Core Competencies

Introduction

Seizures are the most common neurologic disorder of childhood. Febrile seizures occur in up to 5% of children under age 5, and many children experience one afebrile seizure by adolescence. A subset of these children will develop epilepsy. In 2015, the CDC estimated that close to a half a million children were afflicted with this disorder. Seizures may range from self-limited to life-threatening events. Status epilepticus is defined as seizure activity of greater than five minutes duration without return to baseline. Optimal management of seizures not only includes identification of the underlying cause and initiation of appropriate anticonvulsant therapy or other treatments, but also the maintenance and management of an adequate airway and circulation. Pediatric hospitalists frequently encounter patients with active seizures and underlying epilepsy and should render both acute care and coordination of multidisciplinary care to the ambulatory setting.

Pediatric hospitalists should be able to:

• Discuss the pathophysiology of seizure activity.
• List the most common etiologies of seizures in various age groups such as the neonate, infant, preschool aged, school aged, and adolescent.
• List the various etiologies of seizures attending to both acute (such as electrolyte imbalance, infection, toxins, trauma, and others) and chronic (such as central nervous system malformations, metabolic diseases, and others) causes.
• Describe and distinguish between the various manifestations of seizure activity, such as involuntary motor activity, alterations of consciousness, behavior changes, disturbances of sensation, autonomic dysfunction, and others.
• Classify seizures based on where seizures begin in the brain, level of awareness during the seizures, and other distinguishing features.
• Review alternate diagnoses which may mimic the presentation of seizures including behavioral abnormalities, movement disorders, conversion disorders, and others.
• Compare and contrast distinguishing features of seizures versus other paroxysmal events.
• Define simple and complex febrile seizures and discuss evaluation, treatment, prognosis, and indications for admission.
• State the common complications associated with seizures and status epilepticus.
• Compare and contrast commonly used seizure medications and therapies, attending to treatments for specific seizure types, adverse drug events, and ease of use.
• Review the management of status epilepticus, including stabilization, testing, monitoring, and patient placement.
• Compare and contrast the risk and benefits of commonly used imaging modalities.
• Review the goals of inpatient diagnostic evaluation and therapy.
• Discuss indications for hospitalization or transfer to a higher level of care and/or comprehensive epilepsy care unit.
• List the indications for EEG monitoring and/or subspecialty consultation with neurology, psychiatry, and others as indicated.
• Summarize the risks for readmission, attending to medication management (such as dosing, availability, pharmacokinetics, and side effect profiles), compliance, and changes in disease state.

Pediatric hospitalists should be able to:

• Diagnose seizures by efficiently performing an accurate history and physical examination, with focus on the neurologic exam.
• Order appropriate laboratory and radiographic studies to identify the etiology of the seizure and potential underlying disorders.
• Interpret laboratory studies including drug levels and make therapy adjustments based on results.
• Order appropriate studies for patients with epilepsy, avoiding unnecessary duplication of testing and radiation exposure.
• Identify and efficiently treat the cause of the seizure where appropriate.
• Identify status epilepticus and initiate appropriate evidence-based treatment.
• Diagnose complications due to seizures and institute an appropriate medication plan and cardiorespiratory support as needed.
• Identify patients at increased risk for seizure recurrence or morbidity and ensure appropriate monitoring and treatment, including prescription of seizure rescue medications.
• Engage consultants when appropriate, including neurologists, epileptologists, and others.
• Create a comprehensive evaluation and management plan, addressing the needs of patients and the family/caregivers.
• Anticipate, monitor for, identify, and treat potential side effects of treatment.
• Recognize and efficiently transfer patients requiring higher level of care.

Pediatric hospitalists should be able to:

• Realize the importance of effective communication with patients, the family/caregivers, hospital staff, subspecialists, and primary care providers regarding the reasons for diagnostic testing and therapy choices.
• Recognize the role of education of patients and the family/caregivers in improving compliance with treatment and follow-up.
• Realize the impact that anxiety related to seizures in their child has on the family/caregivers.
• Prioritize anticipatory guidance and education of the family/caregivers regarding outcomes of febrile seizures, including the risk of the child developing epilepsy.
• Acknowledge the value of collaboration with subspecialists and the primary care provider to ensure coordinated longitudinal care for children with epilepsy.

In order to improve efficiency and quality within their organizations, pediatric hospitalists should:

• Lead, coordinate, or participate in the development and implementation of cost-effective safe, evidence-based care pathways to standardize the evaluation and management of hospitalized children with seizures and status epilepticus.
• Collaborate with hospital administration and community partners to develop and sustain referral networks for both transport and subspecialty services for children with seizures and chronic epilepsy.
• Collaborate with primary care providers, subspecialists, and other healthcare providers to create effective discharge plans that reduce the likelihood of readmission.

Introduction

Seizures are the most common neurologic disorder of childhood. Febrile seizures occur in up to 5% of children under age 5, and many children experience one afebrile seizure by adolescence. A subset of these children will develop epilepsy. In 2015, the CDC estimated that close to a half a million children were afflicted with this disorder. Seizures may range from self-limited to life-threatening events. Status epilepticus is defined as seizure activity of greater than five minutes duration without return to baseline. Optimal management of seizures not only includes identification of the underlying cause and initiation of appropriate anticonvulsant therapy or other treatments, but also the maintenance and management of an adequate airway and circulation. Pediatric hospitalists frequently encounter patients with active seizures and underlying epilepsy and should render both acute care and coordination of multidisciplinary care to the ambulatory setting.

Pediatric hospitalists should be able to:

• Discuss the pathophysiology of seizure activity.
• List the most common etiologies of seizures in various age groups such as the neonate, infant, preschool aged, school aged, and adolescent.
• List the various etiologies of seizures attending to both acute (such as electrolyte imbalance, infection, toxins, trauma, and others) and chronic (such as central nervous system malformations, metabolic diseases, and others) causes.
• Describe and distinguish between the various manifestations of seizure activity, such as involuntary motor activity, alterations of consciousness, behavior changes, disturbances of sensation, autonomic dysfunction, and others.
• Classify seizures based on where seizures begin in the brain, level of awareness during the seizures, and other distinguishing features.
• Review alternate diagnoses which may mimic the presentation of seizures including behavioral abnormalities, movement disorders, conversion disorders, and others.
• Compare and contrast distinguishing features of seizures versus other paroxysmal events.
• Define simple and complex febrile seizures and discuss evaluation, treatment, prognosis, and indications for admission.
• State the common complications associated with seizures and status epilepticus.
• Compare and contrast commonly used seizure medications and therapies, attending to treatments for specific seizure types, adverse drug events, and ease of use.
• Review the management of status epilepticus, including stabilization, testing, monitoring, and patient placement.
• Compare and contrast the risk and benefits of commonly used imaging modalities.
• Review the goals of inpatient diagnostic evaluation and therapy.
• Discuss indications for hospitalization or transfer to a higher level of care and/or comprehensive epilepsy care unit.
• List the indications for EEG monitoring and/or subspecialty consultation with neurology, psychiatry, and others as indicated.
• Summarize the risks for readmission, attending to medication management (such as dosing, availability, pharmacokinetics, and side effect profiles), compliance, and changes in disease state.

Pediatric hospitalists should be able to:

• Diagnose seizures by efficiently performing an accurate history and physical examination, with focus on the neurologic exam.
• Order appropriate laboratory and radiographic studies to identify the etiology of the seizure and potential underlying disorders.
• Interpret laboratory studies including drug levels and make therapy adjustments based on results.
• Order appropriate studies for patients with epilepsy, avoiding unnecessary duplication of testing and radiation exposure.
• Identify and efficiently treat the cause of the seizure where appropriate.
• Identify status epilepticus and initiate appropriate evidence-based treatment.
• Diagnose complications due to seizures and institute an appropriate medication plan and cardiorespiratory support as needed.
• Identify patients at increased risk for seizure recurrence or morbidity and ensure appropriate monitoring and treatment, including prescription of seizure rescue medications.
• Engage consultants when appropriate, including neurologists, epileptologists, and others.
• Create a comprehensive evaluation and management plan, addressing the needs of patients and the family/caregivers.
• Anticipate, monitor for, identify, and treat potential side effects of treatment.
• Recognize and efficiently transfer patients requiring higher level of care.

Pediatric hospitalists should be able to:

• Realize the importance of effective communication with patients, the family/caregivers, hospital staff, subspecialists, and primary care providers regarding the reasons for diagnostic testing and therapy choices.
• Recognize the role of education of patients and the family/caregivers in improving compliance with treatment and follow-up.
• Realize the impact that anxiety related to seizures in their child has on the family/caregivers.
• Prioritize anticipatory guidance and education of the family/caregivers regarding outcomes of febrile seizures, including the risk of the child developing epilepsy.
• Acknowledge the value of collaboration with subspecialists and the primary care provider to ensure coordinated longitudinal care for children with epilepsy.

In order to improve efficiency and quality within their organizations, pediatric hospitalists should:

• Lead, coordinate, or participate in the development and implementation of cost-effective safe, evidence-based care pathways to standardize the evaluation and management of hospitalized children with seizures and status epilepticus.
• Collaborate with hospital administration and community partners to develop and sustain referral networks for both transport and subspecialty services for children with seizures and chronic epilepsy.
• Collaborate with primary care providers, subspecialists, and other healthcare providers to create effective discharge plans that reduce the likelihood of readmission.

Introduction

Seizures are the most common neurologic disorder of childhood. Febrile seizures occur in up to 5% of children under age 5, and many children experience one afebrile seizure by adolescence. A subset of these children will develop epilepsy. In 2015, the CDC estimated that close to a half a million children were afflicted with this disorder. Seizures may range from self-limited to life-threatening events. Status epilepticus is defined as seizure activity of greater than five minutes duration without return to baseline. Optimal management of seizures not only includes identification of the underlying cause and initiation of appropriate anticonvulsant therapy or other treatments, but also the maintenance and management of an adequate airway and circulation. Pediatric hospitalists frequently encounter patients with active seizures and underlying epilepsy and should render both acute care and coordination of multidisciplinary care to the ambulatory setting.

Pediatric hospitalists should be able to:

• Discuss the pathophysiology of seizure activity.
• List the most common etiologies of seizures in various age groups such as the neonate, infant, preschool aged, school aged, and adolescent.
• List the various etiologies of seizures attending to both acute (such as electrolyte imbalance, infection, toxins, trauma, and others) and chronic (such as central nervous system malformations, metabolic diseases, and others) causes.
• Describe and distinguish between the various manifestations of seizure activity, such as involuntary motor activity, alterations of consciousness, behavior changes, disturbances of sensation, autonomic dysfunction, and others.
• Classify seizures based on where seizures begin in the brain, level of awareness during the seizures, and other distinguishing features.
• Review alternate diagnoses which may mimic the presentation of seizures including behavioral abnormalities, movement disorders, conversion disorders, and others.
• Compare and contrast distinguishing features of seizures versus other paroxysmal events.
• Define simple and complex febrile seizures and discuss evaluation, treatment, prognosis, and indications for admission.
• State the common complications associated with seizures and status epilepticus.
• Compare and contrast commonly used seizure medications and therapies, attending to treatments for specific seizure types, adverse drug events, and ease of use.
• Review the management of status epilepticus, including stabilization, testing, monitoring, and patient placement.
• Compare and contrast the risk and benefits of commonly used imaging modalities.
• Review the goals of inpatient diagnostic evaluation and therapy.
• Discuss indications for hospitalization or transfer to a higher level of care and/or comprehensive epilepsy care unit.
• List the indications for EEG monitoring and/or subspecialty consultation with neurology, psychiatry, and others as indicated.
• Summarize the risks for readmission, attending to medication management (such as dosing, availability, pharmacokinetics, and side effect profiles), compliance, and changes in disease state.

Pediatric hospitalists should be able to:

• Diagnose seizures by efficiently performing an accurate history and physical examination, with focus on the neurologic exam.
• Order appropriate laboratory and radiographic studies to identify the etiology of the seizure and potential underlying disorders.
• Interpret laboratory studies including drug levels and make therapy adjustments based on results.
• Order appropriate studies for patients with epilepsy, avoiding unnecessary duplication of testing and radiation exposure.
• Identify and efficiently treat the cause of the seizure where appropriate.
• Identify status epilepticus and initiate appropriate evidence-based treatment.
• Diagnose complications due to seizures and institute an appropriate medication plan and cardiorespiratory support as needed.
• Identify patients at increased risk for seizure recurrence or morbidity and ensure appropriate monitoring and treatment, including prescription of seizure rescue medications.
• Engage consultants when appropriate, including neurologists, epileptologists, and others.
• Create a comprehensive evaluation and management plan, addressing the needs of patients and the family/caregivers.
• Anticipate, monitor for, identify, and treat potential side effects of treatment.
• Recognize and efficiently transfer patients requiring higher level of care.

Pediatric hospitalists should be able to:

• Realize the importance of effective communication with patients, the family/caregivers, hospital staff, subspecialists, and primary care providers regarding the reasons for diagnostic testing and therapy choices.
• Recognize the role of education of patients and the family/caregivers in improving compliance with treatment and follow-up.
• Realize the impact that anxiety related to seizures in their child has on the family/caregivers.
• Prioritize anticipatory guidance and education of the family/caregivers regarding outcomes of febrile seizures, including the risk of the child developing epilepsy.
• Acknowledge the value of collaboration with subspecialists and the primary care provider to ensure coordinated longitudinal care for children with epilepsy.

In order to improve efficiency and quality within their organizations, pediatric hospitalists should:

• Lead, coordinate, or participate in the development and implementation of cost-effective safe, evidence-based care pathways to standardize the evaluation and management of hospitalized children with seizures and status epilepticus.
• Collaborate with hospital administration and community partners to develop and sustain referral networks for both transport and subspecialty services for children with seizures and chronic epilepsy.
• Collaborate with primary care providers, subspecialists, and other healthcare providers to create effective discharge plans that reduce the likelihood of readmission.

Introduction

Lower respiratory tract infections cause substantial morbidity and mortality in the pediatric population. Worldwide, pneumonia is the leading cause of death in children under 5 years of age. In the United States, pneumonia accounts for just over 7% of pediatric hospitalizations. Pneumonia is commonly caused by a viral infection, especially in children less than 2 years old. Even with extensive testing, bacterial cause of pneumonia will be identified in the small minority of hospitalized children. Non-viral etiologies for pneumonia differ based upon age and underlying risk factors resulting in the need to tailor antimicrobials appropriately. Surgical intervention may be required when pneumonia is complicated by pleural effusion or abscess. Pediatric hospitalists frequently care for children with pneumonia and should be able to provide evidence-based care and coordinate subspecialty care when necessary.

Pediatric hospitalists should be able to:

• Describe the key features of the history and physical examination that support or refute the diagnosis of pneumonia.
• Discuss the variations in clinical presentation that may accompany chronic health conditions of childhood, such as cystic fibrosis, chronic lung disease, congenital heart disease, immunodeficiency, and others.
• Review alternate diagnoses which may mimic the presentation of pneumonia including anatomic defects, systemic diseases, heart failure, and others.
• List common bacterial, atypical bacterial, and viral organisms causing pneumonia and state how these differ based on age.
• Name other causes of infectious and non-infectious pneumonias such as lipoid, inhalation pneumonitis, aspiration, and others.
• Provide indications for hospital admission and determine the appropriate level of care.
• Discuss the influence of national immunization practices and antimicrobial use on predominant organisms and resistance patterns.
• Describe local resistance patterns for predominant infectious organisms.
• Discuss the benefits and limitations of radiography and laboratory evaluation in the diagnosis of pneumonia.
• Describe common complications seen with pneumonia, including comorbidities or infectious etiologies associated with higher risk for each.
• Describe the indications and options for surgical intervention in patients with complicated pneumonia, including occurrence of parapneumonic effusion, empyema, necrotizing pneumonia, abscess, pneumothorax, and other underlying structural issue.
• Summarize goals for hospital discharge, attending to symptoms, oxygenation saturation, hydration, the family/caregivers’ needs, and outpatient management plans.

Pediatric hospitalists should be able to:

• Diagnose pneumonia by efficiently performing an accurate history and physical examination, determining if key features of the disease are present.
• Order appropriate laboratory and radiographic tests to guide treatment and correctly interpret the results.
• Ensure proper isolation for patients with pneumonia.
• Direct an evidence-based treatment plan, including cardiorespiratory monitoring, oxygen supplementation, and appropriately selected antibiotic therapy as indicated.
• Interpret chest radiographs, distinguishing between consolidation, effusion, mass, and other findings.
• Perform careful reassessments daily and as needed, note changes in clinical status, and respond with appropriate actions.
• Determine when consultation (such as surgical, pulmonary, interventional radiology, or other subspecialty) or transfer to a higher level of care is indicated.
• Identify patients requiring extended evaluation for underlying anatomic or systemic disease.
• Create a comprehensive discharge plan.
• Coordinate discharge efficiently and effectively with patients, the family/caregivers, subspecialists, and the primary care provider, including home care needs and follow-up as appropriate.

Pediatric hospitalists should be able to:

• Role model and advocate for strict adherence to handwashing and other infection control practices.
• Realize the importance of antimicrobial stewardship and consistently modify prescribing practice to reflect best practices attending to local resistance patterns.
• Realize responsibility for communicating effectively with patients, the family/caregivers, and healthcare providers regarding findings and care plans.
• Acknowledge the importance of collaboration with subspecialists to render safe and efficient treatment.
• Exemplify adherence to latest research and guidelines to ensure that prescribed testing and therapeutic modalities are effective and evidence based.

