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1 Curriculum Table of Contents pp. Adolescent Medicine 2-6 Behavioral/Developmental Medicine 7 Community/Advocacy Block 8-11 Emergency Room 12-13 Medical Genetics 14-21 Hematology/Oncology 22 Pediatric Infectious Diseases 23-24 Pediatric Endocrinology 25-27 Nephrology/Urology 28 Pediatric Neurology 29-31 Pediatric Cardiology 32 Pediatric Gastroenterology 33 Pediatric Surgery 34 Pediatric ICU 35-36 Pediatric Pulmonology 37-38 Research Elective 39 General Pediatric Acute Care 40-42 Continuity Clinic 43-44 Inpatient Pediatric Wards 45-49 NICU 50-85 Well Born Nursery 86-93 Dermatology Elective 94 Pediatric Opthalmology 95 Orthopedics and Sports Medicine 96-97 Pediatric Radiology 98 Additional Curricular Experiences 99-100

2 Adolescent Medicine (required) Teaching Objectives PGY 1, 2, or 3 1. Recognize normal and abnormal growth and development in adolescent patients and be able to obtain an adequate outpatient psychosocial history. 2. Become familiar with routine adolescent preventive care, including anticipatory guidance, GAPS guidelines, Bright Futures, immunization needs, and laboratory screening for teens. 3. Understand the fundamentals of anticipatory guidance for parents of teens. 4. Recognize the importance of accidents and non-accidental injuries in adolescent morbidity and mortality. Understand issues related to problem behavior theory. 5. Describe and explain issues of adolescent confidentiality, disclosure, and consent. 6. Be able to provide routine evaluation for sports participation. Understand the disqualifiers for sports involvement and when further evaluation is needed before allowing participation. 7. Recognize and be able to initiate treatment for the common sports injuries, including ACL tears, sprains, strains, and patellofemoral syndrome. 8. Be able to perform an adequate papanicalou smear and pelvic examination. Understand the guidelines for initiation of these procedures. 9. Understand and be able to teach the physiologic actions of the different forms of hormonal contraception. 10. Understand and teach the appropriate use of barrier contraception. 11. Understand the pathophysiology of menstrual disorders in adolescents, their evaluation, and their treatment. 12. Understand the pathophysiology and treatment of sexually transmitted infections and HIV in adolescents. 13. Be familiar with issues of adolescent pregnancy, including reasons for the problem and prevention. 14. Become comfortable with the evaluation of male health issues, including urethritis, epidiymitis, orchitis, testicular torsion, and prostatitis. 15. Become knowledgeable about adolescent mental health issues, including depression, ADHD, anxiety disorders, oppositional defiant disorder, eating disorders, and alcohol and other drug (AOD) abuse. Understand the basic evaluation and treatment of these issues and when referral to a psychiatrist/psychologist is needed. 16. Be familiar with issues of gay and lesbian youth. Course Description The resident physician will spend a minimum of 4 weeks on this rotation. Many will spend two months, one in the first year and one in the last year of residency. The rotation will involve working with adolescents in several locations and at various levels of patient maturity. Time will be spent at MU Student Health with Dr. Robinson and in the MU Adolescent Medicine Clinic with Drs. Lawson and Robinson. Residents will have approximately 6-7 clinical sessions per week, leaving two-three clinical sessions for reading. Occasional inpatient consultations will be done, though this rotation is primarily outpatient. Residents may be asked to give an evidence-based presentation on a topic in adolescent medicine. Finally, residents will do a training session with Dr. Robinson on evaluation of substance abuse in teens. In this session the resident will be taped interviewing a surrogate patient with a substance abuse problem. Emphasis will be placed on screening, evaluation, and intervention, using the Stages of Change model of Prochaska and DiClemente.

3 Requirements by Level of Training During the first adolescent medicine rotation (usually L-1 or L-2 years) the resident is expected, primarily, to become comfortable interviewing adolescent patients with various problems and issues. The resident is expected to read about the conditions he/she sees in clinic. During the second block in adolescent medicine the resident is expected to make certain he/she has become familiar with all of the teaching objectives he/she had not already covered in the first block on the rotation. References 1. English A. Kenney KE. State Minor Consent Laws: A Summary (2nd Edition). Chapel Hill, N.C.: Center for Adolescent Health and the Law; 2003. 2. Neinstein LS. Adolescent Health Care, a Practical Guide. Baltimore, MD.: Lippincott Williams and Wilkins; 2002. 3. AAP. Substance Abuse, A Guide for Health Professionals.: Elk Grove Village, IL. AAP. 2002. 4. AAFP et al. Preparticipation Physical Evaluation (3rd Edition). Minneapolis, MN.: The Physician and Sportsmedicine, a Division of McGraw-Hill Companies; 2004. 5. World Health Organization. Improving Access to Quality Care in Family Planning, Medical Eligibility Criteria for Contraceptive Use (2nd Edition). 2000. 6. Emans SJ, Laufer MR, Goldstein DP. Pediatric and Adolescent Gynecology (5th Edition). Philadelphia: Lippincott Williams and Wilkins; 2004. 7. AAP. ADHD A Complete and Authoritative Guide. Elk Grove Village, IL. 2004. 8. AAP. Substance Abuse, a Guide for Health Professionals. Elk Grove Village, IL: AAP; 2002. 9. Hornbacher M. Wasted, a Memoir of Anorexia and Bulimia. New York, N.Y.: Harper Collins; 1998. 10. Fisher M, Golden NH, Jacobson MS. The Spectrum of Disordered Eating: Anorexia Nervosa, Bulimia Nervosa, and Obesity. Adolescent Medicine State of the Art Reviews. 14 (1); 2003. 11. Hatcher RA, et al. Contraceptive Technology. New York, NY: Ardent Media; 2004. 12. Hoppenfeld S, Hutton R. Physical Examination of the Spine & Extremities. Norwalk, CN: Appleton & Lange; 1976.

4 Adolescent Medicine Curriculum Supplement EVIDENCE-BASED MEDICINE (EBM) Defined as “ the conscientious, explicit, and judicious use of current best evidence in making decisions about the care of individual patients.” We need to: 1. determine why we manage particular conditions the way we do 2. identify unanswered questions Then find relevant, up-to-date medical information and appraise its validity. Clinical decision = External clinical evidence (Research) + Clinical expertise + Patient/family characteristics Using EBM in practice 1. Devise the question a. Patient or problem b. Intervention (a cause, prognostic factor, or treatment) c. Comparison intervention (if necessary) d. Outcome 2. find the best evidence a. search for relevant journal articles b. use EBM summaries prepared by others c. accept clinical practice guidelines based on EBM strategies 3. critically evaluate the information for validity and clinical relevance 4. apply the evidence, follow-up, and reevaluating the clinical decision EBM TUTORIAL** Duke University/University of North Carolina (www.hsl.unc.edu/lm/ebm/index.htm) EBM DATABASES AND SITES

Ovid Technologies (www.ovid.com) Contains access to the Cochrane Database of Systematic Reviews and Best Evidence. *Health Sciences Library (University of Missouri) Clinical Evidence – produced by BMJ Publishing Group EBM Reviews – ACP Journal Club EBM Reviews – Cochrane Central Register of Controlled Trials – bibliographic database of definitive controlled trials

5 **EBM Reviews – Cochrane Database of Systematic Reviews – full text of the regularly updated systematic reviews of the effects of healthcare prepared by The Cochrane Collaboration EBM Reviews – Database of Abstracts of Reviews of Effectiveness – structured abstracts of systematic reviews from all over the world EBM Reviews Full Text All EBM Reviews National Library of Medicine (www.nlm.nih.gov/databases) American College of Physicians (www.acponline.org) Subscription service to two secondary publications – ACP Journal Club and Evidence Based Medicine (staff sifts through over 50 journals, etc for articles of high scientific merit and includes an expert commentary. *Cochrane Collaboration (www.cochrane.org) Subscription service to an international collaboration of centers that prepare, maintain, and promote the accessibility of systematic reviews of the effects of health care. Evidence-based Intensive Care (www.intensivecare.com) University of Michigan (www.med.umich.edu/pediatrics/ebm) EVIDENCE-BASED GUIDELINES American Academy of Pediatrics (www.aap.org) Publishes policy statements and evidence-based practice parameters (internet versions and hardcover book). National Guideline Clearinghouse (www.guideline.gov) Guide to Clinical Preventive Services (http://odphp.osophs.dhhs.gov/pubs/guidecps) JOURNAL ARTICLE SERIES Users’ Guides to the Medical Literature: JAMA 1993;270:2093, 2096, 2598 1996;275:554, 1435

1994;271:59, 389,703, 1615 1997;277:1232, 1552, 1802 1994;272:234, 1367 1998;279:545 1995;273:1292, 1610 1999;281:1214, 1836, 2029 1995;274:570, 1630, 1800 1999;282:67, 771, 1371

6 Critically Appraised Topic (30-minute limit) Date: Clinical Question: Patient or problem - Intervention - Comparison - Outcome - Search Strategy: Evidence Study or Resource Type: Patient Characteristics: Results: * Quality Issues:

*Include clinically relevant measures such as number needed to treat for treatment studies, sensitivity, specificity, and predictive values for diagnostic studies.

7 Behavioral/Developmental Pediatrics (required) Goals and Objectives PGY 1 or PGY2 1. Become familiar with normal and abnormal child development, including cognitive, language, motor, social, and emotional aspects. 2. Understand the importance and process of referral for developmental or behavioral problems and the various resources available in the community. 3. Participate in diagnosis and management of behavioral and developmental problems of varying complexity. This includes psychosocial and medical aspects of care. 4. Become familiar with developmental and psychosocial screening techniques. 5. Develop the ability to identify children at risk for developmental problems, abuse, and family dysfunction. 6. Become adept at interviewing patients and families to assess developmental history, social history, and family structure, including the circumstances and complexity of adoptive and foster care. Course Description Development/Behavioral Pediatrics is a 4 week rotation. Residents on this rotation are expected to become part of the development team and participate in the clinical and academic pursuits of the division. Responsibilities include, but are not limited to: ward consultations, developmental screening exams, development clinics, assigned readings, independent study. A packet for readings will be provided at the start of the rotation. Residents and rotators will be expected to participate in all of these activities equally. The resident will primarily work with Dr. Tracy Stroud, and Ellen Horwitz, PhD; He/she may also spend some time with child neurology. References: Levine: Developmental-Behavioral Pediatrics (Textbook) Baird and Gordon: Neurological evaluation of infants and children. www.dbpeds.org Encounters with Children Dixon, Stein 1992 AAP Diagnostic and Statistical Manual for Primary Care (DSM-PC) 1996

8 Community/Advocacy Block (required) PGY-3 (Pediatrics) or PGY-4 year (Med-Peds) Goals and Objectives 1. Become familiar with community resources that assist families in providing for their child with special needs. 2. Learn how to refer children to and access specific programs for evaluation of speech therapy, learning, physical therapy, occupational therapy, and hearing. 3. Visit the sites where various therapies and services are provided to observe activities in these environments. 4. Understand the problems of underserved children in the community and how to improve the care they receive. 5. Understand how to care for children in a culturally sensitive manner. 6. Understand the role of the pediatrician in the school and daycare settings. 7. Visit community-based primary care treatment settings for children. 8. Understand the role of the pediatrician in the legislative process by visiting with legislators in Jefferson City, MO. 9. Learn to create partnerships and medical homes for children with special needs. 10. Observe, monitor, and participate in SAFE evaluations of abused children. Course Description The senior resident will visit several sites in the community in which service to children are rendered. These will include, but not be limited to, the following: The Head Start Program Department of Family Services School for the Blind School for the Deaf Local homes for abused or neglected children Therapy for Kids The Health Department Clinics A Home Health Service for Children Elementary School, Junior High School, and High School nurses Juvenile Justice Facility for incarcerated youth A Health Center for the Mennonite or Amish Communities A Health Center for area Hispanic Communities The Missouri State Legislature (if in session) with one of the “Doctor’s of the Day” or visit with one or more legislators regarding advocacy The Child Advocacy Center (where SAFE examinations are done). The course may be done in a community in which a resident physician plans to settle, if permission is given by the program director. However, a similar schedule to the one above will need to be kept. Alternate scheduled experiences by resident physicians ( e.g., working on an Indian Reservation or going on a medical missions trip for part of the block) will also be considered. Med-Peds resident physicians may split their time between programs that give services to adults as well as children.

9 The resident physician, with the help of the program director and program coordinator, will schedule the above experiences. The resident is expected to read at least 15 of the resources below (most are short). All of these are in the journal Pediatrics and are easily found on the AAP website: www.aap.org. (look for policy statements to R on main homepage). He/she should make an appointment with the program director to report on and discuss at least 4 of the articles below. Resources: Committee on Community Health Services. Health care for children of immigrant families. Pediatrics. 1997; 100 (1): 153-156. AAP. A consensus statement on health care transitions for young adults with special health care needs. Pediatrics. 2002; 110 (6): 1304-1306 Committee on Pediatric Emergency Medicine. Access to pediatric emergency medical care. Pediatrics. 2000; 105 (3): 647-649. AAP.All-Terrain Vehicle Injury Prevention: Two-, Three-, and Four-Wheeled Unlicensed Motor Vehicles. Pediatrics. 2000; 105 (6): 1352-1354. American Academy of Pediatrics Section on School Health: Residency training and continuing medical education in school health. Pediatrics. 1993; 92(2): 495-96. AAP. Assessement of Maltreatment of Children with Disabilities. Pediatrics. 2001. 108(2): 508-512. Committee on Children With Disabilities. Care Coordination: Integrating Health and Related Systems of Care for Children With Special Health Care Needs Pediatrics. 1999. 104 (4): 978-981. Committee on Adolescence and Committee on Early Childhood and Adoption, and Dependent Care. Care of Adolescent Parents and Their Children Pediatrics. 2001. 107 (2) : 429-434. Committee on Adolescence.Care of the Adolescent Sexual Assault Victim. Pediatrics. 2001. 107 (6) : 1476-1479. Committee on School Health. Corporal Punishment in Schools Pediatrics. 2000. 106 (2) : 343. Committee on Pediatric Workforce. Culturally Effective Pediatric Care: Education and Training Issues. Pediatrics. 1999. 103 (1) : 167-170. Committee on Early Childhood and Adoption and Dependent Care. Developmental Issues for Young Children in Foster Care Pediatrics. 2000. 106 (5) : 1145-1150. Committee on Child Abuse and Neglect and Committee on Bioethics. Forgoing Life-Sustaining Medical Treatment in Abused Children. Pediatrics. 2000. 106 (5) : 1151-1153.

10 Committee on Children with Disabilities. Guidelines for home care of infants, children, and adolescents with chronic disease. Pediatrics. 1995. 96 (1) : 161-164. Committee on School Health. Guidelines for the Administration of Medication in School. Pediatrics. 2003. 112 (3) : 697-699. Committee on School Health. Health Appraisal Guidelines for Day Camps and Resident Camps. Pediatrics. 2000. 105 (3) : 643-644. Committee on Adolescence. Health Care for Children and Adolescents in the Juvenile Correctional Care System. Pediatrics. 2001. 107 (4) : 799-803. AAP. Health care for children of farmworker families. American Academy Pediatrics Committee on Community Health Service. Pediatrics. 1995. 95 (6) : 952-953. Committee on Early Childhood, Adoption, and Dependent Care. Health Care of Young Children in Foster Care. Pediatrics. 2002. 109 (3) : 536-541. Committee on Community Health Services. Health needs of homeless children and families. Pediatrics. 1996. 98 (4) : 789-791. Committee on School Health. Home, Hospital, and Other Non-School-based Instruction for Children and Adolescents Who Are Medically Unable to Attend School. Pediatrics. 2000. 106 (5) : 1154-1155. Committee on Pediatric Workforce. Nondiscrimination in Pediatric Health Care. Pediatrics. 2001. 108 (5) : 1215 Committee on Sports Medicine and Fitness and Committee on School Health. Organized Sports for Children and Preadolescents. Pediatrics. 2001. 107 (6) : 1459-1462. Committee on School Health. Out-of-School Suspension and Expulsion Pediatrics. 2003. 112 (5) : 1206-1209. Committee on Sports Medicine and Fitness and Committee on School Health. Physical Fitness and Activity in Schools. Pediatrics. 2000. 105 (5) : 1156-1157. Committee on Pediatric AIDS. Planning for Children Whose Parents Are Dying of HIV/AIDS. Pediatrics. 1999. 103 (2) : 509-511. Committee on Nutrition. Prevention of Pediatric Overweight and Obesity. Pediatrics. 2003. 112 (2) : 424430. Committee on Sports Medicine and Fitness and American Academy of Ophthalmology Committee on Eye Safety and Sports Ophthalmology. Protective eyewear for young athletes. Pediatrics. 1996. 98 (2) : 311313. Committee on Children With Disabilities. Provision of Educationally-Related Services for Children and Adolescents With Chronic Diseases and Disabling Conditions. Pediatrics. 2000. 105 (2) : 448-451.

11 Committee on Children With Disabilities and Committee on Psychosocial Aspects of Child and Family Health. Psychosocial risks of chronic health conditions in childhood and adolescence. Pediatrics. 1993. 92 (6) : 876-878. Committee on Environmental Health. Radiation Disasters and Children. Pediatrics. 2003. 111 (6) : 14551466. Committee on Injury and Poison Prevention. Reducing the Number of Deaths and Injuries From Residential Fires. Pediatrics. 2000. 105 (6) : 1355-1357. Committee on Bioethics. Religious Objections to Medical Care. Pediatrics. 1997. 99 (2) : 279-281. Committee on Sports Medicine and Fitness. Risk of Injury From Baseball and Softball in Children. Pediatrics. 2001. 107 (4) : 782-784. Committee on Injury and Poison Prevention. School Bus Transportation of Children With Special Health Care Needs. Pediatrics. 2001. 108 (2) : 516-518. Committee on School Health. School Health Assessments. Pediatrics. 2000. 105 (4) : 875-877. Committee on School Health. School Health Centers and Other Integrated School Health Services. Pediatrics. 2001. 107 (1) : 198-201. Committee on School Health and Committee on Injury and Poison Prevention. School Transportation Safety. Pediatrics. 1996. 97 (5) : 754-757. Committee on Injury and Poison Prevention. Skateboard and Scooter Injuries. Pediatrics. 2002. 109 (3) : 542-543. AAP. Sexuality Education for Children and Adolescents . Pediatrics. 2001. 108 (2) : 498-502. Committee on School Health. Soft Drinks in Schools. Pediatrics. 2004. 113 (1) : 152-154. Committee on Community Health Services. The Pediatrician's Role in Community Pediatrics. Pediatrics. 1999. 103 (6) : 1304-1306. Committee on Pediatric Emergency Medicine. The Role of the Pediatrician in Rural EMSC. Pediatrics. 1998. 101 (5) : 941-943. Committee on Children With Disabilities. The Role of the Pediatrician in Transitioning Children and Adolescents With Developmental Disabilities and Chronic Illnesses From School to Work or College. Pediatrics. 2000. 106 (4) : 854-856. Committee on Injury and Poison Prevention and Committee on Adolescence. The teenage driver. Pediatrics. 1996. 98 (5) : 987-990.

12 Emergency Medicine (required) Goals and Objectives 1. To learn the approach of acute medical care in the Emergency Department setting. 2. Develop knowledge of appropriate triage of patients arriving in the ER. 3. Learn the aspects of acute stabilization of a critical patient in the ER. 4. Work in unison with the trauma team in the management of pediatric major trauma patients (Trauma codes, Class I and II trauma). 5. Learn the process and evaluation of trauma patients. 6. Become comfortable in the evaluation, diagnosis, and treatment of Class I and II medical problems. 7. Develop skills needed to management pediatric patients in the emergency department. These include, but are not limited to the following: Abdominal pain Laceration evaluation and repair Orthopedic injuries, including splinting, appropriate follow-up, and Salter-Harris fractures Diagnosis and treatment of sexually transmitted diseases Child abuse Evaluation and treatment of head trauma Gynecologic and obstetric treatment of the adolescent Appropriate use of sedation and procedure of sedation in the ER Overdoses and poisoning including treatment and antidotes Treatment of anaphylaxis Evaluation and treatment of burns Near drowning ALTE Course Description First year Pediatric residents will spend 4 weeks in the Emergency Department. Senior residents in Pediatrics and Med/Peds will work in the ER for 4 weeks. Requirements by Level of Training Senior residents will be given more responsibility for diagnosing and treating conditions seen in the ER and for making decisions about admission of patients seen. The senior resident will also be more involved with the care of trauma patients than will the intern, in terms of giving medical treatment advice to the surgeons. Senior residents are expected to see 10-12 patients per shift in the ER (depending on the conditions seen, of course. The resident might see many more than that if most of the patients have routine, non-threatening pediatric conditions and fewer if more patients are quite ill)., while interns will be expected to see approximately 8 patients per shift. Both interns and senior residents are expected to check out their patients to the attending physician in the emergency room. The ER will be covered by the pediatric service daily from 5 p.m. until 1 a.m. The resident on the ER rotation will be covered by other pediatric residents when he/she is off for the day. There is a procedural lab that is conducted by Terry Carlisle PA that the ER is expected to attend. There are also lectures provided during the month by the ER attendings. You should attend and participate in all provided lectures. Reading for this block is independent and should cover the topics noted above and other interesting cases that are encountered during the rotation.

