Pediatrics

History

Pediatrics gained recognition as a distinct medical discipline in the United States in the mid-19th century as an appreciation of the burden of infant mortality and awareness of the unique vulnerability of children to certain diseases increased. Before that, the medical concerns of children were viewed as the domain of internal medicine or obstetrics/gynecology, and there was little consideration given to the unique development and physiology of children. The first hospital dedicated to the treatment of children was the Children’s Hospital of Philadelphia, founded in 1855. Abraham Jacobi, a German immigrant considered by many to be the father of American pediatrics, established the children’s clinic at New York Medical College in 1860. In 1876 an emerging leader in pediatric medicine, Job Lewis Smith, was appointed Clinical Professor of the Diseases of Children at Bellevue Hospital in New York City. Lewis authored a textbook, Treatise on the Diseases of Infancy and Children, which was adopted by virtually all medical schools until the late 1890s.

The decline in infant mortality rates seen in the 20th century remains one of the great public health success stories of modern times. In 1900, mortality rates in the first year of life approached 30% in some U.S. cities. By the end of the 20th century, infant mortality rates had declined by 99%, with fewer than 0.1 death per 1000 live births. In the early part of the 20th century, improvements in infant mortality were largely because of public health measures, such as milk hygiene, clean water, and improved sanitation. In 1912 the Children’s Bureau was formed within the Department of Labor and played an important role in improving maternal and infant welfare in the first half of the century. The discovery and widespread use of antibiotics, fluid and electrolyte replacement therapy, and safe blood transfusions were also critically important factors in improving infant mortality rates.

The latter half of the 20th century saw continued improvements in medical care and public health measures, including great strides in perinatal and neonatal medicine, precipitous declines in vaccine-preventable illnesses, and improved access through the implementation of Medicaid in 1965. In 1994, with funding from the Maternal and Child Health Bureau sector of the Health Resources and Services agency within the U.S. Department of Health and Human Services, the first edition of Bright Futures: Guidelines for Health Supervision of Infants, Children, and Adolescents was published, with the goal of ensuring that all children in the United States could look forward to a bright future, regardless of race, religion, or socioeconomic factors. With the release of the third edition in 2008, the American Academy of Pediatrics (AAP)’s Bright Futures: Guidelines for Health Supervision of Infants, Children, and Adolescents became recognized as the standard for recommendations on preventive care of children. In 2010 the Patient Protection and Affordable Care Act was passed into law and included a provision that all children receive the standard of preventive screenings and services, as recommended in the third edition of the AAP’s Bright Futures Guidelines . As of 2017, the book is now on its fourth edition.

In 1930, the AAP formed when the pediatric section of the American Medical Association (AMA) broke away. The American Board of Pediatrics was founded in 1933 with the goal of raising the standards of pediatric care in the United States. The first pediatric board examination was administered in 1934. In 1965, Henry Silver, MD, and Loretta Ford founded the nurse practitioner (NP) profession by creating a pediatric nurse practitioner (PNP) program at the University of Colorado. Dr. Silver then created the Child Health Associate program at the University of Colorado School of Medicine 3 years after the first physician assistant (PA) program was founded at Duke University in 1965. This program, based on the PA model, offered specialty training in pediatrics and was the first PA program to confer a master’s degree.

Approach to the patient

In pediatrics, the focus is on the safety and comfort of the child and family. The approach to the physical examination of the child depends on the age, verbal capacity, and cooperativeness of the patient. With preverbal children, typically birth through age 2 or 3 years, careful observation of the child for developmentally appropriate behaviors, including interactions with the caregiver, is an important component of the examination and should be accomplished before approaching or touching the child. Children often develop stranger anxiety, beginning between 6 and 12 months of age and persisting until age 2 or 3 years.

It is important for the clinician to develop effective strategies for examining the apprehensive child. It is best to approach the child with slow movements and a soothing, calm voice. With most children in this age group, it is best to perform most elements of the physical examination with the child in the caregiver’s lap. The sequence of the examination is best approached case by case, and the PA should take advantage of opportunities unique to this age group. For example, with a sleeping infant, auscultation of the heart and chest with a warmed stethoscope may yield excellent results without waking the child.

The most invasive examinations, such as the ear and throat examination, should be reserved until the end of the examination for this age group. It is important to prevent the child from moving when the otoscope tip is in the auditory canal; therefore take extra care that the child is properly restrained either against the caregiver’s shoulder or chest. If the caregiver is not able to effectively hold the child, the ear examination is probably best done on the examination table with the child restrained on his or her side by a caregiver. Fig. 23.1 , A and B provide an example of techniques that parents can perform to help with the ear examination. The knee-to-knee position, shown in Fig. 23.2 , is helpful for examining the oropharynx of young children. The PA should sit facing the caregiver with his or her knees close together, forming a “table” on which to lay the child. The caregiver initially holds the child on the lap facing him or her and then lays the child back so that the child’s head lies in the lap of the provider. The examination of the oropharynx is generally viewed as invasive by most small children, so this examination position is helpful in reducing their anxiety.

