The Peds NP: Pearls of Pediatric Evidence-Based Practice

The context of bias (S7 Ep. 50)

There are many factors that contribute to the way we perceive and interpret information... and lots of ways that our brains skew our perspectives that can lead to cognitive bias.  The second episode in our Cognitive Bias in Healthcare mini-series discusses the features of information delivery that impact our decision-making and how our brains distort them to cause diagnostic error.  

References:

Arokszallasi, T., Balogh, E., Csiba, L., Fekete, I., Fekete, K., & Olah, L.. (2019). Acute alcohol intoxication may cause delay in stroke treatment – case reports. BMC Neurology, 19, 14. https://doi.org/10.1186/s12883-019-1241-6

Berkwitt, A., & Grossman, M. (2014). Cognitive bias in inpatient pediatrics. Hospital pediatrics, 4(3), 190–193. https://doi.org/10.1542/hpeds.2014-0002

Clark, B. W., Derakhshan, A., & Desai, S. V. (2018). Diagnostic Errors and the Bedside Clinical Examination. The Medical clinics of North America, 102(3), 453–464. https://doi.org/10.1016/j.mcna.2017.12.007

Croskerry, P., Singhal, G., & Mamede, S. (2013). Cognitive debiasing 2: impediments to and strategies for change. BMJ quality & safety, 22 Suppl 2(Suppl 2), ii65–ii72. https://doi.org/10.1136/bmjqs-2012-001713

Galvani, A. P., Parpia, A. S., Foster, E. M., Singer, B. H., & Fitzpatrick, M. C. (2020). Improving the prognosis of health care in the USA. Lancet (London, England), 395(10223), 524–533. https://doi.org/10.1016/S0140-6736(19)33019-3

Mamede, S., Splinter, T.A.W., Gog, T., Rikers, R., & Schmidt, H.G. (2012). Exploring the role of salient distracting clinical features in the emergence of diagnostic errors and the mechanisms through which reflection counteracts mistakes. BMJ Quality & Safety, 21, p. 295-300. doi:10.1136/bmjqs-2011-000518

Marshall, T.L., Rinke, M.L., Olson, A.P.J., Brady, P.W. (2022). Diagnostic error in pediatrics: A narrative review. Pediatrics, 149 (Supplement 3): e2020045948D. 10.1542/peds.2020-045948D

Cognitive Bias in Healthcare (S7 Ep. 49)

This episode is the first installment on a new mini series on cognitive bias in pediatric healthcare.  We begin by discussing what cognitive bias is, how it becomes diagnostic error, and the impact on healthcare in America.  Begin to think about how you think and explore the interesting ways our brains use mental shortcuts to arrive at an answer.

References:

Balogh, E. P., Miller, B. T., Ball, J. R., Committee on Diagnostic Error in Health Care, Board on Health Care Services, Institute of Medicine, & The National Academies of Sciences, Engineering, and Medicine (Eds.). (2015). Improving Diagnosis in Health Care. National Academies Press (US).

Berkwitt, A., & Grossman, M. (2014). Cognitive bias in inpatient pediatrics. Hospital pediatrics, 4(3), 190–193. https://doi.org/10.1542/hpeds.2014-0002

Bordini, B. J., Stephany, A., & Kliegman, R. (2017). Overcoming Diagnostic Errors in Medical Practice. The Journal of pediatrics, 185, 19–25.e1. https://doi.org/10.1016/j.jpeds.2017.02.065

Carberry, A. R., Hanson, K., Flannery, A., Fischer, M., Gehlbach, J., Diamond, C., & Wald, E. R. (2018). Diagnostic Error in Pediatric Cancer. Clinical pediatrics, 57(1), 11–18. https://doi.org/10.1177/0009922816687325

CRICO. (2014). Malpractice risks in the diagnostic process. Retrieved from

https://www.rmf.harvard.edu/Malpractice-Data/Annual-Benchmark-Reports/Risks-in-the-Diagnostic-Process

Institute of Medicine (US) Committee on Quality of Health Care in America. (2001). Crossing the Quality Chasm: A New Health System for the 21st Century. National Academies Press (US).

Institute of Medicine (US) Committee on Quality of Health Care in America, Kohn, L. T., Corrigan, J. M., & Donaldson, M. S. (Eds.). (2000). To Err is Human: Building a Safer Health System. National Academies Press (US).

National Geographic Kids. (No date). 10 facts about great white sharks! Retrieved from https://www.natgeokids.com/uk/discover/animals/sea-life/great-white-sharks/

Royce, C.S., Hayes, M.M., & Schwartzstein, R.M. (2019). Teaching critical thinking: A case for instruction in cogntitive biases to reduce diagnostic errors and improve patient safety.