13 Emergency Room Addendum 1. It is the responsibility of the resident covering the ER to perform most of the initial work involved in the admission of pediatric patients to the ward or PICU. This includes determining whether the patient needs to be admitted (along with the ER attending, possibly after consulting the pediatric ward attending), informing the ward attending of the admission, calling the Admissions Office with info about the patient, writing orders and writing or dictating a note. The idea is to lighten the load on the ward team. If the ER resident is overwhelmed with other patients, it is reasonable to request the ward team to handle the admission, although this should not be routine. Conversely, if the ER is relatively light and the ward team is very busy, it is reasonable for the ER resident (with permission of the ER attending) to escort the patient to the ward/PICU and continue the workup (such as LPs, etc) there. Such procedures can be done in the ER, but the pediatric nurses on the 7th floor are more familiar with pediatric patients and procedures and at times may be less busy. 2. Discharge instructions: currently the standard is to use the computer discharge instructions or write your own. However, the computer has woefully inadequate pediatric instructions. Therefore we are currently working on compiling a file of common discharge diagnoses so that we as a department can provide current, appropriate instructions for our patients. In the meantime, it is strongly suggested that you hand write your instructions on the triplicate forms available. Remember, these instructions are being given to parents, you should NOT use abbreviations AT ALL. Something as simple as tsp. for teaspoons may be misinterpreted as tablespoons leading to an overdose of medication. Further, handwriting is crucial. Medico-legally, if it is written down but can’t be read, there is no leg to stand on. When writing over the counter medication doses be sure to clearly write the concentration of the medication that you are referring to and explain to the parent/caregiver to match these numbers to those on the label. For example, Tylenol comes in a variety of strengths; simply writing ~ teaspoon could be dangerous unless you state that you are referring to the children’s concentration of 160mg/5ml. Take nothing for granted. Finally, it is important to always include in writing when and why a patient should return or seek further medical attention. If you just tell a family to return if thus and such happens and they don’t and there is a bad outcome, you cannot prove you told them to return unless it is in writing. 3. In order to track our exposure as a residency program to Emergency Care in terms of diagnoses and numbers, a list of patients seen in the ER should be turned in to the chief residents~ mailbox the next day. This can be done very simply by using the labels printed for each patient to be used to order labs. Affix a label from each patient to a sheet of paper and write the diagnosis next to it. At the end of your shift or the next day place the paper with all your labels in it in the chief residents~ mailbox. Your adherence to this policy will help decide if our time is being used effectively. Resource AAP. APLS. The Pediatric Emergency Medicine Resource, 4th Edition. 2004. See Dr. Robinson to check book out.

14 MEDICAL GENETICS ROTATION WELCOME TO RESIDENTS, FELLOWS AND STUDENTS Goals of the Medical Genetics rotation for residents and medical students 1. Develop a genetics knowledge base. a) How to take a genetic history. b) How to take a family history and analyze a pedigree. c) How to perform and interpret a dysmorphology exam d) Genetics readings - book list, journals, computer searches. e) Genetics network - where to refer and where to ask for help. f) Read one recent issue of American Journal of Medical Genetics or other Genetics Journal to learn about breadth of medical syndromes. 2. Genetic diagnosis: Solving complex clinical problems. a) Collect data - green sheet, medical records. Complete a genetics database green sheet on each patient. b) Organize data - problem list. c) Literature search - Computer competency in: OMIM; London Dysmorphology Database; Medline; Reprotox. d) Diagnostic plan - is there clinical testing available? e) Interpretation of genetic laboratory data: cytogenetics, metabolic, molecular e) Follow-up. 3. Long term clinical care plans for children with chronic problems. a) Team participation in order to understand the roles of genetics counselors, therapists, and education specialists. b) Interact with parents. c) Interact with other specialists. d) Generate a list of resources in Missouri (Regional Centers for the Developmentally Disabled, Early Intervention Programs, Genetic Disease Associations - Neurofibromatosis, Down Syndrome, etc.) e) Learn management protocols for genetic conditions. 4. Genetic Counseling: Learn what counseling entails, techniques and steps. a) Recurrence risk assessment. b) Options. c) Supportive counseling. 5.. Develop an appreciation and contribution to the genetics literature (for residents or students on one month rotations) a) Select one case or topic early in the rotation that may be suitable for publication. b)Complete a literature review including: texts, journals, computer search, and personal communication. c)Consider patient review of the University of Missouri "experience". d) Prepare an abstract suitable for submission to a meeting for presentation. e)Complete paper for publication, if possible. f) Present discussion of topic in Genetics Monday Rounds.

15 MEDICAL GENETICS STAFF Clinical Staff Judith H. Miles, M.D., Ph.D. Clinical Genetics Cytogenetics Richard E. Hillman, M.D. Clinical Genetics Metabolic Genetics Stephen R. Braddock, M.D. Clinical Genetics Dysmorphology Teratology Genetic Counselors/Nurses/Dietitian Jennifer Kussman, M.S. - Genetic Counselor- Coordinate General Genetics Clinic, Hannibal and Kirksville Genetics Outreach Clinics, H.D. Presymptomatic Testing Program, and Down Syndrome Clinic Dawn Peck, M.S. - Genetic Counselor - Coordinate Metabolic Genetics Clinic, Versailles & Springfield Outreach Clinic Janda Bucholz, M.S.- Genetic Counselor-Prenatal Diagnosis & Counseling Coordinator Robin Troxell, M.S. -Genetic Counselor - Southern Missouri Outreach (Springfield, Poplar Bluff, Rolla). Donna LeBlanc, RN, MS, Certified Nurse Practitioner, - Southern Missouri Outreach Carrie Chou - Coordinator, MO Teratogen Information Service and Missouri Fetal Alcohol Syndrome Clinic Cyndy Jones, R.N. - Autism Clinic Nicole Takahashi - Autism Research Assistant Julie Grasela, R.D. - Metabolic Clinic Dietician Laboratory/Research Dennis Lubahn, Ph.D. - Molecular Biology, Biochemistry Charlotte Phillips, Ph.D. - Molecular Biology, Biochemistry Joyce Mitchell, Ph.D. - Director of Information Sciences, Asst Dean Merribeth Muskopf - Senior technologist, Metabolic Lab Office staff Diane Kirby - Administrative Assistant, Room NW507 Nayshea Rice - Senior Secretary, Clinic scheduling and organization, GOAS, files Kelly Arndt - Chief Clerk, MSAFP program and prenatal scheduling Donna Nale - Southern Missouri Regional Genetics Program Outreach

16 GENETICS CALENDAR Monday: 1:00-3:00 Genetics Staffing (Genetics Library) 3:30-4:30 X-ray Rounds - 3rd Monday with Dr. Brown in Reading MRI Rounds - 1st Monday with Dr. Vaslow - MRI Reading Room Tuesday: 9:00-1:00 Prenatal Counseling Only Patients (MFM Clinic, UP Building) 12:00-1:00 Molecular Genetics Hot Topics Journal Club (Genetics Library) 9:00-5:00 Autism Clinic (Pediatric Clinic, UP Building) - Genetics and Psychiatric Medical Management Autism Clinic Wednesday: 8:00-12:00 Metabolic Clinic with Dr. Hillman (Pediatric Clinic - qo week) Outreach Clinics are often scheduled on Wednesday. 8:00-12:00 Prenatal Clinic Counseling/Procedures (MFM Clinic, UP Build) Thursday: 8:00-1:00 Genetics Clinic (Pediatric Clinic, UP Building) 1:00-5:00 Down Syndrome Clinic - third Thursday of the month 1:00-3:00 Autism Clinic (return patients only for Dr. R. Hillman and Dr. Miles) - except every third Thursday (Peds. Cl.) Friday: 8:15-9:15 Grand Rounds 8:00-12:00 Prenatal Clinic Counseling/Procedures, MFM Clinic 8:30-12:00 Cleft Palate Clinic - Every third Friday (Pediatric Clinic) 8:00-3:30 FAS Clinic - 4th Friday of each month (Pediatric Clinic) 1:00-2:30 Prenatal Staffing and Preclinic (Genetics Library) CLINICS INFORMATION AND ASSIGNMENTS: * Obtain clinic patient assignments for the next week at the Friday 1:00 rounds and prepare by 1) reading the available files/charts, 2) reading about the disorder in appropriate Genetics books (not Nelson) which are in the genetics Library, 3)run a medline search and OMIM search and pull at least one paper that updates the information in the text book, 4) make a plan for what needs to be done in clinic for that patient.

17 * Give your beeper number/home number and schedule to Diane Kirby when you start the rotation so it can be posted on Division black board. * Meet with Dawn Peck (NW503) on the first day of your rotation for orientation 1. Prenatal Diagnosis & Counseling Clinic - Tuesday for counseling only and Wednesday and Friday mornings for prenatal counseling with amniocentesis or other procedures. Patients may be scheduled throughout the week according to emergency situations. Overflow patients are scheduled Monday mornings. a) Attend at least one (if on genetics for one week) counseling appointment with one of the genetic counselors to become familiar with genetic history and prenatal diagnosis counseling. 2. Medical Genetics Clinic - Wednesday afternoon and Thursday morning a) Clinic for evaluation and follow-up of children and adults with genetic or metabolic diseases, dysmorphic features, mental retardation and birth defects. b) Work up at least one new patient each week and dictate comprehensive consultation report. 1. Green chart is given to Nayshea Rice and dictation is put in the transcriptionist work box 2. Genetic history must be completed (green form), along with the visit and diagnosis sheet (blue form). This information is recorded into the GOAS (Genetics Office Automated System.) c) See one to two follow-up patients. 3. Metabolic Clinic - every other Wednesday with Dr. Hillman, Dawn Peck and Julie Grasela. Obtain patient assignment from Dawn Peck.. 4. Genetics Outreach Clinic - Every other Wednesday. a) Work up one or two new patients and dictate consultation report. b) See one or two patients in follow-up. 5. Down Syndrome Clinic - 3rd Thursday afternoon of the month. 6. Cleft Palate Clinic -Third Friday of the month. Students and residents don’t generally attend because of time constraints for the evaluations but may observe if approved by Dr. Braddock. 7. FAS Clinic - 4th Friday of the month. Need permission from Dr. Braddock. 7. Autism Clinic - Tuesdays and Thursdays. Genetics and Psychiatric Autism Clinics - Miles, Hillman, Jones - Obtain patient assignment from Cyndy Jones INPATIENT CONSULTATIONS 1. See in-hospital consultations; do family history, dysmorphology exam, and formulate diagnostic plan and differential diagnosis. Diane Kirby or one of the counselors will page you with consults as they are received.

18 2. Review with genetics staff before writing the consultation. 3. Complete blue consult sheet within 24 hours. 4. Complete green sheet on each patient and return to attending with copy of the consult. MEDICAL GENETICS CONFERENCES - Genetics Library 1. Clinical Genetics Rounds - Monday 1:00-3:00. All staff, residents and students present cases evaluated during previous week. 2. Prenatal Counseling Conference - Friday 1:00-2:30. 3. Pediatric Grand Rounds - 8:15 a.m. Friday. 4. Molecular Journal Club - Tuesday, noon - 1:00 pm. Each week a geneticist presents a recent search article to the group. 5. X-ray Rounds - 3rd Monday of the month with Dr. Brown in radiology booth. Give patient names and numbers to Diane Kirby for each film you want to review by the previous Friday (announced as scheduled). 6. MRI Rounds - 1st Monday of the month with Dr. Vaslow in MRI reading room. Give patient names and numbers to Diane Kirby for each film you want to review by the previous Friday (announced as scheduled). REFERENCE LIST - MEDICAL GENETICS Clinical Medical Genetics * Aase, J.M.: Diagnostic Dysmorphology, PlenumMedical, 1990. -a great ‘how-to’ approach to the dysmorphology exam. Easy reading. • Beighton, P.: McKusick’s Heritable Disorders of Connective Tissue, 5th edition, Mosby, 1993. • Emery & Rimoin (eds): Principles and Practices of Medical Genetics, Churchill Livingston, 1996, Vol I & II, 2nd edition. - Excellent, up-to-date coverage of Medical Genetics including basic principles and specific diseases. • Gorlin, R., Cohen, M.M., Hennekam R.C.M.: Syndromes of the Head and Neck, 4th edition, Oxford Press, 2001. • Gorlin, Toriello, Cohen: Hereditary Hearing Loss and Its Syndromes, Oxford Press, 1995. • King, Rotter, Motulsky: The Genetic Basis of Common Diseases, 2nd edition, Oxford Press, 2002. • Stevenson, Hall, Goodman (ed): Human Malformations and Related Anomalies, Vol I & II, 1993. - Excellent treatise on malformations. • Milunski (ed): Genetic Disorders and the Fetus: Diagnosis, Prevention & Treatment, 4th edition,

19 Johns Hopkins Press, 1998. • Jones, Kenneth L.: Recognizable Patterns of Human Malformation, W.B. Saunders, 5th edition, 1997. - The “Bible” of syndromes. Clinical handbook of syndromology. Inexpensive and valuable to own. • McKusick, V.A.: Mendelian Inheritance in Man, Catalogues of Autosomal Dominant, Autosomal Recessive and X-Linked Phenotypes, 10th edition, Johns Hopkins Press, 1992. (See OMIM on-line) • Spranger, et al: Bone Dysplasias, An Atlas of Constitutional Disorders of Skeletal Development, 2nd edition, Oxford, 2002. • Taybi and Lachman: Radiology of Syndromes, Metabolic Disorders, and Skeletal Dysplasias, 4th edition, Mosby, 1996. *Wells, R.D. and Warren S.T.: Genetic Instabilities and Hereditary Neurological Diseases, Academic Press, 1998. Basic Genetics • Thompson & Thompson: Genetics in Medicine, W.B. Saunders, 5th edition, 1991. - excellent clinical genetics overview and good book to read cover to cover during rotation. • Jorde, Carey, Bamshad & White: Medical Genetics, 2nd edition, Mosby, 1999. - excellent overview of clinical genetics, easy to read. • Sack, G.H.: Medical Genetics, McGraw Hill, 1999. • Vogel & Motulsky: Human Genetics, Springer-Verlag, 1985, 2nd edition. - comprehensive Human Genetics textbook. • Mange, A.P. & Mange: Human Genetics Aspects, Sinauer Ass., 1990. Cytogenetics *de Grouchy, Jean and Turleau, C.: Clinical Atlas of Human Chromosomes, John Wiley & Sons, 2nd edition, 1984. - Catalog of chromosomal disorders. • Gardner, R.J.M., Sutherland, G.R.: Chromosome Abnormalities and Genetic Counseling, 2nd edition, Oxford Press, 1996. ISCN, An International System for Human Cytogenetic Nomenclature, Cytogenetics and Cell Genetics, 21:6, 1978. Sandberg, A. A.: The Chromosomes in Human Cancer & Leukemia, Elsevier, 2nd edition, 1986. Heim, S., Mitelman, S.: Cancer Cytogenetics, Alan R. Liss, 1987. Thurman, Eva: Human Chromosomes, Structure, Behavior and Effects, Springer-Verlag, 2nd edition, 1986. Embryology *MooreK.L., Persaud, T.V.N.: The Developing Human: Clinically Oriented Embryology, 6th edition, W.B Saunders, 1998. *Sadler T.W.: Langman’s Medical Embryology, 7th edition, 1995. *Skandalakis, J.E.& Gray, S.W.: Embryology for Surgeons, 2nd edition, Williams & Wilkins, 1994.

20 Metabolic Genetics * Adams & Lyon: Neurology of Hereditary Metabolic Disease of Children, McGraw-Hill & Hemisphere Publishing Corp., 1982. * Ampola: Metabolic Diseases in Pediatric Practice, Little, Brown & Company, 1982. • Scriver, C.R., et al: The Metabolic Basis of Inherited Disease, McGraw-Hill, 7th edition, 2000. Molecular Genetics * Ross, D.W.: Introduction to Molecular Medicine, Springer-Verlag, 1992. • Strachan & Read: Human Molecular Genetics, Wiley-Liss, 1996. - Comprehensive Text Book Counseling * Applebaum & Firestein: A Genetic Counseling Casebook, The Free Press, A Division of MacMillan, Inc., 1983. • Kelly, T.E., Clinical Genetics and Genetic Counseling, Year Book Publishing, 1986.

21 Journals * American Journal of Medical Genetics • Clinical Genetics • Journal of Medical Genetics • Clinical Dysmorphology • The American Journal of Human Genetics • Molecular and Genetic Medicine • Prenatal Diagnosis • Birth Defects Research (formerly Teratology) Human Genetics Human Heredity Annals of Human Genetics Cytogenetics and Cell Genetics Cancer Genetics and Cytogenetics Human Molecular Genetics • Journal of Autism and Related Disorders Computer Software Ovid Access to Medline, etc. Robin Winter (London) Dysmorphology Database, OMD On- line Mendelian Inheritance in Man: OMIM. • Reprotox Database *In Genetics Library. DO NOT TAKE BOOKS OR JOURNALS OUT OF THE GENETICS LIBRARY ON PENALTY OF REARRANGEMENT OF YOUR DNA. * Additional Medical Genetics Schedules are available at our Web site << www.genetics.missouri.edu>> Revised: July, 2004 C:DOCUME~1CHPENNYLOCALS~1TEMPOR~1OLK2MEDICA~1.WPD

22 Hematology/Oncology Rotation Goals and Objectives PGY 2&3 At the end of this rotation the resident should 1. Be able to recognize, evaluate and treat (if necessary) common types of anemia, leukopenia/neutropenia or thrombocytopenia. 2. Be able to recognize bone marrow failure in a patient. 3. Be able to evaluate a patient with a bleeding disorder and screen a patient for a bleeding disorder. 4. Be able to evaluate a patient with a possible malignancy. 5. Be familiar with the common side effects of chemotherapeutic agents. 6. Be able to run a formal tumor board presentation of a new or interesting oncology patient. 7. Know when to refer and be able to co-manage a complicated hematology or oncology patient. Course Description The hematology/oncology rotation is a 4-week rotation involving inpatient and outpatient care. The resident on service should be in the PGY2 or PGY3 years. He/she will participate in all aspects of patient care with the exception of consultations. He/she will follow all inpatients in the hospital, attend the outpatient clinics in the Children’s Blood disorder and Cancer Unit and participate in procedures in clinic and in the OR. He/she will coordinate with the ward teams for coverage on nights and weekends. The supervising attendings are Dr. Gruner and Dr. Hakami. References 1. Hillman and Clement: Red Cell Manual, current edition 2. Schmaier and Petruzzelli: Hematology for the Medical Student 3. Nathan and Orkin: Nathan and Oski’s Hematology of Infancy and Childhood, 6th edition 4. Pizzo and Poplack: Principles and Practice of Pediatric Oncology, 4th edition 5. Your favorite General Pediatrics text (Rudolph, Nelson, Oski, etc.) 6. The collection of articles in the Heme/Onc conference room

23 Pediatric Infectious Disease Goals and Objectives: PGY 2 or 3 1. Understand the mechanism or infection, incubation period, and pathophysiology, as well as treatment of the major infections that occur in the pediatric and adolescent population. These include: a. upper respiratory infections b. lower respiratory infections c. sinusitis d. gastrointestinal infections (including viral hepatitis) e. urinary tract infections f. bacterial sepsis g. rickettsial infections h. infectious exanthems i. musculoskeletal infections (including joint space infections and osteomyelitis). j. central nervous system infections (including encephalitis, meningitis, and brain abscess) k. intrauterine and neonatal infections l. HIV m. fever of unknown origin n. tuberculosis and other infections seen in the immigrant population o. sexually transmitted infections p. rare infections seen in travelers (malaria and traveler’s diarrhea, for example) 2. Understand the mechanism of action, spectrum and pharmacokinetics of routine antimicrobial therapy such as penicillins, macrolides, cephalosporins, and vancomycin, etc. Understand the challenges of growing antibiotic resistance. 3. Understand the rationale for immunizations in the pediatric population and the arguments in favor of continuation of this practice. 4. Understand basic immunology and be able to screen for/recognize immunodeficiency states. Course Description: The resident physician elective is available for 2-4 weeks. During this time, they will perform all consults, follow inpatients under care or consultation by the ID attending, and participate in all available ID outpatient clinics. Additional readings and projects are often assigned by the attending physician. Small projects or reports will be decided upon based on the interest of the resident and opportunities provided by patients seen. The resident’s work will be supervised by Dr. Michael Cooperstock. Additional rotators on the ID elective are made by approval with Dr.

