1. Opendak, M., Robinson-Drummer, P., Blomkvist, A., Zanca, R. M., Wood, K., Jacobs, L., Chan, S., Tan, S., Woo, J., Venkataraman, G., Kirschner, E., Lundström, J. N., Wilson, D. A., Serrano, P. A., & Sullivan, R. M. (2019). Neurobiology of maternal regulation of infant fear: the role of mesolimbic dopamine and its disruption by maltreatment. Neuropsychopharmacology : official publication of the American College of Neuropsychopharmacology, 44(7), 1247–1257. https://doi.org/10.1038/s41386-019-0340-9.
2. Robinson-Drummer, P. A., Opendak, M., Blomkvist, A., Chan, S., Tan, S., Delmer, C., Wood, K., Sloan, A., Jacobs, L., Fine, E., Chopra, D., Sandler, C., Kamenetzky, G., & Sullivan, R. M. (2019). Infant Trauma Alters Social Buffering of Threat Learning: Emerging Role of Prefrontal Cortex in Preadolescence. Frontiers in behavioral neuroscience, 13, 132. https://doi.org/10.3389/fnbeh.2019.00132

I really enjoyed my pediatrics rotation because I was able to float through the pediatrics ER, NICU, and outpatient clinic. It was in the ER (first three weeks) where I learned how to identify pediatric emergencies and how they may present differently compared to adults, it was in the NICU (4th week) where I got to see children at their earliest days of life and learn anticipatory conditions in a neonate given the risk factors of the mother, and finally it was in the  outpatient clinic (final week) where I learned more about pediatric routine visits and patient education on asthma, obesity etc.

I got to see pediatric patients in three different settings. I was comfortable with working in the ER from my first rotation and I could already see how much more proactive I was as a student. I was able to build upon my skills that I had established in the ER before and improve on working with more efficiency. The nurses allowed me to be more involved in their duties whether it was retaking vitals, conducting an oral challenge, taking viral swabs, collecting urine or blood etc. One particular part of the ER that was different from my previous experience was collecting the history from psychiatric patients. For almost all my shifts, there were at least 2 patients on the board with a chief complaint of “suicide attempt”. I learned that from an ER point of view, we were there to medically clear the child. I found myself conflicted when I received different stories from the child compared to the parents. I am looking forward to my psychiatry rotation to gain the skills in handling such situations. My NICU experience was an amazing and completely new experience for me. I mostly observed but was able to participate in the immediate post-care of the neonate after being born, including drying the baby off, determining APGAR score, suctioning the nose and mouth, and taking the appropriate measurements (head, chest, abdomen, length, weight). I was also able to assist in adjusting umbilical catheters. During my time in the outpatient clinic, I was pleasantly surprised that I was not only going to participate in pediatric well visits, but work with pediatric specialist in endocrinology, pulmonary, and cardiology. I got a more in depth learning on how to form an asthma action plan and perform a doppler ultrasound. I even got the chance to practice interpreting multiple EKGs. Patient education was crucial at every visit, including exercise and diet for obese children, how to use a spacer with inhaler for asthma exacerbations, immunizations benefits, developmental milestones etc.  

Patience and distraction were key skills to learn during this rotation. I had exercised patience in my other rotations which helped me with uncooperative children during the exam or in situations where the child was disruptive in the room while you are trying to talk to the parents. One time I even had to run after a child in the ER who was very scared about getting an IV placed. Understanding the environment you are in and acknowledging that it can be stressful for the child, who is already not feeling well, along with the parents can give you a little more empathy towards the situation. Mastering the art of distraction, especially among younger children, during procedures is also a crucial skill to have in creating a positive experience for the child. It reduces stress, increases cooperation, and provides better safety from adverse events occurring if the patient is moving. Videos, toys, reading, games can all be used as distraction tools. Another method that I found to be helpful was any participation that the patient can take part in helped increase cooperation. In the ER, I performed many many COVID-swabs. The child saw the swab and instantly started to retract away from me, remembering the days when the swab had to reach all the way back into the nasal cavity. However, given that we didn’t have to go that deep, I had the patient hold the cotton swab with me and together, we swabbed her nose. It worked almost every time ! 

When I first started my pediatrics rotation, it felt unfamiliar to move away from what I knew about adults and learn how lab values, medications, disease presentations, or simply regular check ups were different in children. An area that I particularly felt weak in was pediatric drug dose calculations. The providers would work so quickly and call out numbers at me that it was hard to follow at times. Safe medication administration in children is based on the child’s height and weight. I realized in studying drugs, I put more of an emphasis on the drug name and class, over the dosages. One application that I found particularly useful in helping me learn more about these drug dosages was epocrates. It breaks down the drug information in a clear and concise way. With some cases that I looked back on through my Epic access, I tried performing my own calculations with drugs such as Ibuprofen and amoxicillin. With more familiarity with the dosages of at least the most commonly prescribed drugs, I will be able to do these calculations more quickly. Though I may not pursue the pediatric specialty specifically, it is important to know how to properly dose children because I still may encounter them in another setting such as in the ER. 