Review of the CDC’s Developmental Surveillance Checklist (S6 Ep. 48)

Developmental surveillance and screening work best to identify delays when used together.  The AAP and CDC teamed up to create a standardized developmental milestone checklist in order to improve the longitudinal monitoring of pediatric milestones at home by caregivers.  This episode reviews their publication and discusses what went into the checklist, its strengths, and areas for further research.   View the CDC's website for the full checklist and read the article here.

References:

CDC. (2022). Developmental surveillance resources for healthcare providers. Retrieved from https://www.cdc.gov/ncbddd/actearly/hcp/index.html.

Zubler JM, Wiggins LD, Macias MM, et al. Evidence-InformedMilestones for Developmental Surveillance Tools. Pediatrics. 2022;149(3):e2021052138

Undiagnosed Congenital Heart Disease in Primary Care (S6 Ep. 47)

When accelerated BSN student Sam Mahaney wanted more practical bedside application of his knowledge of pediatric cardiology, we sat down to discuss the approach to assessment and management of undiagnosed and undifferentiated congenital heart disease from a primary care perspective.  The primary care clinician should be on the lookout for red flags in the history and physical exam that might suggest critical congenital heart disease and screen appropriately.  This episode has helpful perspectives for both the nurse and advanced practice provider.

References:

Abdurrahman, L., Bockoven, J. R., Pickoff, A. S., Ralston, M. A., & Ross, J. E. (2003). Pediatric cardiology update: Office-based practice of pediatric cardiology for the primary care provider. Current problems in pediatric and adolescent health care, 33(10), 318–347. https://doi.org/10.1016/s1538-5442(03)00137-8

CDC. (2022). Critical congenital heart defects. Retrieved from https://www.cdc.gov/ncbddd/heartdefects/cchd-facts.html.

Cleveland Clinic. (2022). Cyanotic heart disease. Retrieved from https://my.clevelandclinic.org/health/diseases/22441-cyanotic-heart-disease

Glidewell, J., Grosse, S.D., Riehle-Colarusso, T., Pinto, N., Hudson, J., Daskalov, R., Gaviglio, A., Darby, E., Singh, S., & Sontag, M. (2019) Actions in support of newborn screening for critical congenital heart disease — United States, 2011–2018. Morbity and Mortality Weekly Report, 68:107–111. DOI: http://dx.doi.org/10.15585/mmwr.mm6805a3external icon

Mahle, W. T., Martin, G. R., Beekman, R. H., 3rd, Morrow, W. R., & Section on Cardiology and Cardiac Surgery Executive Committee (2012). Endorsement of Health and Human Services recommendation for pulse oximetry screening for critical congenital heart disease. Pediatrics, 129(1), 190–192. https://doi.org/10.1542/peds.2011-3211

Martin, G. R., Ewer, A. K., Gaviglio, A., Hom, L. A., Saarinen, A., Sontag, M., Burns, K. M., Kemper, A. R., & Oster, M. E. (2020). Updated Strategies for Pulse Oximetry Screening for Critical Congenital Heart Disease. Pediatrics, 146(1), e20191650. https://doi.org/10.1542/peds.2019-1650

Puri, K., Allen, H. D., & Qureshi, A. M. (2017). Congenital Heart Disease. Pediatrics in review, 38(10), 471–486. https://doi.org/10.1542/pir.2017-0032

Strobel, A. M., & Lu, l. (2015). The Critically Ill Infant with Congenital Heart Disease. Emergency medicine clinics of North America, 33(3), 501–518. https://doi.org/10.1016/j.emc.2015.04.002

Infant dyschezia (S6 Ep. 46)

Infant dyschezia refers to the discomfort an infant experiences when bearing down against a closed anal sphincter, and is often misidentified as constipation by parents.  As long as red flags are absent, this functional, self-limited condition is easily diagnosed using the Rome IV Criteria.  In this episode, you will learn how to reassure parents and what contraindicated treatments should be discussed.  

References:

Children’s Wisconsin. (2020). Infants straining to move bowels. https://childrenswi.org/-/media/chwlibrary/publication-media-library/2020/03/30/20/48/2144en.pdf

LeLeiko, N. S., Mayer-Brown, S., Cerezo, C., & Plante, W. (2020). Constipation. Pediatrics in review, 41(8), 379–392. https://doi.org/10.1542/pir.2018-0334

Tabbers, M. M., DiLorenzo, C., Berger, M. Y., Faure, C., Langendam, M. W., Nurko, S., Staiano, A., Vandenplas, Y., Benninga, M. A., European Society for Pediatric Gastroenterology, Hepatology, and Nutrition, & North American Society for Pediatric Gastroenterology (2014). Evaluation and treatment of functional constipation in infants and children: evidence-based recommendations from ESPGHAN and NASPGHAN. Journal of pediatric gastroenterology and nutrition, 58(2), 258–274. https://doi.org/10.1097/MPG.0000000000000266

Zeevenhooven, J., Koppen, I. J., & Benninga, M. A. (2017). The New Rome IV Criteria for Functional Gastrointestinal Disorders in Infants and Toddlers. Pediatric gastroenterology, hepatology & nutrition, 20(1), 1–13. https://doi.org/10.5223/pghn.2017.20.1.1

Infant Vision Screening (S6 Ep. 45)

Vision screening is one of the most important preventative health screenings that a primary care provider does at well visits.  But the infant eye exam can feel obtuse and complicated if you don't understand vision development, physical exam maneuvers, and red flags for referral.  Because of the risk of significant amblyopia if ocular pathology is left untreated, every pediatric provider should know how to complete an age-appropriate vision screening in an infant.

