Reflection: Pediatrics Rotation
The experience of rotating in a pediatrics office was a stark contrast to my first rotation in a hospital emergency department. Of course the environment is more orderly and focused, patients are managed one by one, and the pace is a bit slower, but beyond that there were several ways the interactions were quite different. First off, the patients are all children, and for that reason there is almost always a second party present, that being the parents. At this particular location I was lucky enough to have my own small office and computer to work with, along with a scale and examination bench. Because of this arrangement I felt a certain amount of independence and had the best environment to approach each patient as though I were their provider. While the rotation in the ED allowed me to practice a wide range of skills, this rotation was just as valuable in different ways.
The amount of independence afforded by the private workspace was one of the features of this rotation that I enjoyed the most. In comparison with the ED, having just one patient in calm and quiet environment was a big change, and one that allowed more time to investigate their symptoms, concerns, and evaluate by physical exam. I did notice that with this more isolated environment I could more intensely feel the “spotlight” as I practiced skills such as blood draws, especially considering the parental scrutiny that was almost always present. Thankfully the plenty practice I was allowed in the ED paid off and helped me to get over this different type of pressure right away. After I had finished taking a history, performing a physical exam, and drawing blood, I would document findings in the EMR and present the patient to the doctor.
The EMR used for this rotation site was eClinicalWorks and having so much time with this software was another benefit of this particular rotation. I was able to review the patients’ medical history, prior encounters, medications, previous lab work, and immunization records to better address their current complaint as well as make sure they were all up to date on all immunizations and yearly physicals. During patient interactions I updated information in their records as well as observed how to order medications and lab work as well as update immunization status. Being allowed more access and time with this type of software will serve me well in my future rotations.
Lastly, one of the most striking differences between the ED and my rotation in pediatrics was how the greater amount of time and one-on-oneness stressed the element of patient rapport. This was especially important considering family members were almost always present. Making sure that they were comfortable and truly being listened to was crucial in order to get a good history. The patients were well aware that I was not the doctor, so many naturally had the impulse to try and answer my questions as briefly as possible in order to see the doctor immediately. By the end of the rotation I was able to put patients at ease, have them understand my role in the office, and help them become comfortable in sharing the details of their reason for visiting the office.
Journal Article With Summary
Schwimmer JB, Ugalde-Nicalo P, Welsh JA, et al. Effect of a Low Free Sugar Diet vs Usual Diet on Nonalcoholic Fatty Liver Disease in Adolescent Boys: A Randomized Clinical Trial. JAMA. 2019;321(3):256–265. doi:10.1001/jama.2018.20579
Importance: Pediatric guidelines for the management of nonalcoholic fatty liver disease (NAFLD) recommend a healthy diet as treatment. Reduction of sugary foods and beverages is a plausible but unproven treatment.
Objective: To determine the effects of a diet low in free sugars (those sugars added to foods and beverages and occurring naturally in fruit juices) in adolescent boys with NAFLD.
Design, setting, and participants: An open-label, 8-week randomized clinical trial of adolescent boys aged 11 to 16 years with histologically diagnosed NAFLD and evidence of active disease (hepatic steatosis >10% and alanine aminotransferase level ≥45 U/L) randomized 1:1 to an intervention diet group or usual diet group at 2 US academic clinical research centers from August 2015 to July 2017; final date of follow-up was September 2017.
Interventions: The intervention diet consisted of individualized menu planning and provision of study meals for the entire household to restrict free sugar intake to less than 3% of daily calories for 8 weeks. Twice-weekly telephone calls assessed diet adherence. Usual diet participants consumed their regular diet.
Main outcomes and measures: The primary outcome was change in hepatic steatosis estimated by magnetic resonance imaging proton density fat fraction measurement between baseline and 8 weeks. The minimal clinically important difference was assumed to be 4%. There were 12 secondary outcomes, including change in alanine aminotransferase level and diet adherence.
Results: Forty adolescent boys were randomly assigned to either the intervention diet group or the usual diet group (20 per group; mean [SD] age, 13.0 [1.9] years; most were Hispanic [95%]) and all completed the trial. The mean decrease in hepatic steatosis from baseline to week 8 was significantly greater for the intervention diet group (25% to 17%) vs the usual diet group (21% to 20%) and the adjusted week 8 mean difference was -6.23% (95% CI, -9.45% to -3.02%; P < .001). Of the 12 prespecified secondary outcomes, 7 were null and 5 were statistically significant including alanine aminotransferase level and diet adherence. The geometric mean decrease in alanine aminotransferase level from baseline to 8 weeks was significantly greater for the intervention diet group (103 U/L to 61 U/L) vs the usual diet group (82 U/L to 75 U/L) and the adjusted ratio of the geometric means at week 8 was 0.65 U/L (95% CI, 0.53 to 0.81 U/L; P < .001). Adherence to the diet was high in the intervention diet group (18 of 20 reported intake of <3% of calories from free sugar during the intervention). There were no adverse events related to participation in the study.