In order to improve efficiency and quality within their organizations, pediatric hospitalists should:

• Work with hospital, community, and infectious disease experts to develop and sustain local communications regarding resistance pattern changes.
• Lead, coordinate, or participate in the development and implementation of cost-effective, safe, evidence-based care pathways to standardize the evaluation and management of hospitalized children with pneumonia.

Introduction

Lower respiratory tract infections cause substantial morbidity and mortality in the pediatric population. Worldwide, pneumonia is the leading cause of death in children under 5 years of age. In the United States, pneumonia accounts for just over 7% of pediatric hospitalizations. Pneumonia is commonly caused by a viral infection, especially in children less than 2 years old. Even with extensive testing, bacterial cause of pneumonia will be identified in the small minority of hospitalized children. Non-viral etiologies for pneumonia differ based upon age and underlying risk factors resulting in the need to tailor antimicrobials appropriately. Surgical intervention may be required when pneumonia is complicated by pleural effusion or abscess. Pediatric hospitalists frequently care for children with pneumonia and should be able to provide evidence-based care and coordinate subspecialty care when necessary.

Pediatric hospitalists should be able to:

• Describe the key features of the history and physical examination that support or refute the diagnosis of pneumonia.
• Discuss the variations in clinical presentation that may accompany chronic health conditions of childhood, such as cystic fibrosis, chronic lung disease, congenital heart disease, immunodeficiency, and others.
• Review alternate diagnoses which may mimic the presentation of pneumonia including anatomic defects, systemic diseases, heart failure, and others.
• List common bacterial, atypical bacterial, and viral organisms causing pneumonia and state how these differ based on age.
• Name other causes of infectious and non-infectious pneumonias such as lipoid, inhalation pneumonitis, aspiration, and others.
• Provide indications for hospital admission and determine the appropriate level of care.
• Discuss the influence of national immunization practices and antimicrobial use on predominant organisms and resistance patterns.
• Describe local resistance patterns for predominant infectious organisms.
• Discuss the benefits and limitations of radiography and laboratory evaluation in the diagnosis of pneumonia.
• Describe common complications seen with pneumonia, including comorbidities or infectious etiologies associated with higher risk for each.
• Describe the indications and options for surgical intervention in patients with complicated pneumonia, including occurrence of parapneumonic effusion, empyema, necrotizing pneumonia, abscess, pneumothorax, and other underlying structural issue.
• Summarize goals for hospital discharge, attending to symptoms, oxygenation saturation, hydration, the family/caregivers’ needs, and outpatient management plans.

Pediatric hospitalists should be able to:

• Diagnose pneumonia by efficiently performing an accurate history and physical examination, determining if key features of the disease are present.
• Order appropriate laboratory and radiographic tests to guide treatment and correctly interpret the results.
• Ensure proper isolation for patients with pneumonia.
• Direct an evidence-based treatment plan, including cardiorespiratory monitoring, oxygen supplementation, and appropriately selected antibiotic therapy as indicated.
• Interpret chest radiographs, distinguishing between consolidation, effusion, mass, and other findings.
• Perform careful reassessments daily and as needed, note changes in clinical status, and respond with appropriate actions.
• Determine when consultation (such as surgical, pulmonary, interventional radiology, or other subspecialty) or transfer to a higher level of care is indicated.
• Identify patients requiring extended evaluation for underlying anatomic or systemic disease.
• Create a comprehensive discharge plan.
• Coordinate discharge efficiently and effectively with patients, the family/caregivers, subspecialists, and the primary care provider, including home care needs and follow-up as appropriate.

Pediatric hospitalists should be able to:

• Role model and advocate for strict adherence to handwashing and other infection control practices.
• Realize the importance of antimicrobial stewardship and consistently modify prescribing practice to reflect best practices attending to local resistance patterns.
• Realize responsibility for communicating effectively with patients, the family/caregivers, and healthcare providers regarding findings and care plans.
• Acknowledge the importance of collaboration with subspecialists to render safe and efficient treatment.
• Exemplify adherence to latest research and guidelines to ensure that prescribed testing and therapeutic modalities are effective and evidence based.

In order to improve efficiency and quality within their organizations, pediatric hospitalists should:

• Work with hospital, community, and infectious disease experts to develop and sustain local communications regarding resistance pattern changes.
• Lead, coordinate, or participate in the development and implementation of cost-effective, safe, evidence-based care pathways to standardize the evaluation and management of hospitalized children with pneumonia.

Introduction

Lower respiratory tract infections cause substantial morbidity and mortality in the pediatric population. Worldwide, pneumonia is the leading cause of death in children under 5 years of age. In the United States, pneumonia accounts for just over 7% of pediatric hospitalizations. Pneumonia is commonly caused by a viral infection, especially in children less than 2 years old. Even with extensive testing, bacterial cause of pneumonia will be identified in the small minority of hospitalized children. Non-viral etiologies for pneumonia differ based upon age and underlying risk factors resulting in the need to tailor antimicrobials appropriately. Surgical intervention may be required when pneumonia is complicated by pleural effusion or abscess. Pediatric hospitalists frequently care for children with pneumonia and should be able to provide evidence-based care and coordinate subspecialty care when necessary.

Pediatric hospitalists should be able to:

• Describe the key features of the history and physical examination that support or refute the diagnosis of pneumonia.
• Discuss the variations in clinical presentation that may accompany chronic health conditions of childhood, such as cystic fibrosis, chronic lung disease, congenital heart disease, immunodeficiency, and others.
• Review alternate diagnoses which may mimic the presentation of pneumonia including anatomic defects, systemic diseases, heart failure, and others.
• List common bacterial, atypical bacterial, and viral organisms causing pneumonia and state how these differ based on age.
• Name other causes of infectious and non-infectious pneumonias such as lipoid, inhalation pneumonitis, aspiration, and others.
• Provide indications for hospital admission and determine the appropriate level of care.
• Discuss the influence of national immunization practices and antimicrobial use on predominant organisms and resistance patterns.
• Describe local resistance patterns for predominant infectious organisms.
• Discuss the benefits and limitations of radiography and laboratory evaluation in the diagnosis of pneumonia.
• Describe common complications seen with pneumonia, including comorbidities or infectious etiologies associated with higher risk for each.
• Describe the indications and options for surgical intervention in patients with complicated pneumonia, including occurrence of parapneumonic effusion, empyema, necrotizing pneumonia, abscess, pneumothorax, and other underlying structural issue.
• Summarize goals for hospital discharge, attending to symptoms, oxygenation saturation, hydration, the family/caregivers’ needs, and outpatient management plans.

Pediatric hospitalists should be able to:

• Diagnose pneumonia by efficiently performing an accurate history and physical examination, determining if key features of the disease are present.
• Order appropriate laboratory and radiographic tests to guide treatment and correctly interpret the results.
• Ensure proper isolation for patients with pneumonia.
• Direct an evidence-based treatment plan, including cardiorespiratory monitoring, oxygen supplementation, and appropriately selected antibiotic therapy as indicated.
• Interpret chest radiographs, distinguishing between consolidation, effusion, mass, and other findings.
• Perform careful reassessments daily and as needed, note changes in clinical status, and respond with appropriate actions.
• Determine when consultation (such as surgical, pulmonary, interventional radiology, or other subspecialty) or transfer to a higher level of care is indicated.
• Identify patients requiring extended evaluation for underlying anatomic or systemic disease.
• Create a comprehensive discharge plan.
• Coordinate discharge efficiently and effectively with patients, the family/caregivers, subspecialists, and the primary care provider, including home care needs and follow-up as appropriate.

Pediatric hospitalists should be able to:

• Role model and advocate for strict adherence to handwashing and other infection control practices.
• Realize the importance of antimicrobial stewardship and consistently modify prescribing practice to reflect best practices attending to local resistance patterns.
• Realize responsibility for communicating effectively with patients, the family/caregivers, and healthcare providers regarding findings and care plans.
• Acknowledge the importance of collaboration with subspecialists to render safe and efficient treatment.
• Exemplify adherence to latest research and guidelines to ensure that prescribed testing and therapeutic modalities are effective and evidence based.

In order to improve efficiency and quality within their organizations, pediatric hospitalists should:

• Work with hospital, community, and infectious disease experts to develop and sustain local communications regarding resistance pattern changes.
• Lead, coordinate, or participate in the development and implementation of cost-effective, safe, evidence-based care pathways to standardize the evaluation and management of hospitalized children with pneumonia.

Introduction

Jaundice due to unconjugated hyperbilirubinemia is the most common complication of the normal newborn period and occurs to some degree in more than 80% of healthy term and late preterm newborns. Physiologic jaundice occurs in the first three to five days of age when the total serum bilirubin levels rise before subsequently declining. Transient hyperbilirubinemia does not cause morbidity but must be monitored closely and treated if appropriate, to ensure that it does not progress to severe hyperbilirubinemia and/or chronic bilirubin encephalopathy (kernicterus). Severe or prolonged hyperbilirubinemia that cannot be explained by an infant’s birth and family history, blood type, breastfeeding status, and other clinical factors may require further laboratory testing and work-up. In addition, jaundice due to unconjugated hyperbilirubinemia must be distinguished from conjugated hyperbilirubinemia, when the conjugated bilirubin level is either greater than 1 mg/dL or more than 20% of the total bilirubin concentration. Pediatric hospitalists often provide consultation regarding necessity for admission as well as render inpatient care; therefore, they must be knowledgeable about the diagnosis and management of neonatal hyperbilirubinemia.

Pediatric hospitalists should be able to:

• Describe the physiology of bilirubin production and metabolism, including the pathophysiology that leads to hyperbilirubinemia.
• List the elements of the birth and family histories and review of systems which may aid in determining the etiology of the hyperbilirubinemia.
• Cite the physical examination findings that support a potential underlying diagnosis attending to skin, abdomen, dysmorphic features, and others.
• Discuss the risk factors for severe unconjugated hyperbilirubinemia, including lower gestational age, isoimmune hemolytic disease, and exclusive breastfeeding.
• Describe indications for inpatient admission for the management of hyperbilirubinemia.
• Compare and contrast the pathophysiology and epidemiology of breast milk jaundice versus breastfeeding jaundice.
• Describe the differential diagnosis of prolonged unconjugated hyperbilirubinemia.
• Discuss the risk factors for bilirubin neurotoxicity, such as prematurity, isoimmune hemolytic disease, and sepsis.
• Review the pathophysiology involved in the development of kernicterus.
• Compare and contrast the features that distinguish unconjugated hyperbilirubinemia from conjugated hyperbilirubinemia.
• Describe the differential diagnosis of conjugated hyperbilirubinemia.
• Describe the syndrome of bilirubin-induced neurologic dysfunction (BIND).
• Review the approach toward diagnosis, including commonly performed laboratory tests.
• Describe the use of diagnostic imaging in evaluating conjugated hyperbilirubinemia.
• Explain the current national recommendations and evidence-based standards for the management of hyperbilirubinemia in the newborn.

Pediatric hospitalists should be able to:

• Obtain accurate, relevant information from the newborn and maternal histories, such as prenatal laboratory results, maternal and infant blood types, delivery information, feeding history, and others.
• Perform a comprehensive exam, identifying jaundice and eliciting findings to support potential underlying diagnoses.
• Identify symptoms of bilirubin encephalopathy, such as poor feeding, lethargy, irritability, hypertonia, seizures, and others.
• Order and interpret bilirubin results in a timely manner based on risk factors for developing severe hyperbilirubinemia.
• Order and interpret other studies as needed to diagnose associated underlying conditions.
• Provide support and advice for breastfeeding mothers in order to optimize breastfeeding and enable understanding when it is medically necessary to start supplementation with expressed breast milk or formula.
• Recognize indications for initiating, continuing, and discontinuing phototherapy and/or exchange transfusion based on risk factors for bilirubin neurotoxicity.
• Avoid routine intravenous fluids during phototherapy, unless there are concerns about inadequate oral intake or severe dehydration.
• Obtain appropriate consultative services for infants with conjugated hyperbilirubinemia or unexplained severe or prolonged unconjugated hyperbilirubinemia who may need further evaluation.
• Identify neonates requiring a higher level of care and efficiently coordinate transfer.
• Perform careful reassessments daily and as needed, note changes in clinical status, and respond with appropriate actions.
• Create a discharge plan that includes comprehensive hand-off communication and addresses specific outpatient follow-up needs, such as weight checks, repeat laboratory testing, and others as appropriate.

Pediatric hospitalists should be able to:

• Appreciate the impact of successful breastfeeding on the primary prevention of neonatal hyperbilirubinemia.
• Realize responsibility for educating the family/caregivers and other professional staff regarding the risks, evaluation, and therapies available for hyperbilirubinemia.
• Acknowledge the importance of coordinating discharge plans with the primary care provider and home care agencies as appropriate.

In order to improve efficiency and quality within their organizations, pediatric hospitalists should:

• Lead, coordinate, or participate in the development and implementation of policies and procedures that promote the successful initiation and continuation of breastfeeding for newborns.
• Lead, coordinate, or participate in the development and implementation of cost-effective, safe, evidence-based care pathways to standardize the evaluation and management of hospitalized neonates with hyperbilirubinemia.
• Lead, coordinate, or participate in education programs for the family/caregivers and the community to increase awareness of evidence-based guidelines and strategies to reduce admission rates.

Introduction

Jaundice due to unconjugated hyperbilirubinemia is the most common complication of the normal newborn period and occurs to some degree in more than 80% of healthy term and late preterm newborns. Physiologic jaundice occurs in the first three to five days of age when the total serum bilirubin levels rise before subsequently declining. Transient hyperbilirubinemia does not cause morbidity but must be monitored closely and treated if appropriate, to ensure that it does not progress to severe hyperbilirubinemia and/or chronic bilirubin encephalopathy (kernicterus). Severe or prolonged hyperbilirubinemia that cannot be explained by an infant’s birth and family history, blood type, breastfeeding status, and other clinical factors may require further laboratory testing and work-up. In addition, jaundice due to unconjugated hyperbilirubinemia must be distinguished from conjugated hyperbilirubinemia, when the conjugated bilirubin level is either greater than 1 mg/dL or more than 20% of the total bilirubin concentration. Pediatric hospitalists often provide consultation regarding necessity for admission as well as render inpatient care; therefore, they must be knowledgeable about the diagnosis and management of neonatal hyperbilirubinemia.

Pediatric hospitalists should be able to:

• Describe the physiology of bilirubin production and metabolism, including the pathophysiology that leads to hyperbilirubinemia.
• List the elements of the birth and family histories and review of systems which may aid in determining the etiology of the hyperbilirubinemia.
• Cite the physical examination findings that support a potential underlying diagnosis attending to skin, abdomen, dysmorphic features, and others.
• Discuss the risk factors for severe unconjugated hyperbilirubinemia, including lower gestational age, isoimmune hemolytic disease, and exclusive breastfeeding.
• Describe indications for inpatient admission for the management of hyperbilirubinemia.
• Compare and contrast the pathophysiology and epidemiology of breast milk jaundice versus breastfeeding jaundice.
• Describe the differential diagnosis of prolonged unconjugated hyperbilirubinemia.
• Discuss the risk factors for bilirubin neurotoxicity, such as prematurity, isoimmune hemolytic disease, and sepsis.
• Review the pathophysiology involved in the development of kernicterus.
• Compare and contrast the features that distinguish unconjugated hyperbilirubinemia from conjugated hyperbilirubinemia.
• Describe the differential diagnosis of conjugated hyperbilirubinemia.
• Describe the syndrome of bilirubin-induced neurologic dysfunction (BIND).
• Review the approach toward diagnosis, including commonly performed laboratory tests.
• Describe the use of diagnostic imaging in evaluating conjugated hyperbilirubinemia.
• Explain the current national recommendations and evidence-based standards for the management of hyperbilirubinemia in the newborn.

Pediatric hospitalists should be able to:

• Obtain accurate, relevant information from the newborn and maternal histories, such as prenatal laboratory results, maternal and infant blood types, delivery information, feeding history, and others.
• Perform a comprehensive exam, identifying jaundice and eliciting findings to support potential underlying diagnoses.
• Identify symptoms of bilirubin encephalopathy, such as poor feeding, lethargy, irritability, hypertonia, seizures, and others.
• Order and interpret bilirubin results in a timely manner based on risk factors for developing severe hyperbilirubinemia.
• Order and interpret other studies as needed to diagnose associated underlying conditions.
• Provide support and advice for breastfeeding mothers in order to optimize breastfeeding and enable understanding when it is medically necessary to start supplementation with expressed breast milk or formula.
• Recognize indications for initiating, continuing, and discontinuing phototherapy and/or exchange transfusion based on risk factors for bilirubin neurotoxicity.
• Avoid routine intravenous fluids during phototherapy, unless there are concerns about inadequate oral intake or severe dehydration.
• Obtain appropriate consultative services for infants with conjugated hyperbilirubinemia or unexplained severe or prolonged unconjugated hyperbilirubinemia who may need further evaluation.
• Identify neonates requiring a higher level of care and efficiently coordinate transfer.
• Perform careful reassessments daily and as needed, note changes in clinical status, and respond with appropriate actions.
• Create a discharge plan that includes comprehensive hand-off communication and addresses specific outpatient follow-up needs, such as weight checks, repeat laboratory testing, and others as appropriate.