24 Cooperstock, the Chief Resident, and the Program Director. All evaluations will be performed by Dr. Cooperstock. References 1. Feigin and Cherry. Textbook of Pediatric Infectious Diseases, 5th Edition, Saunders, 2004. 2. Long SS, et al. Principles and Practice of Pediatric Infectious Diseases. Churchill- Livingstone, 2003. 3. Remington J, Klein J. Infectious Diseases of the Fetus and Newborn, 5th Edition, Saunders, 2001.

25 Pediatric Endocrinology (Elective) Updated June 11, 2004 (BB) Goals and Objectives: 1. Provide Residents and Students Approach to Diagnosis and Treatment of Endocrine Disorders. • Thyroid Disorders-Hypothyroidism/Hyperthyroidism • Disorders of Growth • Disorders of Calcium, Phosphate, PTH and Vitamin D • Disorders of Pubertal Development • Delayed Puberty • Turner’s Syndrome • Obesity H. Autoimmune Endocrinopathies and Multiple Endocrine Neoplasias I. Adrenal Disorders • Carbohydrate Metabolism and Hypoglycemia • Genetic Aspects of Endocrine Diseases L. Sexual Differentiation and Ambiguity M. Water Regulation and It’s Disorders 2. Interpreting Endocrine History and Physical • Interpreting Growth Curves • Interpreting Bone ages and Endocrine Imaging • Examining Patient and Interpreting Physical Exam Signs • Learning Pubertal Tanner Staging • Reviewing History Pertinent to Endocrine Disorders 3. Understand Type 1 and Type 2 Diabetes as well As MODY and Cystic Fibrosis Diabetes • Learn How to Manage Diabetic Ketoacidosis • Learn Various Types of Insulin Regimens • Learn About Insulin Pumps • Learn About Managing Chronic Disease with a Team of Nurse Practioners, Social Service and Nutritionists • Learn how to Diagnose Type 1 vs Type 2 • Learn about MODY and Cystic Fibrosis Diabetes 4. Conferences • Combined Adult Endocrine and Pediatric Endocrine Tuesdays 1 PM • Genetics Journal Club 2nd and 4th Tuesday @ 12:15 PM • Metabolism Conference 2 PM Thursdays – Dr. Richard Hillman • Journal Club/Adult Fellow Education- Fridays 8:15 Am • Combined Pediatric Endocrine/Adolescent Medicine Thursdays 8:15 Am

26 Course Description: Residents/4th Year Students: Residents and 4th Year Students will be under the guidance of Bert Bachrach, MD. The goal is to provide an exciting learning experience that is enjoyable for both the Attending and Resident/4th Year Student. The expectations are that students participate in the rotation and take as much of an active role in their learning experience. They will be expected to present an oral presentation. The topic is not necessarily Endocrine in nature but a topic agreed upon by both the Attending, Resident or 4th Year Student. Residents and Students will be expected to round on inpatients as well as perform consultations. An Endocrine Textbook can be provided to the student as well as Handouts upon initiating rotation. The goal is to further enhance one’s skills as a primary care provider, specialist or budding Endocrinologist to not only evaluate patients and determine a diagnosis; but to research topics and determine the best course of action in management. References: 1. Pediatric Endocrinology- Radovik/MacGillivary 2. Pediatric Endocrinology and Growth- Wales/Witt/Rogol 3. Williams Textbook of Endocrinology 4. Inborn Metabolic Diseases-Fernandes/Saudubray/ Van den Berghe 5. Wilkins The Diagnosis and Treatment Endocrine Disorders in Childhood and AdolescenceKappy, Blizzard, and Migeon 6. Gruelich and Pyle Bone age Standards 7. And much much more………….. Questions: If you have any questions regarding this rotation please feel free to contact me or stop by my office. This is a fantastic rotation that is really enjoyable and will enhance your skills as Pediatrician, Family Practicioner, Internist or whatever your chosen career. Utmost Importance: During Football and Basketball Season being a Tiger Fan is mandatory. Pro Football teams must root for the New England Patriots, Chiefs and Rams. If any of these Teams play the Patriots must root for the New England, no exceptions. No Jayhawk fans allowed on this rotation. You are not allowed to challenge the Attending on matters of Pro Football Teams and Mizzou Basketball or Football.. Sincerely, BB Bert Bachrach, MD Director Pediatric Endocrinology/Diabetes DC058.00, N714

27 One Hospital Drive Columbia, MO 65212 Tel: 573-882-6979 Email: bachrachb@health.missouri.edu P.S.: Faint Hearted need not apply for this rotation

28 Nephrology/Urology (elective) Goals and Objectives: PGY 2 or PGY 3 1. Learn the differential diagnosis and initial evaluation of proteinuria and hematuria by incidence and age group (i.e. nephritic syndrome and nephrotic syndrome). 2. Understand the initial evaluation and cost effective laboratory testing for common renal disorders of nephritic syndrome, orthostatic proteinuria, UTI, hematuria, and renal tubular acidosis. 3. Learn a logical approach to enuresis (nocturnal and diurnal) for diagnosis and management. 4. Recognize and diagnose common nephrologic conditions, such as; common causes of acute and chronic renal failure in children, hemolytic uremic syndrome, hypertension, vesico- ureteral reflux, and hydronephrosis (both prenatal and postnatal). 5. Understand urinalysis results in diagnosis and management of common urologic and nephrologic disorders. 6. Learn the basic principles of fluid and electrolyte management, such as, dehydration, hyponatremia, hyper or hypocalcemia, and uremia. 7. Understand the pathophysiology and management of common systemic conditions that present with renal involvement such as: Henoch-Schonlein Purpura, systemic lupus erythematosus, sickle cell disease, and urinary tract infections. 8. Become familiar with dialysis techniques in children. 9. Become familiar with the more common urologic conditions seen in children: hydrocele, hypospadias, epispadius, varicocele, undescended testis, and scrotal conditions such as epididymitis and testicular torsion. 10. Become knowledgeable about the evaluation of babies born with ambiguous genitalia. Course Description: To provide the resident physician with exposure to kidney disorders affecting children. Patients are seen primarily in an outpatient setting, but residents on this elective are expected to follow inpatient consults and nephrology patients in the consultant role. The resident will also spend time in Pediatric Urology clinic with Dr. Lynn Teague. In the urology section of the rotation the resident will be expected to observe at least 10 common urologic procedures. Most of said procedures will be done Friday mornings. All activities are supervised by Drs. Ted D. Groshong and Lynn Teague. This includes dealing with psychosocial aspects of chronic disease and participating in the team approach to care. Evaluations will be performed by the above attending physicians. References Huner, C.D., Harman, W.E., Niaudet, PI; Pediatric Nephrology, 5th Edition, Lippincott. Williams and Williams, New York, 2004 Several Pediatric Urology texts available for loan by Dr. Teague.

29 Pediatric Neurology Rotations (required) Welcome to the Pediatric Neurology Rotation!! Pediatric neurology is an exciting field in medicine. It offers interdisciplinary experience in pediatrics, neurology, and developmental neurobiology. We are glad to have a chance to share this experience with you. We hope this rotation will be productive and enjoyable for you. Learning Objectives: In order to make your time and effort worthwhile we have identified the following objectives for your learning during this rotation. We understand that your rotation may be brief and may not be able to cover all areas in one stint but we will try our best to achieve these goals. (1). To understand the dynamics of a developing brain and to identify the consequences of insults and defects occurring in different developmental stages. (2). To be able to take a comprehensive medical history pertinent to the pediatric neurological disorders. (3). To learn to perform neurological examinations in children of different ages. (4). To be able to generate some differential diagnosis after evaluating a child with neurological disorders. To become familiar with some of the diagnostic work-up for the common pediatric neurological disorders. (6). To understand the choice and rationale for the various therapeutic interventions in pediatric neurological disorders. Daily Schedule: The residents are allowed to attend morning reports and continuity clinics in their perspective departments. The residents should inform the attendings of their schedules at the beginning of the (1). rotation. In general, they should report to the clinics or the pediatric neurology attending on service no later that 9:00 AM each day on weekdays. (2). All residents are expected to attend the weekly neurology/neurosurgery grand rounds on Wednesday mornings from 8:15 to 9:15. All residents are expected to participate in the outpatient clinics and inpatient care both on neurology service and on consult service. (3).

30 Clinic schedules: Dr. Patel has clinics on Monday all day, Tuesday AM, Wednesday PM , and Friday AM. Inpatient Care: The inpatient care is directed by Dr. Patel. Whenever there is no clinic session the team should round with Dr. Patel. Inpatient rounds are conducted daily whenever there are neurology patients on the ward or on consult service that requires continuing attention. The residents may be delegated to evaluate a patient on the consult service or as a new admission to the neurology service. The resident will gather the clinical information and report to the attending on service and then see the patient together with the attending. The neurology team is expected to help the pediatric team to schedule diagnostic tests and to gather results of these tests. Didactic Lectures: In addition to the scheduled lectures and conferences listed above the pediatric neurology attending will conduct didactic lectures on selected topics during opportune times and when rounding with the pediatric ward teams. Reading materials: G. Fenichel: Clinical Pediatric Neurology, A Signs and Symptoms Approach. 4th Edition, 2000. Bruce O. Berg: Principle of Child Neurology. McGraw Hill, 1996. John H. Menkes: Textbook of Child Neurology. Sixth Ed. Williams and Wilkins, 2000. The attendings will hand out supplemental reading materials when appropriate. Evaluation/Expected Performance: We expect that the residents will perform satisfactorily before they pass this rotation. Their performance will be evaluated on the basis of their progress in knowledge acquisition and skills in clinical evaluation of a child. An enthusiastic attitude and willingness to learn is required for this rotation. Reading on the topics related to the clinic and inpatient cases is the best way to learn. The residents are expected to dictate a complete clinic note on all patients they see. They should follow the format used by the attendings and gather all the information before dictation the note. Residents will fill out the history part of the consult form on all neurology consultation requested by other services. The attending will complete the physical examination and the impression/plan sections.

31 Contact phone #’s: Secretary of Pediatric Neurology: Zinda Cody 882-5779 or 882-1043 Dr. Patel’s pager 808-7822 Pediatric Neurology Nurses: Robin Davenport, RN, BC, PNP 3663 pgr.

32 Pediatric Cardiology (elective) Goals and Objectives: PGY 2 or 3 1. Become familiar with important elements of the cardiovascular exam in children of all ages. 2. Be able to effectively evaluate children with chest pain and syncope. 3. Understand the pathophysiology and treatment of common arrythymias of childhood, such as supraventricular tachycardia (SVT). 4. Know the appropriate pathophysiology, diagnostic evaluation and treatment of cyanotic and acyanotic congenital heart disease in infants, obstructive left-sided lesions and obstructive right-sided lesions. 5. Become familiar with commonly used cardiac medications in children, understand their pharmacology and recognize their toxic effects. 6. Recognize when to refer patients to a cardiologist 7. Understand how to read and perform a pediatric electrocardiograms (ECG) 8. Learn how and when to obtain an echocardiogram on a patient. Course Description: The resident should participate in all availabe cardiology clinics during their rotation. They will share patients with medical students, cardiac fellows, and other resident rotators during their time. Teaching will be done by reading assignments and by informal talks with Dr. Lababidi, Dr. Carter and Dr. Skimming. Residents will be expected to perform inpatient consults with the attending cardiologist, as well as, follow inpatient cardiology patients following cardiac catheterization or open-heart surgery. Residents are expected to attend and assist in diagnostic and interventional catheterization procedures. References: Fink BW. Congenital Heart Disease: A deductive Approach to its Diagnosis, 3rd edition. Mosby Yearbook 1991. Moss: Heart diseases in infants, children and adolescents, 5th edition. Behrman: Nelson Textbook of Pediatrics; 15th edition. Oski: Principles and Practice of Pediatrics; 2nd edition. Rudolphs: Rudolph~s Fundamentals of Pediatrics; 20th edition. Schamberger MS. Cardiac emergencies in children. Pediatric Annals 1996; 25(6):339-44. Schamburger MS. Cardiac Emergencies. In Tobias JD, ed. Pediatric Critical Care: The ssentials, Futura Publishing, E Lababidi Z. Neonatal catheter palliations. In Long, ed: Fetal and Neonatal Cardiology. Carsons: The Science and Practice of Pediatric Cardiology.

33 Pediatric Gastroenterology (elective) PGY 2, PGY 3, or PGY 4 (Med Peds) Goals and Objectives 1. Resident will be able to recognize, diagnose and successfully treat GERD in children. 2. Residents will learn how to treat encopresis successfully in the pediatric population. 3. Residents will understand situations in which the rectal examination is important in the diagnostic evaluation. 4. Learn how to evaluate failure to thrive in children. 5. Learn the differential diagnosis and evaluation of hepatitis. 6. Residents will learn how to recognize and treat functional disease, including when referral is necessary. 7. Residents will learn how to screen for and diagnose inflammatory bowel disease (IBD) and understand its pathophysiology, long term complications, and treatment. 8. Learn how to interpret a liver panel appropriately. 9. Learn the differential diagnosis and treatment of diarrhea. 10. Become familiar with the principles and indications for endoscopy in children. 11. Resident may, if he/she wishes, work with Dr. Fleisher to become familiar with the biopsychosocial model of medicine and its application in the treatment of children with recurrent abdominal pain. Course description The resident will spend 4 weeks with the pediatric GI service. He/she will be involved in both inpatient consultations and outpatient clinics. The GI resident will follow GI inpatients in a consulting capacity, but the resident will not be primarily responsible for the patients. When available the resident should attend all endoscopies and outreach clinics. References The GI service will give out appropriate papers and resources on request.

34 Pediatric Surgery Block (required) PGY 2-PGY3 Goals and Objectives At the end of the rotation the resident should 1. Be proficient in recognizing common pediatric surgical conditions and rationale for the management algorithms. 2. Recognize acute surgical conditions and institute appropriate immediate therapy as needed before definitive surgical intervention. 3. Participate in at least 10 minor and major operations in the operating room. Special focus will be placed on minimally invasive techniques including thoracoscopic and laparoscopic procedures. 4. Become proficient at wound closure, recognizing various tissue planes and understand basic suturing and wound care. 5.Develop an understanding of chronic surgical problems and specific management goals in these patients. Description: This rotation will enable the resident to participate in the preoperative assessment, workup and management of surgical patients. They will also be able to interpret relevant CAT/ Ultrasound scans. Residents will participate or perform central line placements in appropriate patients. They will also participate in assessment of pediatric trauma. References: 1. Principles of Pediatric surgery James O'Neill, Jay Grosfeld, Eric fonkalsrud 2002 2. Pediatric Surgery: Ashcraft et al 2003 3. Operative Pediatric Surgery: by Moritz Zeigler.Richard Azizkhan Thomas Weber. 2004

35 Pediatric Intensive Care Unit/Post-Operative Care (required) PGY I and 2 Goals and Objectives 1. Recognition of respiratory and hemodynamically compromised patients. Involvement in the resuscitation/stabilization of these critically ill children. 2. Integration of clinical and laboratory data in formulating therapeutic and management plans for critically ill patients. Examples: ventilation management, electrolyte abnormalities, nutrition. 3. Develop an understanding of invasive and non-invasive techniques for monitoring and supporting pulmonary, cardiovascular, cerebral, and metabolic functions. 4. Participation in pre- and post-operative management of surgical patients, including identifying the responsibilities of the general pediatrician and intensivist. 5. Evaluation and management of patients following traumatic injury, including head injuries. 6. Gain experience with intubation, peripheral intravenous catheter placement, central line placement, arterial line placement, and chest tube insertion. 7. Communication with child and/or family members regarding status and treatment plan for patient. Involvement with transfers and discharge planning. Participation in discussions with families regarding psychosocial issues and end of life counseling. Course Description: All Pediatric and Med/Peds residents are required to rotate 2 months and 1 month, respectively, in the Pediatric Intensive Care Unit (PICU).(The ward senior will also cover the PICU as a night float.) During the PICU rotation the resident has no direct call requirements in the ICU (though they may have call elsewhere). The resident is expected to follow and assist the intensivist in the care of all patients in the PICU, unless otherwise specified, under the direction of Dr. Tobias or Dr. Wankum. This entails collection of patient data, presentations of patient information during rounds, daily notes, and assisting the primary care teams in their care of these sick patients. These patients include both medical and surgical subspecialty patients. Surgical patients include general pediatric surgery, cardiothoracic, neurosurgery, ENT and ortho patients. Requirements by Level of Training There will be an intern and a senior level resident in the PICU for 9 months of the year. When both are present, each will be assigned his own or her own patients. However, the senior level resident will be expected to supervise the intern in the care of his/her group of patients. The senior resident will check that orders are written appropriately and that the proper care plan has been given. Interns will informally present his/her patients to the senior resident on prerounds, before both round with the attending physicians. The senior resident will also help the intern, when necessary, to gather data about patients. Both residents will work under the direct supervision of the attending physicians, as noted below.

36 Currently, Dr. Joseph Tobias, and Dr. Patricia Wankum are the faculty Pediatric Intensivists and will directly supervise and instruct the rotating resident. Literature searches and in-depth reading will be required on specific patients, in addition to the assigned reading selection. The resident will have access to and encouraged to view video tapes on topics such as Dr. Frost's lecture, "Determining Brain Death," as well as read the section on "Critical Care, end of life, and futility issues" in the Ethics (vol. 1) kept in the Residency Coordinators Office. Rotators outside the Departments of Child Health and Anesthesiology may rotate in the PICU after written request and approval from Dr. Joseph Tobias, the Chief Resident and the Program Director. References: Rogers: Handbook of Pediatric Intensive Care Tobias: Pediatric Pain Handbook Tobias: Pediatric Critical Care: The Essentials

37 Pulmonology (required) Inpatient Pulmonary Medicine (much of which will be taught on the inpatient ward rotation) 1. Learn and understand the pathophysiology of chronic lung conditions of cystic fibrosis, asthma, pulmonary hemosiderosis, and bronchopulmonary dysplasia. 2. Understand the diagnostic and therapeutic methods of bronchoscopy and thoracocentesis. 3. Learn interventional techniques for management of asthma, hemoptysis, and bronchiolitis. 4. Provide differential diagnosis and evaluation of central and obstructive apnea and other sleep disorders. 5. Participate in the management and coordination of resources with chronically ill patients, working with nursing, social services, dietetians and other health professionals. 6. Obtain an adequate medical and psychological history in complicated pulmonary/allergic patients. 7. Learn the basics of blood gases, acid-base balance. Outpatient Pulmonary Medicine 1. Understand management techniques for outpatient asthma, cystic fibrosis, allergic rhinitis, environmental allergies, sinusitis, bronchiolitis, pneumonia, eczema, food allergies, immune deficiency diseases, and drug allergies. 2. Be able to recognize and diagnose common problems of recurrent respiratory infections, stridor, cough, wheezing and formulate appropriate management plans. 3. Know the pharmacologic mechanisms of commonly used medications for asthma, allergy and cystic fibrosis. 4. Demonstrate and refine the ability to read and utilize diagnostic chest, sinus, and neck radiographs in respiratory disease. 5. Learn to evaluate and diagnose upper airway obstruction such as foreign body, tracheomalacia, vascular ring, and laryngeal web. 6. Adequately interpret spirometry and lung volumes for the diagnosis and management of restrictive and obstructive lung disease in chronic and acute disease states. Learn to interpret skin tests for allergies and other tests for allergic diseases. 7. Recognize the role of upper airway diseases such as allergic rhinitis and sinusitis as aggravating factors of asthma. 8. Learn NIH classification of asthma severity and the appropriate treatment of each group. 9. Learn to interpret the sweat test and other diagnostic tests for cystic fibrosis. 10. Recognize the signs and symptoms of obstructive sleep apnea syndrome. Distinguish the different types of apnea (central versus obstructive) and the various etiologies of each. Know the differential diagnosis for apnea of infancy.

38 References: 1997 NIH Asthma Management Consensus Statement and 1997 Cystic Fibrosis Consensus Statement Nimmagadda and Evans. Allergy: Etiology and Epidemiology. Pediatrics in Review 1999; 20: 111115.

39 Research/Reading Block (elective) PGY 1-4 (Peds-Med Peds) Note: This block can only be taken with permission of the Pediatric or Med-Peds Program Director. Only one block for research/reading may be taken during one’s residency (unless leave is taken which will need to be made up), and it may be taken only if requirements are on track for completion by the end of the resident’s training. Goals and Objectives 1. Help with or complete a research project with a faculty member. 2. Research and write a case report or scientific paper or research and prepare a major talk on a topic in Pediatrics (not including the required Grand Rounds). 3. Read deeply about one or more topics in Pediatrics. If this option is taken a referenced report must be written about at least one of the subjects. Course Description The resident will work with a faculty member advisor on this rotation, who will help by guiding the reading program, or making sure the reading is appropriate for the resident’s needs. If a research project is chosen, the resident will also work with a faculty member who will help plan and execute the research. The faculty advisor will be responsible for evaluating the resident on the rotation. A copy of the completed paper or report should be kept in the resident physician’s file.

