Robert Karp, MD
Avrahom Gurwitz, MPH
Department of Pediatrics
SUNY-Downstate Medical Center
Brooklyn, NY
Darwin Deen
Department of Family Practice
Albert Einstein College of Medicine
Pretest for evaluation of taking a history and providing guidance for a healthy infant:
Note: A full discussion for this extensive list of questions found as pretest (healthy child) and posttest (diabetic child) will be found in the Pediatric Nutrition Notes introductions section on Guidance and in specific modules on diabetes care. They are used here to illustrate teaching and not specific fact.
Q1. An appropriate duration and timing for infant breast feeding is:
A. 5 to 10 minutes on each breast every 3 to 4 hours
B. 15 to 20 minutes on each breast every 2 to 3 hours
C. 5 to 10 minutes on each breast every 1 to 2 hours
D. 15 to 20 minutes on each breast every 3 to 4 hours
Q2. True or False: A breast-feeding infant should be wetting at least 6 diapers each day.
Q3. True or False: The mother of a breast-fed newborn who is jaundiced should be told to formulae feed for a 24-hour period and then restart.
Q4. The nutrient(s) uniquely required of breast-feeding infants is (are):
A. Iron
B. Vitamin K
C. Vitamin D
D. All of the above
E. None of the above
Q5. One of these formulas may have been prepared incorrectly? If so, which one?
A. Ready to feed formulae given directly from the can.
B. Powdered formulae prepared 1 scoop of powder in one ounce of water.
C. Concentrated formulae prepared 1 can of concentrate with 1 can of water.
D. They are all prepared correctly.
Q6. A recommendation for juice consumption that is both reasonable nutritionally and likely to be followed by parents is:
A. No juice for children until 6 years of age.
B. Limit juice consumption to 6 ounces a day dilution is preferred.
C. Two cups are sufficient. They provide two servings of fruit.
D. Substitute natural juices for soda or "drinks".
Q7. Food insecurity is a direct antecedent to:
A. Micronutrient deficiency
B. Protein-energy malnutrition
C. Obesity
D. Metabolic syndrome
Objectives:
Objectives one through six were derived from The Nutrition Curriculum Guide for Training Physicians developed by the Nutrition Academic Award Program Curriculum Committee for the National Institutes of Health is available at:
We provide # 7, emphasizing "active learning." This is an effective as a way to reinforce understanding and facilitate creation of a "working memory." This will be discussed more fully in Section 3.
On completion of this module, teachers will be able to:
1. Include appropriate elements in a history and physical examination appropriate for dietary and nutritional assessment.
2. Recognize deviations from a healthy diet (inadequate or inappropriate feeding).
3. Develop a differential diagnosis that includes elements of diet and nutrition.
4. Chose appropriate laboratory tests and anthropometric measures.
5. Take appropriate steps to intervene with the child or family members.
6. Make appropriate referrals to supportive professionals (Registered Dieticians) or agencies for food or other support.
7. Provide effective teaching and evaluation experiences to achieve each of the objectives listed above to support "active learning."
Introduction:
Providing good nutritional care to patients is a part of the professional responsibility of every physician. Pediatricians must provide guidance to parents of their patients (as well as to children and adolescents themselves) to assist them in achieving optimal health both for now and for their future. Thus, teachers of future pediatricians have responsibilities, first, to continue to update the body of nutrition knowledge required for optimal pediatric nutrition-related practice and, second, to assure that what has been taught has also been learned. That is, the information must be retained in both "long-term" and "working" memory not simply short-term retention of specific facts.
For example, the current pandemic of obesity and its attendant impact on rates of diabetes in adults and children means that students and residents must be prepared to assist patients with lifestyle changes including improved dietary intake and increasing physical activity. Thus, it is necessary to identify those steps taken to assure that the educational material provided to pediatricians is effective in addressing their ability to appreciate problems in their larger context, convey information, and affect behavior change.
Case Study #1
Ask several participants in workshop to play the roles of Preceptor and Resident for this presentation. The role-play can be performed in the real-time setting of a continuity clinic.
You are precepting in clinic when Yulia, one of your better new PL-1's, comes in to present a case to you. The content of the presentation is as follows:
"Charlie is a 3 ½ year old boy who has been brought in by his mother because she is concerned he isn't eating enough. Asked about his diet, she reports that he won't eat what the family eats for dinner. She says the mother complains that, "I have to make him a grilled cheese sandwich or chicken nuggets every night". When asked about meals during the day, the mother reports that he eats cereal for breakfast with 2% milk and drinks Hi-C juice. He has lunch at the day-care so she doesn't really know what or how much he eats. When she picks him up he has a snack of more Hi-C and some cookies. Then he plays until dinner. After dinner he may have some ice cream or some more cookies and juice.
Yulia: "I plotted his growth. He is stable at the 50% for weight and the 75% for height, so I reassured her that there is nothing to worry about. She wants a prescription for Pediasure® (a commercial high calorie liquid supplement), but I don't think that is indicated."
Q1. What are the strengths and weaknesses of the presentation?
A2. Some teaching points to consider are a follows:
- Reinforce Dr Y's pride in the comprehensive job he has done in getting the diet history from this mother.