Pediatric hospitalists should be able to:

• Appreciate the impact of successful breastfeeding on the primary prevention of neonatal hyperbilirubinemia.
• Realize responsibility for educating the family/caregivers and other professional staff regarding the risks, evaluation, and therapies available for hyperbilirubinemia.
• Acknowledge the importance of coordinating discharge plans with the primary care provider and home care agencies as appropriate.

In order to improve efficiency and quality within their organizations, pediatric hospitalists should:

• Lead, coordinate, or participate in the development and implementation of policies and procedures that promote the successful initiation and continuation of breastfeeding for newborns.
• Lead, coordinate, or participate in the development and implementation of cost-effective, safe, evidence-based care pathways to standardize the evaluation and management of hospitalized neonates with hyperbilirubinemia.
• Lead, coordinate, or participate in education programs for the family/caregivers and the community to increase awareness of evidence-based guidelines and strategies to reduce admission rates.

Introduction

Jaundice due to unconjugated hyperbilirubinemia is the most common complication of the normal newborn period and occurs to some degree in more than 80% of healthy term and late preterm newborns. Physiologic jaundice occurs in the first three to five days of age when the total serum bilirubin levels rise before subsequently declining. Transient hyperbilirubinemia does not cause morbidity but must be monitored closely and treated if appropriate, to ensure that it does not progress to severe hyperbilirubinemia and/or chronic bilirubin encephalopathy (kernicterus). Severe or prolonged hyperbilirubinemia that cannot be explained by an infant’s birth and family history, blood type, breastfeeding status, and other clinical factors may require further laboratory testing and work-up. In addition, jaundice due to unconjugated hyperbilirubinemia must be distinguished from conjugated hyperbilirubinemia, when the conjugated bilirubin level is either greater than 1 mg/dL or more than 20% of the total bilirubin concentration. Pediatric hospitalists often provide consultation regarding necessity for admission as well as render inpatient care; therefore, they must be knowledgeable about the diagnosis and management of neonatal hyperbilirubinemia.

Pediatric hospitalists should be able to:

• Describe the physiology of bilirubin production and metabolism, including the pathophysiology that leads to hyperbilirubinemia.
• List the elements of the birth and family histories and review of systems which may aid in determining the etiology of the hyperbilirubinemia.
• Cite the physical examination findings that support a potential underlying diagnosis attending to skin, abdomen, dysmorphic features, and others.
• Discuss the risk factors for severe unconjugated hyperbilirubinemia, including lower gestational age, isoimmune hemolytic disease, and exclusive breastfeeding.
• Describe indications for inpatient admission for the management of hyperbilirubinemia.
• Compare and contrast the pathophysiology and epidemiology of breast milk jaundice versus breastfeeding jaundice.
• Describe the differential diagnosis of prolonged unconjugated hyperbilirubinemia.
• Discuss the risk factors for bilirubin neurotoxicity, such as prematurity, isoimmune hemolytic disease, and sepsis.
• Review the pathophysiology involved in the development of kernicterus.
• Compare and contrast the features that distinguish unconjugated hyperbilirubinemia from conjugated hyperbilirubinemia.
• Describe the differential diagnosis of conjugated hyperbilirubinemia.
• Describe the syndrome of bilirubin-induced neurologic dysfunction (BIND).
• Review the approach toward diagnosis, including commonly performed laboratory tests.
• Describe the use of diagnostic imaging in evaluating conjugated hyperbilirubinemia.
• Explain the current national recommendations and evidence-based standards for the management of hyperbilirubinemia in the newborn.

Pediatric hospitalists should be able to:

• Obtain accurate, relevant information from the newborn and maternal histories, such as prenatal laboratory results, maternal and infant blood types, delivery information, feeding history, and others.
• Perform a comprehensive exam, identifying jaundice and eliciting findings to support potential underlying diagnoses.
• Identify symptoms of bilirubin encephalopathy, such as poor feeding, lethargy, irritability, hypertonia, seizures, and others.
• Order and interpret bilirubin results in a timely manner based on risk factors for developing severe hyperbilirubinemia.
• Order and interpret other studies as needed to diagnose associated underlying conditions.
• Provide support and advice for breastfeeding mothers in order to optimize breastfeeding and enable understanding when it is medically necessary to start supplementation with expressed breast milk or formula.
• Recognize indications for initiating, continuing, and discontinuing phototherapy and/or exchange transfusion based on risk factors for bilirubin neurotoxicity.
• Avoid routine intravenous fluids during phototherapy, unless there are concerns about inadequate oral intake or severe dehydration.
• Obtain appropriate consultative services for infants with conjugated hyperbilirubinemia or unexplained severe or prolonged unconjugated hyperbilirubinemia who may need further evaluation.
• Identify neonates requiring a higher level of care and efficiently coordinate transfer.
• Perform careful reassessments daily and as needed, note changes in clinical status, and respond with appropriate actions.
• Create a discharge plan that includes comprehensive hand-off communication and addresses specific outpatient follow-up needs, such as weight checks, repeat laboratory testing, and others as appropriate.

Pediatric hospitalists should be able to:

• Appreciate the impact of successful breastfeeding on the primary prevention of neonatal hyperbilirubinemia.
• Realize responsibility for educating the family/caregivers and other professional staff regarding the risks, evaluation, and therapies available for hyperbilirubinemia.
• Acknowledge the importance of coordinating discharge plans with the primary care provider and home care agencies as appropriate.

In order to improve efficiency and quality within their organizations, pediatric hospitalists should:

• Lead, coordinate, or participate in the development and implementation of policies and procedures that promote the successful initiation and continuation of breastfeeding for newborns.
• Lead, coordinate, or participate in the development and implementation of cost-effective, safe, evidence-based care pathways to standardize the evaluation and management of hospitalized neonates with hyperbilirubinemia.
• Lead, coordinate, or participate in education programs for the family/caregivers and the community to increase awareness of evidence-based guidelines and strategies to reduce admission rates.

Introduction

Fever in a neonate (≤ 28 days of age) is defined as a rectal temperature above 38°C. Fever in this population is notable as it leads to concern for serious bacterial infection. However, infection may also present with hypothermia, usually defined as a rectal temperature below 36.5°C. Infection in neonates may occur as a result of both a naïve immune system and exposure to pathogenic bacteria during delivery, although pathogens acquired in the postnatal period must also be considered. Serious bacterial infections in neonates are most predominant in the renal, pulmonary, central nervous, and blood systems. The prevalence of each varies by age and gender. Neonates may also develop serious illness when they are exposed to viral infections, especially herpes simplex virus (HSV) which typically manifests between 7-21 days of life. In febrile neonates without a clear source of illness, distinguishing between those with self-limiting versus life-threatening infection is challenging. Well-appearing infants over 28 days of age may be managed without hospitalization in selected circumstances. However, more conservative inpatient evaluation, monitoring, and management of neonates younger than 28 days of age with abnormal temperature is currently the standard of care. Pediatric hospitalists should render evidence-based care for these neonates.

Pediatric hospitalists should be able to:

• Define hypothermia and hyperthermia in neonates and describe how to correctly obtain a temperature using a variety of modalities.
• Discuss the basic mechanisms of temperature regulation in neonates.
• Compare and contrast basic immune maturity differences in neonates versus older infants.
• Delineate the elements of the history (such as birth history, perinatal exposures, maternal infections, and others) and physical examination (such as skin lesions, neurobehavioral exam, and others) that aid in determining a diagnosis.
• Describe the differential diagnosis of neonatal sepsis and discuss how other potentially serious illnesses, such as inborn errors of metabolism, may mimic its presentation.
• List the organisms responsible for serious bacterial infection in neonates, including the types of infections they cause and the relative prevalence of each.
• Review the approach toward evaluation of the preterm infant, attending to extent of prematurity and neonatal intensive care course.
• Compare and contrast the signs and symptoms suggestive of bacterial versus viral illnesses.
• Distinguish between the standard laboratory evaluation for neonates with fever versus older infants with fever, using current literature for reference.
• Describe the role of viral testing, including interpretation of frequencies of disease, co-infections with bacterial disease, local turnaround time, and predictive value of testing.
• Describe indications for the use of antibiotics versus inpatient monitoring without the use of antibiotics, considering current validated scoring tools and evidence about reported rates of neonatal serious bacterial infection.
• Summarize the approach to empiric antimicrobial therapy and give examples of situations warranting expanded antimicrobial coverage.

Pediatric hospitalists should be able to:

• Obtain a complete history, including pregnancy and birth history, attending to prenatal laboratory screening and the use of antibiotic prophylaxis prior to delivery.
• Perform a comprehensive physical examination, attending to signs and symptoms that may indicate a source of infection or signify severe illness.
• Perform, supervise, or direct basic procedures to obtain specimens, including venipuncture, bladder catheterization, lumbar puncture, and placement of intravenous access, according to local context.
• Interpret the results of laboratory evaluations efficiently and adjust the differential diagnosis and plan of care accordingly.
• Select appropriate empiric antimicrobial coverage in an evidence-based manner.
• Perform careful reassessments daily and as needed, note changes in clinical status, and respond with appropriate actions.
• Communicate with the family/caregivers and healthcare providers regarding findings and care plans.
• Create a discharge plan which can be expediently activated when appropriate.

Pediatric hospitalists should be able to:

• Elicit and allay the concerns of the family/caregivers, educating them regarding the importance of a thorough evaluation for the source of infection and the need for empiric antimicrobial therapy.
• Realize the importance of educating the family/caregivers about the final diagnosis, clearly explaining the value of negative test results if applicable.
• Recognize the significance of performing invasive procedures on a neonate from the family/caregivers’ perspective, maintaining empathy when discussing the risks and benefits of necessary procedures.
• Ensure an effective and safe discharge by communicating and coordinating effectively with the primary care provider.

In order to improve efficiency and quality within their organizations, pediatric hospitalists should:

• Lead, coordinate, or participate in the development and implementation of cost-effective, safe, evidence-based care pathways to standardize the evaluation and management of hospitalized neonates with fever.

• Lead, coordinate, or participate in efforts to develop institutional guidelines for the judicious use of antimicrobials in neonates with fever.

1. Roberts KB. Management and outcomes of care of fever in early infancy. J Pediatr. 2004;145(3):417. https://doi.org/10.1016/j.jpeds.2004.06.036.

2. Vachani JG, McNeal-Trice K, and Wallace SS. Current Evidence on the Evaluation and Management of Fever Without a Source in Infants Aged 0-90 Days: A Review. Rev Recent Clin Trials. 2017;12(4):240-246. https://doi.org/10.2174/1574887112666170816143308.

3. Puopolo KM, Benitz WE, and Zaoutis TE. Committee on Fetus and Newborn, Committee on Infectious Diseases. Management of Neonates Born at ≥35 0/7 Weeks’ Gestation with Suspected or Proven Early-Onset Bacterial Sepsis. Pediatrics Dec 2018, 142 (6) e20182894. https://pediatrics.aappublications.org/content/142/6/e20182894.full Accessed August 28, 2019.

Introduction

Fever in a neonate (≤ 28 days of age) is defined as a rectal temperature above 38°C. Fever in this population is notable as it leads to concern for serious bacterial infection. However, infection may also present with hypothermia, usually defined as a rectal temperature below 36.5°C. Infection in neonates may occur as a result of both a naïve immune system and exposure to pathogenic bacteria during delivery, although pathogens acquired in the postnatal period must also be considered. Serious bacterial infections in neonates are most predominant in the renal, pulmonary, central nervous, and blood systems. The prevalence of each varies by age and gender. Neonates may also develop serious illness when they are exposed to viral infections, especially herpes simplex virus (HSV) which typically manifests between 7-21 days of life. In febrile neonates without a clear source of illness, distinguishing between those with self-limiting versus life-threatening infection is challenging. Well-appearing infants over 28 days of age may be managed without hospitalization in selected circumstances. However, more conservative inpatient evaluation, monitoring, and management of neonates younger than 28 days of age with abnormal temperature is currently the standard of care. Pediatric hospitalists should render evidence-based care for these neonates.

Pediatric hospitalists should be able to:

• Define hypothermia and hyperthermia in neonates and describe how to correctly obtain a temperature using a variety of modalities.
• Discuss the basic mechanisms of temperature regulation in neonates.
• Compare and contrast basic immune maturity differences in neonates versus older infants.
• Delineate the elements of the history (such as birth history, perinatal exposures, maternal infections, and others) and physical examination (such as skin lesions, neurobehavioral exam, and others) that aid in determining a diagnosis.
• Describe the differential diagnosis of neonatal sepsis and discuss how other potentially serious illnesses, such as inborn errors of metabolism, may mimic its presentation.
• List the organisms responsible for serious bacterial infection in neonates, including the types of infections they cause and the relative prevalence of each.
• Review the approach toward evaluation of the preterm infant, attending to extent of prematurity and neonatal intensive care course.
• Compare and contrast the signs and symptoms suggestive of bacterial versus viral illnesses.
• Distinguish between the standard laboratory evaluation for neonates with fever versus older infants with fever, using current literature for reference.
• Describe the role of viral testing, including interpretation of frequencies of disease, co-infections with bacterial disease, local turnaround time, and predictive value of testing.
• Describe indications for the use of antibiotics versus inpatient monitoring without the use of antibiotics, considering current validated scoring tools and evidence about reported rates of neonatal serious bacterial infection.
• Summarize the approach to empiric antimicrobial therapy and give examples of situations warranting expanded antimicrobial coverage.

Pediatric hospitalists should be able to:

• Obtain a complete history, including pregnancy and birth history, attending to prenatal laboratory screening and the use of antibiotic prophylaxis prior to delivery.
• Perform a comprehensive physical examination, attending to signs and symptoms that may indicate a source of infection or signify severe illness.
• Perform, supervise, or direct basic procedures to obtain specimens, including venipuncture, bladder catheterization, lumbar puncture, and placement of intravenous access, according to local context.
• Interpret the results of laboratory evaluations efficiently and adjust the differential diagnosis and plan of care accordingly.
• Select appropriate empiric antimicrobial coverage in an evidence-based manner.
• Perform careful reassessments daily and as needed, note changes in clinical status, and respond with appropriate actions.
• Communicate with the family/caregivers and healthcare providers regarding findings and care plans.
• Create a discharge plan which can be expediently activated when appropriate.

Pediatric hospitalists should be able to:

• Elicit and allay the concerns of the family/caregivers, educating them regarding the importance of a thorough evaluation for the source of infection and the need for empiric antimicrobial therapy.
• Realize the importance of educating the family/caregivers about the final diagnosis, clearly explaining the value of negative test results if applicable.
• Recognize the significance of performing invasive procedures on a neonate from the family/caregivers’ perspective, maintaining empathy when discussing the risks and benefits of necessary procedures.
• Ensure an effective and safe discharge by communicating and coordinating effectively with the primary care provider.

In order to improve efficiency and quality within their organizations, pediatric hospitalists should:

• Lead, coordinate, or participate in the development and implementation of cost-effective, safe, evidence-based care pathways to standardize the evaluation and management of hospitalized neonates with fever.

• Lead, coordinate, or participate in efforts to develop institutional guidelines for the judicious use of antimicrobials in neonates with fever.

1. Roberts KB. Management and outcomes of care of fever in early infancy. J Pediatr. 2004;145(3):417. https://doi.org/10.1016/j.jpeds.2004.06.036.

2. Vachani JG, McNeal-Trice K, and Wallace SS. Current Evidence on the Evaluation and Management of Fever Without a Source in Infants Aged 0-90 Days: A Review. Rev Recent Clin Trials. 2017;12(4):240-246. https://doi.org/10.2174/1574887112666170816143308.

3. Puopolo KM, Benitz WE, and Zaoutis TE. Committee on Fetus and Newborn, Committee on Infectious Diseases. Management of Neonates Born at ≥35 0/7 Weeks’ Gestation with Suspected or Proven Early-Onset Bacterial Sepsis. Pediatrics Dec 2018, 142 (6) e20182894. https://pediatrics.aappublications.org/content/142/6/e20182894.full Accessed August 28, 2019.

Introduction

Fever in a neonate (≤ 28 days of age) is defined as a rectal temperature above 38°C. Fever in this population is notable as it leads to concern for serious bacterial infection. However, infection may also present with hypothermia, usually defined as a rectal temperature below 36.5°C. Infection in neonates may occur as a result of both a naïve immune system and exposure to pathogenic bacteria during delivery, although pathogens acquired in the postnatal period must also be considered. Serious bacterial infections in neonates are most predominant in the renal, pulmonary, central nervous, and blood systems. The prevalence of each varies by age and gender. Neonates may also develop serious illness when they are exposed to viral infections, especially herpes simplex virus (HSV) which typically manifests between 7-21 days of life. In febrile neonates without a clear source of illness, distinguishing between those with self-limiting versus life-threatening infection is challenging. Well-appearing infants over 28 days of age may be managed without hospitalization in selected circumstances. However, more conservative inpatient evaluation, monitoring, and management of neonates younger than 28 days of age with abnormal temperature is currently the standard of care. Pediatric hospitalists should render evidence-based care for these neonates.

