PAEDIATRICS

DEFINITION:Pediatrics is that branch of medicine concerned with the study of infants, children and adolescents in health and disease, their growth and development, and their opportunity to achieve full potential as adults.

GENERAL OBJECTIVES:A pediatrician is a specialist trained in the diagnosis and treatment of a broad range of diseases involving children based on a sound knowledge of normal growth and development and of the wide range of clinical conditions encountered in infants, children, and adolescents. On completion of the educational program, the graduate physician will be competent to function as a consultant pediatrician in the essential roles and key competencies of pediatricians, that is — medical expert/clinical decision-maker, communicator, collaborator, manager, health advocate, scholar and professional. The resident will have acquired a degree of independent responsibility for clinical decisions and an understanding of the nature of the relationships between a referring physician and a consultant clinical pediatrician. Following certification in Pediatrics, the resident will be prepared for independent practice.

General Content of Core Training

The resident will have had an adequate experience in both the in-hospital services and the ambulatory facilities of a children's hospital or of the pediatric department of a general hospital. A portion of the training must include experience and study in the comprehensive care of children with physical and psychosocial challenges. The resident will learn the skills to work collaboratively with and to provide consultation to other medical and health disciplines dealing with infants and children, especially with psychiatry, surgery and obstetrics. The resident will acquire the professional attitudes to work with other health disciplines in a variety of health care service models. The resident will develop the skills of a self-directed, life-long learner. The resident will learn the skills to critically appraise both his/her practice as well as the practice of pediatrics.

Specific Content

The resident will have been registered in an accredited pediatric postgraduate residency program. The resident will have had experiences in core general pediatrics and in the various pediatric subspecialties, in both in-patient and ambulatory settings. Core pediatric training must include rotations in critical care pediatrics, emergency pediatrics and neonatology. The resident will learn to set his/her own educational goals and will have had opportunities for elective experiences outside of the core training program, the essential feature being that these must be arranged with the understanding and approval of the postgraduate program director.

General Educational Objectives for Pediatrics

A broad educational experience in Pediatrics is essential if residents are to understand infants, children and adolescents in health and in sickness, and if they are to deal effectively with their physical, mental, emotional and social problems.

The resident will demonstrate a variety of personal attributes which are relevant to the broad range of clinical work with pediatric patients and their families. These important attributes which apply in all pediatric settings are described below and are not repeated for each special area. For certain clinical fields, specific additional points regarding attitudes are incorporated within the appropriate section.

Essential Roles and Key Competencies

1. Medical Expert / Clinical Decision-Maker

Pediatricians possess a defined body of knowledge and procedural skills which are used to collect and interpret data, make appropriate clinical decisions and carry out diagnostic and therapeutic procedures within the boundaries of their discipline and expertise. Their care is characterized by up-to-date ethical, and cost-effective clinical practice and effective communication in partnership with patients, other health care professionals, and the community. The role of medical expert/clinical decision-maker is central to the function of pediatricians and draws upon the competencies included in the roles of scholar, communicator, health advocate, manager, collaborator, and professional. In this role, the resident will demonstrate diagnostic and therapeutic skills for ethical and effective patient care.

1.1. Knowledge of normal body structure and function as expressed in a biopsychosocial model of human development. The resident will understand the normal human anatomy, physiology and psychology with emphasis on physiological and psychological changes during growth and development.

1.2. Knowledge of disturbed body structure and function
The resident will understand the pathophysiological and psychological processes underlying departures from normal.

The resident should therefore be able to recognize, diagnose and manage;

1. the normal healthy state
2. the natural course of pediatric problems, variations in and deviations from the normal

1.3. Knowledge of promotion and maintenance of optimal functioning in biological and psychological aspects. This will include knowledge of therapy in its broadest sense, to include life-style, dietary, nutritional, physical and drug therapies. The resident will demonstrate the ability to access and apply relevant information to clinical practice.

1.4. Interviewing and communication skills

The  resident will be able to establish a  professional  relationship and to interact with the patient (infant, child or adolescent) and parent, guardian or other care giver in order to obtain a history, to conduct a physical examination and to provide ongoing care. The pediatric resident will establish an atmosphere of open communication appropriate to the situation and will convey interest, sensitivity, empathy and support.

