H&P/ SOAP notes:
Journal Article and Summary:
Pierre Robin sequence (PRS) is characterized by a small lower jaw (micrognathia) and displacement of the tongue toward the back of the oral cavity (glossoptosis). Some infants also have an abnormal opening in the roof of the mouth (cleft palate). PRS is believed to be caused by multiple contributing factors, which lead to a series of physical changes within the oral cavity. The altered anatomy of the oral cavity makes breathing difficult, which can range in severity from mild disturbance to life-threatening respiratory distress. Since food must pass through the altered oral cavity to get into the gastrointestinal tract, feeding difficulties are also common. Swallowing difficulties may be directly related to the glossoptosis and there is a considerable risk of failure to thrive and consequently, these patients are often in need of nasogastric (NG)-tube feeding. These physiological abnormalities impede successful coordination of breathing, sucking, and swallowing. The features of PRS can be present as an isolated sequence or as part of a genetic syndrome. PRS affects males and females in equal numbers, with an estimated prevalence of about 1 in 8,500-14,000 individuals.
This study is the first to identify factors that influence feeding and growth in PRS and describe weight gain in the first 2 years of life. Feeding difficulty (FD) was defined as (parentally) reported feeding problems, such as choking, regurgitation, gagging, distress, long-lasting feedings (≥30 min), impaired intake, and/or nasal regurgitation. FD can lead to insufficient weight gain, failure to thrive, need for NG-tube feeding, and can potentiate airway or respiratory compromise. The following variables were collected: presence of FD, need and duration of NG-tube feeding, and weight at birth and at 1, 3, 6, 9, 11, 14, 17, and 24 months of age. Growth was measured as a change between the consecutive measurements at these nine time points. In addition, normal weight standard deviation scores of healthy controls were collected.
Sixty-nine PRS patients (study group) and 64 consecutive iCPO patients (control group) were included. PRS patients expressed FD (91 %; n = 63) more than iCPO patients (72 %; n = 38, p = 0.004). NG-tube feeding was more often necessary in RS patients (80 %; n = 55) than iCPO patients (19 %; n = 12, p < 0.001). Furthermore, NG-tube feeding lasted longer in RS patients (median 59.0 days in study group vs. median 9.6 days in control group, p < 0.001). Birth weights of the two groups were comparable (iCPO group 3302 g vs. RS group 3217 g, p = 0.41). However, the iCPO group showed a significantly higher overall growth over the time points 1–9 (birth to 24 months of age) than the RS group (p = 0.008). This increased growth in the iCPO group was also visible when separately analyzing time points 1–4 (birth to 6 months of age) and 5–9 (9-24 months of age.
In this retrospective study, the prevalence of FD was significantly higher and NG-tube feeding was more frequent and for a longer period in infants with RS than iCPO. Growth in the first 2 years of life was significantly lower in RS than iCPO infants, although following a steady curve between the 0 and −1 SD line compared with healthy counterparts. Thus it is important to define feeding issues together with parents, feeding therapists, and pediatricians as early as possible. NG-tube feeding should be started when there is insufficient weight gain. By gaining insight about this challenging patient group, treatment strategies can be optimized and expectations of caretakers and parents better managed.
Site Evaluation Presentation Summary:
For both the mid and final evaluations, it was conducted on Blackboard Collaborate Ultra meeting. It was also conducted with my fellow peer, Melinda who was rotating in Pediatrics at NYC HHC Queens with me. We spoke about the site and how rotations were at Queens Hospital Center Pediatric Emergency Department and subsequently in the Neonatal ICU and Pediatric Clinic. I presented a history and physical along with an associated journal article and went over our drug cards at each evaluation.
We spoke about how to diagnose asthma and developing an asthma plan, with a step-wise approach to treatment and maintenance. We also discussed the importance of documentation and proofreading. This is especially true with medication prescription of the pediatric population, as most drugs are weight based. However one should keep in mind when patients outgrown either by age or weight of weight base dosing; such that they become adults and are given standard doses for treatment, such as in the treatment of Otitis Media. We also discussed the types of procedures and patients seen at QHC, for which I told him I was able to practice placing IV’s, and also perform a few laceration repairs. I was also able to see a variety of patients in from neonates to adults under 21 years of age.
Typhon Log:
Self-Reflection:
Being my last rotation, I was looking forward to being almost done but also excited because I had a general interest in pediatrics. I like being able to take care of the young and giving assurance to parents however I also knew how challenging it would be since it was a different patient population, and also having to take care of parents concerns. Most people describe it as taking care of two patients as the children are sick while the parents are overly concerned and can be overbearing. Originally I was scheduled to rotate at NYPQ, which I knew would be good exposure, however due to the hectic nature this year has brought I was lucky to rotate at NYC HHC Queens. I was glad to be in a hospital because I knew working in the outpatient setting would be a different experience. At Queens Hospital they schedule you to work in the Pediatric Emergency Department for three weeks and then onto the inpatient Neonatal ICU and Pediatric Clinic. In the ED it was much like working in the Adult ED as they had recently started treating patients up to 21 years of age, to increase the census and relieve some of the burden on the Adult practitioners. So I was able to see newborns up to 21 year olds, from bilirubin checks to common vaginal bleeding complaints. We worked with attending’s and Nurse Practitioners during each shift as the pediatric ED did not have PAs working there. They mentioned that in Pediatrics there are not as many PAs unless it was in an outpatient setting. I was comfortable with eliciting a history and performing a physical exam to teenagers and up, however when it came to infants and adolescents I knew it would be difficult. You have to rely much on the parents, and a lot of times they are not able to give you clear answers as they may not be the sole guardian or not present when their child becomes ill. However you also get parents who are able to give you all their history, medications, specialists the kids see, and more. They tend to be the ones with many questions and want clear instruction and reasons. I learned that with infants and children they do not like to be handled as much so the invasive exams should be towards the end such as checking their ears or examining the mouth. Most of the time you need to involve the parent/family because the child is comfortable in their arms, or you just need them to hold the kid down. It can be a little traumatic as you have to restrain the child as best to finish your exam, as it is justified. Another thing to note is that if they are crying or yelling then their lungs are in “good shape.” I was glad that the providers trusted me with seeing the patients and also performing procedures, however during this pandemic they preferred less expose as most patients are suspected COVID-19 positive until proven otherwise. Also since I was rotating in the cold winter month of Nov/Dec, I saw quite a lot of upper respiratory infections, but a decrease of Flu since most people were wearing masks. During my NICU week, I was able to observe a few C-sections and also assist the nurse practitioner with a PICC line insertion. It was a bit nerve wracking having to insert a peripheral line in a neonate approximately 2700 grams. A lot can go wrong especially since this procedure is not done with ultrasound, but it was a great experience. Unfortunately students are mainly there on an observational capacity, so we rounded on patients twice in the morning and I watched the nurses bathe and feed the neonates, which was adorable. Clinic week was organized and eventful as we worked with different providers each day in the morning and afternoon. Additionally I was exposed to many specialties from infants, toddlers, adolescents, pediatric cardiology, pulmonology/asthma clinic, neurology, and premature follow/up. What was amazing was the ability to watch a couple of bedside Echo’s, and seeing how the heart works and the individual valves and following the blood flow. Overall I will miss working in different fields and learning as I may not encounter these experiences again.
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