An alternative to the knee-to-knee position in an apprehensive child is to lay the child on the examination table with a caregiver holding the child’s arms above his or her head with the elbows positioned against the ears so the child’s head cannot move side to side. Many young children will clench their teeth together to prevent the tongue blade from entering their mouths. Because young children do not have a second molar, it is very effective to slide a tongue blade, held on its side, into the mouth between the teeth and buccal mucosa and then turn the blade so it is flat when it is at the back of the teeth and move it through the gap between their mandible and maxilla directly onto the base of the tongue. This will elicit a gag reflex and allow an opportunity for a quick look at the child’s pharynx.

Preschool-aged children (aged 3–5 years) are generally cooperative and curious and may engage in the visit without protest. It is often helpful to engage the child in conversation or tell a story while performing the examination. Allowing the child to hold the stethoscope or other diagnostic equipment; demonstrating the examination techniques on yourself, an older sibling, or a doll; and encouraging engagement of the parent or other caregiver are strategies that can help alleviate apprehensiveness. When possible, attempt to make the examination fun for the child, using toys or games. Some children may have unpleasant memories associated with previous visits or may have anxiety about immunizations or other painful procedures. Unusual reticence or avoidance at this age warrants additional investigation to determine whether the child is reaching age-appropriate developmental milestones or has been the victim of child abuse. Most children develop modesty around age 4 or 5 years, so the PA should expect some reluctance to remove the gown or clothing. This is an excellent opportunity to engage the child and caregiver in a discussion around teaching the child appropriate interactions with adults that protect the child from becoming a victim of sexual abuse.

School-aged children (5–10 years) are typically easy to engage in conversation, and the PA will find few barriers to performing a thorough and thoughtful evaluation in this age group. It is very important to establish rapport with children in this age range and appreciate that modesty is very important to many school-aged children. Allowing the child to disrobe out of sight of others and offering appropriate gowning and draping can help develop trust and maintain modesty. The assessment of school performance or any school-based concerns is an important component to the pediatric well visit that begins in this age range. Addressing school performance issues and any school-based social concerns early and directing caregivers to resources may be helpful in preventing self-esteem and school avoidance issues in the future.

The approach to adolescent patients (11–18 years) is similar to that taken with an adult patient with some important caveats. The visit should be scheduled for an appropriate amount of time, usually 30 to 40 minutes, in anticipation of taking an extensive psychosocial history and spending some or all of the patient interview with the caregiver out of the room. It is appropriate to take a past medical history, family history, and general social history with the caregiver present. Providers should develop a strategy for asking caregivers of adolescents to leave the room, increasing the possibility that the adolescent will be more candid in his or her responses. One option is to advise the caregiver that there are interview questions for the adolescent that are typically asked privately and would the caregiver be willing to wait outside the room and be brought back into the room for the physical exam.

The HEEADSSS (home, education and employment, eating, activities, drugs and alcohol, sexuality, suicide and depression, safety) psychosocial inventory is a guiding tool frequently used to collect information related to the sensitive adolescent psychosocial interview. It is important for providers to develop an approach to validating the perspectives of adolescents through reflective listening. This takes some practice and patience. It is often beneficial to begin the interview with adolescent patients by asking less intrusive questions related to past medical history and family history. To limit apprehension, the PA may inquire about HEEADSSS behaviors in friends and acquaintances before addressing these behaviors in the patient. Be thoughtful about the amount of information that is provided to adolescents regarding risky behaviors at each visit because the goal of the visit should be building and maintaining rapport and trust. Additional visits may be necessary to revisit concerns that are identified. Encourage healthy choices regarding tobacco, alcohol, sexual behaviors, and recreational drug use by helping them articulate life goals that might be unattainable if unhealthy choices are made. Overall, the PA should focus on identifying any serious or concerning issues, with an emphasis on observation as an important adjunct to verbal communication.

Daily routine for pediatric physician assistants

There is significant variety in the daily routine of pediatric PAs. Pediatric PAs divide their time between well-care and routine sick visits throughout the day. As an example, in a typical day in the outpatient setting, one might see patients of all ages and developmental stages, such as a newborn, a 9-month-old, a 14-year-old, and 2-year old twins, all for well-child care. In addition to well-care visits, the PA may see acute care visits with patients of all ages and needs, such as a 2-year-old with a fever, a 6-year-old with vomiting and diarrhea, a 9-year-old with parental concerns about obesity, and a 13-year-old with declining school performance who is acting out. The variety of daily experiences in general pediatric practice makes for an engaging and rewarding career for PAs.