1.5. History taking skills
The resident will be able to obtain and record a complete history including:

• identifying data and date of contact
• reasons the patient was brought for or sought medical help (chief complaint)
• the important symptoms in sufficient detail to provide a clear picture of the clinical problem(s) - history of present illness
• all other important information from the past history, perinatal history, developmental history, medications, allergies, review of systems, family history, and social history

1.6. Physical examination skills

The resident will carry out an efficient, orderly physical examination, demonstrating sensitivity to the patient's needs, modified according to the patient's age, gender and problem, and record this information by regions or systems.

1.7. Problem Solving and Decision Making

The resident should demonstrate the ability to correlate, evaluate, priorize and synthesize information, including the relevant ethical issues, acquired by interview, history taking and physical examination. The resident should recognize and define problems (formulation) and generate a differential diagnosis and problem list.

The resident will be able to demonstrate the ability to manage problems by:

• appropriate application of knowledge derived from critical appraisal of the literature
• formulation of a problem oriented plan of management
• generating a rational plan of diagnostic and therapeutic measures with use of information on cost benefit ratios
• interpretation and modification of a plan of management with explanation and ongoing communication with parents and child
• participating suitably in multi-disciplinary group discussion, initiating or facilitating as required
• maintaining confidential information as appropriate
• evaluating and modifying management plans by periodic reassessment of the patient's progress
• ensuring proper recording of care and its effectiveness
• participating in medical quality assurance activities to review quality of care issues in provision of health care.

1.8. The resident should demonstrate effective consultation skills in presenting well-documented assessments and recommendations in written and/or verbal form in response to a request from another health care provider, with respect to patient care, education and legal opinions.

1.9. The resident should recognize personal limitations and demonstrate a willingness to call upon others with special expertise and make referrals where appropriate.

1.10.Technical Skills

The resident must demonstrate knowledge and skills required for the safe and efficient practice of the following procedures.

• intravenous access and blood-drawing
• umbilical venous and umbilical arterial catheterization
• arterial puncture
• suture of a one layer laceration, simple wound closure
• cardiopulmonary resuscitation (newborn and child)
• tracheal intubation (newborn and child)
• lumbar puncture
• bladder catheterization and/or suprapubic aspiration
• gastric tube placement (oro or nasogastric)
• intraosseous insertion, chest tube placement and thoracentesis as demonstrated in either a patient or model

The resident should also have knowledge and proficiency of the specific technical skills.

2. Communicator

To provide humane high quality care, pediatricians establish effective relationships with patients, other physicians and other health care professionals. Communication skills are essential for the functioning of a pediatrician and are necessary for obtaining information from, conveying information to patients and their families and establishing therapeutic relationships with patients and families. Furthermore these abilities are critical in eliciting patients' and/or families' beliefs, concerns and expectations about their illnesses, and for assessing key factors impacting upon patients' health.

2.1. Communication Skills
The resident will be able to demonstrate the ability to:

• listen effectively and obtain and synthesize relevant history from patients, families and communities
• communicate effectively and discuss appropriate information with patients and families and all members of the interdisciplinary health care team
• educate patients, families and health care professionals in formal and informal educational settings
• present the patient's problem(s) clearly, concisely and correctly, in the following ways:
  • verbally, in the clinical setting or formal presentation
  • in a written medical record (in standard or problem oriented form) or consultation report

2.2. The resident will demonstrate caring and empathy for patients and their families, and especially for those individuals who are vulnerable.

2.3. The resident will give close attention to the impact of such factors as age, gender, disability, ethnocultural background, social support, and emotional influences on a patient's illness.

2.4. The resident will demonstrate respect for individual patients, families, colleagues and for their value systems which may be different from the resident's own values.

2.5. The resident will demonstrate an appreciation of the parents' perspective of and concerns for a child's health and the impact of a child's illness on family relationships.

2.6. The resident will demonstrate a willingness to communicate effectively with patients and families and all members of the interdisciplinary team.

2.7. The resident will demonstrate an ability to support and counsel a child (and his/her family) with chronic illness and/or impending death and provide bereavement counselling.

3. Collaborator

Pediatricians work in partnership with others who are appropriately involved in the care of children and adolescents. It is therefore essential for pediatricians to be able to collaborate effectively with patients, their families and a multidisciplinary team of expert health professionals for provision of optimal patient care, education, and research.

3.1. The resident will demonstrate a capacity to establish and maintain a productive and responsible relationship with young patients and families, and a capacity to establish and maintain cooperative interpersonal relationships with a multi-disciplinary team and thus contribute effectively to other interdisciplinary team activities.