Pediatric hospitalists should be able to:

• Define hypothermia and hyperthermia in neonates and describe how to correctly obtain a temperature using a variety of modalities.
• Discuss the basic mechanisms of temperature regulation in neonates.
• Compare and contrast basic immune maturity differences in neonates versus older infants.
• Delineate the elements of the history (such as birth history, perinatal exposures, maternal infections, and others) and physical examination (such as skin lesions, neurobehavioral exam, and others) that aid in determining a diagnosis.
• Describe the differential diagnosis of neonatal sepsis and discuss how other potentially serious illnesses, such as inborn errors of metabolism, may mimic its presentation.
• List the organisms responsible for serious bacterial infection in neonates, including the types of infections they cause and the relative prevalence of each.
• Review the approach toward evaluation of the preterm infant, attending to extent of prematurity and neonatal intensive care course.
• Compare and contrast the signs and symptoms suggestive of bacterial versus viral illnesses.
• Distinguish between the standard laboratory evaluation for neonates with fever versus older infants with fever, using current literature for reference.
• Describe the role of viral testing, including interpretation of frequencies of disease, co-infections with bacterial disease, local turnaround time, and predictive value of testing.
• Describe indications for the use of antibiotics versus inpatient monitoring without the use of antibiotics, considering current validated scoring tools and evidence about reported rates of neonatal serious bacterial infection.
• Summarize the approach to empiric antimicrobial therapy and give examples of situations warranting expanded antimicrobial coverage.

Pediatric hospitalists should be able to:

• Obtain a complete history, including pregnancy and birth history, attending to prenatal laboratory screening and the use of antibiotic prophylaxis prior to delivery.
• Perform a comprehensive physical examination, attending to signs and symptoms that may indicate a source of infection or signify severe illness.
• Perform, supervise, or direct basic procedures to obtain specimens, including venipuncture, bladder catheterization, lumbar puncture, and placement of intravenous access, according to local context.
• Interpret the results of laboratory evaluations efficiently and adjust the differential diagnosis and plan of care accordingly.
• Select appropriate empiric antimicrobial coverage in an evidence-based manner.
• Perform careful reassessments daily and as needed, note changes in clinical status, and respond with appropriate actions.
• Communicate with the family/caregivers and healthcare providers regarding findings and care plans.
• Create a discharge plan which can be expediently activated when appropriate.

Pediatric hospitalists should be able to:

• Elicit and allay the concerns of the family/caregivers, educating them regarding the importance of a thorough evaluation for the source of infection and the need for empiric antimicrobial therapy.
• Realize the importance of educating the family/caregivers about the final diagnosis, clearly explaining the value of negative test results if applicable.
• Recognize the significance of performing invasive procedures on a neonate from the family/caregivers’ perspective, maintaining empathy when discussing the risks and benefits of necessary procedures.
• Ensure an effective and safe discharge by communicating and coordinating effectively with the primary care provider.

In order to improve efficiency and quality within their organizations, pediatric hospitalists should:

• Lead, coordinate, or participate in the development and implementation of cost-effective, safe, evidence-based care pathways to standardize the evaluation and management of hospitalized neonates with fever.

• Lead, coordinate, or participate in efforts to develop institutional guidelines for the judicious use of antimicrobials in neonates with fever.

1. Roberts KB. Management and outcomes of care of fever in early infancy. J Pediatr. 2004;145(3):417. https://doi.org/10.1016/j.jpeds.2004.06.036.

2. Vachani JG, McNeal-Trice K, and Wallace SS. Current Evidence on the Evaluation and Management of Fever Without a Source in Infants Aged 0-90 Days: A Review. Rev Recent Clin Trials. 2017;12(4):240-246. https://doi.org/10.2174/1574887112666170816143308.

3. Puopolo KM, Benitz WE, and Zaoutis TE. Committee on Fetus and Newborn, Committee on Infectious Diseases. Management of Neonates Born at ≥35 0/7 Weeks’ Gestation with Suspected or Proven Early-Onset Bacterial Sepsis. Pediatrics Dec 2018, 142 (6) e20182894. https://pediatrics.aappublications.org/content/142/6/e20182894.full Accessed August 28, 2019.

Introduction

Neonatal abstinence syndrome (NAS), also referred to as Neonatal Opioid Withdrawal Syndrome, is the constellation of opioid withdrawal symptoms exhibited by newborns that have been exposed to opioid medications in utero. The incidence of NAS has increased dramatically over the past two decades, such that a baby at risk for NAS is born every 15 minutes in the United States. Neonatal abstinence syndrome symptoms typically begin between 24 and 96 hours of life and manifest as disturbances in the central nervous system, autonomic nervous system, and gastrointestinal system. During the birth hospitalization, many newborns with NAS receive care from pediatric hospitalists in Level 1 nurseries and/or on pediatric units. Pediatric hospitalists must therefore be equipped both to provide coordinated acute care and to develop an integrated transition plan for post-discharge care.

Pediatric hospitalists should be able to:

• Describe the physiology of NAS due to maternal use of prescribed or illicit, long- or short-acting opioid medications.
• Describe newborn risk factors for NAS, such as the maternal history, medication list, and toxicology laboratory results.
• List common symptoms and exam findings in NAS, such as central nervous system, autonomic nervous system, and gastrointestinal system withdrawal effects.
• Compare and contrast items on the differential diagnosis for NAS, including sepsis, hypoglycemia, electrolyte abnormalities, tobacco withdrawal, and maternal antidepressant use.
• List the available maternal and infant toxicology screening and confirmatory tests, including those from the urine, meconium, and umbilical cord tissue.
• Cite the importance of using a standardized NAS symptom severity tool to assess newborn withdrawal severity.
• Discuss the elements of appropriate non-pharmacologic care, including rooming-in, skin-to-skin, swaddling, breastfeeding, and a calm environment.
• Explain when and how to initiate and taper pharmacologic treatment of NAS with an opioid medication.
• List the indications for initiation of adjunct medications such as clonidine.
• Discuss special considerations for nutritional support in NAS, including determining when breastfeeding is or is not recommended and when additional caloric supplementation is needed.
• Describe local laws governing reporting to child protective services in cases of NAS and discuss indications for referral.
• Cite reasons for continued hospitalization, such as persistent and substantial withdrawal symptoms or poor weight gain.
• List criteria for hospital discharge, including withdrawal that can be controlled in the home setting with or without continued pharmacotherapy, adequate oral intake and weight gain, safe home environment, and a follow up plan with a primary care provider.
• Discuss the role of various community support services in the care of newborns with NAS and their family/caregivers, such as substance abuse treatment programs, home visitation programs, parenting resources, and maternal-child nutrition programs.

Pediatric hospitalists should be able to:

• Identify newborns at risk for NAS based on maternal history, medication list, and toxicology testing.
• Perform a physical examination specifically assessing for signs of opioid withdrawal, regardless of presence of risk factors.
• Use a standardized NAS symptom severity tool to assess the severity of newborn withdrawal symptoms.
• Order and interpret toxicology tests.
• Initiate non-pharmacologic care for all newborns at risk for NAS.
• Perform daily, comprehensive reassessments of newborns with NAS.
• Describe indications for initiating pharmacologic treatment for NAS with a standard opioid and/or adjunct medications at the correct dose and dosing interval.
• Identify indications for weaning pharmacologic treatment for NAS, including lower and stable standardized scores and normal newborn physiologic functioning.
• Coordinate care with other providers, including social work, nutrition, lactation services, and speech therapy.
• Identify severe or unusual NAS that requires consultation with a neonatologist, including NAS symptoms not controlled by standard therapy, ongoing weight loss, seizures, respiratory distress, or serious consequences of other drugs of abuse.
• Assess readiness of newborn and family for discharge, including caretaker ability to control withdrawal symptoms in the home setting and establishment of a safe home environment.
• Coordinate comprehensive discharge plans with primary care providers, home care agencies, community support services, early intervention programs, and child protection agencies as appropriate.

Pediatric hospitalists should be able to:

• Appreciate the role of the family/caregivers, nurses, and other professional staff in providing non-pharmacologic care for newborns with NAS and empower them to assume this role.
• Exemplify family-centered communication that is trauma-informed and sensitive to the needs of parents and the family/caregivers in different stages of addiction and recovery.
• Appreciate the impact of newborn opioid exposure on neonates, mothers, the family/caregivers, communities, and the health care system.
• Contextualize NAS within the broader opioid epidemic.

In order to improve efficiency and quality within their organizations, pediatric hospitalists should:

• Collaborate with colleagues in obstetrics, midwifery, and other disciplines to provide comprehensive care for mothers with substance use disorders and newborns with NAS throughout the perinatal continuum.
• Advocate for appropriate health system resources to provide family-centered, high-value care to opioid-exposed newborns and their family/caregivers.
• Lead, coordinate, or participate in the development and implementation of clinical care pathways to standardize the evaluation and management of newborns that have been exposed to opioids in utero.
• Lead, coordinate, or participate in education programs for the family/caregivers and the community to increase awareness of the opioid epidemic, emphasizing the role of the family/caregivers and community members in supporting newborns with NAS.
• Engage in public policy discussions and legislative advocacy related to the opioid epidemic and NAS.

Introduction

Neonatal abstinence syndrome (NAS), also referred to as Neonatal Opioid Withdrawal Syndrome, is the constellation of opioid withdrawal symptoms exhibited by newborns that have been exposed to opioid medications in utero. The incidence of NAS has increased dramatically over the past two decades, such that a baby at risk for NAS is born every 15 minutes in the United States. Neonatal abstinence syndrome symptoms typically begin between 24 and 96 hours of life and manifest as disturbances in the central nervous system, autonomic nervous system, and gastrointestinal system. During the birth hospitalization, many newborns with NAS receive care from pediatric hospitalists in Level 1 nurseries and/or on pediatric units. Pediatric hospitalists must therefore be equipped both to provide coordinated acute care and to develop an integrated transition plan for post-discharge care.

Pediatric hospitalists should be able to:

• Describe the physiology of NAS due to maternal use of prescribed or illicit, long- or short-acting opioid medications.
• Describe newborn risk factors for NAS, such as the maternal history, medication list, and toxicology laboratory results.
• List common symptoms and exam findings in NAS, such as central nervous system, autonomic nervous system, and gastrointestinal system withdrawal effects.
• Compare and contrast items on the differential diagnosis for NAS, including sepsis, hypoglycemia, electrolyte abnormalities, tobacco withdrawal, and maternal antidepressant use.
• List the available maternal and infant toxicology screening and confirmatory tests, including those from the urine, meconium, and umbilical cord tissue.
• Cite the importance of using a standardized NAS symptom severity tool to assess newborn withdrawal severity.
• Discuss the elements of appropriate non-pharmacologic care, including rooming-in, skin-to-skin, swaddling, breastfeeding, and a calm environment.
• Explain when and how to initiate and taper pharmacologic treatment of NAS with an opioid medication.
• List the indications for initiation of adjunct medications such as clonidine.
• Discuss special considerations for nutritional support in NAS, including determining when breastfeeding is or is not recommended and when additional caloric supplementation is needed.
• Describe local laws governing reporting to child protective services in cases of NAS and discuss indications for referral.
• Cite reasons for continued hospitalization, such as persistent and substantial withdrawal symptoms or poor weight gain.
• List criteria for hospital discharge, including withdrawal that can be controlled in the home setting with or without continued pharmacotherapy, adequate oral intake and weight gain, safe home environment, and a follow up plan with a primary care provider.
• Discuss the role of various community support services in the care of newborns with NAS and their family/caregivers, such as substance abuse treatment programs, home visitation programs, parenting resources, and maternal-child nutrition programs.

Pediatric hospitalists should be able to:

• Identify newborns at risk for NAS based on maternal history, medication list, and toxicology testing.
• Perform a physical examination specifically assessing for signs of opioid withdrawal, regardless of presence of risk factors.
• Use a standardized NAS symptom severity tool to assess the severity of newborn withdrawal symptoms.
• Order and interpret toxicology tests.
• Initiate non-pharmacologic care for all newborns at risk for NAS.
• Perform daily, comprehensive reassessments of newborns with NAS.
• Describe indications for initiating pharmacologic treatment for NAS with a standard opioid and/or adjunct medications at the correct dose and dosing interval.
• Identify indications for weaning pharmacologic treatment for NAS, including lower and stable standardized scores and normal newborn physiologic functioning.
• Coordinate care with other providers, including social work, nutrition, lactation services, and speech therapy.
• Identify severe or unusual NAS that requires consultation with a neonatologist, including NAS symptoms not controlled by standard therapy, ongoing weight loss, seizures, respiratory distress, or serious consequences of other drugs of abuse.
• Assess readiness of newborn and family for discharge, including caretaker ability to control withdrawal symptoms in the home setting and establishment of a safe home environment.
• Coordinate comprehensive discharge plans with primary care providers, home care agencies, community support services, early intervention programs, and child protection agencies as appropriate.

Pediatric hospitalists should be able to:

• Appreciate the role of the family/caregivers, nurses, and other professional staff in providing non-pharmacologic care for newborns with NAS and empower them to assume this role.
• Exemplify family-centered communication that is trauma-informed and sensitive to the needs of parents and the family/caregivers in different stages of addiction and recovery.
• Appreciate the impact of newborn opioid exposure on neonates, mothers, the family/caregivers, communities, and the health care system.
• Contextualize NAS within the broader opioid epidemic.

In order to improve efficiency and quality within their organizations, pediatric hospitalists should:

• Collaborate with colleagues in obstetrics, midwifery, and other disciplines to provide comprehensive care for mothers with substance use disorders and newborns with NAS throughout the perinatal continuum.
• Advocate for appropriate health system resources to provide family-centered, high-value care to opioid-exposed newborns and their family/caregivers.
• Lead, coordinate, or participate in the development and implementation of clinical care pathways to standardize the evaluation and management of newborns that have been exposed to opioids in utero.
• Lead, coordinate, or participate in education programs for the family/caregivers and the community to increase awareness of the opioid epidemic, emphasizing the role of the family/caregivers and community members in supporting newborns with NAS.
• Engage in public policy discussions and legislative advocacy related to the opioid epidemic and NAS.

Introduction

Neonatal abstinence syndrome (NAS), also referred to as Neonatal Opioid Withdrawal Syndrome, is the constellation of opioid withdrawal symptoms exhibited by newborns that have been exposed to opioid medications in utero. The incidence of NAS has increased dramatically over the past two decades, such that a baby at risk for NAS is born every 15 minutes in the United States. Neonatal abstinence syndrome symptoms typically begin between 24 and 96 hours of life and manifest as disturbances in the central nervous system, autonomic nervous system, and gastrointestinal system. During the birth hospitalization, many newborns with NAS receive care from pediatric hospitalists in Level 1 nurseries and/or on pediatric units. Pediatric hospitalists must therefore be equipped both to provide coordinated acute care and to develop an integrated transition plan for post-discharge care.

Pediatric hospitalists should be able to:

• Describe the physiology of NAS due to maternal use of prescribed or illicit, long- or short-acting opioid medications.
• Describe newborn risk factors for NAS, such as the maternal history, medication list, and toxicology laboratory results.
• List common symptoms and exam findings in NAS, such as central nervous system, autonomic nervous system, and gastrointestinal system withdrawal effects.
• Compare and contrast items on the differential diagnosis for NAS, including sepsis, hypoglycemia, electrolyte abnormalities, tobacco withdrawal, and maternal antidepressant use.
• List the available maternal and infant toxicology screening and confirmatory tests, including those from the urine, meconium, and umbilical cord tissue.
• Cite the importance of using a standardized NAS symptom severity tool to assess newborn withdrawal severity.
• Discuss the elements of appropriate non-pharmacologic care, including rooming-in, skin-to-skin, swaddling, breastfeeding, and a calm environment.
• Explain when and how to initiate and taper pharmacologic treatment of NAS with an opioid medication.
• List the indications for initiation of adjunct medications such as clonidine.
• Discuss special considerations for nutritional support in NAS, including determining when breastfeeding is or is not recommended and when additional caloric supplementation is needed.
• Describe local laws governing reporting to child protective services in cases of NAS and discuss indications for referral.
• Cite reasons for continued hospitalization, such as persistent and substantial withdrawal symptoms or poor weight gain.
• List criteria for hospital discharge, including withdrawal that can be controlled in the home setting with or without continued pharmacotherapy, adequate oral intake and weight gain, safe home environment, and a follow up plan with a primary care provider.
• Discuss the role of various community support services in the care of newborns with NAS and their family/caregivers, such as substance abuse treatment programs, home visitation programs, parenting resources, and maternal-child nutrition programs.

Pediatric hospitalists should be able to:

• Identify newborns at risk for NAS based on maternal history, medication list, and toxicology testing.
• Perform a physical examination specifically assessing for signs of opioid withdrawal, regardless of presence of risk factors.
• Use a standardized NAS symptom severity tool to assess the severity of newborn withdrawal symptoms.
• Order and interpret toxicology tests.
• Initiate non-pharmacologic care for all newborns at risk for NAS.
• Perform daily, comprehensive reassessments of newborns with NAS.
• Describe indications for initiating pharmacologic treatment for NAS with a standard opioid and/or adjunct medications at the correct dose and dosing interval.
• Identify indications for weaning pharmacologic treatment for NAS, including lower and stable standardized scores and normal newborn physiologic functioning.
• Coordinate care with other providers, including social work, nutrition, lactation services, and speech therapy.
• Identify severe or unusual NAS that requires consultation with a neonatologist, including NAS symptoms not controlled by standard therapy, ongoing weight loss, seizures, respiratory distress, or serious consequences of other drugs of abuse.
• Assess readiness of newborn and family for discharge, including caretaker ability to control withdrawal symptoms in the home setting and establishment of a safe home environment.
• Coordinate comprehensive discharge plans with primary care providers, home care agencies, community support services, early intervention programs, and child protection agencies as appropriate.

