His Weight Gain is Slowing Down

Patient Presentation

A 6-month-old male came to clinic for his health supervision visit. His parents had several questions about when he would start crawling and saying full words. They became more concerned when they saw the actual numbers of his weight gain since his 4 month appointment because they had had the sense that he was “slowing down” in his growth. He was breastfeeding every 4 hours for 20 minutes and they had started some cereal with iron in the past month. The past medical history showed a previously healthy, full-term infant with normal growth and development to date. The pertinent physical exam revealed an interactive infant who easily grabbed objects, sat by himself, said consonants and was rolling over. His vital signs were normal. His head circumference and length were consistently about 50%. His weight was slowly decreasing from the 50% at 2 months of age to between the 25%-50% currently. His examination was normal.

The diagnosis of a healthy male was made with normal growth and development. Although the resident had tried to educate the family that this was normal, the parents were still concerned when the attending physician came to see the infant. She reiterated what the resident had said and when showing the family the growth chart, pointed out the sharp vertical slope during the first 3 months of life, and how the growth curve slope changed over time. She said, “If your son keeps growing at the rate he was in the first few months of life, he is going to be Dad’s size when he is 2 years old.” She went on to say, “I know that seems kind of crazy, but I’ve actually done the calculations and its true, so he has to slow down how fast he’s growing.” She also discussed how in his case, the small, slow difference of being at the 25-50% currently was normal. “We’re also going to continue to watch how he grows and develops. If at any time you are concerned about his weight, just come back and we’ll re-weigh and measure him.” The parents seemed happy with the explanation, but afterwards the resident was skeptical about the growth rates. The attending and resident did a couple of sample calculations between seeing patients that day and the resident was then convinced about the growth rates.

Case Image

Discussion
Since growth is such an important indicator of health in infants and children, parents are appropriately concerned that their children are growing well. A common concern for parents is that the child began at a certain percentile and is crossing growth percentiles but at a normal rate (i.e. moving toward their genetic potential). Some other parents believe that “fat babies” are healthy babies and want to see children growing at the top of the growth charts. Even if they do not believe in the “fat babies” idea, many families of children who are at the normal lower percentiles of the growth chart are worried that their child is not gaining enough weight. A careful review of the growth charts and parental education usually can assuage the concerns for most families.

Learning Point
Many parents will notice the normal changes in the growth rates of children particularly over the first 12 months of life, and will raise questions such as the parent above. Again careful review and explaining this normal phenomenon to parents in a way that they can comprehend usually helps the family to understand that their child is normal.

Newborn and young infants are growing at fantastic rates, almost so much that it is difficult to comprehend the rate. However if these infants were to continue growing at these rates, they would be too large much too soon. Therefore there must be a normal decrease in the growth rate such that the child continues to grow but more slowly. In the figure below, using a starting weight of 3.35 kg (50% for males) and the growth rate for an individual month, the predicted weight that a male infant would have attained was calculated at 2 and 5 years later. Weight gain was assumed to be compounded monthly.

Using the rate of weight gain between 2-3 months (= 14.5%), the infant would be around the size of an adult male by age 2 or 86.7 kg! This is obviously too great a weight gain for a normal infant. Using the weight gain rate at 6 months of age (=5.64%), the infant would be around 12.5 kg at 2 years of age, which is about the normal average weight of a male infant at that age (= 12.1 kg). And using the weight gain rates at 12 and 24 months of age, the infant would only be 6.1 kg and 5.0 kilograms at 2 years. Obviously this is too small a weight gain for a normal infant. Thus, one can see why there are normal decreases in weight gain rates particularly around 3 and 6 months of life. A growth chart is available to review here,

Not only is it imperative that the weight gain slow for the infant’s own health, but also for the mother. A breastfeeding mother would need to produce ~66,000 calories or ~940 liters of breastmilk to supply only the weight gain of the infant who was growing at the 3 month old rate over 2 years. This is about an additional 90 calories and 3 liters of fluid/day for the mother to consume that solely would be going toward the weight gain of the infant.

Questions for Further Discussion
1. How do the weight gain rates for premature infants compare to normal weight infants?
2. How do you determine mid-parental height? see How Do I Calculate Mid-Parental Height and Other Growth Parameters?

Related Cases

To Learn More
To view pediatric review articles on this topic from the past year check PubMed.

Evidence-based medicine information on this topic can be found at SearchingPediatrics.com, the National Guideline Clearinghouse and the Cochrane Database of Systematic Reviews.