40 Resident Curriculum for Outpatient General Pediatrics Thomas J. Selva, M.D. Associate Professor of Clinical Pediatrics ACUTE-CARE EXPERIENCE: The acute-care experience provides the resident an opportunity to master the evaluation of the acutely ill child in a problem-based setting. In this setting the resident serves as an educational resource to students as well as junior residents in dealing with commonly presenting acute illnesses. During the three years of training, the resident will also develop the skills to serve as a resource for consultation for outside physicians. A board certified general pediatrician currently maintaining an active primary care practice in the same setting will provide supervision of acute-care service delivery. It is in this setting the resident will master the skills necessary to adequately assess and triage patients with acute illnesses, determining whether clinic evaluation is warranted or admission to the hospital for inpatient evaluation and care is necessary. FIRST-YEAR EXPECTATIONS: The first-year resident is expected to serve as the primary care provider in the acute care clinic. During the first-year the resident will acquire the skills necessary to evaluate acutely ill patients and determine an appropriate plan for disposition. The skills for adequately documenting the patient encounter as well as adequately assessing the level of care delivered for appropriate billing will also be mastered. In the latter months of the first-year the resident will develop the skills necessary to manage patient flow in a busy acute care clinic setting. Phone management will be introduced during the first-year and will be supervised an ongoing basis. SECOND-YEAR EXPECTATIONS: The second-year resident will serve as the primary care provider in the acute care clinic as well as an educational resource to junior residents and students. Supervision of student encounters with patients as well as review of student documentation will be included in the resident’s responsibilities. The resident will serve as a resource for managing patient flow through the waiting area and acute care facility. In addition to supervising patient encounters and providing care directly to the patients, the secondyear resident will also be responsible for providing educational interludes for the students during low- volume periods. THIRD YEAR EXPECTATIONS: The third year resident will be expected to master the skills necessary for properly assessing and triaging the acutely ill child in an outpatient setting. During rotations in the outpatient acute care clinic, the resident will be expected to serve as an educational resource for junior residents as well as students, supervising both patient encounters and documentation. During this year the resident

41 will have mastered the skills necessary to properly determine the level of service provided as well as appropriate coding of the patient encounters. The resident will master the skills necessary for managing nursing care as well as scheduling in the outpatient setting. Phone management of patients as well as phone triage will be mastered. At the end of the third year the resident will be capable of managing a busy clinic of acutely ill children in a thorough and efficient manner insuring success in the private or academic sector. PROCEDURES TO BE MASTERED IN THE OUTPATIENT SETTING: 1. Intravenous fluid administration 2. Intravenous access 3. Oral rehydration 4. Simple laceration closure a. Suture closure i. Layered ii. Unlayered b. Tissue adhesive closure 5. Immunization administration 6. Administration of aerosolized medications 7. Splinting techniques a. Upper extremity i. Sugar tong splint ii. Gutter spling iii. Cock-up splint iv. Use of preformed splinting materials b. Lower extremity i. Posterior splint ii. Sugar tong splint iii. Use of preformed splinting materials 8. Closed reduction of dislocations a. Subluxation of the radial head b. Finger dislocations 9. Incision and drainage of simple abscesses 10. Foreign body removal a. Eye b. Ear c. Simple subcutaneous 11. Ear curretage 12. Ear irrigation 13. Tympanometry a. Application of instrument b. Interpretation of results 14. Vision screening a. Titmus screening b. Auto-refraction

42 15. Office Audiometry a. Speech thresholds with handheld unit b. Acoustic impedance tympanometry

43 Resident Curriculum for Outpatient General Pediatrics Continuity Clinic Experience Thomas J. Selva, M.D. Associate Professor of Clinical Pediatrics Continuity Experience: The goal of the continuity experience is to allow residents the opportunity to develop an understanding of and appreciation for the longitudinal nature of general pediatric care. This includes aspects of physical and emotional growth and development, health promotion and disease prevention, management of chronic and acute medical conditions, family and environmental impacts, and practice management. Residents will assume responsibility for the continuing care of a group of patients throughout their training. Inherent in the principal of continuity of care is that patients are seen on a regular and continuing basis, rather than a single occasion. The location where care is delivered will be kept as consistent as possible throughout the resident’s three years of training. The continuity experience will include a setting structured and designed to emulate the practice of General pediatrics and conducive to the efficient processing and management of patients. Residents will devote at least one-half day per week to their continuity experience throughout the three years residency training, and (space permitting) an additional one half-day session per week will be provided to those residents who express interest. This experience will receive priority over other responsibilities, interrupted only for vacations, compliance with resident work hour restrictions per the ACGME, or outside rotations located at too great a distance to allow residents to return. Residents expressing an interest in a primary care career track will be given the option to spend their second half- day of continuity clinic in a primary care setting. Patient populations in the continuity experience will include well patients as well as those with complex and chronic problems. Patients will be recruited by the residents from those managed in the normal newborn nursery, emergency department, inpatient service, intensive care unit (both pediatric and neonatal), specialty clinics, and in other sites where resident training takes place. As a guideline, each half-day experience will include three to six patients per resident in the firstyear of training, four to eight patients per half-day in the second-year training and 5 to 10 patients per half- day in the third year training. Semi-annual reviews of resident patient populations will be conducted. Ultimately first-year residents will have built a panel of approximately 50 patients or more by the end of the first-year. Second and third year residents will be expected to maintain a panel of at least 100 patients or more. Each year the resident will be expected to conduct a Quality Assurance review of their patient care using the EQIPP educational modules as a guide. AAP practice guidelines will be used as a standard to measure resident management of selected clinical problems.

44 The curriculum delineated below emphasizes the generalist approach to common office-based pediatric issues including anticipatory guidance from birth to young adulthood, developmental and behavioral issues, and immunization practices and health promotion, as well as the care of children with chronic conditions. Through this curriculum residents will learn to serve as the coordinator of comprehensive primary care for children with complex and multiple health-related problems and to function is part of a integrated comprehensive health-care system. FIRST-YEAR EXPECTATIONS: With more time allocated for each patient encounter, the first-year resident will acquire the skills necessary to obtain a comprehensive history allowing for the thorough evaluation of the well child. In the first-year the pediatric resident will learn the appropriate milestones used to assess gross motor and fine motor development in the growing child. Anticipatory guidance for all of the wellchild evaluations in the first 18 years of life will be mastered. Superb explanation and management of routine childhood immunization schedules will also be mastered. Management of the chronically ill child with multiple medical problems as part of an integrated health care delivery system will be introduced. SECOND-YEAR EXPECTATIONS: Having acquired the skills necessary to obtain a thorough history in the evaluation of the well child, the second-year resident will develop and efficiently manage a larger patient population. Masterful coordination of social as well as medical services will be developed during the second year. Management of the acutely ill child within the limitations of a continuity clinic service, paying special attention to the time constraints of a general clinic will also be mastered. During the second year continuity experience, the concept of office and practice management will be introduced. This will include the management of office staff, nursing staff, supplies, and patient scheduling. THIRD YEAR EXPECTATIONS: The third year resident will maintain at least 5 - 10 patients per half-day session and will stay within scheduling constraints. He or she will serve as a resource to less experienced residents and students. The third year resident will obtain the skills necessary to advance to full-time general practice in an outpatient setting upon finishing the third year. Management of office staff, nursing care, phone triage, and supplies will be mastered by the end of the third year. During the third year the concepts of financial management, risk management, and contract negotiation will be introduced.

45 Inpatient Pediatrics (required) Goals and Objectives PGY 1 1. Develop an understanding and competence in diagnosis and management of a variety of common pediatric illnesses, severe enough to require in-paitent care. 2. Develop the skills of order writing. 3. Become familiar with an inpatient health care team; including nursing, child life therapy, social services, physical therapy, occupational therapy, consultants and discharge planning. 4. Begin development of skills in recognition and stabilization of ill children. PGY 2 & 3 1. Become adept at determining which patients can be managed in a general inpatient setting and which require more specialized care (i.e. surgical or intensive care). 2. Understand the timing and appropriate utilization of consultants. 3. Be able to develop a complex differential diagnosis and discriminate use of diagnostic testing in the care of ill children. 4. Develop skills of supervision and teaching of students and residents. 5. Become competent in the evaluation, diagnosis, management, and placement into the hospital of ill children. 6. Understand and participate in all psychosocial, medical, and environmental aspects of inpatient care, as well as, discharge planning. Course Description: PGY 1 residents will rotate 4 to 5 months on the in-patient service during their intern year. Med/Ped residents will rotate 2 to 3 blocks during their intern year. The interns will become immersed in the daily care of children with common and interesting conditions that require inpatient care. They will be supervised at all times by a senior resident (PGY 2 or 3) and the attending physician. The intern will follow an average of 6 to 10 inpatients. Call during this block is every 4th night. PGY 2 and 3 residents will rotate 2 to 3 blocks per year (minimum 4 and maximum 6) on the inpatient service. This will be based on the preference of the resident and approval by the Chief Resident and Program Director. The senior resident is responsible for all aspects of patient care on their in-patient service. They are expected to supervise and administer over 1 to 4 interns and 3 to 5 medical students. They are in close communication with the Attending physician at all times. On average, senior residents will be responsible for 15 to 20 patients and do an average of q 4 night call. References: Medical Emergencies I & II - Pediatric Annals 1996. Oski FA, DeAngelis CD, Feigin RD, et al, editors: Principles and Practice of Pediatrics, 2nd edition. Philadelphia: J. B. Lipincott, 1994.

46 Rudolph AM, Hoffman JIE, Rudolph CD, editors. Rudolph=s Pediatrics, 20th edition. Stamford, Connecticut: Appleton and Lange, 1996. Behrman RE, Kliegman RM, Arvin AM, editors: Nelson=s Textbook of Pediatrics, 15th edition. Philadelphia: WB Saunders, 1996. AAP: 2000 Red Book Green: Pediatric Diagnosis: Interpretation of symptoms and signs in children and adolescents; 6th edition. Zitelli: Atlas of Pediatric Physical Diagnosis; 3rd edition. Hurwitz: Clinical Pediatric Dermatology; 2nd edition. Jones: Smith=s Recognizable Patterns of Human Malformations Learning Objectives for Pediatric Wards: To include but not limited too… Fluid and Electrolytes 1) Relate maintenance fluid and electrolyte needs to body weight and metabolic rate. 2) Recognize the differences in mild, moderate and severe deficits among infants compared with children or adults when expressed as percentage of body weight. 3) Describe the indication for a ‘bolus’ and specify the amount and composition. 4) Specify a rehydration plan without the use of a calculator for an infant who has moderate dehydration. 5) List the measures most valuable for monitoring the state of hydration. Reference: Pediatrics in Review, Vol. 22, No. 11, Nov 2001 Respiratory Infections 1) List the most typical bacterial pathogens that cause pneumonia in a newborn infant, list the antibiotics that are appropriate to cover these pathogens and state which antibiotics cover which pathogens, and describe specific CXR findings typical for these pathogens. 2) List the most typical bacterial pathogens that cause pneumonia in a child less than five years of age, the antibiotics that are appropriate to cover these pathogens and describe the CXR findings most typical of these pathogens. 3) List the most typical pathogens that cause pneumonia in a adolescent or adult, ant antibiotics that are appropriate for these pathogens, and the typical CXR findings with each pathogen. 4) List the most typical viral respiratory causes of respiratory distress in young infants and children, the effective treatment strategies and the risks for infants that are admitted to the hospital with RSV, in particular.

47 5) List the medical problems that make patients more likely to admitted to the hospital with RSV. 6) List the isolation strategies used to prevent transmission of respiratory, contact and nosocomial pathogens. Reference: Respiratory Syncitial Virus and Parainfluenza Virus, NEJM, vol 344:1917-1928, June 21, 2001. No. 25. Acid-Base Disorders 1) Identify the primary disorder 2) Calculate the anion gap. 3) Calculate the excess anion gap. 4) Identify at least five causes of an acute respiratory alkalosis. 5) Identify at least three causes of a chronic respiratory acidosis with metabolic compensation. 6) Identify at least three cause of metabolic alkalosis with respiratory compensation with a low urinary chloride level and normal or high urinary chloride level. 7) Identify at least 7 causes of a metabolic acidosis with respiratory compensation with and without an anion gap. Reference: Haber, R.J. : A practical approach to acid-base disorders. West. J. Med 1991 Aug; 155:146-51. SIDS/ALTE 1) Describe the effects of the ‘Back to Sleep’ campaigns on the incidence of SIDS. 2) Delineate modifiable risk factors of SIDS. 3) Explain the relationship of apnea and SIDS. 4) Delineate recommendations for the prevention of SIDS. 5) Know the most common disorders causing ALTE. Reference: SIDS, ALTE, Apnea and the Use of Home Monitors, PIR, Vol. 23 No. 1, January 2002. Failure to Thrive 1) Plot growth data accurately. 2) Recognize normal and abnormal patterns of growth. 3) Describe the common bases for FTT and the approximate percentages of patients who have these etiologies. 4) Characterize the mainstay of intervention for FTT. 5) Describe the effect of FTT on future development, behavior and cognition. Reference: FTT: An Old Nemesis in the New Millennium, PIR, Vol 21, No. 8 Aug 2000. Pediatric Seizures 1) Define febrile seizures and differentiate between simple and complex febrile seizures. 2) List risk factors for each of the following: development of a fist febrile seizure, recurrence of febrile seizures, and risk of epilepsy in children who have had febrile seizures. 3) Discuss the etiology for febrile seizures in infants and young children.

48 4) Discuss whether the control of fever with antipyretics such as acetaminophen or ibuprofen has any effect on the prevention of febrile seizures. 5) Describe the appropriate medical management of a patient with status epilepticus. 6) Describe the typical presentation(including pre- and postictal presentations, any typical EEG findings, associated syndromes, and appropriate lab, physical evaluation) of simple partial seizures, partial complex seizures, benign Rolandic seizures, absence seizures, Juvenile Myoclonic Epilepsy, Infantile Spasms, and Lennox-Gastaut Syndrome. Reference: The Neurodiagnostic Evaluation of athe Child with a First Simple Febrile Seizure. AAP Practice Guideline. Fever 1) Define fever and describe noninfectious causes of temperature elevation in infants. 2) Define ‘fever without a source’, toxic, and ‘low-risk criteria’ and describe what this predicts for children who meet the criteria of theses phrases. 3) List at least five causes of serious bacterial infection. 4) Describe the appropriate management of febrile infants less than 28 days of age and explain why this management is appropriate. 5) Describe the appropriate management for low-risk infant 28-90 days of age and explain why this management is appropriate. 6) Define the incidence of children 3 to 36 months of age with fever without a source. 7) Delineate the risk of bacteremia in febrile children. 8) Describe the risks, benefits, and cost of both antibiotic treatment and not treatment for children 3 to 36 months of age with fever without a source. 9) Define the management guidelines for febrile children 1 to 90 days of age and 3 to 36 months of age. 10) Discuss the utility of the recommended diagnostic test recommended for febrile infants/children. 11) Define occult bacteremia and its significance in infants. Reference: The Febrile Child. Emergency Medicine Reports. Sept 1995. Antiobiotic Choices: The critical first hour. Pediatric Annals. June 1996. UTI 1) Know the AAP’s Clinical Practice Parameters for the diagnosis, treatment and evaluation of the initial UTI in febrile infants and young children. 2) List the primary factor that differentiates cystitis from pyelonephritis. 3) Determine the appropriate empiric antibiotic before culture sensitivity results are known and make necessary modifications in treatment when results become available. 4) Explain the circumstances when a child who has pyelonephritis should be admitted to the hospital. 5) Explain which patients need further workup such as imaging studies for workup of urinary tract anomalies. Sepsis/Meningitis 1) Be able to recognize the clinical signs of sepsis, and its effects on organ systems.

49 2) Know the clinical syndromes associated with sepsis in infants and children including primary bacteremia, toxic shock due to Group A Strep, secondary bacteremia, those secondary to operations/instrumentation, and sepsis syndrome. 3) Understand appropriate initial antibiotic therapy to treat suspected sepsis in the neonate, child and immunocompromised host. 4) Know the etiology of bacterial meningitis, and recognize the differences in the neonate and older child. 5) Know the management of a child with suspected meningitis, including surveillance of late complications and prophylaxis.

50 NICU A. GOALS AND OBJECTIVES In addition to those of the Level I Nursery Rotation, the following objectives shall be attained: 1. Acquire competence in evaluation, diagnosis and management of sick newborn infants of all gestational ages in the intensive care setting. This includes infants with RDS, congenital anomalies, infections, metabolic disease, genetic disease, anemia, polycythemia, hyperbilirubinemia, shock and neurologic dysfunction. 2. Acquire competence in conventional as well as high frequency jet ventilation, high frequency oscillation ventilation and nitric oxide use in newborn infants. 3. Acquire competence in interpretation of laboratory data of sick newborn infants. 4. Acquire competence in the performance of common neonatal procedures, i.e. endotracheal intubation (all gestational ages), umbilical artery and vein catheterization, suprapubic bladder tap, lumbar puncture, thoracentesis, chest tube placement, exchange transfusion, PIV placement, and peripheral artery puncture. 5. Acquire competence in the nutritional management of preterm and term infants, both enteral and parenteral, from the early newborn period through the later management of infants with chronic disease. 6. Acquire an appreciation of the family stresses which occur when a newborn requires intensive care, and develop competence in helping families deal effectively with those stresses. 7. Develop competence in keeping families and referring physicians informed of their infant's condition. 8. Develop competence in effective team discharge planning and pre-discharge teaching of parents. 9. Become competent in resuscitation of preterm and term infants. 10. Learn common radiographic findings in neonatal diseases.

51 B. NICU RESIDENT GUIDELINES The following is a collection of information which is intended to guide you through your months in the NICU. It has been accumulated over a number of years by a number of people. These are guidelines, not rules. We hope you will find these things helpful in providing a good learning experience for you, as well as providing quality care for our patients - our #1 goal. 1. Tips for NICU Survival! a. Daily schedule ~ Interns (not post-call) round on their babies between 6:30-7:30 a.m. (between 7:00 and 8:15 on weekends). Collect your data, such as 24~ ins and outs, weight, lab values, what has happened over night, any emesis or guaiac positive stools, feeding intolerance, apnea/bradycardia, ventilator changes, etc. and do physical exams. ~~Interns who are post-call should round on their babies between 6:00-7:00 a.m. (between 6:30 and 7:45 on weekends). Collect your data, such as 24~ ins and outs, weight, lab values, what has happened over night, any emesis or guaiac positive stools, feeding intolerance, apnea/bradycardia, ventilator changes, etc. and do physical exams. The post-call intern should be the first to do work rounds with the senior resident. The post-call intern should also update the other interns about any major changes on their patients that occurred overnight. ~ Work rounds with the senior resident between 7:15-8:00 a.m. daily and 7:45 and 9:00 on weekends. Together the senior resident and intern are expected to write basic orders such as labs, IV fluids, TPN, and make ventilator changes based on the a.m. CXR and blood gases, etc. Do not wait until attending rounds to make these ventilator changes!! If you are unsure what to do, ask the senior resident, neonatal fellow or attending. Make sure the nurse responsible for that patient knows about any STAT orders (i.e. ventilator changes or IV fluid changes). ~ The senior resident who is post-call is responsible for reviewing all a.m. X-rays and blood gases and making sure ET tube adjustments and ventilator changes are made prior to his/her departure from the NICU. In addition the post-call senior resident must check-out with the senior resident between 7:00 and 7:15 daily and 7:30 and 7:45 on weekends. They must discuss any significant changes that occurred with the patients and all new admissions. The post-call senior must confirm with the senior resident that all X-rays were reviewed and ventilator changes were made based on the morning blood gases. Make sure any abnormal lab results were addressed. ~~The fellow arrives at 0800 daily when he/she is on service. The senior resident will review all the new admissions and all of the ventilated/critically ill patients with the fellow at 0800 daily. A brief history and plan of care should be presented to the fellow for all new admissions. The senior must confirm with the fellow that all X-rays were reviewed and ventilator changes were made based on the morning blood gases. Make sure any abnormal lab results were addressed. ~ X-ray rounds occur at 9:00 a.m. on weekdays. ~ Attending rounds occur directly following x-ray rounds on weekdays and at 9:00 on weekends. Potentially attending rounds may start at 8:30 if no conferences or other events interfere with that time.