Pediatric hospitalists should be able to:

• Appreciate the role of the family/caregivers, nurses, and other professional staff in providing non-pharmacologic care for newborns with NAS and empower them to assume this role.
• Exemplify family-centered communication that is trauma-informed and sensitive to the needs of parents and the family/caregivers in different stages of addiction and recovery.
• Appreciate the impact of newborn opioid exposure on neonates, mothers, the family/caregivers, communities, and the health care system.
• Contextualize NAS within the broader opioid epidemic.

In order to improve efficiency and quality within their organizations, pediatric hospitalists should:

• Collaborate with colleagues in obstetrics, midwifery, and other disciplines to provide comprehensive care for mothers with substance use disorders and newborns with NAS throughout the perinatal continuum.
• Advocate for appropriate health system resources to provide family-centered, high-value care to opioid-exposed newborns and their family/caregivers.
• Lead, coordinate, or participate in the development and implementation of clinical care pathways to standardize the evaluation and management of newborns that have been exposed to opioids in utero.
• Lead, coordinate, or participate in education programs for the family/caregivers and the community to increase awareness of the opioid epidemic, emphasizing the role of the family/caregivers and community members in supporting newborns with NAS.
• Engage in public policy discussions and legislative advocacy related to the opioid epidemic and NAS.

Introduction

Kawasaki Disease (KD), also known as mucocutaneous lymph node syndrome, is a multisystem inflammatory disease of childhood. It most commonly presents in children ages 6 months to 5 years but can be seen as early as 1 month of age and into early adulthood. Pediatric hospitalists must have a high index of suspicion for KD; diagnosis can be difficult, as the classic signs and symptoms may not all manifest and the presentation may mimic other febrile illnesses. Consideration for KD must be particularly high in children being evaluated for fever of unknown origin, as this is a population in which KD is commonly missed or diagnosed late. Although many organs may be affected, involvement of cardiac structures is the most concerning, often leading to persistent morbidity. Coronary aneurysms occur in up to 25% of untreated children with KD. If diagnosed and treated within the first 10 days of illness, the cardiac complications can be reduced. Therefore, it is important that pediatric hospitalists have a complete understanding of the diagnosis and treatment of KD, as well as the associated complications.

Pediatric hospitalists should be able to:

• Describe the range of clinical presentations for KD, including typical, incomplete, isolated cervical lymphadenopathy KD, and KD shock syndrome.
• Discuss currently established criteria and guidelines for diagnosis and treatment.
• Define incomplete KD and note age groups in which this is more common.
• Identify patients at the highest risk for coronary artery aneurysms.
• List the broad categories of alternate diagnoses and give examples from each.
• Discuss the appropriate laboratory and imaging studies that aid in diagnosis.
• Explain the pathophysiology of the disease, including the current understanding of development and manifestation of cardiac complications.
• Define refractory KD and list factors that indicate the need for further treatment.
• Compare and contrast the risks, benefits, and side effects of available treatments such as immunoglobulin, steroids, anti-platelet medications, and immunomodulators.
• Discuss the immediate and long-term follow up care needed, and the impact, if any, on physical activity and sports participation.
• List appropriate discharge criteria for KD.

Pediatric hospitalists should be able to:

• Diagnose KD by efficiently performing an accurate history and physical examination and ordering appropriate diagnostic studies.
• Consult appropriate subspecialists to assist in evaluation and treatment.
• Perform an evidence-based, cost-effective diagnostic evaluation and correctly interpret laboratory and imaging results.
• Demonstrate basic proficiency in reading electrocardiograms.
• Perform careful reassessments daily and as needed, noting changes in clinical status, and respond appropriately.
• Initiate prompt treatment once the diagnosis is established.
• Anticipate and treat complications and side effects of instituted therapies.
• Identify treatment failure (refractory KD) and institute appropriate repeat or alternate therapy.
• Coordinate care with subspecialists and the primary care provider, arranging appropriate transition and follow-up plans for after hospital discharge.

Pediatric hospitalists should be able to:

• Realize the importance of effective communication with patients, the family/caregivers, and other healthcare providers regarding findings and care plans.
• Realize the importance of educating patients and the family/caregivers on the natural course of the disease.
• Acknowledge the importance of collaborating with subspecialists and the primary care provider to ensure coordinated longitudinal care for children with KD.

In order to improve efficiency and quality within their organizations, pediatric hospitalists should:

• Lead, coordinate, or participate in early multidisciplinary care to promote efficient diagnosis, treatment, and discharge of patients with KD.
• Work with hospital staff and subspecialists to educate other healthcare providers regarding the diagnosis and treatment of KD.
• Lead, coordinate, or participate in community education efforts regarding KD.

Introduction

Kawasaki Disease (KD), also known as mucocutaneous lymph node syndrome, is a multisystem inflammatory disease of childhood. It most commonly presents in children ages 6 months to 5 years but can be seen as early as 1 month of age and into early adulthood. Pediatric hospitalists must have a high index of suspicion for KD; diagnosis can be difficult, as the classic signs and symptoms may not all manifest and the presentation may mimic other febrile illnesses. Consideration for KD must be particularly high in children being evaluated for fever of unknown origin, as this is a population in which KD is commonly missed or diagnosed late. Although many organs may be affected, involvement of cardiac structures is the most concerning, often leading to persistent morbidity. Coronary aneurysms occur in up to 25% of untreated children with KD. If diagnosed and treated within the first 10 days of illness, the cardiac complications can be reduced. Therefore, it is important that pediatric hospitalists have a complete understanding of the diagnosis and treatment of KD, as well as the associated complications.

Pediatric hospitalists should be able to:

• Describe the range of clinical presentations for KD, including typical, incomplete, isolated cervical lymphadenopathy KD, and KD shock syndrome.
• Discuss currently established criteria and guidelines for diagnosis and treatment.
• Define incomplete KD and note age groups in which this is more common.
• Identify patients at the highest risk for coronary artery aneurysms.
• List the broad categories of alternate diagnoses and give examples from each.
• Discuss the appropriate laboratory and imaging studies that aid in diagnosis.
• Explain the pathophysiology of the disease, including the current understanding of development and manifestation of cardiac complications.
• Define refractory KD and list factors that indicate the need for further treatment.
• Compare and contrast the risks, benefits, and side effects of available treatments such as immunoglobulin, steroids, anti-platelet medications, and immunomodulators.
• Discuss the immediate and long-term follow up care needed, and the impact, if any, on physical activity and sports participation.
• List appropriate discharge criteria for KD.

Pediatric hospitalists should be able to:

• Diagnose KD by efficiently performing an accurate history and physical examination and ordering appropriate diagnostic studies.
• Consult appropriate subspecialists to assist in evaluation and treatment.
• Perform an evidence-based, cost-effective diagnostic evaluation and correctly interpret laboratory and imaging results.
• Demonstrate basic proficiency in reading electrocardiograms.
• Perform careful reassessments daily and as needed, noting changes in clinical status, and respond appropriately.
• Initiate prompt treatment once the diagnosis is established.
• Anticipate and treat complications and side effects of instituted therapies.
• Identify treatment failure (refractory KD) and institute appropriate repeat or alternate therapy.
• Coordinate care with subspecialists and the primary care provider, arranging appropriate transition and follow-up plans for after hospital discharge.

Pediatric hospitalists should be able to:

• Realize the importance of effective communication with patients, the family/caregivers, and other healthcare providers regarding findings and care plans.
• Realize the importance of educating patients and the family/caregivers on the natural course of the disease.
• Acknowledge the importance of collaborating with subspecialists and the primary care provider to ensure coordinated longitudinal care for children with KD.

In order to improve efficiency and quality within their organizations, pediatric hospitalists should:

• Lead, coordinate, or participate in early multidisciplinary care to promote efficient diagnosis, treatment, and discharge of patients with KD.
• Work with hospital staff and subspecialists to educate other healthcare providers regarding the diagnosis and treatment of KD.
• Lead, coordinate, or participate in community education efforts regarding KD.

Introduction

Kawasaki Disease (KD), also known as mucocutaneous lymph node syndrome, is a multisystem inflammatory disease of childhood. It most commonly presents in children ages 6 months to 5 years but can be seen as early as 1 month of age and into early adulthood. Pediatric hospitalists must have a high index of suspicion for KD; diagnosis can be difficult, as the classic signs and symptoms may not all manifest and the presentation may mimic other febrile illnesses. Consideration for KD must be particularly high in children being evaluated for fever of unknown origin, as this is a population in which KD is commonly missed or diagnosed late. Although many organs may be affected, involvement of cardiac structures is the most concerning, often leading to persistent morbidity. Coronary aneurysms occur in up to 25% of untreated children with KD. If diagnosed and treated within the first 10 days of illness, the cardiac complications can be reduced. Therefore, it is important that pediatric hospitalists have a complete understanding of the diagnosis and treatment of KD, as well as the associated complications.

Pediatric hospitalists should be able to:

• Describe the range of clinical presentations for KD, including typical, incomplete, isolated cervical lymphadenopathy KD, and KD shock syndrome.
• Discuss currently established criteria and guidelines for diagnosis and treatment.
• Define incomplete KD and note age groups in which this is more common.
• Identify patients at the highest risk for coronary artery aneurysms.
• List the broad categories of alternate diagnoses and give examples from each.
• Discuss the appropriate laboratory and imaging studies that aid in diagnosis.
• Explain the pathophysiology of the disease, including the current understanding of development and manifestation of cardiac complications.
• Define refractory KD and list factors that indicate the need for further treatment.
• Compare and contrast the risks, benefits, and side effects of available treatments such as immunoglobulin, steroids, anti-platelet medications, and immunomodulators.
• Discuss the immediate and long-term follow up care needed, and the impact, if any, on physical activity and sports participation.
• List appropriate discharge criteria for KD.

Pediatric hospitalists should be able to:

• Diagnose KD by efficiently performing an accurate history and physical examination and ordering appropriate diagnostic studies.
• Consult appropriate subspecialists to assist in evaluation and treatment.
• Perform an evidence-based, cost-effective diagnostic evaluation and correctly interpret laboratory and imaging results.
• Demonstrate basic proficiency in reading electrocardiograms.
• Perform careful reassessments daily and as needed, noting changes in clinical status, and respond appropriately.
• Initiate prompt treatment once the diagnosis is established.
• Anticipate and treat complications and side effects of instituted therapies.
• Identify treatment failure (refractory KD) and institute appropriate repeat or alternate therapy.
• Coordinate care with subspecialists and the primary care provider, arranging appropriate transition and follow-up plans for after hospital discharge.

Pediatric hospitalists should be able to:

• Realize the importance of effective communication with patients, the family/caregivers, and other healthcare providers regarding findings and care plans.
• Realize the importance of educating patients and the family/caregivers on the natural course of the disease.
• Acknowledge the importance of collaborating with subspecialists and the primary care provider to ensure coordinated longitudinal care for children with KD.

In order to improve efficiency and quality within their organizations, pediatric hospitalists should:

• Lead, coordinate, or participate in early multidisciplinary care to promote efficient diagnosis, treatment, and discharge of patients with KD.
• Work with hospital staff and subspecialists to educate other healthcare providers regarding the diagnosis and treatment of KD.
• Lead, coordinate, or participate in community education efforts regarding KD.

Introduction

Disorders of the head and neck, including infectious processes and anatomic abnormalities, are some of the most common encountered by pediatric hospitalists. Upper respiratory tract infections (URIs) are the most common reason for acute pediatric medical care. Children under age six years of age average six to eight URIs per year. Acute illness with an infectious process often exacerbates underlying anatomic abnormalities, such as laryngomalacia, tracheomalacia, subglottic stenosis, and others, but these abnormalities alone can require acute intervention and lead to hospitalization. Bacterial infections have the potential to invade other structures or compromise the airway, rapidly resulting in both immediate and long-term sequelae if not appropriately treated. Pediatric hospitalists frequently encounter patients with disorders of the head and neck and should be able to recognize their signs and symptoms and provide evidence-based and efficient care. In particular, pediatric hospitalists must be able to identify impending airway obstruction, provide immediate care, and arrange for the appropriate subsequent level of care.

Pediatric hospitalists should be able to:

• Compare and contrast the head and neck anatomy of children at different chronological ages, including how abnormalities of airflow in different locations may alter the clinical presentation at different ages.
• Discuss the symptoms of various anatomic abnormalities (such as laryngomalacia, tracheomalacia, subglottic stenosis, and others), including the acute infectious processes which may exacerbate their clinical presentation.
• Discuss the pathophysiology, presenting features, and common pathogens associated with bacterial infections of the head and neck (such as otitis media, otitis externa, retropharyngeal abscess, orbital cellulitis, dental infections, mastoiditis, peritonsillar abscess, and others).
• Describe the differential diagnosis of common presenting symptoms of head and neck disorders, such as shortness of breath, stridor, cough, nasal discharge, neck swelling/pain, dysphagia/drooling, facial swelling, and others.
• Describe the features of upper airway obstruction, such as stertor, stridor, tripod positioning, dysphagia, drooling, trismus, and others.
• Discuss alternate diagnoses that may mimic the presentation of acute upper respiratory infection such as allergic reaction, toxic inhalant exposure, and others.
• List the indications for hospital admission, explain the utility of various monitoring options, and review the indications for emergent and non-emergent subspecialist consultation.
• Describe the signs and symptoms of obstructive sleep apnea (OSA) including snoring, respiratory pauses, and hypoxia, and discuss appropriate evaluation, referral, and management.
• Explain the types of studies available to assess the head and neck (including plain radiographs, fluoroscopy, ultrasonography, computed tomography, magnetic resonance imaging, and direct laryngoscopy) and discuss the risks, benefits, and indications for each.
• Discuss the indications, contraindications, and mechanisms of action of pharmacological agents used to treat various disorders of the head and neck, such as antibiotics, nebulized epinephrine, glucocorticoids, proton pump inhibitors, histamine 2 blockers, and others.
• Compare and contrast the benefits and limitations of various modalities of airway stabilization and respiratory support (including heated humidified high flow nasal cannula, non-invasive positive pressure support, and intubation with mechanical ventilation) in patients with varying degrees of upper airway obstruction.
• Discuss the changes in clinical status that indicate need for escalation of care, such as worsening stridor or work of breathing, decreased air entry, cyanosis, altered mental status, and others.
• Describe the patient characteristics that indicate the need for higher level of care and/or transfer to a referral center in cases requiring pediatric-specific services not available at the local facility.
• Describe criteria, including specific measures of clinical stability, that must be met before discharging patients with head and neck disorders, including oxygenation, hydration, and patient/family education.

Pediatric hospitalists should be able to:

• Perform an appropriately focused medical history, attending to symptoms of potential airway obstruction.
• Conduct a thorough physical examination directed by signs and symptoms that may indicate the location, etiology, or severity of the disorder.
• Identify patients with comorbidities or underlying anatomic abnormalities that impact the management plan and order appropriate testing, correctly interpreting results.
• Order appropriate monitoring and correctly interpret monitor data.
• Adhere consistently to infection control practices.
• Identify complications and respond with appropriate actions.
• Perform an evidence-based, cost-effective diagnostic evaluation and treatment plan, avoiding unnecessary testing.
• Perform careful reassessments daily and as needed, note changes in clinical status, and respond with appropriate actions and escalation of care as appropriate.
• Stabilize the airway and provide appropriate respiratory support for patients with impending or actual airway obstruction or respiratory failure, including head tilt/chin lift, nasal trumpet, and intubation, or arrange for the appropriate personnel to perform the procedure in an effective and efficient manner.
• Engage consultants (such as otolaryngologists, pulmonologists, surgeons, speech and feeding specialists, dentists, and others) efficiently and effectively when needed.

Pediatric hospitalists should be able to:

• Role model and advocate for strict adherence to infection control practices.
• Realize responsibility for effective communication with patients and the family/caregivers regarding the diagnosis, management plan, and follow-up needs.
• Recognize the value of collaboration with the primary care provider, subspecialists, nursing, the hospital staff, and other outpatient providers to ensure coordinated longitudinal care at the time of discharge.

In order to improve efficiency and quality within their organizations, pediatric hospitalists should:

• Lead, coordinate, or participate in the development, implementation, and improvement of cost-effective, safe, evidence-based care within a multidisciplinary team for hospitalized children with head and neck disorders.
• Collaborate with hospital administration and community partners to develop and sustain referral networks between local facilities and tertiary referral centers for hospitalized patients with head and neck disorders.

Introduction

Disorders of the head and neck, including infectious processes and anatomic abnormalities, are some of the most common encountered by pediatric hospitalists. Upper respiratory tract infections (URIs) are the most common reason for acute pediatric medical care. Children under age six years of age average six to eight URIs per year. Acute illness with an infectious process often exacerbates underlying anatomic abnormalities, such as laryngomalacia, tracheomalacia, subglottic stenosis, and others, but these abnormalities alone can require acute intervention and lead to hospitalization. Bacterial infections have the potential to invade other structures or compromise the airway, rapidly resulting in both immediate and long-term sequelae if not appropriately treated. Pediatric hospitalists frequently encounter patients with disorders of the head and neck and should be able to recognize their signs and symptoms and provide evidence-based and efficient care. In particular, pediatric hospitalists must be able to identify impending airway obstruction, provide immediate care, and arrange for the appropriate subsequent level of care.