Information prescriptions for patients can be found at MedlinePlus for these topics: Child Development and Growth Disorders.

To view current news articles on this topic check Google News.

To view images related to this topic check Google Images.

To view videos related to this topic check YouTube Videos.

Centers for Disease Control. Data Table for Boys Length-for-age and Weight-for-age Charts.
Available from the Internet at http://www.cdc.gov/growthcharts/who/boys_length_weight.htm (rev. 9/9/10, cited 4/30/14).

DePaul University, Quantitative Reasoning Center. Compound Interest Formula. Medscape.
Available from the Internet at https://qrc.depaul.edu/StudyGuide2009/Notes/Savings%20Accounts/Compound%20Interest.htm (rev. 2009, cited 4/30/14).

ACGME Competencies Highlighted by Case

  • Patient Care
    1. When interacting with patients and their families, the health care professional communicates effectively and demonstrates caring and respectful behaviors.
    2. Essential and accurate information about the patients’ is gathered.
    3. Informed decisions about diagnostic and therapeutic interventions based on patient information and preferences, up-to-date scientific evidence, and clinical judgment is made.
    4. Patient management plans are developed and carried out.
    5. Patients and their families are counseled and educated.

  • Medical Knowledge
    10. An investigatory and analytic thinking approach to the clinical situation is demonstrated.
    11. Basic and clinically supportive sciences appropriate to their discipline are known and applied.

  • Practice Based Learning and Improvement
    12. Evidence from scientific studies related to the patients’ health problems is located, appraised and assimilated.
    13. Information about other populations of patients, especially the larger population from which this patient is drawn, is obtained and used.
    14. Knowledge of study designs and statistical methods to appraisal clinical studies and other information on diagnostic and therapeutic effectiveness is applied.
    16. Learning of students and other health care professionals is facilitated.

  • Interpersonal and Communication Skills
    17. A therapeutic and ethically sound relationship with patients is created and sustained.
    18. Using effective nonverbal, explanatory, questioning, and writing skills, the healthcare professional uses effective listening skills and elicits and provides information.
    19. The health professional works effectively with others as a member or leader of a health care team or other professional group.

    Author

    Donna M. D’Alessandro, MD
    Professor of Pediatrics, University of Iowa Children’s Hospital

  • Are Probiotics Effective and If So, For What Problems?

    Patient Presentation
    A 6-week-old male came to clinic for his health supervision visit. His mother was concerned because he seemed to have excessive crying more in the evenings but also during the day. The episodes would last 30-60 minutes and were intractable with no soothing techniques helping. The episodes could occur once or more times/day and occurred 5-7 days a week. Between episodes he was a happy baby who was breastfeeding well. He had soft bowel movements 1-2 times per day and the mother did not think he was particularly gassy. His mother denied any rashes. She said that she, her husband and a close friend took turns watching him and they were all very good at handing him over to another person, or putting him down and walking away for a few minutes when they became frustrated with the crying. The past medical history showed a full-term infant with mild jaundice perinatally who did not need phototherapy. The family history was positive for atopic dermatitis in the mother, but no other allergic, immunological or gastrointestinal diseases. The review of systems was negative.

    The pertinent physical exam showed a healthy male with weight and head circumference at the 25%, and height at the 75%. His examination was normal and he was happy and playful during the visit. The diagnosis of a healthy male was made who had colic. The physician recommended to continue some of the soothing techniques and reiterated the need for breaks from the crying. He also said that there were some studies that reported crying improvement with probiotics and that the mother could try it if she wanted to. The patient’s clinical course over the next two months showed that the mother had tried the probiotics with the infant for 1 months and didn’t really see much difference. She felt that the child overall was just generally improving and he was having fewer crying episodes. “When he has them though, they are still just as intense,” she told the physician. However they were only occurring 2-3 days/week. At his 6 month check up, the episodes continued to decrease and were occurring 1-2 days/week.

    Discussion
    Colic is often defined by Wessel’s rule of threes: crying 3 or more hours/per day, 3 or more days per week, for 3 weeks or more. Colic is a diagnosis of exclusion based upon through history and physical examination in a healthy growing child being fed properly. It usually starts at 1-2 weeks of age, stops around 3-4 months and has no predictable long-term outcomes such as behavioral, tempermental or psychological problems.