52 ~ After rounds the interns must finish writing their orders including TPN orders. The goal is to get all TPN orders written by noon ~ Once all orders are written, the interns are to write their daily progress notes on powerchart. ~ The post-call intern is to have all his/her work completed and be checked out to the intern on-call by 12:30 (1:00 on weekends). The post-call senior is to have all his/her work done and be checked out to the senior on-call, fellow, or attending by 1:00 (1:30 on weekends). ~ Check out rounds: 1. The non-post-call interns will check out to the intern on-call at 1600 daily and once all of their work is done on the weekends. 2. The NICU senior resident will check out to the intern and the senior resident on-call at 1630 daily and once all the work is done on the weekends. 3. During check out rounds, the on-call team must be told a brief summary of each patient’s history, any lab work that is pending, any complications that the infant may be a set up for, and anything that helped reverse these complications, etc. Handing the on-call team a list and leaving is unacceptable! In addition, you must visit each infant’s bedside during check out to review current ventilator settings and make any adjustments at that time! b. Physician's Orders and Laboratory Work ~ A copy of the preprinted standard admission orders and transition orders are attached. You will notice that there are a lot of blanks to fill out on these orders. This is to make you think about your particular patient and order what is appropriate for that patient. Routine orders are depicted in parentheses after the blanks. ~ Each patient will have his/her chart/order book at their bedside. Make sure you flag the chart and place it on the counter behind the infant’s bed to indicate a new order was written. Please notify the patient~s nurse of any STAT orders as they are written so that they can be performed promptly. ~ Routine lab workups are usually ordered at 0500 and 1600. Remember some patients need more frequent or less frequent labs. ~ New TPN is ordered each a.m., but that bag does not get hung until 1800-1900 hours. If you need to change the fluids sooner than 1800, then have the nurse add or dilute the current TPN. An example of the TPN order form and how to fill it out is included, along with a handout on TPN calculations. c. Daily Report Forms ~ These will be your "ectopic brains" for each baby and will be where you keep and record your daily data. An example is included at the end of this chapter. d. Handouts

53 ~ TPN calculations and fluid and electrolytes: (these handouts are very informative and you will use them over and over - Hold on to them! They are located at the end of this chapter). e. Blood Bank Requests ~ Consent all admissions < 28 weeks for transfusion. PRBC's stand for packed RBC's which has a Hct >65. Always order 5cc more than the calculated amount to give so you can account for IV tubing. We usually order 10cc/kg of blood for transfusion. We use O negative CMV negative blood that has been irradiated. This should be stated in the comment section on the request. ~ Parents may ask to donate their own blood. This is done at the Red Cross and takes 72 hours. Remember only fresh blood <5 days old is used in the NICU secondary to the risk of giving the patient a large potassium load with older blood. In addition, the more closely related a donor is to a recipient, the higher the risk of graft vs. host disease in the recipient. Finally, the donor must be CMV negative before the blood can be used in the neonate. There is a handout for blood transfusions for parents in the NICU. ~ Blood transfusion risks: Hepatitis B 1/66,000 - 1/200,000 Hepatitis C 1/121,000 HIV 1/563,000 - 1/825,000 f. Think Small!! ~ We're talking 1kg, not that average 70kg white male they talk about in medical school; for example, these babies may only get a total of 120 cc of fluid per day, not 2-3 liters! It is not 20 meq KCl/liter, but 2 meq KCl/100 cc, etc., etc. g. Nurses ~ NICU nursing care is very specialized. The staff experience level ranges from the new graduate level to 25 years. The nurses working in our NICU have various titles - Nursing assistants, LPN, RN, transport nurses, clinical nurse supervisors and masters prepared nurses. The NICU practices primary nursing as the basic framework for providing patient care. The bedside nurse is an integral part of the multidisciplinary team and has a wealth of information to share with you. They can assist you in understanding routines, finding equipment, supplies, etc. An additional resource is the nursing supervisor/charge nurse which is designated for every shift. There are approximately 60 nurses in our NICU and it may take a while to get to know them. As everyone becomes better acquainted you will see how effective working as a team can be! h. Case Managers: Judy Bildner, Clinical Nurse Specialist/Case Manager ~ Purpose: Continuity of care link across all disciplines for the patient from admission to discharge with the attention to cost and quality outcomes. ~ Case managers assist with: Collaborative problem-solving for clinical issues (patient care, PCVC placement, etc.), insurance coverage, potential back transfers, f/u care providers, discharge planning, parent needs, f/u appointments, home health arrangements, and durable medical equipment.

54 ~ Case managers will: round with the team Monday-Friday for X-ray and patient rounds, coordinate discharge planning, critical path development and tracking, follow all patients in the NICU and serve as a resource for other areas with neonates. ~ Case managers will be actively involved with you in the following: plan of care for the patients in the NICU, anticipated discharge date/needs, family concerns/conference requests, anticipated transfers/transports, insurance issues. 2. Days Off ~ Each intern and the senior resident will have 1 day off per week. It will not necessarily be on the weekend. ~ Only 1 intern will be allowed to have the day off per day. No golden weekends will be allowed during your NICU rotation! ~ When the intern is off, the other interns with the aid of the senior resident will cover the intern's patients. ~ When the senior is off (usually on the weekend) the NICU senior on-call will cover and do work rounds with the team. If it is during the week, the fellow and attending will cover. No golden weekends will be allowed during your NICU rotation! 3. Continuity Clinic ~ When an intern is at clinic, the other interns will cover his/her patients. However, it is the intern~s responsibility to get as much of the work done before he/she has to go to clinic including pre-round with the senior and write orders. Progress notes can be written when you return from clinic. ~ The senior resident will be limited to only 1 continuity clinic per week during his/her NICU rotation. 4. Check-Out Rounds 4. The non-post-call interns will check out to the intern on-call and senior at 1600 daily and once all of their work is done on the weekends. 5. The NICU senior resident will check out to the intern and the senior resident on-call at 1630 daily and once all the work is done on the weekends. 6. During check-out rounds, the on-call team must be told a brief summary of each patient’s history, any lab work that is pending, any complications that the infant may be a set up for, and anything that helped reverse these complications, etc. Handing the on-call team a list and leaving is unacceptable! In addition, you must visit each infant’s bedside during check-out to review current ventilator settings and make any adjustments at that time! 5. Check-In Rounds ~ The post-call intern should update the post call senior so he/she can update the senior coming on in the morning. The post-call intern should update the other interns about any major changes on their patients that occurred overnight when they arrive.

55 ~ The senior resident who is post-call is responsible for reviewing all a.m. X-rays and blood gases and making sure ET tube adjustments and ventilator changes are made prior to his/her departure from the NICU. In addition the post-call senior resident must check-out with the senior resident between 7:00 and 7:15 daily and 7:30 and 7:45 on weekends. They must discuss any significant changes that occurred with the patients and all new admissions. They must confirm with the senior resident that all X-rays were reviewed and ventilator changes were made based on the morning blood gases. Make sure any abnormal lab results were addressed. ~ The senior resident will review all the new admissions and all of the ventilated/critically ill patients with the fellow at 0800 daily. A brief history and plan of care should be presented to the fellow for all new admissions. The senior must confirm with the fellow that all X-rays were reviewed and ventilator changes were made based on the morning blood gases. 6. NICU CALL a. Intern ~~~ Each intern is on call every 4th night during his/her NICU rotation. If we have more than 4 interns due to the number of medical students on a given block, then the students will either double up or take call less frequently. The integrated residents will take call just like a pediatric intern (every 4th night with 1 day off per week). ~ Call starts at 7:00 a.m. daily (7:30 a.m. on weekends) ~ Check-out the other interns whenever they have completed all their work but no sooner than 1600 during the weekdays. The senior should be present to review the patients as well to prepare to check out with the senior on call. If a M-4 or no intern is on call, one Intern must stay in the NICU until 1700. ~ Fill out: * Admit orders * Powerchart procedure notes must be completed in the computer for all procedures done. ~ Help cross cover the patients of the intern who has the day off with the other interns/externs who are present ! Document in the chart any major events that occur. b. Senior ~~~ Each senior is on call 8 times during their month on service (4 weekdays and 4 weekend days). They are on call every 4th night except for an every 3rd night x 2. They get 1 day off per week. I. Weekday ! Call starts at 1630 for seniors who are not on service ! Call ends at 0730 ~ Come to the NICU at 1630 to check out with the Senior Resident/Fellow/Attending ~ Help the Senior Resident finish any work that needs to be done so that he/she can go home ~ Check out with the Resident in the WBN at 1700. Help him/her finish any work that must be done ~ Check-in with the senior resident at 0700

56 ! See above for check-out/in requirements II. Weekend/Holiday ! Call starts at 0730 for seniors who are not on service ! Call ends at 0800 ~ Check-in with the senior resident at 0730 ! See above for check-out/in requirements ! Help the post-call Senior Resident finish with any work needed to be done so that he/she can go home ! Check out with the Resident in the WBN as soon as rounds are done. Help him/her finish any work that must be done ! As per the schedule determine if the NICU team needs a Senior Resident to do work rounds. An oncoming moonlighter, NICU fellow, or the NICU Senior resident should relieve the post-call Senior as soon as possible. The assigned NICU Senior Resident’s post- call duty isn~t done until rounds, orders, and notes are finished. III. Moonlighter ! Call starts at 1700 on weekdays (0730 on weekends/holidays) ! Call ends at 0730 on weekdays (0800 on weekends/holidays) ! Hours worked: M-Th 14.5 hours, F 15 hours, Sat 24.5 hours, and Sun 24 hours. ! Come to the NICU at 1700 to check-out with the Fellow/Attending ! Help the Senior Resident finish any work that needs to be done so that he/she can go home ~ Check-out with the Resident in the WBN at 1700. Help him/her finish any work that must be done ~ Check-in with the senior resident at 0700 (0730 on weekends/holidays) ! See above for check-out/in requirements IV. Responsibilities ! Cover the NICU. Help the interns write orders and admit infants to the NICU. The senior writes the admit note in Powerchart. Help the intern with any procedures. ! Make sure the NICU check-out sheet is updated daily. This form has all the vital information about each infant in the NICU. It is helpful during rounds as well as at night to make sure information is transmitted accurately from resident to resident. You may have the interns update the form, but ultimately the senior is responsible to keep it up to date. ! If there is a fellow on service, make sure you keep the fellow updated about any changes with the patients and all new admissions. ! At 1600 meet with the interns to check out the patients to the intern on call. Make sure the interns reviewed all the afternoon labs and ventilated infants and make any changes prior to the interns departure. ~ For babies admitted to the WBN who are born before midnight, an admit note and orders must be done by the Senior NICU resident. For a baby born after midnight, the nursing staff will admit under standard orders and unless there are questions, the admission orders and paperwork can be done when the WBN team arrives the next morning. These orders should be taken care of promptly. ~ Attend all complicated deliveries (C/S, meconium, forceps, VBAC, etc.) with the intern and assist them in their resuscitation skills ~ Run all codes in the NICU and WBN

57 ~ Serve as Neonatal consultant for L&D when asked to talk to expectant parents when the Attending or Fellow are not present. Please report to them prior to going to see the patient ! You are expected to be near the nursery and available by pager at all times. ! There are times where triplets, quadruplets or other multiples are expected imminently. At these times, other senior residents/fellows/attendings may be made available to help with resuscitation, but the admission orders and paperwork are the responsibility of the assigned NICU Senior/Intern. ! Any major changes on the babies at night must have a note documenting the change in the chart. The intern should do this but it is the responsibility of the senior resident to make sure it is done. c. Fellow ~~~ Each fellow is on call every 4th night during his/her NICU rotation as well as during other clinical rotations. They get 1 day off per week. ~~~ The fellows have no call requirements during their research rotations. ~~~ In addition to the items outlined above under the senior resident call schedule/responsibilities, the fellow will also: ! Arrive to the NICU at 0800 and get report from the senior resident about all new admissions and any critically ill patients. Make sure all X-rays have been reviewed and ventilator changes were made based on a.m. blood gases. Make sure abnormal lab results were addressed. ~ Attend all complicated deliveries (C/S, meconium, forceps, VBAC, etc.) with the intern and senior residents and assist them in their resuscitation skills ~ Run all codes in the NICU and WBN ~ Serve as Neonatal consultant for L&D when asked to talk to expectant parents when the Attending is not present. Please report to them prior to going to see the patient ! You are expected to be near the nursery and available by pager at all times when you are on service. ! There are times where triplets, quadruplets or other multiples are expected imminently. At these times, other senior residents/fellows/attendings may be made available to help with resuscitation, but the admission orders and paperwork are the responsibility of the assigned NICU Senior/Intern. ! Any major changes on the babies at night must have a note documenting the change in the chart. The intern should do this but it is the responsibility of the senior resident/fellow on call to make sure it is done. C. Nursery Levels The following are suggested ~levels of care~ for newborns based on the care needs of the patient rather than any financial code, geographic location or charges incurred (i.e., room rates, professional fees). This schema is based on Guidelines for Perinatal Care, 2002 (pp 41-46). Level I: Well Baby Nursery Generally associated with full or near full-term, apparently normal newborns who have demonstrated successful adaptation to extra-uterine life

58 * no feeding problems • physiologically stable infant Level II: Low Birth Weight/Continuing Care Neonate Includes preterm infants that are approaching discharge or term/near-term infants whose care exceeds that of the routine well baby • gavage/po feedings • apnea monitoring • psycho-social, education support • IV antibiotics and heparin/saline lock • Peripheral central venous lines • limited physiologic instability requiring minimal intervention • stable chronic O2 (corrected age of 36 weeks and requiring oxygen by nasal cannula) Level III: Intermediate Infants admitted to intensive care but beyond the most critical/unstable stages of their illness and newborns requiring close monitoring/procedures but not unstable • O2 per nasal cannula or oxyhood (corrected age of 36 weeks and requiring oxygen by nasal cannula) * continuous IV fluids or TPN • q 12-24 or more frequent lab draws • IV medications • Peripheral central venous lines • mild to moderate physiologic instability but requiring infrequent interventions * frequent aprea & bradycardia • beginning gavage/PO feedings * frequent desaturation • pulse oximetry Level IV: Intensive Critically ill/unstable infants and very low birth weight infants requiring constant nursing care and monitoring • central lines • acute oxygen therapy • mechanical ventilation • NPCPAP/FlowPAP • complex procedures • continuous IV fluids, TPN • IV medications • moderate to severe physiologic instability requiring frequent interventions * frequent labs Level V * As per above, but extremely critical • Specialized ventilation: Jet, Oscillator, Nitric Oxide • Multiple drips • Requires 1:1 nursing D. Patient Care Routines

59 1. Admission a. Paperwork i. initial admission orders (level-specific pre-printed sheet available) ii. other orders iii. meconium drug screen survey form (see appendix to WBN) iv. admit note - by senior resident v. growth curve (see appendix to WBN) vi. Dubowitz form (see appendix to WBN) b. Must include routine orders and any change from routine orders (frequency of vital signs, feedings, glucose, Hct, specific gravity, guaiacs, abdominal girths, labs and patient condition). c. One hour after birth or on admission if the patient is a transport, the nurse will routinely do a blood glucose and Hct. d. If the baby's condition permits, please give the nurse time to perform basic assessment of the baby before you begin procedures. e. The nurse will pass an NG tube into both nares, give vitamin K and give Ilotycin Eye Ointment upon admission. Vitamin K is given IM unless otherwise ordered. 2. Discharge/Transfer Paperwork In addition to a discharge summary, the following three items must be completed before a patient is discharged or transferred to another institution. a. Discharge orders forms b. Write D/C patient in order book. When transferring a patient to another institution, a complete transfer/progress note outlining the patient~s treatment plan should be written prior to transfer. c. If transferring to another institution, be sure COBRA forms are completed. 3. Orders a. All of your infant's orders are kept in his/her chart at the bedside. b. After an order is written, make sure you flag it and place the chart on the counter behind the infant’s bed. a. Green flag = new order b. Red flag = STAT order c. Yellow flag = Verbal order needing to b co-signed. d. Blue flag = Unit clerk has order to transcrib

60 A nurse will then review the orders and sign them off. Only registered nurses can sign off and administer IV fluids and medications. Medical students must have their orders co-signed by a physician before they will be transcribed by the nurse/unit clerk. It is the medical students responsibility to review his/her orders with the resident and get them co-signed immediately. Orders that need cosignature are flagged yellow. *If you have an order that you would like done immediately, please tell the nurse as well as write the order. c. During a.m. rounds please notify the nurse of any "now" orders so they can be carried out promptly. d. Verbal orders can be given in emergency situations only by an MD (not med students) and only to an RN (not LPN, GN, or NA). Please limit the use of these - it is the physician's responsibility to make sure orders are written and signed. All verbal orders need to be signed, dated, and timed as soon as possible, ideally within 24 hours. e. Telephone orders must be given by an MD to an RN and signed by the MD as soon as he/she returns to the unit. f. Please coordinate time of lab work orders with the routine Hct and glucose or other lab work so that the baby will not be stuck unnecessarily. h. If an order is missed, do not squeeze it into a previous order but write a new one. The g. Orders must be correctly dated, timed and signed to be followed through. previous orders may have been already transcribed and this new order will be missed if it isn~t a separate order. i. Write AM labs & x-ray daily as needed. Rewrite IVF drips every 24 hours. 4. Vital Signs (heart rate, respiratory rate, axillary temperature, blood pressure). a. Heart rate and respiratory rate are recorded every hour with continuous cardiopulmonary monitoring on all NICU infants. b. Level 4 - BP and temp every 4 hrs. unless ordered more frequently. c. Level 3 - BP and temp every 4 hrs. d. Level 2 - Temp every 6-8 hrs. BP daily 5. Weights (in grams) All daily weights are done on night shift unless ordered more frequently. Please keep in mind that weights are stressful to many of our infants so their frequency should be determined by the baby's condition.

61 6. Feeds a. Whether to breast feed, bottle feed, or gavage feed is determined by gestational age, illness, and vigor of the infant. Most infants under 34 weeks gestation nipple poorly and have immature gag and swallowing reflexes and therefore should have gavage feeding only. We may try 1 PO feed per day starting at 32 weeks gestation if the baby is stable. b. Feeding orders need to include: i. type of formula (include kcal/fluid ounce) ii. route of feeding (p.o., n.g., g.t., o.g.) iii. frequency of feedings iv. amount of feeding v. any additives (e.g. breast milk fortifier) c. Feeding orders may be written to increase as tolerated to a specified upper limit. d. Aspirates of 25% of total feeding or greater before the next feeding will be reported to the doctor. e. Babies with respiratory rate consistently greater than 60 are gavage fed except with specific orders stating otherwise. f. Babies with a respiratory rate greater than 80 are orally or gavage fed only with doctor's order. Babies over 3000 grams should usually be on ad lib demand p.o. feedings at intervals not greater than every 5 hours. Some 2000 gram infants will go ad lib demand p.o. feedings not to exceed g. every 4 hours. 7. IV Fluid Orders a. All IV orders must be written every 24 hours even if the baby is to continue receiving the same fluid at the same rate. Remember that all additives (i.e. KCl, Ca Gluconate, Na Acetate, etc.) are ordered per 100 cc of IVF. b. IV tubing is routinely changed every 72 hours for clear fluids. TPN tubing is routinely changed every 24 hours. c. Please do not change the IV rate on the infusion pump without first writing an order and telling the baby's nurse immediately. d. If a central line is used, then add 0.5 units of heparin/cc of IVF~s. A platelet count should be drawn every Monday while the patient receives heparin. This can be ordered on the preprinted order sheets. e. Hyperalimentation and Intralipid orders are written on a special physician's order form and must be completed every morning by noon.

62 In addition, documentation that TPN and Lipids were ordered must appear on the doctor's order sheet also by writing: TPN and Lipids as ordered. TPN and Intralipids routinely arrive to the unit every evening around 1800 hours. If any changes are made with the TPN by phone with the Pharmacy, you must document the change on the order sheet. In addition, once the TPN form is faxed, then any change with the TPN must be called to the Pharmacy (499-9384). 8. Blood a. Blood volume is 80 –100 cc/kg b. Initial Hct is generally 45-65. c. Anemia: i. Hct < 30 in a newborn who is distressed generally requires a transfusion. ii. With numerous frequent lab studies, you may need to consider a blood transfusion when 10-15% of baby~s blood volume has been used. (We usually pick 10cc/kg as the cut off.) iii. We generally transfuse 10 cc/kg of PRBC~s over ~ 2-4 hours (Hct of transfused blood > 65). d. Polycythemia: i. If a warmed (5 min) heel stick hematocrit is greater than 70 then do a central venous hematocrit. ii. If the central venous hematocrit is greater than 70 and the child is symptomatic or less than 6 hours of age, a partial exchange transfusion with normal saline should be performed. iii. Causes: delayed clamping of cord, cord stripping, SGA babies, mother with toxemia, IDM. iv. Symptoms: respiratory distress, CHF, cyanosis, hypoglycemia, jaundice, renal vein thrombosis, seizures, lethargy, irritability. v. Volume for partial exchange in cc~s = Blood volume x weight x (observed Hct - desired Hct) observed Hct e. Administration of a Blood Transfusion i. All newborns will have a type and screen done on their cord blood sample when it is available. If not available, it can be done on 1 cc of blood. If the blood is drawn through a heparinized line, then label the sample ~heparinized.~ ii. To order a blood transfusion you must: (a) Obtain consent from the parents. (b) On the Blood order: * Specify volume of packed red blood cells (PRBC) needed, i.e., 10cc PRBC/Kg is to be transfused plus an additional 5cc for the tubing.