Pediatric hospitalists should be able to:

• Compare and contrast the head and neck anatomy of children at different chronological ages, including how abnormalities of airflow in different locations may alter the clinical presentation at different ages.
• Discuss the symptoms of various anatomic abnormalities (such as laryngomalacia, tracheomalacia, subglottic stenosis, and others), including the acute infectious processes which may exacerbate their clinical presentation.
• Discuss the pathophysiology, presenting features, and common pathogens associated with bacterial infections of the head and neck (such as otitis media, otitis externa, retropharyngeal abscess, orbital cellulitis, dental infections, mastoiditis, peritonsillar abscess, and others).
• Describe the differential diagnosis of common presenting symptoms of head and neck disorders, such as shortness of breath, stridor, cough, nasal discharge, neck swelling/pain, dysphagia/drooling, facial swelling, and others.
• Describe the features of upper airway obstruction, such as stertor, stridor, tripod positioning, dysphagia, drooling, trismus, and others.
• Discuss alternate diagnoses that may mimic the presentation of acute upper respiratory infection such as allergic reaction, toxic inhalant exposure, and others.
• List the indications for hospital admission, explain the utility of various monitoring options, and review the indications for emergent and non-emergent subspecialist consultation.
• Describe the signs and symptoms of obstructive sleep apnea (OSA) including snoring, respiratory pauses, and hypoxia, and discuss appropriate evaluation, referral, and management.
• Explain the types of studies available to assess the head and neck (including plain radiographs, fluoroscopy, ultrasonography, computed tomography, magnetic resonance imaging, and direct laryngoscopy) and discuss the risks, benefits, and indications for each.
• Discuss the indications, contraindications, and mechanisms of action of pharmacological agents used to treat various disorders of the head and neck, such as antibiotics, nebulized epinephrine, glucocorticoids, proton pump inhibitors, histamine 2 blockers, and others.
• Compare and contrast the benefits and limitations of various modalities of airway stabilization and respiratory support (including heated humidified high flow nasal cannula, non-invasive positive pressure support, and intubation with mechanical ventilation) in patients with varying degrees of upper airway obstruction.
• Discuss the changes in clinical status that indicate need for escalation of care, such as worsening stridor or work of breathing, decreased air entry, cyanosis, altered mental status, and others.
• Describe the patient characteristics that indicate the need for higher level of care and/or transfer to a referral center in cases requiring pediatric-specific services not available at the local facility.
• Describe criteria, including specific measures of clinical stability, that must be met before discharging patients with head and neck disorders, including oxygenation, hydration, and patient/family education.

Pediatric hospitalists should be able to:

• Perform an appropriately focused medical history, attending to symptoms of potential airway obstruction.
• Conduct a thorough physical examination directed by signs and symptoms that may indicate the location, etiology, or severity of the disorder.
• Identify patients with comorbidities or underlying anatomic abnormalities that impact the management plan and order appropriate testing, correctly interpreting results.
• Order appropriate monitoring and correctly interpret monitor data.
• Adhere consistently to infection control practices.
• Identify complications and respond with appropriate actions.
• Perform an evidence-based, cost-effective diagnostic evaluation and treatment plan, avoiding unnecessary testing.
• Perform careful reassessments daily and as needed, note changes in clinical status, and respond with appropriate actions and escalation of care as appropriate.
• Stabilize the airway and provide appropriate respiratory support for patients with impending or actual airway obstruction or respiratory failure, including head tilt/chin lift, nasal trumpet, and intubation, or arrange for the appropriate personnel to perform the procedure in an effective and efficient manner.
• Engage consultants (such as otolaryngologists, pulmonologists, surgeons, speech and feeding specialists, dentists, and others) efficiently and effectively when needed.

Pediatric hospitalists should be able to:

• Role model and advocate for strict adherence to infection control practices.
• Realize responsibility for effective communication with patients and the family/caregivers regarding the diagnosis, management plan, and follow-up needs.
• Recognize the value of collaboration with the primary care provider, subspecialists, nursing, the hospital staff, and other outpatient providers to ensure coordinated longitudinal care at the time of discharge.

In order to improve efficiency and quality within their organizations, pediatric hospitalists should:

• Lead, coordinate, or participate in the development, implementation, and improvement of cost-effective, safe, evidence-based care within a multidisciplinary team for hospitalized children with head and neck disorders.
• Collaborate with hospital administration and community partners to develop and sustain referral networks between local facilities and tertiary referral centers for hospitalized patients with head and neck disorders.

Introduction

Disorders of the head and neck, including infectious processes and anatomic abnormalities, are some of the most common encountered by pediatric hospitalists. Upper respiratory tract infections (URIs) are the most common reason for acute pediatric medical care. Children under age six years of age average six to eight URIs per year. Acute illness with an infectious process often exacerbates underlying anatomic abnormalities, such as laryngomalacia, tracheomalacia, subglottic stenosis, and others, but these abnormalities alone can require acute intervention and lead to hospitalization. Bacterial infections have the potential to invade other structures or compromise the airway, rapidly resulting in both immediate and long-term sequelae if not appropriately treated. Pediatric hospitalists frequently encounter patients with disorders of the head and neck and should be able to recognize their signs and symptoms and provide evidence-based and efficient care. In particular, pediatric hospitalists must be able to identify impending airway obstruction, provide immediate care, and arrange for the appropriate subsequent level of care.

Pediatric hospitalists should be able to:

• Compare and contrast the head and neck anatomy of children at different chronological ages, including how abnormalities of airflow in different locations may alter the clinical presentation at different ages.
• Discuss the symptoms of various anatomic abnormalities (such as laryngomalacia, tracheomalacia, subglottic stenosis, and others), including the acute infectious processes which may exacerbate their clinical presentation.
• Discuss the pathophysiology, presenting features, and common pathogens associated with bacterial infections of the head and neck (such as otitis media, otitis externa, retropharyngeal abscess, orbital cellulitis, dental infections, mastoiditis, peritonsillar abscess, and others).
• Describe the differential diagnosis of common presenting symptoms of head and neck disorders, such as shortness of breath, stridor, cough, nasal discharge, neck swelling/pain, dysphagia/drooling, facial swelling, and others.
• Describe the features of upper airway obstruction, such as stertor, stridor, tripod positioning, dysphagia, drooling, trismus, and others.
• Discuss alternate diagnoses that may mimic the presentation of acute upper respiratory infection such as allergic reaction, toxic inhalant exposure, and others.
• List the indications for hospital admission, explain the utility of various monitoring options, and review the indications for emergent and non-emergent subspecialist consultation.
• Describe the signs and symptoms of obstructive sleep apnea (OSA) including snoring, respiratory pauses, and hypoxia, and discuss appropriate evaluation, referral, and management.
• Explain the types of studies available to assess the head and neck (including plain radiographs, fluoroscopy, ultrasonography, computed tomography, magnetic resonance imaging, and direct laryngoscopy) and discuss the risks, benefits, and indications for each.
• Discuss the indications, contraindications, and mechanisms of action of pharmacological agents used to treat various disorders of the head and neck, such as antibiotics, nebulized epinephrine, glucocorticoids, proton pump inhibitors, histamine 2 blockers, and others.
• Compare and contrast the benefits and limitations of various modalities of airway stabilization and respiratory support (including heated humidified high flow nasal cannula, non-invasive positive pressure support, and intubation with mechanical ventilation) in patients with varying degrees of upper airway obstruction.
• Discuss the changes in clinical status that indicate need for escalation of care, such as worsening stridor or work of breathing, decreased air entry, cyanosis, altered mental status, and others.
• Describe the patient characteristics that indicate the need for higher level of care and/or transfer to a referral center in cases requiring pediatric-specific services not available at the local facility.
• Describe criteria, including specific measures of clinical stability, that must be met before discharging patients with head and neck disorders, including oxygenation, hydration, and patient/family education.

Pediatric hospitalists should be able to:

• Perform an appropriately focused medical history, attending to symptoms of potential airway obstruction.
• Conduct a thorough physical examination directed by signs and symptoms that may indicate the location, etiology, or severity of the disorder.
• Identify patients with comorbidities or underlying anatomic abnormalities that impact the management plan and order appropriate testing, correctly interpreting results.
• Order appropriate monitoring and correctly interpret monitor data.
• Adhere consistently to infection control practices.
• Identify complications and respond with appropriate actions.
• Perform an evidence-based, cost-effective diagnostic evaluation and treatment plan, avoiding unnecessary testing.
• Perform careful reassessments daily and as needed, note changes in clinical status, and respond with appropriate actions and escalation of care as appropriate.
• Stabilize the airway and provide appropriate respiratory support for patients with impending or actual airway obstruction or respiratory failure, including head tilt/chin lift, nasal trumpet, and intubation, or arrange for the appropriate personnel to perform the procedure in an effective and efficient manner.
• Engage consultants (such as otolaryngologists, pulmonologists, surgeons, speech and feeding specialists, dentists, and others) efficiently and effectively when needed.

Pediatric hospitalists should be able to:

• Role model and advocate for strict adherence to infection control practices.
• Realize responsibility for effective communication with patients and the family/caregivers regarding the diagnosis, management plan, and follow-up needs.
• Recognize the value of collaboration with the primary care provider, subspecialists, nursing, the hospital staff, and other outpatient providers to ensure coordinated longitudinal care at the time of discharge.

In order to improve efficiency and quality within their organizations, pediatric hospitalists should:

• Lead, coordinate, or participate in the development, implementation, and improvement of cost-effective, safe, evidence-based care within a multidisciplinary team for hospitalized children with head and neck disorders.
• Collaborate with hospital administration and community partners to develop and sustain referral networks between local facilities and tertiary referral centers for hospitalized patients with head and neck disorders.

Introduction

Complaints related to the gastrointestinal (GI) and digestive system are common in childhood and may indicate the presence of a broad range of both routine and serious, life-threatening conditions. Pediatric hospitalists commonly encounter children who present with GI complaints such as abdominal pain, gastrointestinal bleeding, or feeding intolerance, as well as new or established GI conditions such as gastroesophageal reflux (GER), malabsorption, disorders of motility, and a variety of obstructive, infectious, and inflammatory diagnoses. Pediatric hospitalists are often tasked with identifying presenting signs and symptoms, initiating appropriate investigational studies and therapies, and coordinating care across subspecialties as appropriate.

Pediatric hospitalists should be able to:

• Discuss essential elements of the history for patients with GI complaints, including location, radiation, and duration of pain; emesis and stool pattern and description; pertinent non-GI symptoms such as rash, fever, and joint pain; and growth parameters and weight trend.
• Describe the differential diagnosis for common GI complaints for children of varying ages, including:

–Acute and chronic abdominal pain

–Emesis, with and without diarrhea

–Acute and chronic diarrhea

–Upper and lower GI bleeding

• Discuss disorders of other organ systems that may present with GI complaints, such as lower lobe pneumonia, urinary tract infection, and others.
• Describe medical and surgical urgent and emergent conditions that present with abdominal pain or a digestive disorder, such as intussusception, volvulus, biliary atresia, pyloric stenosis, Hirschsprung’s disease, and others.
• Describe the unique diagnostic considerations for adolescents with abdominal pain, including sexually transmitted infections and pelvic inflammatory disease, pregnancy related conditions, and testicular conditions.
• Discuss organisms associated with common infections of the GI tract, including those of the esophagus, stomach, small intestines, and colon.
• Compare and contrast the epidemiology, historical elements, and physical examination findings for various infectious or inflammatory conditions, such as pancreatitis, cholecystitis, hepatitis, and inflammatory bowel disease (IBD).
• Compare and contrast the clinical presentation, radiographic findings, and pharmacologic and non-pharmacologic treatment modalities for physiologic GER versus GER disease.
• Describe common causes of dysphagia and dysmotility, such as congenital anomalies, neurological impairment, and others, and discuss approaches to evaluation and treatment.
• Explain the indications for hospital admission, including clinical monitoring, fluid resuscitation, correction of electrolyte disturbances, and further diagnostic evaluation.
• Explain the indications for diagnostic laboratory and imaging tests, attending to variation by age, predictive value of tests, and cost-effectiveness.
• Describe common laboratory, imaging, endoscopic, and pathologic findings associated with specific GI disorders, such as eosinophilic esophagitis, IBD, Celiac Disease, and others.
• Discuss indications for subspecialty consultation, including speech and feeding therapy, radiology, gastroenterology, and surgery.
• Discuss indications for patient transfer to a referral center, such as need for pediatric-specific services not available at the local facility.
• Describe specific clinical discharge criteria for hospitalized patients with various GI disorders.

Pediatric hospitalists should be able to:

• Diagnose disorders of the GI tract and digestive system by efficiently performing an accurate history and physical examination, with specific focus on the oral pharynx, anus and rectum, abdomen, and integument, determining if key features of diseases are present.
• Formulate a targeted differential diagnosis based on elements from the history and physical examination to direct the need for further investigation.
• Identify and effectively manage complications of GI disorders such as sepsis, ileus or obstruction, and GI bleeding.
• Formulate an individualized, evidence-based evaluation and treatment plan, including fluid and nutritional management, laboratory and radiological testing, coordination of endoscopic and surgical interventions, medication, and pain management.
• Adhere to infection control practices when indicated.
• Engage consultants efficiently and appropriately when indicated.
• Communicate effectively with the family/caregivers and healthcare providers regarding findings and care plans.
• Coordinate care with the primary care provider and subspecialists if indicated and arrange an appropriate transition plan for hospital discharge.

Pediatric hospitalists should be able to:

• Recognize the importance of coordinating care for diagnostic tests and treatment between subspecialists, such as gastroenterologists, radiologists, and surgeons.
• Realize responsibility for effective communication with the patients, the family/caregivers, subspecialists, and primary care providers regarding diagnostic findings, plan of care, and anticipatory guidance after discharge.

In order to improve efficiency and quality within their organizations, pediatric hospitalists should:

• Lead, coordinate, or participate in the development and implementation of cost-effective, safe, evidence-based care pathways to standardize the evaluation and management for hospitalized children with GI disorders.
• Collaborate with hospital administration to create and sustain a process to follow up on laboratory tests pending at discharge.

Introduction

Complaints related to the gastrointestinal (GI) and digestive system are common in childhood and may indicate the presence of a broad range of both routine and serious, life-threatening conditions. Pediatric hospitalists commonly encounter children who present with GI complaints such as abdominal pain, gastrointestinal bleeding, or feeding intolerance, as well as new or established GI conditions such as gastroesophageal reflux (GER), malabsorption, disorders of motility, and a variety of obstructive, infectious, and inflammatory diagnoses. Pediatric hospitalists are often tasked with identifying presenting signs and symptoms, initiating appropriate investigational studies and therapies, and coordinating care across subspecialties as appropriate.

Pediatric hospitalists should be able to:

• Discuss essential elements of the history for patients with GI complaints, including location, radiation, and duration of pain; emesis and stool pattern and description; pertinent non-GI symptoms such as rash, fever, and joint pain; and growth parameters and weight trend.
• Describe the differential diagnosis for common GI complaints for children of varying ages, including:

–Acute and chronic abdominal pain

–Emesis, with and without diarrhea

–Acute and chronic diarrhea

–Upper and lower GI bleeding

• Discuss disorders of other organ systems that may present with GI complaints, such as lower lobe pneumonia, urinary tract infection, and others.
• Describe medical and surgical urgent and emergent conditions that present with abdominal pain or a digestive disorder, such as intussusception, volvulus, biliary atresia, pyloric stenosis, Hirschsprung’s disease, and others.
• Describe the unique diagnostic considerations for adolescents with abdominal pain, including sexually transmitted infections and pelvic inflammatory disease, pregnancy related conditions, and testicular conditions.
• Discuss organisms associated with common infections of the GI tract, including those of the esophagus, stomach, small intestines, and colon.
• Compare and contrast the epidemiology, historical elements, and physical examination findings for various infectious or inflammatory conditions, such as pancreatitis, cholecystitis, hepatitis, and inflammatory bowel disease (IBD).
• Compare and contrast the clinical presentation, radiographic findings, and pharmacologic and non-pharmacologic treatment modalities for physiologic GER versus GER disease.
• Describe common causes of dysphagia and dysmotility, such as congenital anomalies, neurological impairment, and others, and discuss approaches to evaluation and treatment.
• Explain the indications for hospital admission, including clinical monitoring, fluid resuscitation, correction of electrolyte disturbances, and further diagnostic evaluation.
• Explain the indications for diagnostic laboratory and imaging tests, attending to variation by age, predictive value of tests, and cost-effectiveness.
• Describe common laboratory, imaging, endoscopic, and pathologic findings associated with specific GI disorders, such as eosinophilic esophagitis, IBD, Celiac Disease, and others.
• Discuss indications for subspecialty consultation, including speech and feeding therapy, radiology, gastroenterology, and surgery.
• Discuss indications for patient transfer to a referral center, such as need for pediatric-specific services not available at the local facility.
• Describe specific clinical discharge criteria for hospitalized patients with various GI disorders.

Pediatric hospitalists should be able to:

• Diagnose disorders of the GI tract and digestive system by efficiently performing an accurate history and physical examination, with specific focus on the oral pharynx, anus and rectum, abdomen, and integument, determining if key features of diseases are present.
• Formulate a targeted differential diagnosis based on elements from the history and physical examination to direct the need for further investigation.
• Identify and effectively manage complications of GI disorders such as sepsis, ileus or obstruction, and GI bleeding.
• Formulate an individualized, evidence-based evaluation and treatment plan, including fluid and nutritional management, laboratory and radiological testing, coordination of endoscopic and surgical interventions, medication, and pain management.
• Adhere to infection control practices when indicated.
• Engage consultants efficiently and appropriately when indicated.
• Communicate effectively with the family/caregivers and healthcare providers regarding findings and care plans.
• Coordinate care with the primary care provider and subspecialists if indicated and arrange an appropriate transition plan for hospital discharge.