    Parental and caregiver support is the most important treatment for excessive crying and colic as these infants can be very intense individuals who require a great deal of attention. For more information about crying and colic, see What Should I Do? I Just Can’t Get Him to Stop Crying?

    Learning Point
    “Probiotics are foods that are composed of the same live bacteria that are present in the gut microflora.” They should not be confused with prebiotics which are “…specific nondigestible oligosaccharides that stimulate the growth of certain types of bacteria in the colon…. prebiotics assist the survival of the microflora of the colon, whereas probiotics contribute to the intestinal flora.” Probiotics work by colonizing the bowel, secreting antibacterial substances, competing with other organisms for nutrients and preventing adhesion to the intestinal epithelium and regulation of the immune system.

    According to the current clinical practice guideline of the North American Society of Pediatric Gastroenterology, Hepatology and Nutrition society from 2006, probiotic efficacy is supported for acute infectious diarrhea, antibiotic-associated diarrhea, and atopic dermatitis.

    For acute gastroenteritis, Lactobacillus rhamnosus GG (LGG) started as soon as possible at a dose of 10 billion colony forming units/day (1010 CFU) for 5-7 days is recommended by Cincinnati Children’s Hospital. One product that is available is Culturelle® packets, capsules or chewable tablets. Capsules can be opened and placed into a cool-beverage (not warm or hot). LGG has been effective for prevention of atopic dermatitis when used by the child and the mother. A recent metaanalysis found that Lactobacillus reuteri (108 CFU) may be effective for treatment of colic in exclusively breastfed infants.

    Questions for Further Discussion
    1. How common is probiotic or other complementary and alternative medicine use among your patients?
    2. What other potential uses could probiotics have?

    Related Cases

    To Learn More
    To view pediatric review articles on this topic from the past year check PubMed.

    Evidence-based medicine information on this topic can be found at SearchingPediatrics.com, the National Guideline Clearinghouse and the Cochrane Database of Systematic Reviews.

    Information prescriptions for patients can be found at MedlinePlus for these topics: Colonic Diseases and Dietary Supplements.

    To view current news articles on this topic check Google News.

    To view images related to this topic check Google Images.

    To view videos related to this topic check YouTube Videos.

    NASPGHAN Clinical Practice Guideline. Clinical Efficacy of Probiotics: Review of the Evidence With Focus on Children. Journal of Pediatric Gastroenterology and Nutrition
    2006:43:550-557.

    Cincinnati Children’s Hospital Medical Center. Best evidence statement (BESt). Use of Lactobacillus rhamnosus GG in children with acute gastroenteritis. Cincinnati (OH): Cincinnati Children’s Hospital Medical Center; 2011 Apr 15. 6 p.

    Foolad N, Brezinski EA, Chase EP, Armstrong AW. Effect of nutrient supplementation on atopic dermatitis in children: a systematic review of probiotics, prebiotics, formula, and fatty acids. JAMA Dermatol. 2013 Mar;149(3):350-5.

    Freedman SB, Ali S, Oleszczuk M, Gouin S, Hartling L. Treatment of acute gastroenteritis in children: an overview of systematic reviews of interventions commonly used in developed countries. Evid Based Child Health. 2013 Jul;8(4):1123-37.

    Bernaola Aponte G, Bada Mancilla CA, Carreazo NY, Rojas Galarza RA. Probiotics for treating persistent diarrhoea in children. Cochrane Database Syst Rev. 2013 Aug 20;8:CD007401.

    Sung V, Collett S, de Gooyer T, Hiscock H, Tang M, Wake M. Probiotics to prevent or treat excessive infant crying: systematic review and meta-analysis. JAMA Pediatr. 2013 Dec;167(12):1150-7.

    ACGME Competencies Highlighted by Case

  • Patient Care
    1. When interacting with patients and their families, the health care professional communicates effectively and demonstrates caring and respectful behaviors.
    2. Essential and accurate information about the patients’ is gathered.
    3. Informed decisions about diagnostic and therapeutic interventions based on patient information and preferences, up-to-date scientific evidence, and clinical judgment is made.
    4. Patient management plans are developed and carried out.
    5. Patients and their families are counseled and educated.

  • Medical Knowledge
    10. An investigatory and analytic thinking approach to the clinical situation is demonstrated.
    11. Basic and clinically supportive sciences appropriate to their discipline are known and applied.

