the home?
    • Adolescents - Use the HEADSS assessment!  Always ask about:
      • Home
      • Education
      • Activities
      • Sex
      • Suicide/Mental health
    • Physical Exam - modify approach based on age
      • Infants - Always listen to heart/lungs first while they're quiet before you make them cry
      • Toddlers - Do as much as you can on parent's lap
    • Anticipatory Guidance - we ask all these questions for a reason; provide parents with advice based on their responses!
  • Sick Visits
    • Focus on the problem at hand
    • Always check for recent ER/specialist visits, changes in meds or allergies
    • Regardless of the complaint, always ask about
      • PO intake and urine output
      • Energy level
    • Keys to common complaints
      • Asthma
        • What meds do they take?  How often do they need them?
        • When is the last time they used their albuterol?
        • Ever hospitalized for their asthma?
        • Ever need to be intubated?
      • Dehydration (assess in the setting of ANY acute illness in a child)
        • PO intake, especially fluids
        • Number of wet diapers (should have at least 6/day) or number of bathroom visits
        • Dry lips/mouth
        • Sunken-in eyes or fontanelles (if still open)
        • Tears when crying
        • Capillary refill
        • Cool extremities

Inpatient
Inpatient pediatrics will be very similar to your internal medicine rotation. You will see patients, admit patients, and present patients on rounds. However, like all things in pediatrics, children's inpatient units present unique challenges. Your differential diagnoses will have to take the patient's age into account (for example, the differential diagnosis for chest pain is very different in a 6-year-old than a 60 year old) and you will be working much closer with the families of your patients than you probably did on internal medicine. Thus, in addition to the anticipatory guidance that you provide in the outpatient office, you will also have the opportunity to counsel families on why their child was hospitalized and how they can avoid re-hospitalization. Once again, this may seem like an important job for a medical student. However, for children with bread and butter peds stuff like asthma, you may be surprised by how much you know and how much information you can provide parents!

For those of you who have not been on a pediatrics unit before, there are a few unique things to know about. Most units or hospitals are equipped with playrooms, which can be used as motivation to get a child out of bed. However, note that children on any sort of isolation cannot go into the playroom. The playrooms are often run by the Child Life Department, which is a unique department in the pediatric world. Child Life specialists have backgrounds in psychology and work to reduce the stress of hospitalization on a child. They accomplish this by maintaining a sense of normalcy for the kids (i.e. the playroom), engaging in medical play (using dolls and pictures to prepare children for procedures), and using distraction techniques to help a child get through a procedure. In line with that same theme, most pediatric floors have a treatment room. This is a room where the kids go for any bedside procedures (i.e. IV placement, LP, pulling drains). What can be done at the bedside v. what needs to occur in the treatment room varies based on the institution, but the goal is for the kids to feel safe in their rooms. Therefore, we try to have scary or painful procedures occur in a separate space.

Some students find their pediatrics clerkship to be overwhelming because of how different everything is from adult medicine; however, most students will also describe their time in pediatrics as fun and rewarding. Hopefully these tips will reduce your stress and allow you to focus on the joy that occurs when working with children!

Resources

  1. Ganti L, Kaufman MS, Waseem M. First Aid for the Pediatrics Clerkship. McGraw Hill Professional; 2010.

  2. Hagan JF, Shaw JS, Duncan P, eds. 2008. Bright Futures: Guidelines for Health Supervision of Infants, Children, and Adolescents, Third Edition. Pocket Guide. Elk Grove Village, IL: American Academy of Pediatrics. 

  3. Brown LJ, Miller LT. BRS Pediatrics. Philadelphia: Lippencott Williams & Wilkins; 2005.

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