63 * Under comments specify that the blood must be CMV negative and O negative and that it be irradiated. (c) Write an order for 1) volume of blood to be transfused (10cc/kg); 2) over how much time to transfuse it. (d) Order a 4-hour post-transfusion Hct. (e) If the patient has only one IV site, then you may need to consider checking a D-stix halfway through the transfusion. (f) You may need to consider decreasing the IV fluid rate during the transfusion. iii. Occasionally we double transfuse the patients about 12 hours apart. In addition, write ~single donor~ in the comments so the patient is exposed to only 1 donor. E. Nursing Functions 1. Please do not schedule procedures or tests that require the assistance of nursing personnel during nursing report which occurs at 0700-0730 and 1900-1930. This is a very busy time for patient care personnel. The nurses will be better prepared and happy to help following report. 2. Each baby has a chart at his/her bedside that contains the nurses' cardex and medication record (occasionally flowsheets when paper charting is done), lab reports and all consults. Please do not remove these charts from the bedside without telling the baby's nurse. 3. The nurses are available to offer assistance and many have been working in the NICU for some time. 4. Most babies have a case manager, primary nurse and up to four associate nurses. This team is responsible for the planning and coordination of the baby's care and discharge plans, communication between services involved in the baby's care and the family, and direct provision of care when possible. These nurses are excellent resources about the baby and family and have input into the plan of care. The case manager is the neonatal clinical nurse specialist. F. Emergency Situations 1. A Code Blue is called in the NICU by activating the Code Blue lever at the baby~s bedside. The Senior Resident and the intern on call for the nursery will be paged on their personal pagers with a ~6180-911" message which represents a code situation and you should get to the nursery as fast as possible. The attending physician, the transport nurse and respiratory therapist will also be called. 2. We have 2 crash carts stocked with all the code medications and supplies in the NICU. G. Procedures 1. Starting IVs - We encourage every resident to learn how to start IV~s in neonates. The nurses will be more than happy to teach you the proper technique.

64 a. Limit yourself to 2 sticks; if not successful have someone else try. The long term babies have very few veins left to choose from. Saphenous and antecubital veins are off limits and are reserved for peripheral central venous catheters. b. After an IV is started, order heparin lock or saline lock with routine flushes. We usually use saline locks/flushes unless it is a central line. Chest Tubes/ Thoracentesis and Paracentesis Neonatal fellows get to attempt these procedures first when they are on service in the NICU. Once they have enough of these procedures that they feel confident in performing them, they will teach the residents how to perform these procedures. Intubation a. There are numerous people in the unit who need practice intubating. We have a staff of specially trained RNs and RTs that comprise our neonatal transport team. They all need experience. b. It will be the responsibility of the senior resident/fellow to decide who will intubate an infant. c. PL-1's or students are to have first attempt at intubation as long as the patient is stable enough to allow this. (Not during a code or during a delivery with meconium stained fluids unless the PL-1 or student has already been deemed proficient at intubating babies.) ~ PL-1's and students must become proficient in the technique of intubation on the mannequin before they can attempt intubating a patient. There is a mannequin located in the physician lounge in the NICU on which to practice. Have the senior resident or fellow show you the proper technique in intubation. In addition, all PL-1’s and students must be NRP certified before attempting to intubate a neonate. ~ At the being of each quarter during the first 2 weeks of the first 2 months (January, February, April, May, July, August, October and November), the transport team members should be allowed first attempt at intubation if they haven~t had their one successful intubation for the quarter. They are required to have one successful intubation per quarter to be allowed to serve on the team. ~ Intubation for meconium delivery should be performed by an experienced/proficient intubator. This is usually the senior resident, fellow, attending, or transport team. d. NRP certification is expected before active participation in resuscitation. Books are available at the resident coordinator~s desk. Interns will be instructed/certified in NRP during the orientation week. 3. Blood gases

65 a. Capillary blood gases (CBG) are drawn by a nurse who has been certified in using the proper technique, when ordered by a physician. O.2 cc blood is drawn from the warmed heel. Only the pH and PCO2 is accurate with this method. b. ABG's from UAC's are drawn by the nurse. The nurse will show you the correct procedure if you want to learn how to draw them yourself. c. Arterial Sticks: i. The radial artery should always be tried first. Brachial artery sticks are discouraged. Femoral artery sticks are never done. ii. RN's who have been tested and certified may do radial artery sticks. iii. If you have questions concerning the technique for drawing arterial blood gases in a premature infant, please ask the senior resident, fellow, attending physician or charge nurse. iv. Pressure must be applied to the puncture site for a minimum of five minutes after the stick to avoid formation of a hematoma. v. 0.2 cc of blood is needed for the RT to run an ABG. If less than 0.2cc is obtained RT may be able to run the sample, but the results will be affected by the heparin dilution. vi. We encourage all residents/felllows to learn how to do a radial arterial stick. Limit 1 stick per patient. The senior resident or nurse will show you the proper technique. H. Medications 1. When ordering medications, you must indicate the type, amount, route, and frequency. In addition include the infants weight on which the drug dose was calculated in the order. 2. Nurses are responsible for checking the appropriateness of medications and their dosage before they administer them. Occasionally a nurse may question a medication if she/he feels it is inappropriate. This is a double check system to guarantee the safety of the patient. 3. When a baby's IV is discontinued, please remember to change the IV meds to NG or PO with adjusted dosages. 4. Check medications on MAR daily to remain up-to-date on any changes. Count total antibiotic doses when considering total duration of therapy I. O2 and Ventilator Changes All O2 and ventilator changes must have a written order in the chart to be carried out. Do not make O2 or vent changes yourself. The nurse and respiratory therapist each have flow sheets where time and changes must be recorded. The nurse can do FiO2 changes by using a pulse oximeter to keep the saturation between the limits you order. The respiratory therapist does all ventilator changes. J. Safety

66 1. Good hand washing is essential. It is our best way of fighting nosocomial infection. Everyone must wash hands between infants. 2. Please remove all rings (except plain bands), watches and bracelets. 3. Observe universal precautions with all patients. You should wear gloves, masks, gowns, etc., when you may be contacting body fluids. 4. Use coat hooks provided for hanging lab coats. 5. Incubator doors are to remain closed whenever possible. Try to do your procedures through the port holes. This is for infectious disease control as well as maintenance of the thermal neutral environment for the baby. Close the portholes when you are through. 6. If you must raise the door, remember, when you close it to "lift" it inside the little ledge on the front of the incubator so that it cannot be pushed open by an active baby; all sides of an Ohio or Air Shields warmer must be up before you walk away from a baby even if it~s for "just a second". 7. Do not leave needles, razors or other equipment in the bed. Sharp disposal containers are available throughout the unit. It is the responsibility of the person doing the procedure to dispose of sharp equipment. 8. Each baby has his/her own stethoscope at his bedside. Please do not carry equipment from baby to baby. 9. Whenever a baby leaves the unit to go to x-ray, he/she must be taken in the warm transport incubator. Upon return to the unit, please notify the nurse so that the incubator can be cleaned and restocked. 10. If you note a potential hazard, please alert the nursing staff. K. Visiting Policies 1. Parents may visit at any time. Parents may bring whomever they like to visit the infant. Only 2 visitors are allowed at the bedside at any one time. No one may visit without one of the parents, including the grandparents except if prior arrangements have been made with the parents. We ask them to step out of the unit when a procedure is being performed and during attending rounds. 2. Siblings may visit infants with their parents at any time. The bedside nurse/unit clerk screens all children less than 13 years old for communicable diseases upon entering the unit including checking a temperature. If there are infectious illnesses prevalent in the community, a hold may be placed on sibling visitation. 3. Our unit has a toll-free number for parents only. Please do not give information about the baby's status to anyone other than the parents and referring physician. L. Transports from Other Hospitals

67 1. Contact the attending physician - only she/he can accept transports. The attending physician is responsible for maintaining contact with the transport team and giving orders to them. 2. Ascertain from the core nurse the status of the unit so that she/he may make necessary preparations for bed space. 3. If a transport is accepted, the charge nurse will notify the transport team. 4. The transport team is in-house doing patient care until they are dispatched. The transport nurse has a light patient load and is also a good resource person if you have questions or need assistance with procedures. M. Core Nurse 1. There is a core nurse (CS) assigned on every shift who is responsible for patient assignments, and coordination of unit activities. She/he is a valuable resource person who will be able to answer a lot of your questions about procedures, admission, policies, and patient assignments. 2. Please keep the CS aware of impending deliveries of high-risk infants. 3. Please keep the CS informed of changes in an infant's plan of care. 4. Any conflict with personnel should be attempted to be worked out on a 1:1 basis. If it cannot be, it should go through the supervisor, manager and then the attending physician. 5. Please inform the CS prior to informing the parents, of any changes in the time of discharge if it is different from what was discussed in the discharge planning meeting. N. Neonatal Clinical Nurse Specialist An integral part of the NICU, Judy Bildner~s role as a Clinical Nurse Specialist is an important part of the baby~s care. She case manages all high risk infants. She works with the multidisciplinary team to coordinate the infant~s care. She coordinates and manages the PCVC team. She directs discharge planning, participates in attending rounds, and assists in arranging return transports, home health, home apnea monitors, and follow-up appointments. She should be consulted with all breast feeding and PCVC issues. She will formally consult ophthalmology for all high-risk ophthalmology exams. She works very closely with the attendings, fellows, residents, medical students, nurses, and social services. She is an excellent resource and can be reached on pager # 499-8074. O. Social Workers The NICU has full-time social service coverage. The social workers assist with family coping, social evaluation, neonatal deaths, financial assistance, DFS, meconium drug reporting, and discharge planning. P. Discharge Planning We realize that we all have different responsibilities, but the primary objective for all of us is the delivery of optimum patient care through a multi-disciplinary team approach. Questions should be freely asked by any of us to assist our mutual learning and for us to better understand the plan of care for our patients. We hope that we can grow with you through our experiences in the NICU.

68 Discharge planning is a daily event, but it is done on a more formal basis on Mondays and Thursdays at 1330. At these times, all residents, the attending, social worker, clinical nurse specialist, and clinical supervisor get together to discuss the patients in the NICU. On Monday, all new patients and all patients thought to be within two weeks of discharge will be discussed. On Thursday, all patients are discussed. There is a special discharge planning form found in Powerchart under the form browser tab that contains the discharge planning information. As each patient is discussed, these forms are filled in by the clinical nurse specialist. In these times of managed care, it is important to get each patient out of the hospital as quickly and efficiently as possible. Everyone must work together to insure that optimal patient care is provided. In addition to discussing tests, procedures, consults, etc., that must be performed prior to a patient~s discharge, follow-up care is also discussed and documented on these forms. For example, is the patient eligible for First Steps Program? Does the patient need follow-up in High-Risk Clinic? What follow-up appointments does the patient need (i.e. cardiology, neurology, neurosurgery, audiology, ophthalmology, etc.)? Who will be the follow-up primary physician, etc.? Are there any social issues that must be addressed prior to discharge (i.e. what are the results of a meconium drug screen, if appropriately ordered)? Does the patient need a public health nurse or home health referral? Does the Department of Family Services need to be notified for a home visit prior to discharge, or do the parents need rooming-in experience prior to taking the baby home. Hence, when you are discharging a patient, make sure to look at these forms to insure that all follow-up appointments and/or tests have been arranged. The clinical nurse specialist will assist you in arranging this follow-up. Q. IMPORTANT MISCELLANEOUS 1. Babies are easily burned by the Betadine prep solution. Squeeze excess out of cotton balls before applying and be sure to wash area completely with alcohol before procedures. Do not leave baby lying on Betadine soaked bedding or diapers after the procedure. 2. Skin preparation is as follows: a. <26 weeks - use sterile water only <700g b. 27-32 weeks - use alcohol only 700-1500 c. >32 weeks - use Betadine and alcohol >1500 g (on the face, use skin prep only to avoid skin breakdown) 3. When restraining extremities, wrap the extremity first with a 2x2 gauze. Then tape over the 2x2 gauze. This will prevent the skin from being pulled off along with the tape. 4. Please call a baby's parents about any change in the baby's condition (e.g. reintubation, sepsis). They're worried and concerned and rely on you for this information. You are expected to routinely call your patients' parents to update them each night you are on call. Good PR is important! 5. Be sure you have a consent signed before starting a procedure. These include lumbar puncture, UAC placement and blood transfusion. An emergency is the only exception.

69 6. If necessary, consents may be obtained over the telephone but a second person (another Dr. or nurse) must be on another line to hear consent and sign as a witness). 7. No food or drink is allowed in the unit. There is a lounge, refrigerator, and microwave oven for your use in the break room. You may eat in the physician~s lounge or staff lounge. Avoid having food or drink near the computers. 8. Before doing a procedure on a baby, check with the baby's nurse to make sure she/he is not waiting for a blood gas to be drawn or for some other procedure. If you want to draw a blood gas, check to see if the baby has just eaten or been suctioned. This will affect your gas results and the baby could vomit and aspirate. 9. The nursing staff has made each infant's growth and development a priority in the planning and provision of nursing care. Please try to time procedures and other activities that disturb the infant, to provide time for sleep and recovery. Try, when possible, to group procedures and activities that are painful or disturbing to a limited number of times each day. Please be as flexible as possible when writing orders to allow the nurse caring for the baby to coordinate these activities. If you have questions about the baby's schedule or nursing care please speak with the primary or associate primary nurse. A copy of the nursing developmental protocol is available for your review if you so desire. 10. All babies in the NICU have a length and head circumference measured each Monday morning. Please make sure to plot these measurements plus the weight every Monday on the growth curve. Sometimes you will pick up a baby who is developing hydrocephalus this way. 11. The state of Missouri requires that a newborn metabolic screen be done on every newborn prior to discharge from a hospital. It is also preferable to do the test 72 hours after the baby is on full feeds. This, however, can be months after a micro-premee is born. Hence, we have a screen done at 1 week of age if the baby is NPO, then again when the baby is on full feeds, and again at the time of discharge or transfer to another hospital. Please get a screen prior to an infant’s first blood transfusion. In this case only 2 of the circles need to be filled with blood on the screen. This will give us accurate Hemoglobin and galactasemia studies which are interfered by a blood transfusion. 12. Antibiotics: a. Every baby has Ilotycin applied to its eyes when they are born in this institution. This has to be ordered upon admission to both the NICU and WBN. If the baby has fused eyelids at the time of birth, go ahead and order Ilotycin, the nurses will not apply it until the baby~s eyes begin to open. b. All other antibiotics in the NICU are given IV or IM. Commonly used antibiotics include: Ampicillin: Sepsis 50 mg/kg/dose; Meningitis 100 mg/kg/dose Post Menstrual age Postnatal Age Interval (weeks) (days) (hours)

70 < 29 0-28 every 12 hrs > 28 every 8 hrs 30-36 0-14 every 12 hrs > 14 every 8 hrs 37-44 0-7 every 12 hrs >7 every 8 hrs > 45 All every 6 hrs

71 ii. Cefotaxime: 50 mg/kg/dose Post Menstrual age Postnatal Age Interval (weeks) (days) (hours) < 29 0-28 every 12 hrs > 28 every 8 hrs 30-36 0-14 every 12 hrs > 14 every 8 hrs 37-44 0-7 every 12 hrs >7 every 8 hrs > 45 All every 6 hrs Gentamycin: Administer an initial dose of 4 mg/kg, then measure the serum concentration 12 hours post-infusion. Use this level to determine the appropriate dosing interval ( every 12, 24 or 36 hours) by plotting the result on the nomogram posted in the NICU. Repeat a level after the 3rd dose if > 5 days of treatment is anticipated. Trough Level: 0.5 –1 Time Zero Peak Level: 5-12 iv. Vancomycin: 15 mg/kg/dose Postnatal Age Weight < 7 days > 7 days <1kg every 24 hrs every 18 hrs 1-2 kg every 18 hrs every 12 hrs >2 kg every 12 hrs every 8 hrs Trough level: 5-10 Time zero peak level: 25-40, ideally 25-35

72 Dosing Interval Serum Level Draws Dose Adjustment Serum Level Draws Every 6-8 Trough prior to 5th dose < 3 change to every 6 hrs Trough in 7 days hours > 3 to < 5, increase to 19 mg/dose unless renal function 5-15, no change changes 15-20, change q 6 to q 12 or q8 to q24 > 20, draw level and see below Every 12 hours Trough prior to 5th dose < 3 change to every 8 hrs Trough in 7 days > 3 to < 5, increase to 19 mg/dose unless renal function 5-15, no change changes 15-20, change to every 24 hrs > 20, draw level and see below Every 18 hours Trough prior to 3rd dose < 5 change to every 12 hrs Trough in 7 days 5-15, no change unless renal function 15-20, change to every 24 hrs changes > 20, draw level and see below Every 24 hours Trough prior to 3rd dose < 5 change to every 18 hrs Trough in 7 days 5-15, no change unless renal function 15-20, change to every 36 hrs changes > 20, draw level and see below Every 36 hours Trough prior to 3rd dose < 5 change to every 24 hrs Trough in 7 days 5-15, no change unless renal function 15-20, change to every 48 hrs changes > 20, draw level and see below Note: If level > 20, obtain 2nd level in 24-48 hrs and use values to calculate pharmokinetics for further dosing. Note: If possible adjust troughs to 10-15 mcg/ml for Enterococcus infections, endocarditis, meningitis and osteomyelitis infections. v. Antibiotic levels: It is important to know the old way we used to follow drug levels for Gentamicin and Vancomycin because these drugs have toxic side effects. Drug Levels Antibiotic trough level peak level 3rd level Gentamicin 5 min pre 1 hour post ~ of interval Vancomycin 5 min pre 3 hours post ~ of interval Dosing Interval every 24 hrs every 18 hrs every 12 hrs trough level 5 min pre 2nd dose 5 min pre 2nd dose 5 min pre 3rd dose peak level with 1st dose with 2nd dose with 3rd dose 3rd level 12 hrs post 1st dose 9 hrs post 2nd dose 6 hrs post 3rd dose

73 Then 5 days after the onset of antibiotic course check another trough level (5 min pre). Once you obtain the drug levels, then use semi-log paper to plot them out to figure out the proper dose and interval for that patient. ! You plot the drug concentration along the logarithmic axis (Y axis) and time along the arithmetic axis (X axis) (see attached example). Remember that Gentamicin is infused over 30 minutes while vancomycin is infused over 60 minutes at least. Hence, you will have to see when the infusion was completed to find out how many hours post infusion a drug level was obtained. Plot the peak level and 3rd level. ! Use a straight edge to connect these 2 points and continue the line until it intersects the Y-axis. This point is the peak concentration at time zero. ! If the peak concentration isn~t in the desired range, then use the following formula to find what dose your patient needs: current dose new dose = peak concentration at time zero desired peak concentration at time zero ! Next, to figure out the interval between the drug doses, first find out the half-life (t~) of the drug. The half-life means the amount of time it takes for the concentration of the drug to decrease by 50%. To figure this out, pick two points on your graph at which the concentration of one point is exactly half of the other. Ideally try to pick two points between the two points you plotted. Then figure out how much time elapsed between these points by looking at the X-axis. This amount of time equals the half-life (t~). ! To figure out the interval you take interval = t~ X constant for Gentamicin the constant = 3 for Vancomycin the constant = 2 We always round the interval up to the next regular interval (i.e. every 6 hrs, every 8 hrs, every 12 hrs, every 18 hrs, every 24 hrs, every 36 hrs, every 48 hrs, etc.). For example, if you calculate the interval to be 9.5, change the interval to every 12 hours, not every 8 hours. NOTE!: We usually don~t increase the drug dose to >20% of the original dose. If you get some unusual drug levels, feel free to contact the Pharmacist or NICU attending for guidance. If you make a significant change, then reorder drug levels.

74 13. Apnea of prematurity This is a common finding in premature infants. We used to use theophylline PO or aminophylline IV but now we only use caffeine to control an infant’s apnea. Caffeine Citrate route IV or PO loading dose 20-40 mg/kg IV over 30 min or PO maintenance dose 24 hours after load 5-8mg/kg Q24 hrs 14. Calories 20% Lipids 2 kcal/cc IVF D12.5 0.425 kcal/cc D10 0.34 kcal/ cc D7.5 0.255 kcal/cc D5 0.17 kcal/cc D2.5 0.085 kcal/cc Formula 20 cal/ounce 0.67 kcal/cc 22cal .73 kcal/cc 24 cal/ounce 0.81 kcal/cc Breastmilk plain = 20 kcal/ounce milk fortifier = 24 kcal/ounce (i.e., 1 pkt of fortifier/25 cc of breast milk) Babies need 130-140 kcals/kg/day for active growth on average. BPD and SGA babies may need more, >140 kcal/kg/day. Neurologically impaired babies need 80-100 cal/kg/day. From TPN: gm amino acids/kg X 4.0 = protein kcals/kg gm dextrose / kg X 3.4 = dextrose kcals/kg gm fat/ kg X 10.0 = fat kcals/kg Average growth velocity in a stable preterm baby is 15 gm/kg/day. 15. Hyperbilirubinemia A very common condition in both the WBN and the NICU, especially in the first few days of life. Since the direct bilirubin level is a small component of the total bilirubin level, we normally just follow total bilirubin levels (Tbili). We always get a fractionated bilirubin level (Fbili) at first to make sure that the patient doesn~t have direct hyperbilirubinemia, in which case phototherapy would not be indicated. We occasionally see direct hyperbilirubinemia in babies who have been on prolonged TPN secondary to cholestasis because these patients are usually NPO as well.