Conclusions and relevance: In this study of adolescent boys with NAFLD, 8 weeks of provision of a diet low in free sugar content compared with usual diet resulted in significant improvement in hepatic steatosis. However, these findings should be considered preliminary and further research is required to assess long-term and clinical outcomes.
My Summary:
The journal article I chose, “Effect of a Low Free Sugar Diet vs Usual Diet on Nonalcoholic Fatty Liver Disease in Adolescent Boys”, was a randomized clinical trial of 40 boys from ages 11 to 16 with non-alcoholic fatty liver disease. They were followed up for a total of 8 weeks and placed on a diet of weekly meal plans with the help of a dietician and taking the preferences of the family into consideration while keeping free sugar to less than 3% of caloric intake per day. This was well below the World Health Organization’s (WHO) recommendation of 10% or less. Visits were conducted on the first day for baseline, and then 4 and 8 weeks after beginning the new diet. Vital signs, medical history, and fasting blood collection were collected at each visit along with CBC, CMP, lipid panel, liver panel, and prothrombin and INR. Hepatic steatosis was measured by MRI-PDFF. Prior to initiation of the diet, the percentage of steatosis by MRI-PDFF was in fact higher in the intervention group, being 25% vs 21%. There was significant decrease in steatosis in the intervention group from 25% to 17% at conclusion of the study while the non-intervention group only decreased from 21% to 20% (p < 0.001). It was concluded that a diet of low free sugar content had a significant improvement in hepatic steatosis.
Why I Chose This Article:
I chose this entry as I had an 8 year old patient present with obesity, and on labs and imaging was revealed to have non-alcoholic fatty liver disease. I was surprised to see such a diagnosis in a patient of this age and discussed with my preceptor the appropriate treatment. Apparently there is really no pharmacological intervention in a case such as this, with the treatment consisting of lifestyle change and a healthier diet. I was curious as to what specific recommendation I could make regarding diet and found this study to perfectly reflect the demographic and findings involved with this patient. I was pleased to learn of such dramatic improvements by a diet low in free sugars. When coupled with an exercise regimen as recommended by the WHO, I could see this patient making great strides toward a healthy adolescence and adulthood.
Site Evaluation Summary
My site evaluations for pediatrics was with Professor Jeanette Yuan, PA-C. I presented a case of JBC, an 8-year-old male who was brought to the office by his mother saying that his stomach had hurt for the last 7 days and he had not had a bowel movement in 2 days. He rated the pain at a 7/10, indicating that it was diffusely distributed throughout the abdomen, and denied any vomiting, fever, nausea, testicular pain, chest pain, hematochezia, or melena. He did have a history of acute gastritis without bleeding. Review of systems was unremarkable except for the abdominal pain, and on physical exam his BMI was noted to be above the 98th percentile. Because of recurrent episodes of abdominal pain he was sent for imaging, and returned for follow up where the results of lab work and a sonogram were discussed. His complete metabolic panel revealed an elevated alanine aminotransferase (ALT) level, as well as a cholesterol of 214 mg/dL, triglycerides of 189 mg/dL, and LDL of 131.2 mg/dL. The ultrasound findings were of “focal fatty sparing adjacent to the gallbladder” with and impression of “hepatic steatosis with focal fatty sparing.”
Professor Yuan and I discussed the increasing prevalence of obesity in the pediatric population, along with the resultant increase in diseases such as diabetes mellitus and, as in this case non-alcoholic fatty liver disease, in younger patients. I presented a journal article that related directly to this patient entitled “Effect of a Low Free Sugar Diet vs Usual Diet on Nonalcoholic Fatty Liver Disease in Adolescent Boys.” The findings supported my plan for this patient, which included a diet low in saturated fats, added sugars, and fewer carbohydrates. I also made a recommendation for a weekly exercise routine that I was able to discuss with Professor Yuan regarding the CDC’s recommendation for 60 minutes of moderate to vigorous exercise daily to include 3 days of vigorous exercise.