References:

American Academy of Ophthalmology Pediatric Ophthalmology/Strabismus Panel. (2012). Preferred practice pattern guidelines. Pediatric eye evaluations. American Academy of Ophthalmology.

Bell, A.L., Rodes, M.E., & Collier Kellar, L. (2013). Childhood eye examination. American Family Physician, 88(4), p. 241-248.

Brookman K. E. (1983). Ocular accommodation in human infants. American journal of optometry and physiological optics, 60(2), 91–99. https://doi.org/10.1097/00006324-198302000-00001

Loh, A.R., & Chiang, M.F. (2018). Pediatric vision screening. Pediatrics in Review, 39(5), 225-234.

Rosenfield, M. Development of accommodation in human infants. Retrieved from https://entokey.com/development-of-accommodation-in-human-infants/

Wang, J., & Candy, T. R. (2010). The sensitivity of the 2- to 4-month-old human infant accommodation system. Investigative ophthalmology & visual science, 51(6), 3309–3317. https://doi.org/10.1167/iovs.09-4667

Breastfeeding Tips for Struggling Moms (S6 Ep. 44)

With national formula shortages over 40% and growing, the pediatric provider can encourage the establishment and maintenance of breastfeeding in moms who have chosen this path.  Breastfeeding isn't without struggles and woes, so providers can help support mothers by understanding these tips based on breastfeeding physiology and advising the pair when the process isn't as easy as it seems.

References:

American Academy of Pediatrics. (2021). Breastfeeding overview. Retrieved from https://www.aap.org/en/patient-care/breastfeeding/breastfeeding-overview/

La Lache League. (2022). Breastfeeding info A to Z. Retrieved from https://www.llli.org/breastfeeding-info/

Laura R. Kair, Daniel Kenron, Konnette Etheredge, Arthur C. Jaffe, Carrie A. Phillipi (2013). Pacifier restriction and exclusive breastfeeding. Pediatrics, 131 (4): e1101–e1107. 10.1542/peds.2012-2203

Nice, F.J., & Francell, M. (2020). Selection and use of galactogogues. Leader Today. Retrieved from https://www.llli.org/selection-and-use-of-galactagogues-2/

Pisani, J. (2022). Why is there a baby formula shortage? What to know and what is being done about it. The Wall Street Journal. https://www.wsj.com/articles/why-baby-formula-shortage-11652188230

Thompson, D. (2022). What’s behind America’s shocking baby-formula shortage? The Atlantic. https://www.theatlantic.com/ideas/archive/2022/05/baby-formula-shortage-abbott-recall/629828

Practical Prescribing for Acetaminophen and Ibuprofen (S5 Ep. 43)

Two of the most common over-the-counter medications in pediatrics are not as simple and benign as you might think.  This episode uncovers the dark past of acetaminophen, the pearls and pitfalls of prescribing them, and how to talk to families about giving the medications safely.

References:

Clark, E., Plint, A.C., Correll, R., Gaboury, I., & Passi, B. (2007). A randomized, controlled trial of acetaminophen, ibuprofen, and codeine for acute pain relief in children with musculoskeletal trauma. Pediatrics , 119 (3): 460–467. doi: 10.1542/peds.2006-1347

Jones, K., Engler, L., Fonte, E., et al. (2021). Opioid reduction through postoperative pain management in pediatric orthopedic surgery. Pediatrics, 148(6):e2020001487

Kleinman, K., McDaniel, L., & Molloy, M. (2021). The Harriet Lane handbook (the Johns Hopkins Hospital) (22nd ed.). Elsevier.

Miller, T.C. & Gerth, J. (2013). Dose of confusion. Propublica. https://www.propublica.org/article/tylenol-mcneil-fda-kids-dose-of-confusion

National Capital Poison Center. (2020). Poison statistics. https://www.poison.org/poison-statistics-national.