- Agree that a supplement is not indicated.
- Recognize that he has missed an important opportunity to educate Charlie's mother or improve the diet of this toddler.
- You are aware that two of the competencies that your residency strongly supports is that" residents recognize deviations from a healthy diet (inadequate or inappropriate feeding)," and" taking steps to intervene with the child or family members."
Q2. How would you give constructive feed-back both supporting and correcting the resident's performance?
A2. Here are some teaching points to consider:
- Always start by commending the resident on a specific aspect of the presentation. Have as many experiences as possible and do not follow the praise with a "but." Residents who have only experiences with the "Michigan sandwich" paradigm of "praise, critique, praise" call this a "`but[t]' sandwich."
- Praise the resident on the thorough job he/she has done in collecting information. Remind her that it would be important for the mom to talk to the day care provider about what meals and snacks the child is being served during the day.
- You should also ask, "Are you concerned about the child's juice consumption?" Gently remind the resident of the AAP Nutrition Committee's Statement on Fruit Juice.
- Acknowledge that toddlers often have strong preference for sweet foods deriving from an evolutionary adaptation to the lives of our ancestors as hunter-gatherers. Sweet foods contain energy and are generally not poisonous. Food selections of children are simply not rational. Thus, it can be difficult for parents to accommodate them and still provide a healthy diet with a variety of healthy foods.
Q3. What are some potential suggestions you could make to the resident for guiding families with toddlers?
A3. Here are some teaching points to consider:
1. Replace all but one cup per day of fruit juice with low fat milk.
2. Provide a small serving of some kind of vegetable with dinner (peas, green beans, and broccoli).
3. Recognize that the goal is to have the child taste it, not finish it, and to search for something he likes.
4. Acknowledge that it takes as many as 12 exposures to a new food before the child will adopt it.
5. Put some apple sauce or canned mandarin orange slices next to the chicken nuggets to see if the child will try these as a further way of broadening his diet and including another food group.
6. Arrange for the mom to return with the child in 6-8 weeks to follow-up on the progress of these plans.
7. Review the AAP statement of Fruit Juice and talk with the resident about it the next time you see him.
Case Study #2
Melanie is a 9-year-old African American girl. She now weighs 43 kg, and she is 144 cm tall. You note that her height percentile has always been at or above the 95th percentile for her age and gender. Her weight percentile had been rising above the 95th percentile. A recent weight was 49 kg. The height was the same (143 cm). She tells you of her concern for being overweight, and that she has been losing some weight. What was her BMI? [49/1.432 =24.0kg/m2] What is it now? [43/1.442 =20.7kg/m2] How have the percentiles changed? From well above the 95th percentile to just at the 95th percentile for age and gender on the CDC BMI curves. Melanie and her mother are pleased that she is losing weight.
In your history you find that Melanie has been experiencing polyuria, polydipsia, and polyphagia along with the weight loss. You do a physical examination.
Q4. What are the competencies to be achieved by the resident?
A4. Competencies to be achieved:
1. History and PE appropriate?
2. Diet assessed as "healthy" or not?
3. Differential created with nutrition elements?
4. Appropriate tests chosen?
5. Interventions with family?
6. Use resources effectively?
Q5. How might you go about evaluating the knowledge and skill of the resident's competencies?
A5. The following are evaluation tools that are available:
A. Isolated: Questions on specific facts in a true/ false or best choice format
B. Closed: Case study with "T/F" or "Best Choice" questions
C. Open: Case study with learner creating a differential and choice of tests and plan
D. Indirect: Chart review with formatted expectations
E. Observed: Structure Clinical Observations (SCO) with Feed-back
F. Self: SCO with resident doing the evaluation independently prior to Feed-back
Note: As one goes down the list the tools for evaluation become more experiential. It also goes from evaluating facts and short-term memory to evaluating skills and long-term memory.
To evaluate the resident in this case create a model for a case conference. Let one patient and physician dyad construct a review of what will be found and reported. Construct a test bank with annotated answers for the participants to follow. The following is an example of using multiple tools of evaluation to assess different aspects of the resident's knowledge and skills.
Posttest
For A [Isolated without case study] or B (Closed with case study in module above])
Q1. Which of the following should you look for in Melanie as a common concomitant finding in pre-diabetes?
A. Acanthosis nigricans
B. Elevated Fasting plasma glucose level
C. Elevated HgBA1C level
D. Elevations in Triglycerides
Q2. Were Melanie to have Chemical Diabetes, she would have
A. Fasting plasma glucose between 110 and 126mg/dl AND a 2 hour postprandial glucose between 140 and 200 mg/dl
B. Fasting plasma glucose between 110 and 126mg/dl OR a 2 hour postprandial glucose between 140 and 200 mg/dl
C. Acanthosis nigricans
D. A fasting plasma glucose >=126 mg/dl
Q3. Melanie has experienced polyuria, polydipsia, and weight loss. Which of the following would make the diagnosis of Type 2?