4. Manager

Pediatricians function as managers when they make every day practice decisions involving resources, co-workers, tasks, policies, and their personal lives. They do this in the setting of individual patient care, practice organizations and in the broader context of the health care system. Thus pediatricians require the abilities to priorize and effectively execute tasks through teamwork with colleagues, and make systematic decisions when allocating finite health care resources. As managers, pediatricians take on positions of leadership within the context of professional organizations and dynamic health care system.

4.1. Provision of Health Care

The resident will be able to demonstrate the knowledge of various forms of health care provision and to work effectively and efficiently in a health care organization, including the following:

• an understanding of the importance of the families' (parents' and child's) involvement in the provision of health care to the child
• the role of a pediatrician in the provision of preventive and therapeutic health care, based on sound scientific evidence
• the importance of shared responsibility for health care provision in a multidisciplinary setting
• the advantages, disadvantages and relative costs of preventive and therapeutic health care programs
• the advantages, disadvantages and relative costs of care in different settings, including an appreciation of the various forms of health care provision, including hospitals, ambulatory clinics, private offices, home
• care, chronic care and rehabilitation facilities
• the avoidance of unnecessary investigation and/or hospitalization

The resident should exhibit knowledge of the relative advantages and disadvantages and the impact on the child and the family of such forms of care.

4.2. Quality Assurance

• knowledge of the definitions and role of audits, quality improvement, risk management, occurrence / incident reporting, and complaint management in a hospital and ambulatory setting.
• knowledge of cost/benefit ratios of diagnostic and therapeutic interventions, cost-containment and efficacy, effectiveness and efficiency as they relate to quality assurance.

4.3. The resident will demonstrate an awareness of the need to continually balance professional, personal, institutional and social commitments.

4.4. The resident will demonstrate open-mindedness to the consideration of alternative health care practices.

4.5. The resident will demonstrate an awareness of cost and cost-effectiveness of various forms of pediatric care, and the ability to utilize resources effectively and to allocate finite health care resources widely.

• a willingness to participate in cost-containment and quality assurance programs.

4.6. The resident will demonstrate an awareness of the social, societal and governmental aspects of health care provision as applied to the pediatric age group.

4.7. The resident will demonstrate an ability to utilize information technology to optimize patient care, life-long learning and other activities.

5. Health Advocate

Pediatricians recognize the importance of advocacy activities in responding to the challenges represented by those social, environmental, and biological factors that determine the health of children and adolescents within society. They recognize advocacy as an essential and fundamental component of health promotion that occurs at the level of the individual patient, the pediatric population, and the broader community. Health advocacy is appropriately expressed both by the individual and collective responses of specialist physicians in influencing public health and policy.

5.1. The resident will demonstrate an appreciation that the health care needs of children are distinct from those of adults.

5.2. The resident will encourage promotion of active family involvement in decision-making and continuing management of the child.

5.3. The resident will demonstrate the ability to contribute effectively to improved health of patients and communities.

5.4. The resident will identify the important determinants of health that affect children and adolescents. This includes the ability to recognize, assess, and respond to the psychosocial, economic, societal and biologic factors influencing the health of those served.

6. Scholar

Pediatricians engage in a lifelong pursuit of mastery of Pediatrics. They recognize the need to be continually learning and model this for others. Through their scholarly activities, they contribute to the appraisal, collection, and understanding of health care knowledge, and facilitate the education of their students / housestaff, patients, and other health professionals.

6.1. The resident will recognize the importance of self-assessment of professional competence and acceptance of the responsibility for self-directed learning as a life long goal, to develop, implement and monitor a personal continuing education strategy. Learning should incorporate critical appraisal and evaluation of medical and other relevant literature.

6.2. The resident will maintain a questioning and inquisitive attitude towards medical information and an appreciation of the necessity for ongoing research to develop new knowledge.

6.3. The resident will facilitate the education of patients, housestaff/students and other health care professionals and contribute to development of new knowledge.

7. Professional

Pediatricians have a unique societal role as professionals dedicated to improving the health and well-being of children and adolescents. Pediatricians are committed to the highest standards of excellence in clinical care and ethical conduct, and to continually perfecting mastery of their discipline. Pediatricians are committed to delivering highest quality care with integrity, honesty and compassion.