Pediatric rotation expectations

A clinical rotation in pediatrics is required of all PA students. This clinical rotation may occur within an inpatient or outpatient setting and may involve the care of newborns, infants, children, and/or adolescents within general and specialty care clinics. In the typical outpatient pediatric clinic, the PA student will be expected to perform an appropriate history and physical examination and develop an assessment and detailed management plan for their patient, based on the patient’s age and chief complaint. It is critical that the PA student arrives with a strong foundational knowledge of common pediatric disorders. Furthermore, given that preventative care is such an important facet of general pediatric practice, the PA student should have a good understanding of pediatric developmental milestones and up-to-date recommendations for preventive screening, immunizations, nutrition, diet, and exercise.

During the pediatric rotation, the PA student is expected to acquire some very important skills specific to pediatric patients. The ability to evaluate children for appropriate development at any age is of fundamental importance to general pediatric practice. In infants and young children, development should be evaluated by considering language, motor, and personal-social domains. Useful resources regarding child development evaluation instruments can be found in Table 23.1 . Child development should be considered from a biopsychosocial model, recognizing development as an interaction among biological, psychological, and social factors.

The periodic evaluation of a well child is the cornerstone of pediatric primary care practice. From birth through adolescence, the growth and development of children is a complex and variable process that requires frequent monitoring and preventive intervention. The AAP’s Bright Futures guidelines recommends no fewer than 10 scheduled well-care visits between birth and age 2 years, followed by yearly visits through adolescence. Even with this frequency of visits, pediatric PAs are challenged to cover all the necessary tasks in each 15- to 30-minute visit. At each well-care visit, the pediatric patient must be evaluated for disease and screened for problems with nutrition, growth, and development, accompanied by appropriate counseling on prevention and health promotion.

PA students should begin to develop strategies for discussing a wide variety of topics, such as secondhand smoke exposure, advice regarding parental nutritional concern, screening and referrals for behavioral and mental health concerns, and immunizations. Because immunizations are a key feature of every well-child visit in the early child years, the PA student should create a plan for engaging parents concerned about vaccines or those who refuse to vaccinate. The American Academy of Pediatrics provides a recommended yearly immunization schedule that can be accessed at https://www.aap.org . For children with developmental concerns or chronic illness, extra time should be planned for the well-care visit.

During a pediatric rotation, students should be knowledgeable about the signs and symptoms of common pediatric disorders and have resources available to determine the best patient management. Students should be familiar with the seasonal patterns of common pathogens and, if possible, have a resource for identifying when specific pathogens are circulating in the local community.

Upper respiratory diseases frequently seen in the pediatric population include viral upper respiratory infections, acute otitis media, croup, and pharyngitis. Common lower respiratory diseases include community-acquired pneumonias, asthma, and bronchiolitis. Gastrointestinal illnesses are frequently encountered in the pediatric population and always necessitate the evaluation of hydration status. Rashes, common in pediatric patients, have a broad differential diagnosis that may be confusing for the novice clinician. Consultation with a more experienced clinician on the team is usually helpful in arriving at an accurate diagnosis. Fever is often a concerning symptom for the caregiver of a child. Although fever guidelines are not uniformly followed by all community-based pediatric providers, guidelines are available and can be quite useful in determining the most appropriate workup for a febrile child.

The inpatient pediatric clinical experience will provide students with the opportunity to work on a team of providers in the care of children with more complex conditions. The inpatient team generally consists of an attending (usually a physician); residents at various levels of training; other medical trainees; and, depending on the type of pediatric service, social workers, pharmacists, and other health professionals. The attending is a licensed health care provider (HCP) who has completed all training and leads the team in the care of their assigned patients. Pediatric residency is a 3-year program; therefore the residents on the team are designated as first years, second years, and third years, depending on how much training they have completed. Other medical trainees on the team may consist of PA students, medical students, and NP students.

The duties of the team include completing daily rounds on all of the patients assigned to the service, performing admission history and physical examinations, writing hospital orders, developing discharge plans, and working night and weekend calls. Additionally, the team may perform certain bedside procedures. All of these activities are performed by the hospital-based PAs and HCPs on the team. PAs are viewed as important contributors to quality patient care in the hospital settings, and opportunities for PAs to work as hospitalists are growing. Students interested in pursuing careers as hospitalist PAs may consider joining the Society of Hospital Medicine (SHM), where after 3 years of hospitalist experience, clinicians may apply for the designation of Fellow and after 5 years may achieve the designation of Senior Fellow in Hospital Medicine. Additionally, with the increased need for hospitalist PAs, large hospitals are creating postgraduate fellowships for those interested in this field.

Pediatric clinical environments

Pediatric clinical rotations take place in a wide range of settings, including ambulatory experiences in group and private practices, community health centers, public health settings, and school-based clinics. Hospital-based pediatrics experiences are found in children’s hospitals, academic health centers, community hospitals, and charity-funded settings and specialty hospitals. Common to all rotations and experiences is that the care of the pediatric patients must involve the family, the culture, and the socioeconomic factors that may impact access to and the effectiveness of health care.