Two of the most memorable moments of my rotation had to do with observing the ending of a life with my first child death and the beginning of one with my first vaginal birth. As a student, I knew that I could possibly encounter the experience of a death, yet I felt so unprepared when it happened. It was in my second week of being in the pediatrics ER when a unresponsive 13 month old child came in with a fever of 105 F. ACLS was performed unsuccessfully for an hour and he died from suspected hypovolemia and septic shock. The feeling of powerless and the grief felt for someone I barely knew was unlike something I’ve felt before. I think that compartmentalizing is almost a key survival trait for clinicians, but at the same time too much dissociation can cause a lack of empathy. It’s that middle ground that allows you to mourn for your patient but still maintain your professional role. Seeing my first vaginal delivery came with a whole new set of emotions. It was an amazing, emotional process that makes one appreciate the process of labor and delivery at a higher level. The mother was pushing so hard and though I knew the baby was coming out, part of me was convinced it just wasn’t going to work. The sight of the baby’s dark hair would come closer to the opening and then sink back in, but suddenly with a hard extended push, with guidance of the resident, slid out a fully developed baby. It gave a new meaning to changing someone life and making a difference beginning with bringing a new life into the world. 

Site Evaluator: Gary Maida 

The first case I presented was a 5-week-old female born full term via normal spontaneous vaginal delivery who presented in the ED with her parents complaining of looser than normal stools for the past 2-3 days. The mother described the stool as mucous-like yellow color with some blood. Mother notes that she recently switched from Enfamil to Similac about 2 weeks ago. I chose this case because of how uncommon it is to see a child allergic to milk. According to the American College of Allergy, Asthma, and Immunology, only about 2-3% of children younger than 3 years old have milk allergies.* Physical exam was positive for an erythematous, papular rash with areas of scaling around the vaginal area without ulcerations, discharge, or streaking. Positive for nasal congestion. Abdominal exam was unremarkable (no anal issues, hemorrhoids or perirectal lesions). Professor Maida agreed with my assessment of the diarrhea that given the history of recent formula change, it is most likely caused by a milk protein allergy. My other differential diagnosis included bacterial or viral enteritis and Meckel Diverticulum. However, less likely viral or bacterial enteritis as the patient has no systemic signs and symptoms of infectious pathology, will rule out bacterial pathology via pending stool culture. Although the patient is under 10 years of age and is complaining of blood in stool, less likely Meckel diverticulum due to associated diarrhea, absent abdominal pain, and is female. Professor Maida complimented me on my H&P. He gave noted some missing information important to this age group, such as assessment of the anterior and posterior fontanelles. 

*https://acaai.org/allergies/allergic-conditions/food/milk-dairy/

The second patient I presented was a 3-year-old female delivered via c-section with a PMHx of simple febrile seizures presents in the ER with her mother complaining of a febrile seizure at 9 am that morning and high fever of 101.3 degrees F since the night before. Vitals showed tachycardia and a rectal temp of 103.4 degrees F. Physical exam was only positive for clear nasal discharge and tachycardia. Oral mucosa is moist, capillary refill <2 seconds. She is alert and active, tolerating oral intake and is voiding. Negative for nuchal rigidity and focal neuron deficits or other neurological signs. BMP, CBC with diff, urinalysis (bag collected), procalcitonin, blood culture, and respiratory panel were taken. Results showed a CO2 of 13, traces of leukocyte esterase and white blood cells in the urine, and a positive viral panel for rhinovirus/enterovirus and parainfluenza 3 infection. My assessment was that her febrile seizure is likely secondary to the rhinovirus/enterovirus and parainfluenza 3. Additionally, with a CO2 of 13, the patient has mild-moderate degree of hypovolemia. Bacteriemia, sepsis/septic shock, and meningitis were on my differential diagnosis as well. Negative bacterial culture and negative meningeal signs or other neurologic abnormalities, along with the patient appearing alert and not in any distress make bacteremia, sepsis, and meningitis less likely. The patient was also fully immunized. Professor Maida agreed with my workup, but pointed out that the presence of leukocytes cannot be attributed to contamination and must be worked up to rule out UTI. Though the patient’s parents originally denied a foley catheter, the patient would need to be catheterized to get a sterile urine catch. I chose this case because I wasn’t too familiar with febrile seizures and I learned that low CO2 level below 17 is indicative of dehydration.

The third case I submitted was a 4 year old female delivered via C-section with a PMHx of febrile seizures and pneumonia presented in the ED with her mother complaining of progressively worsening nonproductive cough and a fever for the past 3 days. I chose this case because I had actually missed the wheezes on the exam because I failed to check the anterior chest. It prompted a discussion with my preceptor about pneumonia work up, treatment, and the role of radiograph imaging. 

I need to become more familiar with the side effects of common drugs. Professor Maida tested us on our drug cards and I found myself lacking in knowledge on some drugs I would like to have been more familiar with.