Pediatric hospitalists should be able to:

• Recognize the importance of coordinating care for diagnostic tests and treatment between subspecialists, such as gastroenterologists, radiologists, and surgeons.
• Realize responsibility for effective communication with the patients, the family/caregivers, subspecialists, and primary care providers regarding diagnostic findings, plan of care, and anticipatory guidance after discharge.

In order to improve efficiency and quality within their organizations, pediatric hospitalists should:

• Lead, coordinate, or participate in the development and implementation of cost-effective, safe, evidence-based care pathways to standardize the evaluation and management for hospitalized children with GI disorders.
• Collaborate with hospital administration to create and sustain a process to follow up on laboratory tests pending at discharge.

Introduction

Complaints related to the gastrointestinal (GI) and digestive system are common in childhood and may indicate the presence of a broad range of both routine and serious, life-threatening conditions. Pediatric hospitalists commonly encounter children who present with GI complaints such as abdominal pain, gastrointestinal bleeding, or feeding intolerance, as well as new or established GI conditions such as gastroesophageal reflux (GER), malabsorption, disorders of motility, and a variety of obstructive, infectious, and inflammatory diagnoses. Pediatric hospitalists are often tasked with identifying presenting signs and symptoms, initiating appropriate investigational studies and therapies, and coordinating care across subspecialties as appropriate.

Pediatric hospitalists should be able to:

• Discuss essential elements of the history for patients with GI complaints, including location, radiation, and duration of pain; emesis and stool pattern and description; pertinent non-GI symptoms such as rash, fever, and joint pain; and growth parameters and weight trend.
• Describe the differential diagnosis for common GI complaints for children of varying ages, including:

–Acute and chronic abdominal pain

–Emesis, with and without diarrhea

–Acute and chronic diarrhea

–Upper and lower GI bleeding

• Discuss disorders of other organ systems that may present with GI complaints, such as lower lobe pneumonia, urinary tract infection, and others.
• Describe medical and surgical urgent and emergent conditions that present with abdominal pain or a digestive disorder, such as intussusception, volvulus, biliary atresia, pyloric stenosis, Hirschsprung’s disease, and others.
• Describe the unique diagnostic considerations for adolescents with abdominal pain, including sexually transmitted infections and pelvic inflammatory disease, pregnancy related conditions, and testicular conditions.
• Discuss organisms associated with common infections of the GI tract, including those of the esophagus, stomach, small intestines, and colon.
• Compare and contrast the epidemiology, historical elements, and physical examination findings for various infectious or inflammatory conditions, such as pancreatitis, cholecystitis, hepatitis, and inflammatory bowel disease (IBD).
• Compare and contrast the clinical presentation, radiographic findings, and pharmacologic and non-pharmacologic treatment modalities for physiologic GER versus GER disease.
• Describe common causes of dysphagia and dysmotility, such as congenital anomalies, neurological impairment, and others, and discuss approaches to evaluation and treatment.
• Explain the indications for hospital admission, including clinical monitoring, fluid resuscitation, correction of electrolyte disturbances, and further diagnostic evaluation.
• Explain the indications for diagnostic laboratory and imaging tests, attending to variation by age, predictive value of tests, and cost-effectiveness.
• Describe common laboratory, imaging, endoscopic, and pathologic findings associated with specific GI disorders, such as eosinophilic esophagitis, IBD, Celiac Disease, and others.
• Discuss indications for subspecialty consultation, including speech and feeding therapy, radiology, gastroenterology, and surgery.
• Discuss indications for patient transfer to a referral center, such as need for pediatric-specific services not available at the local facility.
• Describe specific clinical discharge criteria for hospitalized patients with various GI disorders.

Pediatric hospitalists should be able to:

• Diagnose disorders of the GI tract and digestive system by efficiently performing an accurate history and physical examination, with specific focus on the oral pharynx, anus and rectum, abdomen, and integument, determining if key features of diseases are present.
• Formulate a targeted differential diagnosis based on elements from the history and physical examination to direct the need for further investigation.
• Identify and effectively manage complications of GI disorders such as sepsis, ileus or obstruction, and GI bleeding.
• Formulate an individualized, evidence-based evaluation and treatment plan, including fluid and nutritional management, laboratory and radiological testing, coordination of endoscopic and surgical interventions, medication, and pain management.
• Adhere to infection control practices when indicated.
• Engage consultants efficiently and appropriately when indicated.
• Communicate effectively with the family/caregivers and healthcare providers regarding findings and care plans.
• Coordinate care with the primary care provider and subspecialists if indicated and arrange an appropriate transition plan for hospital discharge.

Pediatric hospitalists should be able to:

• Recognize the importance of coordinating care for diagnostic tests and treatment between subspecialists, such as gastroenterologists, radiologists, and surgeons.
• Realize responsibility for effective communication with the patients, the family/caregivers, subspecialists, and primary care providers regarding diagnostic findings, plan of care, and anticipatory guidance after discharge.

In order to improve efficiency and quality within their organizations, pediatric hospitalists should:

• Lead, coordinate, or participate in the development and implementation of cost-effective, safe, evidence-based care pathways to standardize the evaluation and management for hospitalized children with GI disorders.
• Collaborate with hospital administration to create and sustain a process to follow up on laboratory tests pending at discharge.

Introduction

A greater understanding of pediatric fluid therapy is one of the most important advances of pediatric medicine and a cornerstone of current inpatient pediatric practice. Despite the use of rotavirus vaccine, gastroenteritis and dehydration with electrolyte abnormalities remains among the top 10 admission diagnoses nationwide, with annual hospitalization rates of 3 to 5 per 1000 U.S. children under 5 years of age. Although the majority of previously healthy hospitalized children can compensate for errors in calculations of fluid therapy, mistakes – even in healthy children admitted for minor illnesses – can have devastating outcomes. Patients with underlying disease processes are at even greater risk for adverse outcomes, if fluids and electrolytes are not meticulously managed. Pediatric hospitalists should be experts at managing frequently encountered fluid and electrolyte abnormalities.

Pediatric hospitalists should be able to:

• Discuss the physiology of fluid and electrolyte homeostasis and the changes that occur with growth and development.
• Discuss maintenance fluid calculations for water and electrolyte homeostasis based on body surface area or the Holliday Segar method, considering alterations in the renin-angiotensin system and vasopressin levels in hospitalized children which predispose them to hyponatremia.
• Describe the methods used for calculation of excessive fluid losses due to gastrointestinal, respiratory, renal, or skin abnormalities and identify the best fluid replacement type for each.
• Describe common errors in clinical estimations of dehydration and fluid and electrolyte requirements.
• Explain the rationale, indications, and contraindications for oral rehydration, including the correct glucose and electrolyte composition and technique for administration.
• Discuss the benefits of and barriers to intravenous (IV) versus enteral methods for fluid and electrolyte repletion and the indications, benefits, and barriers for each.
• Review the indications for administering a parenteral fluid bolus for resuscitation and explain the rationale for the use of isotonic fluids for rehydration.
• Discuss the benefits and risks of repeated lab testing and intravenous access placement, including cost, pain, effect on clinical management, the family/caregivers’ perceptions, staff time, and others.
• Compare and contrast true hyponatremia with pseudohyponatremia and give examples of conditions in which these exist.
• List differential diagnoses for hyponatremia and hypernatremia.
• Summarize the management of hyponatremia and hypernatremia, attending to duration of corrective therapy and potential complications during correction.
• Distinguish between hyperkalemia and pseudohyperkalemia and give examples of the conditions in which these exist.
• List differential diagnoses for hypokalemia and hyperkalemia.
• Distinguish hypocalcemia from pseudohypocalcemia and give examples of the conditions in which these exist.
• Discuss the etiology and sequelae of hypomagnesemia and secondary hypomagnesemia.
• Discuss the interaction of fluid and electrolytes with acid/base balance.
• Describe common acid/base disturbances that accompany frequently encountered causes of fluid deficit and give examples of exacerbating issues including underlying co-morbidity and use of over-the-counter medications.

Pediatric hospitalists should be able to:

• Calculate maintenance fluid and electrolyte requirements for hospitalized infants and children.
• Adjust maintenance fluids for increased insensible losses and ongoing fluid and electrolyte needs.
• Estimate the degree of dehydration for children of various ages based upon clinical symptoms and signs.
• Identify common presenting signs and symptoms associated with an excess or deficit of common electrolytes and glucose in infants and children.
• Correctly estimate osmolar disturbance by interpreting electrolyte, glucose, and blood urea nitrogen results.
• Calculate and administer an isotonic fluid bolus correctly when indicated.
• Obtain IV or intraosseous access in moderate to severely dehydrated patients.
• Assess the success of fluid resuscitation by interpreting clinical changes and laboratory values.
• Calculate and administer maintenance and deficit fluid replacement for isotonic, hypertonic, and hypotonic dehydration.
• Interpret urine and serum electrolytes and osmolality, as well as fluid status (hypo-, hyper-, or isovolemic), to determine the etiology for hyponatremia or hypernatremia.
• Correct hyponatremia using appropriate replacement or restriction of fluids, sodium chloride, and medications depending upon the diagnosis.
• Correct hypernatremia using an appropriate electrolyte composition and rate of fluid replacement, as well as medications depending upon the diagnosis.
• Correct hypoglycemia using an appropriate replacement solution.
• Interpret EKG findings in the context of specific electrolyte abnormalities.
• Prescribe electrolyte replacement therapy and institute proper monitoring for arrhythmias.
• Correct symptomatic hyperkalemia using a combination of therapies to stabilize cardiac conduction, redistribute potassium to the intracellular space, and remove it from the body.
• Consult pediatric subspecialists appropriately to expedite the diagnosis and management of serious electrolyte disorders and transfer to a higher level of care when indicated.

Pediatric hospitalists should be able to:

• Recognize the benefits of oral rehydration and advocate for its use when indicated and clinically appropriate.
• Realize the importance of collaboration with subspecialty and primary care providers to ensure coordinated follow up for patients with persistent fluid and electrolyte disturbances at discharge.
• Consider cost-effectiveness, pain, and patient safety when creating plans for the treatment of fluid deficits.

In order to improve efficiency and quality within their organizations, pediatric hospitalists should:

• Work collaboratively with others such as surgeons, intensivists, and advanced practice nurses to establish institutional protocols for attainment of venous access.
• Lead, coordinate, or participate in plans to develop institutional policies to safely monitor and administer fluids and electrolytes.
• Lead, coordinate, or participate in developing guidelines for the treatment of fluid and electrolyte abnormalities in the hospital and community.

Introduction

A greater understanding of pediatric fluid therapy is one of the most important advances of pediatric medicine and a cornerstone of current inpatient pediatric practice. Despite the use of rotavirus vaccine, gastroenteritis and dehydration with electrolyte abnormalities remains among the top 10 admission diagnoses nationwide, with annual hospitalization rates of 3 to 5 per 1000 U.S. children under 5 years of age. Although the majority of previously healthy hospitalized children can compensate for errors in calculations of fluid therapy, mistakes – even in healthy children admitted for minor illnesses – can have devastating outcomes. Patients with underlying disease processes are at even greater risk for adverse outcomes, if fluids and electrolytes are not meticulously managed. Pediatric hospitalists should be experts at managing frequently encountered fluid and electrolyte abnormalities.

Pediatric hospitalists should be able to:

• Discuss the physiology of fluid and electrolyte homeostasis and the changes that occur with growth and development.
• Discuss maintenance fluid calculations for water and electrolyte homeostasis based on body surface area or the Holliday Segar method, considering alterations in the renin-angiotensin system and vasopressin levels in hospitalized children which predispose them to hyponatremia.
• Describe the methods used for calculation of excessive fluid losses due to gastrointestinal, respiratory, renal, or skin abnormalities and identify the best fluid replacement type for each.
• Describe common errors in clinical estimations of dehydration and fluid and electrolyte requirements.
• Explain the rationale, indications, and contraindications for oral rehydration, including the correct glucose and electrolyte composition and technique for administration.
• Discuss the benefits of and barriers to intravenous (IV) versus enteral methods for fluid and electrolyte repletion and the indications, benefits, and barriers for each.
• Review the indications for administering a parenteral fluid bolus for resuscitation and explain the rationale for the use of isotonic fluids for rehydration.
• Discuss the benefits and risks of repeated lab testing and intravenous access placement, including cost, pain, effect on clinical management, the family/caregivers’ perceptions, staff time, and others.
• Compare and contrast true hyponatremia with pseudohyponatremia and give examples of conditions in which these exist.
• List differential diagnoses for hyponatremia and hypernatremia.
• Summarize the management of hyponatremia and hypernatremia, attending to duration of corrective therapy and potential complications during correction.
• Distinguish between hyperkalemia and pseudohyperkalemia and give examples of the conditions in which these exist.
• List differential diagnoses for hypokalemia and hyperkalemia.
• Distinguish hypocalcemia from pseudohypocalcemia and give examples of the conditions in which these exist.
• Discuss the etiology and sequelae of hypomagnesemia and secondary hypomagnesemia.
• Discuss the interaction of fluid and electrolytes with acid/base balance.
• Describe common acid/base disturbances that accompany frequently encountered causes of fluid deficit and give examples of exacerbating issues including underlying co-morbidity and use of over-the-counter medications.

Pediatric hospitalists should be able to:

• Calculate maintenance fluid and electrolyte requirements for hospitalized infants and children.
• Adjust maintenance fluids for increased insensible losses and ongoing fluid and electrolyte needs.
• Estimate the degree of dehydration for children of various ages based upon clinical symptoms and signs.
• Identify common presenting signs and symptoms associated with an excess or deficit of common electrolytes and glucose in infants and children.
• Correctly estimate osmolar disturbance by interpreting electrolyte, glucose, and blood urea nitrogen results.
• Calculate and administer an isotonic fluid bolus correctly when indicated.
• Obtain IV or intraosseous access in moderate to severely dehydrated patients.
• Assess the success of fluid resuscitation by interpreting clinical changes and laboratory values.
• Calculate and administer maintenance and deficit fluid replacement for isotonic, hypertonic, and hypotonic dehydration.
• Interpret urine and serum electrolytes and osmolality, as well as fluid status (hypo-, hyper-, or isovolemic), to determine the etiology for hyponatremia or hypernatremia.
• Correct hyponatremia using appropriate replacement or restriction of fluids, sodium chloride, and medications depending upon the diagnosis.
• Correct hypernatremia using an appropriate electrolyte composition and rate of fluid replacement, as well as medications depending upon the diagnosis.
• Correct hypoglycemia using an appropriate replacement solution.
• Interpret EKG findings in the context of specific electrolyte abnormalities.
• Prescribe electrolyte replacement therapy and institute proper monitoring for arrhythmias.
• Correct symptomatic hyperkalemia using a combination of therapies to stabilize cardiac conduction, redistribute potassium to the intracellular space, and remove it from the body.
• Consult pediatric subspecialists appropriately to expedite the diagnosis and management of serious electrolyte disorders and transfer to a higher level of care when indicated.

Pediatric hospitalists should be able to:

• Recognize the benefits of oral rehydration and advocate for its use when indicated and clinically appropriate.
• Realize the importance of collaboration with subspecialty and primary care providers to ensure coordinated follow up for patients with persistent fluid and electrolyte disturbances at discharge.
• Consider cost-effectiveness, pain, and patient safety when creating plans for the treatment of fluid deficits.

In order to improve efficiency and quality within their organizations, pediatric hospitalists should:

• Work collaboratively with others such as surgeons, intensivists, and advanced practice nurses to establish institutional protocols for attainment of venous access.
• Lead, coordinate, or participate in plans to develop institutional policies to safely monitor and administer fluids and electrolytes.
• Lead, coordinate, or participate in developing guidelines for the treatment of fluid and electrolyte abnormalities in the hospital and community.

Introduction

A greater understanding of pediatric fluid therapy is one of the most important advances of pediatric medicine and a cornerstone of current inpatient pediatric practice. Despite the use of rotavirus vaccine, gastroenteritis and dehydration with electrolyte abnormalities remains among the top 10 admission diagnoses nationwide, with annual hospitalization rates of 3 to 5 per 1000 U.S. children under 5 years of age. Although the majority of previously healthy hospitalized children can compensate for errors in calculations of fluid therapy, mistakes – even in healthy children admitted for minor illnesses – can have devastating outcomes. Patients with underlying disease processes are at even greater risk for adverse outcomes, if fluids and electrolytes are not meticulously managed. Pediatric hospitalists should be experts at managing frequently encountered fluid and electrolyte abnormalities.

Pediatric hospitalists should be able to:

• Discuss the physiology of fluid and electrolyte homeostasis and the changes that occur with growth and development.
• Discuss maintenance fluid calculations for water and electrolyte homeostasis based on body surface area or the Holliday Segar method, considering alterations in the renin-angiotensin system and vasopressin levels in hospitalized children which predispose them to hyponatremia.
• Describe the methods used for calculation of excessive fluid losses due to gastrointestinal, respiratory, renal, or skin abnormalities and identify the best fluid replacement type for each.
• Describe common errors in clinical estimations of dehydration and fluid and electrolyte requirements.
• Explain the rationale, indications, and contraindications for oral rehydration, including the correct glucose and electrolyte composition and technique for administration.
• Discuss the benefits of and barriers to intravenous (IV) versus enteral methods for fluid and electrolyte repletion and the indications, benefits, and barriers for each.
• Review the indications for administering a parenteral fluid bolus for resuscitation and explain the rationale for the use of isotonic fluids for rehydration.
• Discuss the benefits and risks of repeated lab testing and intravenous access placement, including cost, pain, effect on clinical management, the family/caregivers’ perceptions, staff time, and others.
• Compare and contrast true hyponatremia with pseudohyponatremia and give examples of conditions in which these exist.
• List differential diagnoses for hyponatremia and hypernatremia.
• Summarize the management of hyponatremia and hypernatremia, attending to duration of corrective therapy and potential complications during correction.
• Distinguish between hyperkalemia and pseudohyperkalemia and give examples of the conditions in which these exist.
• List differential diagnoses for hypokalemia and hyperkalemia.
• Distinguish hypocalcemia from pseudohypocalcemia and give examples of the conditions in which these exist.
• Discuss the etiology and sequelae of hypomagnesemia and secondary hypomagnesemia.
• Discuss the interaction of fluid and electrolytes with acid/base balance.
• Describe common acid/base disturbances that accompany frequently encountered causes of fluid deficit and give examples of exacerbating issues including underlying co-morbidity and use of over-the-counter medications.