  • Practice Based Learning and Improvement
    12. Evidence from scientific studies related to the patients’ health problems is located, appraised and assimilated.
    13. Information about other populations of patients, especially the larger population from which this patient is drawn, is obtained and used.

  • Systems Based Practice
    24. Cost-effective health care and resource allocation that does not compromise quality of care is practiced.

    Author

    Donna M. D’Alessandro, MD
    Professor of Pediatrics, University of Iowa Children’s Hospital

  • This Ear Looks Different

    Patient Presentation
    A 15-month-old male came to clinic with a 2 day history of rhinorrhea, fever to 101.7° F, and fussiness especially at night. His mother was unable to console him the previous night and both looked very tired. He had no cough oreye changes and was drinking but not eating very much. The past medical history showed 2 ear infections in the past. The most recent was 3 months ago. The pertinent physical exam revealed a tired male who was afebrile with normal vital signs and growth parameters between 25-50%. He was well-hydrated. There was mild clear rhinorrhea and normal pharynx. His right ear had a bulging, erythematous tympanic membrane without light reflex. The left tympanic membrane was erythematous without normal landmarks but also had some centripetally radiating lines from the malleus. The tympanic membrane appeared to have a material similar to adherent scale attached to the membrane in between these lines.

    The diagnosis of bilateral otitis media was made and the patient was started on antibiotics. The resident who was seeing the patient said she had never seen a tympanic membrane with these types of changes. The attending physician said that she had and it was a variant of acute otitis media but wasn’t sure exactly what the name was for it. The following day the attending found a picture and papers with descriptions of the normal keratinization of the tympanic membrane and normal healing process of tympanic membrane. The attending still wasn’t sure what to call these specific keratin changes but understood how they occurred.

    Discussion
    The tympanic membrane has two parts, the pars flaccida and the pars tensa. Each has 3 major layers: an external keratinizing squamous epithelial layer, a central connective tissue layer, and an internal epithelial layer. The pars flaccida connective tissue layer is less well-organized than the pars tensa.

    Learning Point
    Normally, there is a centripetal migration of the keratinocytes from the central part of the tympanic membrane (along the malleus) outward to the periphery. An india ink stain of this process can be seen here. The cell migration outward is slow to begin with (i.e. new cells stay near the central area for several weeks) then as they move toward the periphery the migration speed increases. This can easily be seen in keratin patch formation. Keratin layers split during the migration forming patches similar to ice flows or the well-demarcated spots on a giraffe. An image can be seen here.

    Tympanic membrane perforations also appear to heal in a similar way, by the movement of keratinocytes from the malleus area to the periphery as one of the initial activities. Repair of the other layers seems to follow for the tympanic membrane. Most acute perforations heal spontaneously, but others may not causing chronic perforations which are associated with ear discharge, recurrent infections, conductive hearing loss, speech and language delays and cholesteatomas. Chronic supprative otitis media is also increased with chronic perforations and is associated with other intra- and extra-cranial morbidities such as meningitis and abscess. Spontaneous healing is less likely depending on the etiology (i.e. trauma vs spontaneous), large perforation size, presence of ear drainage, pre-existing tympanosclerosis and if wrong interventions are used such as ear syringing.

    Questions for Further Discussion
    1. What causes bullous myringitis?
    2. What are the indications for consultation with an otolaryngologist for tympanic membrane perforation?

    Related Cases

    To Learn More
    To view pediatric review articles on this topic from the past year check PubMed.

    Evidence-based medicine information on this topic can be found at SearchingPediatrics.com, the National Guideline Clearinghouse and the Cochrane Database of Systematic Reviews.

    Information prescriptions for patients can be found at MedlinePlus for these topics: Ear Infections and Ear Disorders.

    To view current news articles on this topic check Google News.

    To view images related to this topic check Google Images.

    To view videos related to this topic check YouTube Videos.

    Hawkelibrary.com. Tympanic membrane surface migration. Available from the Internet at http://me.hawkelibrary.com/new/main.php?g2_itemId=336 (rev. 11/30/1999, cited 4/15/2014).

    Hawkelibrary.com. Tympanic membrane keratin patches. Available from the Internet at http://me.hawkelibrary.com/new/main.php?g2_itemId=339 (rev. 11/30/1999, cited 4/15/2014).

    Hawkelibrary.com. Tympanic membrane formation of keratin patches. Available from the Internet at http://me.hawkelibrary.com/new/main.php?g2_itemId=348 (rev. 11/30/1999, cited 4/15/2014).