“Acetaminophen and Febrile Seizure Recurrences During the Same Fever Episode”

Published in The American Academy of Pediatrics publications Volume 142, Issue 5 (November 2018) by Murata, M et al

Febrile seizures are convulsions that occur during infancy or childhood that are characterized by a high fever above 100.4 F, sudden loss of consciousness, followed by uncontrollable jerky movements, and then a return to consciousness. There are two types of febrile seizures, simple and complex. Simple febrile seizures are the most common and they usually occur over a few minutes, with a rapid return to baseline. Complex seizures last longer than 15 minutes, happen more than once in 24 hours, and occur only at one side of the body. Febrile seizures affect about 2% of children in the United States, most of which resolve on their own. However, if another one happens, it is more likely to be prolonged (longer than 15 minutes).

In this randomized control study, researchers sought out to determine if administering acetaminophen reduces the chance of seizure recurrence during the same fever episode and to confirm the safety of acetaminophen use in this context. Data was also collected for baseline characteristics (age, sex, history of febrile seizures, family history of febrile seizures, time between fever and seizure, body temperature taken in the ED, and labwork) and adherence was checked through telephone interviews and parent-recorded data.  

From May 1, 2015, to April 20, 2017, the study analyzed recurrence of febrile seizures in children between the ages 6 and 60 months presenting to the pediatric emergency department at Hirakata City Hospital in the setting of a fever ≥ 100.4 F. The study excluded children who already experienced 2+ convulsions during the fever course, seizures lasting >15 minutes, received diazepam suppository or antihistamines to prevent febrile seizure, and children with underlying chronic medical conditions, chromosomal abnormalities, and history of brain tumor or intracranial hemorrhage. A total of 438 children met the inclusion criteria and were randomly allocated to either receive the acetaminophen suppository (229 children) or no antipyretic (209 children). Within the treatment group, patients were immediately administered acetaminophen 10mg/kg suppository by the pediatrician in the ED and then parents were instructed on how to administer the suppository every 6 hours for 24 hours, starting soon after the first seizure. Parents were to record the number of acetaminophen dosages given. Parents of the children in the control group were instructed to not give any antipyretics to their child for 24 hours post-onset of the febrile seizure, but to bring the patient back to the hospital if another seizure recurred.

Overall, results showed that the rate of recurrence during the same fever episode was 16.0%, with all recurrences occurring within 24 hours of the febrile seizure. The rate of the recurrence was significantly lower in the rectal acetaminophen group compared to the control group across all age groups, with the recurrence rate being 9.1% compared to 23.5%. Greater decreases in the rate of seizure recurrence were observed among children at older ages who were receiving acetaminophen. Between the ages 6-21 months, the recurrence rate among children who received acetaminophen was 13.2% compared to the rate of 24.3% in the control group. In children 22 months to 60 months, recurrence rate among acetaminophen group was 4.1% compared to 22.6% in the control group. No drug-related adverse events were observed, such as hypotension, hypothermia, or anaphylaxis. The researchers used Multiple Logistic Regression analysis to identify if there were other variables that could be associated with febrile seizure recurrence and rectal acetaminophen was found to be the largest contributor to the prevention of febrile seizure recurrence. The analysis also revealed that younger ages and shorter seizure durations were associated with higher recurrence rate of febrile seizure during the same fever episode. Given that acetaminophen is primary used to reduce fever, it was interestingly to see that no significant difference was observed 2 hours after the first acetaminophen administration between the children in the treatment and control group. The researchers hypothesized that acetaminophen may help reduce febrile seizure recurrence through other ways other than antipyretic effects. Further research exploring the biomarkers may help clarify the relationship between acetaminophen and seizure frequency reduction, as well as studies that compare acetaminophen to other antipyretics.

This study demonstrates that scheduled rectal acetaminophen given in the presence of continued fever can significantly reduce the risk for recurrent febrile seizures within 24 hours of the initial seizure. Therefore, rectal acetaminophen should be considered in otherwise healthy children aged 6 months to 5 years with simple febrile seizures and continued fever. Additionally, the researchers state that one of the most important parts of clinical practice is providing the parents with the adequate information about febrile seizures with the goal to relive some of their anxiety. Clear instructions should be given to the parents to make sure that the appropriate use of acetaminophen is given to the child. Constant use of acetaminophen in children is not advised because the outcomes of simple febrile seizures is generally favorable. 

*This study was performed in Japan. It was approved by the ethics committee at Hirakat City Hospital and accepted for publication in The American Academy of Pediatrics publications in November 2018. The researchers used JMP version 13 software by SAS institute, an American developer of analytics software based in North Carolina, for statistical analysis. 

Source: Murata, Shinya et al. “Acetaminophen and Febrile Seizure Recurrences During the Same Fever Episode.” Pediatrics vol. 142,5 (2018): e20181009. doi:10.1542/peds.2018-1009