Sullivan, J.E., Farrar, H.C., & the Section on Clinical Pharmacology and Therapeutics, Committee on Drugs. (2011). Fever and antipyretic use in children. Pediatrics , 127(3): 580–587. doi: 10.1542/peds.2010-3852

Trippella, G., Ciarcià, M., de Martino, M., & Chiappini, E. (2019). Prescribing controversies: An updated review and meta-analysis on combined/alternating use of ibuprofen and paracetamol in febrile children. Frontiers in Pediatrics, 7:217. doi: 10.3389/fped.2019.00217.

Yin, H.S., Neuspiel, D.R., Paul, I.M., et al. (2021). Preventing home medication administration errors. Pediatrics,148(6): e2021054666

Discharge Education for Acute Gastroenteritis (S5 Ep. 42)

Children with acute gastroenteritis and mild or moderate dehydration can be managed at home with oral rehydration.  Learn how to partner with families and take an extra five minutes in your visit to explain the reasoning, detailed instructions, and expectations of home care as we discuss the evidence behind the rationale.  

References:

Carson, R.A., Mudd, S.S., & Madati, P.J. (2016). Clinical practice guideline for the treatment of pediatric acute gastroenteritis in the outpatient setting. Journal of Pediatric Health Care, 30(6), p. 610-616. http://dx.doi.org/10.1016/j.pedhc.2016.04.012

Carson, R.A., Mudd, S.S., & Madati, P.J. (2017). Evaluation of a nurse-initiated acute gastroenteritis pathway in the pediatric emergency department. Journal of Emergency Nursing, 43(5), p. 406-412. doi: 10.1016/j.jen.2017.01.001

Fedorowicz, Z., Jagannath, V. A., & Carter, B. (2011). Antiemetics for reducing vomiting related to acute gastroenteritis in children and adolescents. The Cochrane Collaboration, 9. doi: 10.1002/144651858.CD005506.pub5.

Freedman, S.B., Ali, S., Oleszczuk, M., Gouin, S., & Hartling, L. (2013). Treatment of acute gastroenteritis in children: An overview of systematic reviews of interventions commonly used in developed countries. Evidence-Based Child Health: A Cochrane Review Journal, 8, 1123-1137. doi: 10.1002/ebch.1932

Freedman, S. B., Gouin, S., Bhatt, M., Black, K. J., Johnson, D., Guimont, C.,…Plint, A. (2011). Prospective assessment of practice pattern variations in the treatment of pediatric gastroenteritis. Pediatrics, 127(2), e287-95. doi: 10.1542/peds.2010-2214

Freedman SB, Willan AR, Boutis K, Schuh S. Effect of dilute apple juice and preferred fluids vs electrolyte maintenance solution on treatment failure among children with mild gastroenteritis: a randomized clinical trial. JAMA. 2016;315(18):1966–1974.

Hartman, S., Brown, E., Loomis, E., & Russell, H.A. (2019). Gastroenteritis in children. American Family Physician, 99(3), p. 159-165. PMID: 30702253.

Nir, V., Nadir, E., Schechter, Y., & Kline-Kremer, A. (2013). Parents’ attitudes toward oral rehydration therapy in children with mild-to-moderate dehydration. The Scientific World Journal, 2013, 1-3. http://dx.doi.org/10.1155/2013/828157

Schnadower, D., Tarr, P.I., Casper, T.C., Gorelick, M.H., Dean, J.M., O’Connell, K.J., Mahajan, P., Levine, A.C., Bhatt, S.R., Roskind, C.G., Powell, E.C., Rogers, A.J., & The PECARN Probiotics Study Group. (2018). Lactobacillus rhamnosus GG versus placebo for acute gastroenteritis in children. New England Journal of Medicine, 379(21), p. 2002-2014. doi: 10.1056/NEJMoa1802598

World Health Organization. (2005). The treatment of diarrhoea: A manual for physicians and other senior health workers. 2005. http://apps.who.int/iris/bitstream/10665/43209/1/9241593180.pdf. Accessed March 3, 2022.

Picky Eating in Primary Care (S5 Ep. 41)

The well visit is time to screen for issues in primary care, which includes diet and nutrition.  Picky eating is a common problem that often plagues parents, especially when parenting styles or child development clashes with recommended feeding practices.  Dr. John Lyles joins The Peds NP to discuss evaluation and recommendations for feeding difficulties in primary care. 

References:

Boruta, M.K.R., Lyles, J., Mavis, A.M., & Morgan, S. (in press). Pediatric gastrointestinal and liver disorders. In Encyclopedia of Child and Adolescent Health.

Kerzner, B., Milano, K., MacLean, W.C., Berall, G., Stuart, S., & Chatoor, I. (2015). A practical approach to classifying and managing feeding difficulties. Pediatrics, 135(2), p. 344-353. doi: 10.1542/peds.2014-1630

Menella, J.A., & Bobowski, N.K. (2015). The sweetness and bitterness of childhood: Insights from basic research on taste preferences. Physiology & Behavior, 152(0), p. 502-507. doi: 10.1016/j.physbeh.2015.05.015