Pediatric hospitalists should be able to:

• Calculate maintenance fluid and electrolyte requirements for hospitalized infants and children.
• Adjust maintenance fluids for increased insensible losses and ongoing fluid and electrolyte needs.
• Estimate the degree of dehydration for children of various ages based upon clinical symptoms and signs.
• Identify common presenting signs and symptoms associated with an excess or deficit of common electrolytes and glucose in infants and children.
• Correctly estimate osmolar disturbance by interpreting electrolyte, glucose, and blood urea nitrogen results.
• Calculate and administer an isotonic fluid bolus correctly when indicated.
• Obtain IV or intraosseous access in moderate to severely dehydrated patients.
• Assess the success of fluid resuscitation by interpreting clinical changes and laboratory values.
• Calculate and administer maintenance and deficit fluid replacement for isotonic, hypertonic, and hypotonic dehydration.
• Interpret urine and serum electrolytes and osmolality, as well as fluid status (hypo-, hyper-, or isovolemic), to determine the etiology for hyponatremia or hypernatremia.
• Correct hyponatremia using appropriate replacement or restriction of fluids, sodium chloride, and medications depending upon the diagnosis.
• Correct hypernatremia using an appropriate electrolyte composition and rate of fluid replacement, as well as medications depending upon the diagnosis.
• Correct hypoglycemia using an appropriate replacement solution.
• Interpret EKG findings in the context of specific electrolyte abnormalities.
• Prescribe electrolyte replacement therapy and institute proper monitoring for arrhythmias.
• Correct symptomatic hyperkalemia using a combination of therapies to stabilize cardiac conduction, redistribute potassium to the intracellular space, and remove it from the body.
• Consult pediatric subspecialists appropriately to expedite the diagnosis and management of serious electrolyte disorders and transfer to a higher level of care when indicated.

Pediatric hospitalists should be able to:

• Recognize the benefits of oral rehydration and advocate for its use when indicated and clinically appropriate.
• Realize the importance of collaboration with subspecialty and primary care providers to ensure coordinated follow up for patients with persistent fluid and electrolyte disturbances at discharge.
• Consider cost-effectiveness, pain, and patient safety when creating plans for the treatment of fluid deficits.

In order to improve efficiency and quality within their organizations, pediatric hospitalists should:

• Work collaboratively with others such as surgeons, intensivists, and advanced practice nurses to establish institutional protocols for attainment of venous access.
• Lead, coordinate, or participate in plans to develop institutional policies to safely monitor and administer fluids and electrolytes.
• Lead, coordinate, or participate in developing guidelines for the treatment of fluid and electrolyte abnormalities in the hospital and community.

Introduction

Fever is the most common presenting complaint in the pediatric outpatient and emergency room setting. In most cases, the etiology of acute fever is readily discernable. In contrast, fever of unknown origin (FUO) is typically defined as fever of 38.3° C (101° F) or greater for 14 days duration (range 8-21 days) with no apparent cause after a thorough history, physical examination, and initial laboratory evaluation. The differential diagnosis of FUO is very broad. Infection is the most common cause of prolonged fever; other major etiologic categories include malignancy, rheumatologic conditions, inflammatory bowel disease, drug fever, and miscellaneous causes. When children require hospitalization for prolonged fever with concern for FUO, pediatric hospitalists should develop a thoughtful, stepwise, and cost-effective approach to diagnosis and management.

Pediatric hospitalists should be able to:

• Discuss the pathophysiologic mechanisms that result in fever.
• List the different methods available for obtaining a temperature and explain common errors associated with each.
• Differentiate FUO from disorders known to present with serial or prolonged fevers.
• Describe the differential diagnosis of FUO for children of varying chronological and developmental ages and state the relative prevalence of each etiologic category.
• Identify the common infectious causes of FUO, particularly as they differ by geographic region.
• Describe the key features of the history, including details of the fever pattern and course of illness, immunization status, travel and exposure history, and family history.
• Discuss areas of specific focus when performing the physical examination, including those related to occult infection and/or underlying single or multiple organ-system pathology, such as skin and eye findings, lymph nodes, sinuses, liver and spleen size, bone and joint exam, neurologic exam, and neurobehavioral state.
• Describe the indications for and goals of hospitalization, including the role of close observation without treatment and daily physical examination.
• List common initial laboratory tests for FUO, recognizing the utility, sensitivity, and specificity of diagnostic tests, as well as local availability and processing times.
• Summarize the diagnostic value of advanced testing (such as bone scan, bone marrow aspiration/biopsy, repeated blood cultures with fever, and others) when initial testing and observation is non-diagnostic.
• Recognize indications for subspecialty consultation, such as infectious disease, rheumatology, hematology/oncology, and others.
• Discuss the benefits, risks, and potential complications of empiric antibiotic treatment.
• Compare and contrast the mechanisms of action and modifying effect on systemic symptoms of antipyretics versus anti-inflammatory agents, noting common side effects.
• Discuss reasons for patient transfer to a referral center in cases requiring pediatric-specific services not available at the local facility.
• Explain goals for hospital discharge, including specific measures of clinical stability and a post-discharge care plan for safe transition.

Pediatric hospitalists should be able to:

• Obtain a thorough fever history, including method obtained, duration, height, pattern, associated signs and symptoms.
• Obtain a complete medical history, including signs and symptoms, immunization status, travel history, exposure history (such as animals, tick bites, consumption of raw foods or contaminated water, sick contacts, and others), and family history.
• Perform a comprehensive physical examination, assessing for manifestations of infection and/or underlying single or multiple organ system pathology.
• Access and comprehensively review all relevant prior records.
• Perform careful reassessments daily and as needed, note changes in clinical status and test results, and respond with appropriate actions.
• Interpret basic tests and identify abnormal findings that require further testing or consultation with a subspecialist.
• Engage consultants (such as infectious disease physicians, rheumatologists, and others) efficiently and appropriately when indicated.
• Perform a cost-effective, sequential, evidence-based evaluation, avoiding unnecessary repeat testing.
• Demonstrate the ability to order laboratory studies with appropriate detail to ensure specimens are correctly collected, stored, handled, and processed.
• Determine when to continue inpatient versus outpatient diagnostic evaluation, considering factors including persistence of fever and pending test results.
• Formulate appropriate treatment plans for the presumptive or confirmed diagnosis when indicated.
• Create an effective discharge plan, including specific expectations for home observation of fever and other symptoms.
• Coordinate care with the primary care provider and subspecialists if indicated, arranging an appropriate transition plan for hospital discharge.

Pediatric hospitalists should be able to:

• Recognize the importance of effective collaboration with the primary care provider and consultants regarding the evaluation and treatment conducted in and out of the hospital, along with discharge and follow up needs.
• Acknowledge the significant stress placed on the family/caregivers when the diagnosis is unclear and multiple healthcare providers are involved in care, assist the family through periods of uncertainty, and mobilize other family support resources.
• Realize responsibility for educating patients and the family/caregivers regarding the importance of observation and the need for a thoughtful, stepwise approach to the diagnosis and potential treatment plan.

In order to improve efficiency and quality within their organizations, pediatric hospitalists should:

• Lead, coordinate, or participate in multidisciplinary initiatives to develop and implement evidence-based clinical guidelines to effectively use hospital resources, promote a targeted stepwise clinical approach, and improve quality of care for children with FUO.

Introduction

Fever is the most common presenting complaint in the pediatric outpatient and emergency room setting. In most cases, the etiology of acute fever is readily discernable. In contrast, fever of unknown origin (FUO) is typically defined as fever of 38.3° C (101° F) or greater for 14 days duration (range 8-21 days) with no apparent cause after a thorough history, physical examination, and initial laboratory evaluation. The differential diagnosis of FUO is very broad. Infection is the most common cause of prolonged fever; other major etiologic categories include malignancy, rheumatologic conditions, inflammatory bowel disease, drug fever, and miscellaneous causes. When children require hospitalization for prolonged fever with concern for FUO, pediatric hospitalists should develop a thoughtful, stepwise, and cost-effective approach to diagnosis and management.

Pediatric hospitalists should be able to:

• Discuss the pathophysiologic mechanisms that result in fever.
• List the different methods available for obtaining a temperature and explain common errors associated with each.
• Differentiate FUO from disorders known to present with serial or prolonged fevers.
• Describe the differential diagnosis of FUO for children of varying chronological and developmental ages and state the relative prevalence of each etiologic category.
• Identify the common infectious causes of FUO, particularly as they differ by geographic region.
• Describe the key features of the history, including details of the fever pattern and course of illness, immunization status, travel and exposure history, and family history.
• Discuss areas of specific focus when performing the physical examination, including those related to occult infection and/or underlying single or multiple organ-system pathology, such as skin and eye findings, lymph nodes, sinuses, liver and spleen size, bone and joint exam, neurologic exam, and neurobehavioral state.
• Describe the indications for and goals of hospitalization, including the role of close observation without treatment and daily physical examination.
• List common initial laboratory tests for FUO, recognizing the utility, sensitivity, and specificity of diagnostic tests, as well as local availability and processing times.
• Summarize the diagnostic value of advanced testing (such as bone scan, bone marrow aspiration/biopsy, repeated blood cultures with fever, and others) when initial testing and observation is non-diagnostic.
• Recognize indications for subspecialty consultation, such as infectious disease, rheumatology, hematology/oncology, and others.
• Discuss the benefits, risks, and potential complications of empiric antibiotic treatment.
• Compare and contrast the mechanisms of action and modifying effect on systemic symptoms of antipyretics versus anti-inflammatory agents, noting common side effects.
• Discuss reasons for patient transfer to a referral center in cases requiring pediatric-specific services not available at the local facility.
• Explain goals for hospital discharge, including specific measures of clinical stability and a post-discharge care plan for safe transition.

Pediatric hospitalists should be able to:

• Obtain a thorough fever history, including method obtained, duration, height, pattern, associated signs and symptoms.
• Obtain a complete medical history, including signs and symptoms, immunization status, travel history, exposure history (such as animals, tick bites, consumption of raw foods or contaminated water, sick contacts, and others), and family history.
• Perform a comprehensive physical examination, assessing for manifestations of infection and/or underlying single or multiple organ system pathology.
• Access and comprehensively review all relevant prior records.
• Perform careful reassessments daily and as needed, note changes in clinical status and test results, and respond with appropriate actions.
• Interpret basic tests and identify abnormal findings that require further testing or consultation with a subspecialist.
• Engage consultants (such as infectious disease physicians, rheumatologists, and others) efficiently and appropriately when indicated.
• Perform a cost-effective, sequential, evidence-based evaluation, avoiding unnecessary repeat testing.
• Demonstrate the ability to order laboratory studies with appropriate detail to ensure specimens are correctly collected, stored, handled, and processed.
• Determine when to continue inpatient versus outpatient diagnostic evaluation, considering factors including persistence of fever and pending test results.
• Formulate appropriate treatment plans for the presumptive or confirmed diagnosis when indicated.
• Create an effective discharge plan, including specific expectations for home observation of fever and other symptoms.
• Coordinate care with the primary care provider and subspecialists if indicated, arranging an appropriate transition plan for hospital discharge.

Pediatric hospitalists should be able to:

• Recognize the importance of effective collaboration with the primary care provider and consultants regarding the evaluation and treatment conducted in and out of the hospital, along with discharge and follow up needs.
• Acknowledge the significant stress placed on the family/caregivers when the diagnosis is unclear and multiple healthcare providers are involved in care, assist the family through periods of uncertainty, and mobilize other family support resources.
• Realize responsibility for educating patients and the family/caregivers regarding the importance of observation and the need for a thoughtful, stepwise approach to the diagnosis and potential treatment plan.

In order to improve efficiency and quality within their organizations, pediatric hospitalists should:

• Lead, coordinate, or participate in multidisciplinary initiatives to develop and implement evidence-based clinical guidelines to effectively use hospital resources, promote a targeted stepwise clinical approach, and improve quality of care for children with FUO.

Introduction

Fever is the most common presenting complaint in the pediatric outpatient and emergency room setting. In most cases, the etiology of acute fever is readily discernable. In contrast, fever of unknown origin (FUO) is typically defined as fever of 38.3° C (101° F) or greater for 14 days duration (range 8-21 days) with no apparent cause after a thorough history, physical examination, and initial laboratory evaluation. The differential diagnosis of FUO is very broad. Infection is the most common cause of prolonged fever; other major etiologic categories include malignancy, rheumatologic conditions, inflammatory bowel disease, drug fever, and miscellaneous causes. When children require hospitalization for prolonged fever with concern for FUO, pediatric hospitalists should develop a thoughtful, stepwise, and cost-effective approach to diagnosis and management.

Pediatric hospitalists should be able to:

• Discuss the pathophysiologic mechanisms that result in fever.
• List the different methods available for obtaining a temperature and explain common errors associated with each.
• Differentiate FUO from disorders known to present with serial or prolonged fevers.
• Describe the differential diagnosis of FUO for children of varying chronological and developmental ages and state the relative prevalence of each etiologic category.
• Identify the common infectious causes of FUO, particularly as they differ by geographic region.
• Describe the key features of the history, including details of the fever pattern and course of illness, immunization status, travel and exposure history, and family history.
• Discuss areas of specific focus when performing the physical examination, including those related to occult infection and/or underlying single or multiple organ-system pathology, such as skin and eye findings, lymph nodes, sinuses, liver and spleen size, bone and joint exam, neurologic exam, and neurobehavioral state.
• Describe the indications for and goals of hospitalization, including the role of close observation without treatment and daily physical examination.
• List common initial laboratory tests for FUO, recognizing the utility, sensitivity, and specificity of diagnostic tests, as well as local availability and processing times.
• Summarize the diagnostic value of advanced testing (such as bone scan, bone marrow aspiration/biopsy, repeated blood cultures with fever, and others) when initial testing and observation is non-diagnostic.
• Recognize indications for subspecialty consultation, such as infectious disease, rheumatology, hematology/oncology, and others.
• Discuss the benefits, risks, and potential complications of empiric antibiotic treatment.
• Compare and contrast the mechanisms of action and modifying effect on systemic symptoms of antipyretics versus anti-inflammatory agents, noting common side effects.
• Discuss reasons for patient transfer to a referral center in cases requiring pediatric-specific services not available at the local facility.
• Explain goals for hospital discharge, including specific measures of clinical stability and a post-discharge care plan for safe transition.

Pediatric hospitalists should be able to:

• Obtain a thorough fever history, including method obtained, duration, height, pattern, associated signs and symptoms.
• Obtain a complete medical history, including signs and symptoms, immunization status, travel history, exposure history (such as animals, tick bites, consumption of raw foods or contaminated water, sick contacts, and others), and family history.
• Perform a comprehensive physical examination, assessing for manifestations of infection and/or underlying single or multiple organ system pathology.
• Access and comprehensively review all relevant prior records.
• Perform careful reassessments daily and as needed, note changes in clinical status and test results, and respond with appropriate actions.
• Interpret basic tests and identify abnormal findings that require further testing or consultation with a subspecialist.
• Engage consultants (such as infectious disease physicians, rheumatologists, and others) efficiently and appropriately when indicated.
• Perform a cost-effective, sequential, evidence-based evaluation, avoiding unnecessary repeat testing.
• Demonstrate the ability to order laboratory studies with appropriate detail to ensure specimens are correctly collected, stored, handled, and processed.
• Determine when to continue inpatient versus outpatient diagnostic evaluation, considering factors including persistence of fever and pending test results.
• Formulate appropriate treatment plans for the presumptive or confirmed diagnosis when indicated.
• Create an effective discharge plan, including specific expectations for home observation of fever and other symptoms.
• Coordinate care with the primary care provider and subspecialists if indicated, arranging an appropriate transition plan for hospital discharge.

Pediatric hospitalists should be able to:

• Recognize the importance of effective collaboration with the primary care provider and consultants regarding the evaluation and treatment conducted in and out of the hospital, along with discharge and follow up needs.
• Acknowledge the significant stress placed on the family/caregivers when the diagnosis is unclear and multiple healthcare providers are involved in care, assist the family through periods of uncertainty, and mobilize other family support resources.
• Realize responsibility for educating patients and the family/caregivers regarding the importance of observation and the need for a thoughtful, stepwise approach to the diagnosis and potential treatment plan.

In order to improve efficiency and quality within their organizations, pediatric hospitalists should:

• Lead, coordinate, or participate in multidisciplinary initiatives to develop and implement evidence-based clinical guidelines to effectively use hospital resources, promote a targeted stepwise clinical approach, and improve quality of care for children with FUO.