75 A rough rule of thumb to follow when trying to decide when to start phototherapy or when an exchange transfusion is needed is: 10 X baby~s weight in kg - 2 = total bilirubin level at which to start phototherapy 10 X baby~s weight in kg = total bilirubin level at which to do an exchange transfusion These figures are reduced for infants with sepsis, hypoalbuminemia, hypoxia, hypoglycemia, Rh disease, ABO incompatibility, excessive bruising, etc. This rule works for any baby less than 2 kilograms in weight. For babies greater than 2 kilograms, we usually start phototherapy at a Tbili level of 15 and do an exchange transfusion at a Tbili level of 20. For an example, a 600 gm baby, one would have to start phototherapy when the Tbili level reached (10 X 0.6kg - 2=4) four, hence in the micro-premee~s many times, we automatically start phototherapy at birth. New studies have shown that some bilirubin helps prevent retinal damage from oxygen free radicals so we are allowing our infants to have slightly higher bilirubin levels before phototherapy is initiated. The point at which to do an exchange transfusion has remained the same but now in our smaller infants, we let the bilirubin rise to: 10 x baby’s weight in kg – 2 = total bilirubin level at which to start phototherapy. According to Harriet Lane the following tables can be used: Preterm infants (<36 weeks) who are < 1 week old Weight (grams) Phototherapy Exchange Transfusion 500-1000 5-7 12-15 1000-1500 7-10 15-18 1500-2500 10-15 18-20 > 2500 > 15 > 20 Term infants Age Consider Phototherapy Phototherapy Exchange Transfusion If Exchange Transfusion And (hrs) Intensive Phototherapy Fails Intensive Phototherapy 25-48 > 12 > 15 > 20 > 25 49-72 > 15 > 18 > 25 > 30 > 72 > 17 > 20 > 25 > 30 Head Ultrasounds: a. Routine screening for IVH should be done at 5-7 days of life in all infants less than 32 weeks 16. gestation. Occasionally we will get a head ultrasound within the first 24 hours of age to document any in-utero or perinatal hemorrhage. b. Head ultrasounds should be considered in sick infants between 32 and 35 weeks gestation: i. Significant perinatal depression (low APGAR~S) ii. Significant trauma at delivery iii. Hypotension requiring rapid volume expansion

76 iv. Persistent pulmonary hypertension, particularly if ECMO is being considered v. Bleeding disorders c. Ultrasounds demonstrating hemorrhage should be repeated every 1-2 weeks, as indicated. If an infant develops a grade 3 or 4 IVH, then the HC should be followed daily to look for signs of hydrocephalus. d. All infants at risk should have exams repeated at about 28 days of age to look for evidence of periventricular leukomalacia. 17. Ophthalmology Consults: a. All infants less than 32 weeks gestation or less than 1500 gm, and b. All infants between 32-36 weeks gestation or 1500-2000 gms who required oxygen for longer than 24 hours, will need an eye exam. c. Exams will be done between 4-6 weeks of age. A consult is generated about 1 week prior to the date needed. This usually is handled by the clinical nurse specialist and is discussed during discharge planning. d. Eligible infants discharged prior to 6 weeks of age will be scheduled as outpatients. e. Infants with evidence of congenital infection: toxoplasmosis, rubella, CMV, herpes, syphilis, need an ophthalmology consult immediately after birth, if stable. 18. Audiology Consults: a. Infants with the following risk factors have a higher risk of hearing loss: i. All infants less than 1500 grams at birth ii. Family history of hearing loss iii. Infants with other head or neck anomalies iv. Infants with syndromes in which hearing loss is a component v. Infants with evidence of congenital infection: toxoplasmosis, rubella, CMV, herpes, syphilis. vi. Hyperbilirubinemia approaching exchange levels vii. Bacterial meningitis viii. All infants transferred from the NICU. ix. Infants requiring potentially ototoxic drugs for more than 5 days; gentamicin, vancomycin, kanamycin, tobramycin, furosemide. b. By State mandate all the babies in the NICU and WBN are now required to have a hearing screen performed prior to discharge and a form stating the results is sent to the state. In the NICU this is done when they are stable, usually near the time of discharge. This cannot be done prior to 34 weeks gestational age due to a question about the accuracy of the screening tool.

77 c. If an infant fails to pass his/her audiology screen, he/she will have a screen repeated as an outpatient. The clinical nurse specialist will help you arrange this follow up with audiology. Please include this date on the discharge or transfer orders. 19. Immunizations a. Immune response is most closely related to chronological age. b. Therefore, the usual doses of DPT, IPV, Prevnar, Hepatitis B, and H. Flu should be administered on the standard schedules. c. We only give inactivated polio vaccine in the NICU. Live virus vaccine is no longer recommended for children in the US and it should never be administered in the nursery. Remember, the oral polio vaccine is secreted in the stool for 3 months following a dose and we don~t want one of the micro-premee~s in the NICU coming down with polio. d. Be kind! Please order Tylenol, 10-15 mg/kg/dose, every 4-6 hours for 24 hours, the first dose to be given just prior to the immunizations. While there is little objective data that it helps, it doesn~t hurt. e. Delay vaccine administration only in infants less than 2000 grams at 2 months of age. Remember to give it to them once they are >2000 grams. This criteria is due to the fact that there are no studies that the Hepatitis B vaccine is effective in infants less than 2000 grams. If you have to give the Hepatitis B vaccine at birth to an infant whose mom is HepBsAg positive or unknown and he/she is less than 2000 grams, it doesn’t count as one of his 3 required Hepatitis B vaccines. 20. ET Tube Guide Size Weight Gestational Age Insertional Distance 2.5 < 1000 grams < 28 weeks 7 cm 3.0 1000-2000 grams 28-34 weeks 8 cm 3.5 2000-3000 grams 34-38 weeks 9 cm 4.0 > 3500 grams >38 weeks 10 cm

78 21. Code Meds Epinephrine Atropine Bicarbonat Narcan Weight 1:10,000 0.1 mg/cc e 0.4 mg/cc 0.5mEq/cc Dose 0.01 0.01-0.03 2mEq/kg 0.1mg/kg mg/kg/dose mg/kg/dose 0.1 (1 cc ml/kg/dose to minimum) 0.3 ml/kg/dose 500 grams 0.05 cc-0.15 1 cc 2cc 0.13 cc cc 750 grams 0.07 cc-0.21 1 cc 3 cc 0.19 cc cc 1000 grams 0.1 cc-0.3 cc 1 cc 4 cc 0.25 cc 1500 grams 0.15 cc-0.45 1 cc 6 cc 0.38 cc cc 2000 grams 0.2 cc-0.6 cc 1 cc 8 cc 0.50 cc 2500 grams 0.25 cc-0.75 1 cc 10 cc 0.63 cc cc 3000 grams 0.3 cc-0.9 cc 1 cc 12 cc 0.75 cc 3500 grams 0.35 cc-1.05 1 cc 14 cc 0.88 cc cc 4000 grams 0.40 cc-1.2 1-1.2 cc 16 cc 1 cc cc 22. Neonatal Pain Assessment Tool: Two neonatal researchers at the University of Missouri-Columbia developed an objective scale by which to assess a neonate~s pain. The scale is called ~Cries.~ Cries stands for: C = Crying R = Requires oxygen to keep saturation >95 I = Increased vital signs E = Expression S = Sleepless Each of these areas is scored as 0, 1 or 2 according to the following table and the total score is calculated. If the score is 4 or greater then the patient is considered to be in pain. Currently all post-op patients have the cries scale performed on them usually for 24 hours, but the time is variable depending on the type of surgery.

79 This tool is often used in non-post op patients when pain is suspected. 0 1 2 Crying No High Pitched Inconsolable Requires O2 for No <30% >30% Sat > 95 Increased Vital HR and BP = or < HR or BP ~ < 20% of HR or BP ~ > 20% Signs Pre-Op Pre-Op of Pre-Op Expression None Grimace Grimace/Grunt Sleepless No Wakes at Frequent Constantly Awake Intervals R. TPN Calculation and Monitoring 1. How will the TPN be delivered - via a central line or a peripheral line? 2. Multiply the patient~s weight by the number of ml/kg/day desired from all fluids. This equals the total fluid volume/day. 3. Calculate the total volume of fluids obtained from NG or PO feeds and other IV fluids or IV meds, etc. 4. Next calculate how much 20% lipids to give the patient. ~ We usually don~t start the patient on lipids on the first day. It is usually started 1-2 days after the TPN is started unless the patient has respiratory distress, thrombocytopenia, or hyperbilirubinemia in which case lipids may be contraindicated if the condition is severe. ! Start with 0.5 g/kg/day and increase by 0.5 g/kg/day up to 3.5 g/kg/day if tolerated. ! Order a triglyceride level daily (desired level to be <150-200) while adjusting the dose. ! Once gastric feeds start being tolerated, remember to start cutting back on the lipids. Once you get up to 2/3 of the total feeds then discontinue the lipids. ! Once you decide how many grams of lipids/kg/day to give, multiply it by the patient~s weight in kilograms and divide by 0.2. This equals the total volume/day of lipids to be infused. ! Lipids are infused over about 20 hours allowing at least 4 hours with no lipids infusing for the liver to metabolize what it has received during the day. Hence, divide the total volume of lipids by 20 to get the infusion rate (ml/hr). ! NOTE: Administration rate for lipids should not exceed 0.15 gm/kg/hr. ! NOTE: To meet essential fatty acid requirements, a patient needs 0.5 gm of lipids/kg/day as a minimum.

80 5. Next calculate how much TPN to give the patient. Take the total fluid volume calculated on line 2 and subtract the total volume from lines 3 and 4. What is left is the total volume of TPN to be infused in 24 hours. This is divided over 24 hours to get the infusion rate (ml/hr). ! Next mark the desired dextrose concentration. Remember a peripheral IV can only withstand dextrose of less than or equal to 12.5%. Higher dextrose concentrations are too caustic on the peripheral vein. ! Next mark which amino acid solution is desired. Travasol is an ~adult~ formulation and is rarely used in infants >2.0 kg and in normal acid/base balance. Trophamine/Cysteine is an ~infant~ formulation (~5 times more expensive than Travasol) used in infants <2.0 kg and/or with persistent acidosis. Currently we only use Troplamine/Cysteine in the NICU no matter what size the infant is. ! We also start with 0.5 g of amino acid/kg/day and increase it by 0.5 g/kg/day up to 3.5g/ kg/day if tolerated. ! Babies should be on a minimum of 2.0 grams of amino acids/kg by two weeks of age. ! We monitor for acidosis and check the BUN to tell if the patient is tolerating the amino acids. ! Remember to start cutting the amino acid concentration back once the gastric feeds start being tolerated. Once you get up to 80% of total feeds, then discontinue the TPN. ! It takes a certain volume to dissolve the amino acids, so you may get a phone call from the pharmacy stating that for what volume of TPN you plan to give only a certain amount of amino acids will fit. Please make sure to document this change on the order sheet. 6. Electrolytes are usually given as full strength lytes which equals 1/4 NS with 2 mEqKCl per 100 cc. ~ If you desire full strength lytes, then write FSL next to #6. If you need to limit the Na or K, then write FSL except for ~ strength, 1/4 strength, or No Na etc. ! For calcium, the maximum amount is already added depending on the amino acid concentration so you can~t add any more to the TPN or it will precipitate. 7. Mark any additional electrolytes you may desire. Sodium acetate is the most common electrolyte added. It is added to correct acidosis caused by bicarb being lost through immature kidneys. You should notice an elevated urine pH on the dipsticks. 8. Other additives: ! If the infant is on steroids, or appears to be under a lot of stress (all our babies in the NICU), then famotidine should be started. We use 0.5mg/kg/day, usually. ! Heparin is ordered for any patient with a central line, unless a bleeding diathesis is noted. It is ordered as 0.5 units/ml of fluid. 9. TPN Monitoring. ~ Questions often arise regarding the appropriate laboratory studies to be monitored while an infant is receiving hyperalimentation.

81 ~ Prior to beginning, check a BMP (6/60 with creatinine and calcium), and HPD (unless recently done) ~ 48 hours after initiation, check a BMP (6/60 with creatinine and calcium). ~ While a patient is on TPN, one should check Na and K daily and any other electrolytes that are being supplemented in the TPN until stabilized and then every 2-3 days as discussed with the attending. If the lipid concentration was changed then a triglyceride level should also be ordered daily until you get up to the maximum dose. ~ Once a stable solution is reached, the following should be monitored once a week, usually on Mondays: 6/60 with creatinine, calcium, triglycerides (if on lipids), LFT (Alb, AST, ALT, Alk. Phos, LDH, TBili). Occasionally one should order a fractionated bilirubin to look for an increase in the direct bilirubin which is seen in cholestatic jaundice secondary to prolonged TPN use. 10. TPN Complications. ~ TPN can cause a chemical burn. Skin damage may be by warm soaks infiltrates reduced and elevation of the infiltration site. ~ Liver - progressive cholestasis with direct portal tract fibrosis, damage and infiltration occur with prolonged amino acid administration. Liver function usually returns to normal 1-4 months after of TPN. discontinuation ~ TPN provides no gut stimulation. for bone mineralization. ~ TPN provide adequate Ca and cannot S. Neonatal Fluids and Electrolytes 1. Maintenance a. Definition: total body fluid in balance. b. Total Body I. Components a. b. II. Composition Fluid Requirement: Intracellular Extracellular Na+ 20 mEq/L 145 mEq/L K+ 150 mEq/L 3-5 mEq/L

82 Cl---------------------------------------------------------------------110 mEq/L HCO3 - 10 mEq/L 20-25 mEq/L PO4 - 110-115 mEq/L 5 mEq/L Protein 75 mEq/L 10 mEq/L NOTE: Dehydration for <3 days: 80% ECF and 20% ICF losses. Dehydration for >3 days: 60% ECF and 40% ICF losses. III. Distribution DISTRIBUTIONS OF TOTAL BODY WATER AS PERCENT OF BODY WEIGHT*__________ Weeks Total Body Gestation______Water,%_______ECW,%______ICW,% 24 86 60 26 28 84 57 26 30 83 55 28 32 82 53 29 34 81 51 30 36 80 49 31 TERM__________78_________45____________33 *ECW indicates extracellular water, ICW = intracellular water. (Adapted from Friis-Hansen B.) Amer. J Clin. Nutr. 1972;25:1153. 2. Neonatal Diuresis After birth, total body water falls primarily due to a contraction of the extracellular water. It is felt to be secondary to an improvement in the newborn~s renal function which normally occurs after birth. This weight loss typically occurs over the first 5 to 7 days of life, but in respiratory distress, this may be delayed. The approximate expected weight loss is dependent on the infant~s gestational age.

83 WEIGHT LOSS AS A PERCENT OF BODY WEIGHT (BW) Gestation Weight Loss (WK) AS % OF B W 26 15-20 30 10-15 34 8-10 Term 5-10 3. Types of Body Fluid Loss: a) Insensible losses - normally 40-50 ml/kg/day i. Respiratory tract losses (humidification of exhaled air) 30% ii. Skin losses (evaporation through the skin and not sweat) 65% iii. Feces 5% b) Sensible losses - includes urine, emesis, diarrhea, drains (i.e., chest tubes, surgical drains) and sweat. 4. Insensible Losses: For example, the gestational age of an infant at birth will affect its insensible losses. The more premature an infant, the thinner its skin will be. This will lead to an increase in the evaporative loss of fluid through the skin. In addition, the smaller premature infant has an increased body surface area allowing for more area from which the fluid to evaporate. One can try to prevent some of this insensible loss by placing saran wrap on the infant~s skin to act as a barrier to evaporation. In addition, one can place the infant in a humidified environment like in an incubator whereby the humidity also helps prevent some of the evaporation of body fluids. It is also important to place the infant in a thermoneutral environment. If an infant is cold, it increases its metabolic rate to produce heat. This causes increased caloric utilization which in turn requires increased fluid intake. However, if one places an infant in an environment that is too hot, the infant increases fluid evaporation to bring its temperature down whereby increasing insensible water losses. This is also the case if the infant is running a fever. Hence, it is important to closely monitor an infant~s temperature and the temperature of its environment. One would think that by placing an infant under a radiant warmer, it may help to prevent some insensible fluid loss by controlling its body temperature, but in fact it causes an increase in insensible losses by as much as 50%. This is felt to be secondary to increased skin blood flow or a decrease in the humidity of the air under the radiant warmer both of which lead to increased water evaporation through the skin. Phototherapy also increases insensible water losses by 50% by similar mechanisms. Respiratory fluid losses are increased when minute volume is increased. This is seen in patients with respiratory distress from Hyaline membrane disease or pneumonia because they have tachypnea which increases their minute volume. By using humidified oxygen in an oxygen hood, nasal cannula, or ventilator to treat these patients, one can effectively decrease their fluid losses.

84 In fact if the patient is on a ventilator which uses humidified oxygen, the infant may have a net fluid gain through its respiratory tract. So you may need to adjust your fluid accordingly. 5. Initial Fluid and Electrolyte Therapy in a Newborn. a) Fluid Requirement In our NICU, we usually start off at 80 cc/kg/day. b) Electrolyte requirements: Na 2-5 mEq/kg/day K 1-2 mEq/kg/day Cl 2-3 mEq/kg/day Note: Do not give K to a patient until urine output is noted. We also need to supply the infant with some glucose. A newborn usually needs 6 mg/kg/min of glucose to maintain a normal blood glucose level (40-120). This can be met by using D10 with the IV fluids. However, in the smaller preterm infants, since they require a higher IV fluid rate, you may need to use D5 or the baby may develop hyperglycemia. In addition, we need to give the infant some sodium and potassium. Usually during the first 48 hours of life, the infant is going through a diuresis phase in which the extracellular fluid volume is contracting as we discussed earlier. Hence, the infant is losing more fluid than electrolytes and so doesn~t require supplementation. But by 48 hours one will need to start adding electrolytes. The sodium requirement is 2-5 mEq/kg/day. The potassium requirement is 1-2 mEq/kg/day. By using 1/4 NS with 2 mEq KCl per 100 cc as your IV fluids you can attain these requirements. Hence, one would use D5 or D10W for the initial fluids in a micro-premee, and then later change the infant to D5 or D10 1/4NS. In regular premees, you may go ahead and start with D5 or D10 1/4NS. You may or may not need to add the potassium depending on what the patient~s potassium level is at the time. Remember never give potassium to a patient who is not urinating. 6. Monitoring Fluid and Electrolyte Therapy a) Body weight b) Blood Chemistries i. Glucose 50-130 mg/dl (40-130 mg/dl in first 24 hrs) ii. Sodium 135-145 mEq/l iii. Potassium 3.5 - 6 mEq/l c) Urine i. Output 1-2 cc/kg/hr ii. Specific Gravity 1.003-1.015 d) Vital Signs i. Heart Rate ii. Blood Pressure iii. Peripheral pulses iv. Capillary refill Once you start the patient on IV fluids, the most important thing to remember is to continually monitor the patient so that you can quickly make changes in your IV fluids as indicated.

85 The patient~s weight needs to be checked at least once a day but in very small preterm infants 2-3 times a day. If the weight starts to fall, it may indicate that you need to increase your IV fluid intake. On the other hand, if it is rising more than is expected for normal growth, then one should decrease the IV fluid intake. Infants who are small for gestational age, have low birth weight, or are infants of diabetic mothers run a risk for hypoglycemia. D-sticks must be checked soon after birth and frequently until the glucose stabilizes. If a patient is hypoglycemic, you can give the patient a 2 cc/kg bolus of D10W over 2-3 minutes. The highest concentration of glucose that can be infused through a peripheral line is 12.5%. If higher concentrations are needed, one must use a central line like a UAC or PCVC. Sodium and potassium levels need to be checked frequently especially in the very small preterm infant. The sodium level will increase as the infant loses extracellular water and decrease as the infant becomes fluid overloaded, that is as long as the renal function in normal. Remember not to give potassium until the patient develops good urine output. Hyperkalemia is the most common life- threatening electrolyte disturbance in newborn infants. If an infant develops a cardiac arrhythmia secondary to hyperkalemia, then one can use calcium, sodium bicarbonate, Kayexalate, and insulin with glucose to bring the potassium down. The urine specific gravity may be used to evaluate an infant~s fluid status. As a patient becomes dehydrated, the specific gravity will increase as long as the kidneys are working properly. However, it may be falsely elevated in an infant who is spilling glucose, protein, or blood in his urine or in an infant who received intravenous contrast for a radiologic study. Do not assume that the patient is hypovolemic because of an elevated specific gravity. If an infant shows signs of hypovolemia (tachycardia, prolonged capillary refill, diminished or absent peripheral pulses, decreased urine output) then give the patient a 10 cc/kg bolus of NS over 5-10 minutes. This may be repeated every 5-10 minutes until the signs of hypovolemia correct. (The first bolus may be D5NS but do not give more glucose until the glucose level is known.