E. An elevated random FPG of >200 with these symptoms
F. An elevated HgBA1C
G. An elevated insulin to FPG ratio
H. A reduced insulin to FPG ratio
Annotated Answers
A1. A is the correct answer. Pre-diabetes has minimal changes in chemistry measures, but acanthosis occurs early prior to onset of changes in serum glucose levels.
A2. B is the answer. Either a modest elevation in FPG or a 2-hour postprandial elevation is necessary to diagnose chemical diabetes. Acanthosis may or may not be present. The higher FPG indicates Clinical Diabetes.
A3. C is the answer. Answer A is associated with Clinical Diabetes but does not distinguish between Types 1 and 2; neither does an elevated HgBA1C. In Type 1 DM, the insulin levels fall relative to glucose and in Type 2 they rise. More than one overweight pre-teen or teenager with Type 1 DM has been misdiagnosed because of an assumption that children with Type 1 are lean.
For C - Open - done in dialogue
1: In personal review with the attending, have the resident construct a differential diagnosis for Melanie.
2: Have the resident order appropriate laboratory tests.
Annotated Answers
From the history:
Her prior BMI was 24 kg/m2, it is now 21 kg/m2 and her percentile went from >95 to between 85 and 95. This is a change from "Obese" to "Overweight." In this case, however, the weight loss was not a sign of success.
From the Q and A:
1. A) The resident has to be aware that Melanie could have either Type 1 or Type 2 DM. Other diagnoses are unlikely including bulimia plus polydipsia. A brain tumor is possible. A) The tests commonly used are Fasting Serum Glucose (FSG), insulin, assessment of Insulin to FSG ratio; HgA1C; glucose or microalbuminuria in urine; urine specific gravity (for primary excess water drinking), one would also obtain a fasting lipid profile with attention to HDL and Triglyceride levels. The BP should be noted as well as appearance of truncal obesity including signs of Cushing Syndrome. A careful neurologic exam is essential. Check for other signs of DM including acanthosis nigricans.
For D - Indirect:
Complete a chart review of a resident write-up of the above or other "at-risk" child. Using criteria such as "Is the growth properly charted?" "Is the BMI calculated?" "Are appropriate tests ordered?" etc.
For E and F - Observed and Self
Conduct a Structured Clinical Observation (SCO) of the Resident.
The physician is the observer. Let the Resident evaluate him or herself first and then confirm or correct the assessment. Let resident do this again and see if there are improvements
Use the headings of the SCO for the resident to assess his or her competency. The attending makes a parallel review. They compare assessment and, as with the SCO, make plans for improvements.
Plan to observe the resident the next time he or she sees a child "at-risk" for Metabolic Syndrome.
A6. The following is an example of a Structured Clinical Observation (SCO). It is used for evaluating Pediatric Residents' Nutrition Competencies:
My colleague Laura Dattner developed this format.
Below is a chart with the criteria for diagnosis of diabetes mellitus and impaired glucose homeostasis (pre-diabetes and chemical diabetes): Melanie has clinical Type 2 diabetes mellitus.
Chart by Muschel and Abraham PIV S6C Type 1 DM module.
Annotated Pretest Answers
A1. The answer is B. Common feeding problems include feeding too quickly or too often. Past recommendations have been for 15 minutes on each breast with the somewhat longer feeding of 20 being suggested by some authorities.
A2. This is true. Fewer wet diapers usually mean an inadequate intake. Two problems likely to result are failure to grow and hyperbilirubinemia.
A3. This is False. The first step is always to take a careful history and do a complete physical examination. (It is beyond the scope of this annotated answer to address the differential of jaundice in the newborn). Assuming that all is well with the infant, the common antecedent of breast-feeding jaundice is too little milk. Feeding practices should be evaluated with the goal of increasing input.
A4. The answer is C. All infants are given a Vitamin K without regard to feeding practice. Iron needs kick in later with supplemental feeding. All breast-fed infant need an external source of Vitamin D. This is without regard to their ethnicity or skin color. Babies should not be exposed to the sun without UV absorbing sunscreens so even lightly pigmented infants are vulnerable to rickets.
A5. Then answer is B. Powders are prepared is by putting 1 scoop of powder into each 2 ounces of water. Children receiving a hyper-concentrated preparation are vulnerable to hypernatremic dehydration. Similar errors include giving the concentrate either under or over diluted or the ready-to-feed with dilution.
A6. The answer is B. Juice is unnecessary and as a "sugar beverage" has no advantage over whole fruit. Too restrictive a recommendation, however, is likely to be ignored. The WIC program provides 6 ounces of juice a day. This is a message that should be repeated as an upper limit. Sixteen ounces of juice provides over 50 grams of sucrose and over 200 calories of rapidly absorbed sugar, and that is too much. Organic or not, juice or "drinks", these are sugar beverages with no advantage if the sugar comes from an orange rather than a beet.
A7. The answer is C. The phenomenon of food insecurity, defined as "an uncertainty of having enough food to meet basic needs for all household members because of insufficient money or other resources for food," is associated with over-nutrition. Twenty-two percent of children with incomes at or just above the poverty level are obese as compared to the 12% obesity rate found among children of the very poor. The same 12% rate occurs in children in middle and upper income families. An important difference, however, is that impoverishment increases the risk for concomitant micronutrient deficiency.