7.1. The resident will demonstrate knowledge of Medical Ethics

• basic knowledge of the principles of medical ethics including: "best interest" of the child, autonomy, beneficence and non-maleficence, confidentiality, truth-telling, justice, respect for persons, conflict of
• interest, advanced directives and end-of-life care, and resource allocation
• knowledge of and ability to obtain informed consent
• knowledge of ethical decision-making process
• knowledge of required communication skills
• knowledge of child development and family theory that is applicable to pediatric medical ethics
• knowledge of the legal and ethical codes of professional behaviour and the obligations of a physician that apply to pediatrics including: notification of coroner, reporting of suspected child or sexual abuse, public health issues with respect to infections

7.2. The resident will demonstrate tolerance for ambiguity and uncertainty and the possibility of error in ethical decision-making; flexibility and willingness to adjust appropriately to changing circumstances.

7.3. The resident will demonstrate trustworthiness (honesty, confidentiality) with respect to patients, families and colleagues.

7.4. The resident will demonstrate recognition of personal limitations and a willingness to call upon others with special expertise.

7.5. The resident will demonstrate a willingness to accept peer and supervisor reviews of professional competence.

7.6. The resident will demonstrate an appreciation of the moral and ethical implications of various forms of patient care and research.

Systems-Based Educational Objectives In the Core Program in Pediatrics

These objectives are based on the major systems and classifications of pediatric illness. They are not subspecialty-based objectives. Objectives are listed once in the most appropriate category, rather than repeated under each relevant section.

Knowledge of embryology, anatomy and pathophysiology refers to that which is relevant to common pediatric disorders.

1. ACUTE CARE (Critical Care / Emergency Pediatrics)

1.1. KNOWLEDGE

• pathophysiology of altered consciousness, shock, respiratory failure and principles of mechanical ventilation
• pathophysiology of cardiorespiratory arrest
• role of nutrition and fluid management in the critically ill patient
• principles, techniques and limitations of invasive and non-invasive cardiorespiratory monitoring
• principles, role, and logistics of interhospital transport of critically ill infants and children
• determination of brain death and principles of organ donation
• management of the child with special needs / technology dependence.

1.2. SKILLS

• recognition of the critically ill child and stabilization and / or transfer of the critically ill child
• airway management and cardiorespiratory resuscitation
• access and care for indwelling catheters
• manage a child with a tracheotomy tube including replacement of the tube.
• management of unexpected death

The following technical procedures, in addition to those listed in Essential Roles 1.10.:

• foreign body removal - eye / nose
• perform and interpret oximetry
• assess the traumatized eye
• c-spine immobilization
• immobilization of acute injury including fractures
• gastric lavage
• eye irrigation, and the use of dilating drops, topical fluorescein, topical anesthetics

1.3. PROBLEMS

• cardiorespiratory arrest
• foreign body
• shock
• acute vomiting
• respiratory failure
• acute dehydration
• status epilepticus
• sepsis
• coma
• electrolyte imbalance
• multiple trauma
• burn management
• head injury
• near drowning
• apparent life-threatening events (ALTEs)
• poisonings and drug overdoses
• child abuse

2. ADOLESCENT HEALTH CARE

2.1. KNOWLEDGE

• normal development: cognitive, psychological, peer relations, parent-adolescent relations
• adolescents and society: influencing factors, heterogeneity, sub-cultures
• health needs and health problems
• normal adolescent behaviour
• intervention principles
• laws and resources in adolescence
• normal adolescent gynecology

2.2. SKILLS

• gynecological and pelvic examination and specimen procurement
• breast examination

2.3. PROBLEMS

• eating disorders: anorexia nervosa, bulimia
• behavioural problems: risk taking, delinquency
• gynecological problems and disorders of menstruation
• pregnancy issues, contraception, sexually transmitted diseases
• alcohol, drug, tobacco and other substance use and abuse
• sexual abuse
• chronic diseases and compliance to therapeutic regimen
• sexuality: male / female issues
2. ALLERGY AND IMMUNOLOGY

3.1. KNOWLEDGE

• the normal host defenses and immune response
• variations in normal immune response with age
• pathophysiology of immunodeficiency states and autoimmune disease
• basic diagnostic laboratory techniques involving the immune system
• pathophysiology of allergic disorders
• pharmacologic and immunologic therapy of allergic disorders
• indications for and limitations of skin testing, RAST testing and challenge testing

3.2 SKILLS (included in other sections)

3.3. PROBLEMS

• recurrent infections and immunodeficiency syndromes
• seasonal and non-seasonal rhinitis
• anaphylactic shock
• insect stings
• urticaria/angioedema
• serum sickness
• drug allergy
• food allergy
3. CARDIOVASCULAR SYSTEM