86 Well Baby Nursery/Newborn Care (required) Goals and Objectives: PGY 1 1. Become familiar with routine neonate assessment and resuscitation 2. Perform maternal education of routine newborn care, such as: infant care seats, nutrition/breast feeding, and normal newborn growth and development 3. Identification of common anomalies, birth defects, and syndromes, including counseling to parents 4. Understand the pathophysiology and treatment strategies behind common newborn conditions, such as: hyperbilirubinemia, hypoglycemia, poor feeding, apnea, erythema toxicum, milia, acrocyanosis, etc. PGY 3 (elective rotation) The resident should be able to perform the above objectives, as well as the following: 1. Perform and teach routine neonatal circumcision 2. Understand the significance of adequate maternal history especially concerning blood type, substance abuse, prenatal care, past birth history, family history, sexually transmitted diseases 3. Routine newborn screening and appropriate follow-up of infants with positive test results Course Description: The resident physician in pediatrics will rotate in the Well Baby Nursery (WBN) at least as an intern and other experience is optional during their training. Medicine/Pediatric residents rotate thru the WBN for 4 weeks only and may be as an intern or as a senior level resident. As a PGY 1, the intern will become familiar with the nursery as well as attending routine deliveries and C-sections. In addition, all pediatric residents are expected to instruct and supervised students and rotating residents. All activities in the WBN are supervised by Kara Stewart, MD. As a PGY 2 or PGY 3 residents will continue their training and improve their skills in newborn exam, resuscitation and parent education. Seniors rotating in the WBN may be assigned to NICU call in the call schedule. In the evenings the WBN residents will checkout to the Senior Resident on call for the NICU. The Senior Resident for the NICU will admit any infant born before midnight including completion of all necessary paperwork and orders. Infants delivered after midnight will be checked into the nursery by the nursing staff and unless there are questions or concerns regarding the infant the NICU resident is not required to admit these infants. Occasionally, particularly Sunday mornings, the WBN will be covered and supervised by the NICU attendings, Dr. John Pardalos, Dr. Laura Hillman, Dr. Tony Clark, and Dr. Elizabeth James. Residents rotating from other institutions or departments are expected to perform in the capacity of a pediatric resident when assigned to the WBN. These residents will be supervised and evaluated by Dr. Stewart. References: Tausch WH, Ballard R, Avery ME, editors: Shaefer and Avery - Diseases of the Newborn, 6th edition. Philadelphia: WB Saunders, 1991. Oski FA, DeAngelis CD, Feigin RD, et al, editors: Principles and Practice of Pediatrics, 2nd edition. Philadelphia: J. B. Lipincott, 1994. Rudolph AM, Hoffman JIE, Rudolph CD, editors. Rudolph~s Pediatrics, 20th edition. Stamford, Connecticut: Appleton and Lange, 1996. Behrman RE, Kliegman RM, Arvin AM, editors: Nelson~s Textbook of Pediatrics, 15th edition. Philadelphia: WB Saunders, 1996.

87 Cloherty JP, Stark AR, editors: Manual of Neonatal Care, 3rd edition. Boston: Little, Brown and Company, 1991. Bland HE: Jaundice in the healthy term neonate: when is treatment indicated? Curr Probl Pediatr 1996; 26: 355-36

88 WELL BABY NURSERY A. Resident Responsibilities While in the well baby nursery, the residents have four responsibilities: 1. Take care of the newborns (this includes the dreaded paperwork!). Don't let the name of the nursery fool you. Some of the sickest babies (hypoplastic L heart, Group B strep sepsis) start out in the Well Baby Nursery before becoming symptomatic. You must carefully evaluate all babies, picking up on the problem babies early on. 2. Talk to the mothers! Every mother, experienced or new, wants to talk to her baby's doctor. Give them plenty of time for questions. This is the time for you to learn about educating mothers. First, you must educate yourself. Talk to the attendings, nurses, and fellow residents about breast feeding, bathing babies, cord care, sleep habits of babies, etc. so that you can then educate the mothers. 3. Attend all C-sections and stat calls from Labor and Delivery. You must keep the on-call board in the WBN up to date. If you go to clinic or are absent for whatever reason, it is your duty to identify the resident covering stat calls, notify that resident, and put his/her name on the board. At checkout, before leaving, the resident should put the name of the resident covering L&D stat calls on the on-call board in the WBN. 4. Make sure every baby who leaves the hospital has a primary physician. Any unattached baby should become your Continuity Clinic patient or be assigned to the clinic of another Green Meadows resident or attending. When families have already identified a family practitioner or pediatrician from other clinics you should assist them in arranging the appropriate follow up. In carrying out these responsibilities, you will meet the following educational goals. B. Educational Goals and Objectives of the Level I Nursery 1. Demonstrate competence in the routine physical age assessment (Dubowitz score) of newborn infants. 2. Demonstrate competent application of neonatal resuscitative procedures. 3. Evaluate and manage common neonatal health problems (e.g., hyperbilirubinemia, hypoglycemia). 4. Identify and refer infants requiring intensive care to the NICU. 5. Counsel parents regarding routine infant care.

89 6. Demonstrate a competent knowledge of breast-feeding and the utilization of this knowledge to facilitate the initial stages of breast-feeding. 7. Assess initial maternal-infant bonding. 8. Assess psychosocial concerns arising during the nursery course. 9. Utilize the services of allied health disciplines (i.e., social services, public health nursing). 10. Train medical students to perform a routine neonatal assessment. 11. Become proficient in performing and caring for circumcisions. C. Daily Events 1. Work rounds begin at 0730. Medical Students should be ready to present their patients to the resident at this time. Order in which patients should be seen (All patients belong to Peds except for Family Practice patients and nurse midwife patients). a. all sick newborns b. all newborns born in the previous 24 hours c. newborns to be discharged that day d. any other newborn in the Well Baby Nursery 2. Obtain consent and do circumcision on male infants in the WBN. (Family Practice doctors do their own circumcisions and certain OB attendings do their own circumcisions on their private patients. The nurses can tell you which newborns need to be circumcised). Write a procedure note in chart. All circumcisions must be done in the presence of the attending for billing purposes. Remember to talk to mom about the use of EMLA when obtaining consent and include it on the consent form if mom agrees to its use. 3. Paperwork is to be filled out by the intern: medical students can assist as directed by the attending. a. Admission (see attachments) 1. Admission orders 2. Admission note 3. Growth curve 4. Dubowitz sheet 5 Meconium drug screen survey b. Discharge (see attachments) 1. Discharge summary 2. Discharge orders 4. In addition it is the resident~s responsibility to fill out the face sheet prior to the baby~s discharge. Remember NO abbreviations are allowed on the face sheet.

90 5. Each mother should be visited each and every morning. The resident should talk about feeding plans, circumcision, follow-up pediatricians, newborn metabolic screen, and any maternal (or paternal) questions or concerns. This is a very important part of your job. (We no longer routinely give hepatitis B vaccine to newborns at this hospital.) 6. Attending rounds will be daily at 8:00 a.m. and on weekends will be arranged with Dr. Stewart or the attending in the NICU on that weekend. Discussions on various common pathophysiologic states of the newborn will be included during attending rounds. 7. During the day, the resident in the WBN will go to all C-sections and all complicated vaginal deliveries (meconium, forceps, shoulder dystocia, etc.) no matter what the resident is doing. If they call the resident for a stat delivery, he/she must get to labor and delivery stat. 8. The residents in the WBN do not take WBN call. Therefore, the WBN is covered by the NICU resident at night. During the night, the NICU senior resident will go to all C-sections and all complicated vaginal deliveries. All newborns born before midnight must have an admission note and orders written before midnight. If the resident has not been called to the delivery, then the nurses in the nursery will call the resident to write these when the newborn arrives in the nursery. Newborns born after midnight will not need to be seen unless the nurses have a concern. 9. During Continuity Clinic, the other WBN resident when present or the NICU senior resident is responsible for WBN coverage. Please notify the NICU senior that they will be covering before you leave for clinic and give them the WBN pager. Make sure you write the name of the resident covering on the on-call board in the WBN. 10. If the resident is called about a baby in the WBN with hypoglycemia, increased hematocrit, respiratory distress or anything that makes you think the baby may be septic, etc., then please notify Dr. Stewart Monday through Saturday about your plans for the situation. The NICU attending covers the WBN on Sunday. 11. Days off: The resident in WBN will have Saturday or Sunday off. A resident from the Call Pool will cover the WBN. 12. Neonatal Transport Nurses: We are lucky to have an in-house neonatal transport nurse that goes to all complicated deliveries to help assist the medical students and residents. She/he is a good reference person, and on Mondays, shows the new medical students in the WBN where things are on L&D and how to resuscitate a baby. D. Circumcision Ask all parents if they would like their son circumcised. (Remember Family Practice does its own circumcisions and private OB attendings may do their own circumcisions on some patients. Ask the nurses who these patients are). Discuss the pros and cons of circumcision with your attending. Be prepared to answer questions the parents have about circumcision. (See attached circumcision information sheet). Discuss the use of EMLA Cream as a topical anesthetic for the procedure. Procedure 1. Examine patient's genitalia. If no contraindications for circumcision, then proceed.

91 2. Obtain consent - Make sure there is no history of bleeding disorders in the family. Please make sure to wait 24 hours after mom undergoes a surgical procedure (C-section, Bilateral tubal ligation, etc.) before obtaining consent so that her anesthesia wears off. 3. Patient is to be NPO at least 2 hours prior to the procedure. 4. EMLA Cream is applied 1 hour prior to procedure for analgesia. 5. Do circumcision using the Gomco method. The well baby attending will teach all the residents how to do a circumcision. Each resident must have the 1st 10 circumcisions closely supervised by the attending. Then the attending must be physically present in the WBN for all other circumcisions. 6. Keep the patient in the hospital for at least 2 hours post-circumcision to make sure no bleeding is noted. E. Medical Student Duties 1. Labor and deliveries a. Students will be paged to all deliveries whether going to the WBN or NICU. b. Student should set up the resuscitation table where the delivery is to take place. i. Turn radiant warmer on. ii. Open baby pack: Contents: ~ 3 cloths ~ 2 umbilical clips, scissors, and gauze ~ Spread cloths down according to size - bottom (large coarse cloth), middle (white cloth with stripes), and top (small white cloth). iii. Oxygen set up ~ Connect tubing to O2 hookup and make sure it is secure. ~ Connect the anesthesia bag. ~ Make sure appropriate sized face mask is attached. ~ Make sure the bag is attached to a manometer, and that the manometer is working. ~ Make sure O2 is turned on to a flow rate of 5 liters/min. iv. Make sure a working laryngoscope is present. (#0 blade for preterm and #1 blade for term infants) One doesn~t need to remove it from the package unless Meconium is noted. v. Make sure a stethoscope is present. vi. Make sure a bulb syringe and De Lee suction are present (one doesn~t need to open the De Lee). Try to keep the De Lee out from under the warmer. 2. Procedure During Deliveries a. The student will put on shoe covers. The student needs to wash his/her hands well, but there is no need to scrub up.

92 b. Obtain a warm blanket (kept in the warmer in all three resuscitation rooms) and carefully open it and drape it over ones arms and shoulders. Keep it closed until the time when the baby is born so that it retains its heat. For a C-section a sterile gown will be used instead to prevent contamination of the surgical field. c. The Obstetrician will hand the baby to the student (unless Meconium is present and then the OB resident may carry the baby to the warmer). d. The baby is to be placed on the bed with its head at the foot of the warmer with the blanket discarded. e. The student should listen to the babies' heart rate with a stethoscope and tap out the heart rate with his/her fingers on the mattress until the resident acknowledges. f. The student then participates in the resuscitation and assessment of the baby and helps assign the APGAR scores at 1 minute and 5 minutes after delivery. The student should get a new warm blanket for the baby as soon as the baby is stable. g. h. Prior to transport to the WBN, the baby~s footprints need to be obtained on the footprint sheet and identification bracelets should be attached to both feet of the baby. i. When the baby is stable, it can be returned to mom (if awake) and dad, if the baby was delivered by c-section, it should be kept there for no longer than 5 minutes due to cold stress. j. The baby is transported to the WBN in an isolette. The student must be accompanied to the WBN by a nurse, transport RT or resident. k. The O2 tank on the isolette must be checked once a day to make sure that there is at least 500 lbs/sq.in. of O2 present. l. If the baby is depressed and requires admission to the NICU, then the NICU resident present will assume control, but the student may follow the patient into the NICU and observe how the patient is cared for there. m. The footprint sheet (obtained while the baby is on the warmer) and nursing notes (if available) are to accompany the baby to either nursery. 3. When the baby arrives at the WBN a. The nurses will come to the hallway to take the baby from the isolette. b. The patient is then weighed and placed under a radiant warmer. The baby is not to be left alone in the hallway under any circumstances. c. Assessment will then be carried out by the student with the assistance of the nursing staff (to be reviewed with the students by the nurses). d. Paperwork: to be filled out by the medical students but co-signed by the resident.

93 1. Admission note 2. Admission orders 3. Growth curve 4. Dubowitz sheet 5. Meconium drug screen survey 4. Daily student responsibilities a. Examine the patient daily. b. Obtain VS, Wt, I & O's, any labs (i.e. blood type, Coomb's, Hct, Glu, etc). To obtain the blood type and Coomb~s, one must go down to blood bank to check a board with all the results or wait 24-48 hours until the report gets in the chart. The blood type is not reported in the computer as are the other labs. Usually one makes a daily trip to blood bank to get all the blood types and Coomb~s for every baby born in the last 24 hours. c. Do rounds with the resident and later with the attending. d. Write a daily progress note. e. Fill out discharge papers including orders.

94 Dermatology Rotation (required) Goals and Objectives: PL2 or PL3 MP2 or MP 3 or MP 4 1. Application of destructive agents on skin lesions. 2. Learn to perform and interpret Tzanck smear, scraping of skin for diagnostic procedures (KOH, etc.), and microscopic evaluation for infestations, such as, scabies, nits, etc. 3. Incision, drainage, and aspiration of fluctuant lesions. 4. Become adept at performing skin biopsy and cryotherapy for various lesions 5. Become familiar with diagnostic evaluation and treatment of various benign skin lesions, such as, acne vulgaris, intertrigo, pruritis, skin papules, verrucous lesions, etc. 6. Understand the psychosocial impact and cosmetic treatment of various skin conditions such as, abnormal skin pigmentation, birthmarks, hair loss, hirsutism, etc. 7. Become familiar with various skin manifestations of childhood diseases. 8. Learn to diagnose and treat various nail and mucous membrane infections/abnormalities. 9. Become familiar with the appropriate time to refer various skin conditions to a dermatologist. Course Description: The dermatology rotation is a block that involves general dermatology clinics, including both pediatric and adult patients (though the pediatric residents will se primarily pediatric dermatology). In addition, the resident is expected to participate on consultation rounds on inpatients. Residents will attend all dermatology teaching conferences and Peds or Med/Peds conferences. Residents will be evaluated by the Dermatology faculty. References: Hurwitz: Clinical Pediatric Dermatology, 2nd Edition.

95 Pediatric Opthalmology PGY 2, 3, or 4 Most residents do Pediatric Opthalmology as a two week rotation. Learning Objectives 1. Understand the importance of and become comfortable performing a thorough eye examination on pediatric patients. 2. Understand how to diagnose and treat strabismus and amblyopia and the importance of doing so. 3. Understand treatment of other muscle imbalances 4. Understand eye findings in systemic diseases, e.g. hyperthyroidism, Battan’s disease, etc. 5. Understand how opthalmologists correct refractive error Course Description Residents will rotate with Dr. Giangiacomo and the pediatric ophthalmology residents in the ophthalmology clinic. They will be taught the objectives above. They will not go to surgery or work with hospital inpatients. References Available in the ophthalmology department

96 Orthopedics and Sports Medicine PGY 2,3, or 4 Learning Objectives 1. Become comfortable with a thorough orthopedic physical examination in children and athletes. 2. Understand how to diagnose and treat common sports injuries in athletes: a. Knee injuries, including ACL tears, PCL tears, ilio-tibial band syndrome, patello femoral syndrome, patellar dislocations, patellar tendonitis, medial and lateral collateral ligament strains, meniscal tears, etc. b. Shoulder injuries, including dislocations and strains—and how to treat. c. Ankle strains, including evaluation and grading of ankle injuries. Use of the Ottawa Ankle rules. d. Evaluation and management of head injuries in athletes. Understand issues related to risks of second impact syndrome and current theories about avoidance of syndrome. e. Evaluation and treatment of back pain in athletes (spondylolysis and spondylolisthesis, etc.) f. Understand how to use simple splinting and casting techniques for common injuries 3. Understand common pediatric orthopedic conditions and their evaluation and treatment • Kypho-scoliosis (including importance of thorough skin exam when evaluating this) Orthopedic conditions associated with various birth defects Perthes disease Slipped capital femoral epiphyses • Limp in the child Metatarsus adductus and pes planus, bunions, etc. Femoral torsion Tibial torsions (Genu Varum, etc.) Congenital hip dysplasia Osgood-Schlatter disease Synovitis Orthopedic complications of neuromuscular syndromes Back pain in children Torticollis • Nursemaid’s elbow Clavicular fractures Joint infections and osteomyelitis

97 Course Description Residents will rotate with Drs. Dan Hoernschemeyer (pediatric orthopedics) and Steven Kane (sports medicine). They will primarily evaluate patients in the orthopedic clinics and present the patients to the attending physicians before seeing the patients with the attending physician. They will go to the operating room with the orthopedic surgeons when the attending feels the case would be valuable to their training. References Hoppenfeld. Physical Examination of the Spine and Extremities. 1976 Other texts available in Orthopedics Dept.

98 Pediatric Radiology PGY 2,3, or 4 Learning Objectives 1. Become proficient at reading pediatric chest xrays 2. Learn how to read skeletal xrays in children (including radiographic evaluations for child abuse). 3. Understand best radiologic procedures for various symptoms and signs in pediatric patients. 4. Learn how to evaluate full spine xrays for scoliosis 5. Understand how to read hip films for congenital hip dislocation 6. Residents will learn how to order and interpret radiologic exams for the top 25 emergencies in pediatrics (e.g. intussusception, torsion of the testis, retropharyngeal abscess, small bowel obstruction, appendicitis). 7. Read reference book below. Course Description Residents rotate with Dr. James Brown. They accompany him when he is performing radiologic procedures and reading films. They also accompany him for all of his teaching conferences, both at the University Hospital and Columbia Regional Hospital. Dr. Brown has numerous cases that he goes over with the residents in afternoon didactic sessions. Residents take a final examination based on the emergency situations they might see as a pediatrician. This examination consists of 50 cases and 200 questions. Reference Donnelly. The Fundamentals of Pediatric Radiology

99 Additional Curriculum Experiences The following represents a summation of the curriculum experiences for these particular topics. 1. Medical Ethics Residents have exposure to aspects of medical ethics that apply to the care of children. The reference for this experience is the two volume medical ethics compilation of articles and research which was put together by the American Board of Pediatrics, which is available in the resident call room, in the chief resident’s office and the program director’s office. Residents are expected to become involved in any issue of medical ethics affecting patient care. This may include hospital wide medical ethics conferences, ad hoc medical ethics committee meetings, problem conference discussions or case management discussions. There will be a medical ethics problem conference once a quarter. Discussion about the ethical issues involved in a case will be discussed. Residents should make every effort to go to these conferences. Residents should be aware that they can, at any time, refer a patient case to the Medical Ethics Committee. This committee is chaired by Dr. Bill Bondeson from theUniversity of Missouri- Columbia Department of Philosophy. Our faculty member Tony Clark, M.D J.D, Neonatologist, Associate Professor of Child Health, is a member of this committee. Dr. Bondeson may be contacted thru his office on campus at 302 Reynolds Alumni Center, phone number 884-3128. Tony Clark, M.D. J.D. can be contacted thru his pager number 441-4349. 2. Quality Assurance Residents will have exposure to factual information regarding quality assurance through didactic conferences. These conferences are given by Myra McCoig, Risk Management Coordinator. If issues arise during the meeting where it was not identified a resident was involved, residents will be informed of any issues discussed at the Children’s Hospital QA meeting by the chief resident or the program director. 3. Health Care Organization Practice Management & Health Care Finance Throughout the year the chief resident will arrange noon conferences to include topics on office practice, family finance, and contract negotiations. Residents may also attend the Department of Family & Community Medicine seminars on practice management issues. The chief resident will also arrange noon conferences on issues involving health care finance to discuss the complexities of managed care systems, health insurance, and other issues related to health care finance. Finally, in the spring of 2005 the hospital will have a conference for all residents on practice management. 4. Management Information Systems

100 Other topics on the noon conference schedule will include personal data systems and the use of OVID, other computer medical databases used in research of a subject, evidencebased medicine research and practice and the access of clinical guidelines in the practice of Pediatrics and Medicine-Pediatrics.

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