    Orji FT, Agu CC. Determinants of spontaneous healing in traumatic perforation of the tympanic membrane. Clin Otolaryngol. 2008:33;420-6.

    Santa Maria PL, Redmond SL, Atlas MD, Ghassemifar R. Histology of the healing tympanic membrane following perforation in rats. Laryngoscope. 2010 Oct;120(10):2061-70.

    Lou ZC, Tang YM, Yang J. A prospective study evaluating spontaneous healing of aetiology, size and type-different groups of traumatic tympanic membrane perforation. Clin Otolaryngol. 2011:36;450-60.

    Lou Z. Late crust formation as a predictor of healing of traumatic, dry and minor-sized tympanic membrane perforations. J. Otolaryngology. 2013:34;282-386.

    Mei Teh B, Redmond SL, Shen Y, Atlas MD, Marano RJ, Dilley RJ. TGF-alpha/HA complex promotes tympanic membrane keratinocyte migration and proliferation via ErbB1 receptor. Exp Cell Res. 2013 Apr 1;319(6):790-9.

    ACGME Competencies Highlighted by Case

  • Patient Care
    1. When interacting with patients and their families, the health care professional communicates effectively and demonstrates caring and respectful behaviors.
    2. Essential and accurate information about the patients’ is gathered.
    3. Informed decisions about diagnostic and therapeutic interventions based on patient information and preferences, up-to-date scientific evidence, and clinical judgment is made.
    4. Patient management plans are developed and carried out.

  • Medical Knowledge
    10. An investigatory and analytic thinking approach to the clinical situation is demonstrated.
    11. Basic and clinically supportive sciences appropriate to their discipline are known and applied.

  • Practice Based Learning and Improvement
    12. Evidence from scientific studies related to the patients’ health problems is located, appraised and assimilated.
    13. Information about other populations of patients, especially the larger population from which this patient is drawn, is obtained and used.
    15. Information technology to manage information, access on-line medical information and support the healthcare professional’s own education is used.
    16. Learning of students and other health care professionals is facilitated.

    Author

    Donna M. D’Alessandro, MD
    Professor of Pediatrics, University of Iowa Children’s Hospital

  • What Causes Leg Pain?

    Patient Presentation
    A 13-year-old male came to clinic for his health supervision visit. He was a runner but had had no athletic injuries. He did complain of intermittent bilateral lower leg pain. It occurred mainly in the evenings after running. He wasn’t sure how long it lasted for but less than 1 hour usually. The pain did not awaken him when sleeping and did not occur during school. It occurred approximately 1x/week and wasn’t changing in location, radiation or intensity. It did not cause limping, but was achy with rest and brief massage helping. The pain was a generalized soreness. He was running track, but had not started other events such as jumping or throwing. He was running about the same mileage on grass or a rubber track. His coach would make them run counterclockwise during warm-ups to help decrease stress on the inside track leg. The past medical history was negative. The family history was positive for a benign bone tumor in a maternal adult cousin who currently had no other problems. The review of systems was negative for fevers, chills, night sweats, easy bruising or bleeding, joint swelling, myalgia, or arthralgias.

    The pertinent physical exam showed a well-appearing male with growth parameters around 50% for age. He had normal weight gain compared to a sick visit 3 months previously. His physical examination was normal. The diagnosis of of a healthy male was made. The pediatrician felt that the symptoms were most consistent with growing pains of the legs. He recommended making sure that the patient was stretching adequately before, during and after practices in addition to drinking adequate fluids. The patient was having routine screening laboratory evaluations for his age completed that day, so the physician also ordered an erythrocyte sedimentation rate and C-reactive protein which were normal. The patient was to followup with a diary of the leg pain in 2 months or sooner if new symptoms occurred.

    Discussion
    “Growing pains” of the legs are a common complaint in children. Heterogeneous studies from 1928-2004 have found prevalence rates of 2.6-49.4% in children ages 4-19. The studies are heterogeneous because of time, location, and especially definition of growing pains. A study of 1445, 4-6 year olds in 2004 using a validated tool showed a prevalence rate of 36.9%.

    The definition of growing pains used by Peterson in the 2004 study is chronic “…intermittent (nonarticular) pains in both legs that generally occur late in the day or at night…” with a normal physical examination and laboratory testing (if any is done). The pain is in the thigh or calf muscles. The pain can occur over weeks or months. Patients should not have a history of trauma but because the time period over which the pains occur, patients and families will often relate histories of minor trauma. The cause of growing pains is not known but theories include muscle fatigue, anatomic differences such as flat feet or knock-knees or being part of a larger pain constellation such as headache or abdominal pain.

