Rotation Recap: Pediatrics

I had a lot of trepidation before starting my pediatrics rotation because I don’t have much experience with kiddos.. I never lived with any brothers or sisters, have no nieces or nephews, and only one of my close friends has a baby. Between a fantastic preceptor, an adorable clinic with warm, welcoming staff, and adorable babies every day, I fell in love with peds and had one of the best months of clinical year yet! After grueling rotations in the emergency department and internal medicine, the 4 day work weeks from 8:30 to 4:30 were a welcome break and the low pressure environment allowed me to focus on learning physical exam techniques and asking questions as I went. Although I thought I had prepared for the rotation and reviewed the pediatric sections of didactic year, I don’t think I studied the best topics and started the month feeling a little lost. With that being said, let’s talk about how to prepare.

How To Prepare

Learn the very basics of babyhood! – About 50% of the appointments for any given day were well-child checkups and appointments for routine vaccinations. Parents often asked questions about how much and how often their baby should be eating, when it was okay to give the baby table food, when they could expect the baby to start smiling, and other questions like that. To be honest, I had absolutely no idea. I could tell them all about their baby’s glucuronosyltransferase activity but had no idea how many wet diapers they should be making per day! The realization that I had no idea what was normal for babies hit me hard and I spent much of my time asking my preceptor things like how to choose a baby formula or how often a 2 month old should be eating. Try to read up on these things before you start and you will sound much more credible to parents. I liked the What to Expect When You’re Expecting website for a quick and easy reference for all my (seemingly obvious) questions.

Developmental Milestones – At each well child checkup, you should be able to provide parents with anticipatory guidance on what they should expect to see their child do before their next check up. Anticipatory guidance is also a big part of the EOR for pediatrics! When should a baby be able to sit up without support? At what age can you expect them to take their first steps or sleep through the night? Stuff like that. It’s also helpful to familiarize yourself with the possible reasons why a child is not meeting their milestones. Are they just late bloomers or could something else more insidious be going on? At minimum, know at least one gross motor, fine motor, social, and language milestone for each age bracket.

Rashes, rashes, rashes – I jokingly referred to my preceptor as the RashMaster because he diagnosed so many different conditions (dermatological and otherwise) based on the presentation of the rash. We had at minimum 5 appointments per day with the chief complaint of a rash. I was very disappointed to find that none of the rashes (except maybe the “slapped cheek” appearance of Fifths Disease) presented in the classic, textbook way. For example, pityriasis rosea did not have a Christmas tree pattern and there was no visible umbilication to molluscum contagiosum. Don’t let that throw you off and miss the diagnosis! Get familiar with eczema, baby acne, pityriasis, molluscum, strep rashes, fifth’s disease, impetigo, lip licker’s dermatitis, milia, roseola, poison ivy, tinea capitis/corporis/pedis, etc. If your preceptor has a book of Pediatric Dermatology try to sneak a peek between cases. It helped me a lot to look at pictures before making my final answer. Also be sure to know which conditions require treatment and which do not.

Vaccination scheduling and counseling – Another large portion of the peds EOR is vaccine schedules, at what ages do children get their various vaccines? How many total doses of each is needed for immunity? Much to my dismay, there was a lot of skepticism and sometimes resistance to vaccines from parents who cited all the facebook articles they recently read regarding vaccine safety. Be prepared to have a tactful and non-judgemental conversation with moms and dads about the safety of and need for vaccination. This can be frustrating but I learned that most parents’ fears can be dissipated through kind, understanding counseling.

What To Expect

Otoscopy – Perhaps more common than rashes are ear infections (otitis media to be exact). Confidence using the otoscope is critical in pediatrics and it can be difficult to get a good view of the tympanic membrane, especially in little nuggets. My best advice is to look in the ears of every single patient you have, whether they’re there for ear complaints or not. I tried to see every single eardrum that walked through the door. Most otitis media is not very obvious with an angry bulging TM with pus behind it (although some are). The more normal ears you see, the easier it becomes to say for certain whether there is an infection (or just serous fluid) present. If you are unsure, ask your preceptor. I usually tried to say for myself whether it was normal or infected, then ask my preceptor to confirm. By the end of the month, I was much more accurate with my assessment!

Know when to send to the ED – Sometimes a child will come to the clinic with a condition that is better suited for emergency management. We had to call EMS twice to come get patients and transport them to the ER for things like hypoxia or seizure activity. If a patient’s vitals are looking worrisome or if you’re concerned for something like a septic joint or meningitis, go ahead and send them. Better safe than sorry and children decompensate quickly!

Establishing rapport – Get to know your kiddos! What kinds of foods do they like? What do they do for fun? Are they involved in sports at school? How is school going? Are they struggling with bullying or keeping up with their grades? Do they have pets? As a pediatric clinician, it’s critical to establish relationships with patients and their parents. I was consistently impressed by how well my preceptor knew his patients (who all clearly loved him). He even had patients who were children of former patients, affectionately known as grandpatients! You can’t just go into a room with a kid and ask yes/no questions and leave. Joke around with them, tickle them, whatever it takes to help them relax and trust you. You will be a MUCH more effective provider.

EOR – Again, I used the PAEA blueprint and PANCE Prep Pearls to study. I did find the PPP pediatricsection to be a little lacking and wound up doing a lot of google-studying. I also felt like the exam itself included many things that were nowhere to be found on the blueprint. I performed the worst on this EOR, despite the general notion that it is one of the easier ones. Go figure.

As always, I hope you found this information useful for your clinical rotations! Got something to share? Drop a comment or shoot me an email! If you’re looking for deets on other rotations, check out my recaps on Emergency Medicine, Inpatient Medicine, Family Medicine, General Surgery, Psyche, Trauma ICU, Cardiothoracic Surgery, Plastic Surgery, and OBGYN!