    Leg pain that has different characteristics such as localized, persistent or intensifying pain, pain that occurs at different times of the day, obvious joint involvement, limb swelling or erythema or systemic symptoms demand a more extensive history and laboratory and/or radiological investigation. For many children and young adolescents, intermittent viral syndromes with myalgias or athletic overuse are common problems that may have similar presentations to growing pains.

    Learning Point
    The differential diagnosis of leg pain includes:

    • Infectious Disease
      • Arthritis, septic
      • Toxic synovitis
      • Lyme disease
      • Osteomyelitis
      • Rheumatic fever
      • Viral syndromes
    • Hematology/Oncology
      • Bone tumor
      • Leukemia
      • Muscle tumor
      • Neuroblastoma
    • Orthopaedic
      • Compartment syndrome
      • Entrapments
        • Arterial
        • Nerve
      • Fracture
        • Growth plate
        • Stress
          • Medial tibial stress syndrome (i.e. shin splints)
          • Osgood-Schlatter disease
        • Hypermobility
        • Legg-Calve-Perthes disease
        • Muscle cramps
        • Slipped capital femoral epiphysis
        • Soft tissue injuries
          • Bursitis
          • Condritis
          • Injections
          • Meniscus
          • Myositis
          • Tendonitis
    • Rheumatology
      • Arthritis, reactive
      • Dermatomyositis
      • Henoch Schonlein purpura
      • Juvenile idiopathic arthritis
      • Systemic lupus erythematosus
    • Other
      • Deep vein thrombosis
      • Fibromyalgia
      • Growing pains
      • Psychiatry/psychological problems
        • Conversion reaction
        • Munchausen syndrome or by proxy
        • Stress
      • Radiation from other body area, i.e. hip, back
        • Spinal stenosis
      • Reflex sympathetic dystrophy

    Questions for Further Discussion
    1. If a child has both upper extremity and lower extremity pain, how does that change your differential diagnosis?
    2. What are indications for radiographs for patients with leg pain?
    3. What laboratory evaluations could be considered for patients with leg pain?
    4. What are indications for orthotics or similar shoe devices for the treatment of leg pain?

    Related Cases

      Symptom/Presentation: Pain

    To Learn More
    To view pediatric review articles on this topic from the past year check PubMed.

    Evidence-based medicine information on this topic can be found at SearchingPediatrics.com, the National Guideline Clearinghouse and the Cochrane Database of Systematic Reviews.

    Information prescriptions for patients can be found at MedlinePlus for this topic: Leg Injuries and Disorders

    To view current news articles on this topic check Google News.

    To view images related to this topic check Google Images.

    To view videos related to this topic check YouTube Videos.

    Evans AM, Scutter SD. Prevalence of “growing pains” in young children. J Pediatr. 2004 Aug;145(2):255-8.

    Pell RF 4th, Khanuja HS, Cooley GR. Leg pain in the running athlete. J Am Acad Orthop Surg. 2004 Nov-Dec;12(6):396-404.

    Tse SM, Laxer RM. Approach to acute limb pain in childhood. Pediatr Rev. 2006 May;27(5):170-9.

    ACGME Competencies Highlighted by Case

  • Patient Care
    1. When interacting with patients and their families, the health care professional communicates effectively and demonstrates caring and respectful behaviors.
    2. Essential and accurate information about the patients’ is gathered.
    3. Informed decisions about diagnostic and therapeutic interventions based on patient information and preferences, up-to-date scientific evidence, and clinical judgment is made.
    4. Patient management plans are developed and carried out.
    5. Patients and their families are counseled and educated.

  • Medical Knowledge
    10. An investigatory and analytic thinking approach to the clinical situation is demonstrated.
    11. Basic and clinically supportive sciences appropriate to their discipline are known and applied.

  • Practice Based Learning and Improvement
    13. Information about other populations of patients, especially the larger population from which this patient is drawn, is obtained and used.

  • Systems Based Practice
    24. Cost-effective health care and resource allocation that does not compromise quality of care is practiced.

    Author

    Donna M. D’Alessandro, MD
    Professor of Pediatrics, University of Iowa Children’s Hospital