4.1. KNOWLEDGE

• the anatomy, hemodynamics and electrophysiology of the normal heart and the common congenital and acquired pediatric heart diseases
• the fetal circulation and changes in circulation at birth
• indications for, limitations, benefits, costs and hazards of:
  1. electrocardiogram
  2. chest x-ray
  3. echocardiogram and doppler
  4. diagnostic and interventional cardiac catheterization and angiography
  5. radionuclide studies
  6. exercise ECG
  7. holter monitor
• pre- and post-operative needs of the pediatric heart patient, and long-term complications
• the incidence and recurrence risk for congenital heart disease
• appropriate use of medications commonly used in the treatment of heart disease

4.2. SKILLS

• record and interpret reliably an electrocardiogram in all age groups
• interpret a chest X-ray with respect to heart size, contour and pulmonary vascularity

4.3. PROBLEMS

• common forms of cyanotic and acyanotic congenital heart disease
• cardiac murmurs
• congestive heart failure
• syncope
• cardiac arrhythmia
• chest pain
• cor pulmonale
• endocarditis, myocarditis, and pericarditis
• Kawasaki disease
• rheumatic fever
4. CLINICAL PHARMACOLOGY

5.1. KNOWLEDGE

• mechanisms of action of drugs in relation to their ability to correct a pathophysiologic state
• pharmacokinetics in infants and children
• placental transfer and breast milk excretion of drugs
• drug interactions
• modifications of drug dosage required in altered pathophysiologic states (renal failure, liver failure)
• therapeutic drug monitoring
• the cost of commonly used drugs; choice of drugs with respect to availability of drug plans; issues related to compliance

5.2. SKILLS (included in other sections)

5.3. PROBLEMS

• adverse drug reactions
• drug toxicity
• management of acute and chronic pain
• drug withdrawal
5. DEVELOPMENT AND BEHAVIOUR

6.1. KNOWLEDGE

• normal and abnormal development - gross motor, fine motor language, personal-social and behavioural
• biological and psychosocial factors affecting development and behaviour
• understanding of and interpreting psychological and education testing

6.2. SKILLS

• assessment of psychomotor development
• counselling parents on normal growth, development and behaviour with provision of anticipatory guidance
• counselling of parents regarding developmental and behavioural concerns with attention to available community support and resources

6.3. PROBLEMS

• developmental delay and mental retardation
• pervasive developmental disorders/autism spectrum disorders
• common behavioural problems
• crying infant, infantile colic, sleep disorders, nightmares and night terrors
• learning disabilities
• attention deficit hyperactivity disorders
• school avoidance
6. ENDOCRINOLOGY AND METABOLISM

7.1. KNOWLEDGE

• the normal anatomy, and embryology and physiology of the endocrine glands
• normal physical growth
• physiology of normal and abnormal puberty
• disorders affecting the endocrine gland, producing underactivity or overactivity
• indications and interpretation of endocrine tests
• pharmacology of commonly used drugs and hormones

7.2. SKILLS

• bedside measurement of glucose
• orchidometry

7.3. PROBLEMS

• growth retardation/short stature
• hypoglycemia
• ambiguous genitalia
• early/late sexual development
• thyroid disease
• pituitary disorders
• diabetes mellitus, diabetic ketoacidosis
• diabetes insipidus
• inappropriate ADH secretion
• adrenal disease
• hypo-/hypercalcemia
• hyperlipidemias
7. GASTROINTESTINAL, HEPATIC AND BILIARY SYSTEMS

8.1. KNOWLEDGE

• normal and abnormal development of the gastrointestinal tract, liver and pancreas
• physiology and function of the gastrointestinal tract including liver, biliary tract and pancreas, in normal and abnormal states
• pathophysiology of liver failure
• indications for diagnostic procedures including: endoscopy, plain abdominal
• x-rays, upper gastrointestinal and small bowel x-rays, contrast enema, abdominal ultrasound and CT scan, radionuclide scan
• indications for and interpretation of liver function tests

8.2. SKILLS

• interpretation of abdominal X-rays

8.3. PROBLEMS

• vomiting and regurgitation
• abdominal pain (acute/chronic)
• diarrhea (acute/chronic)
• inflammatory bowel disease
• malabsorption
• constipation / encopresis
• intestinal bleeding
• jaundice
• enlargement of liver
• liver dysfunction/failure
• abdominal masses
• dysphagia
8. GENETICS AND TERATOLOGY

9.1. KNOWLEDGE

• modes and molecular basis of inheritance
• application of cytogenetics
• indications and limitations of prenatal diagnosis
• indications and limitations of screening programs for genetic disease
• principles of assessment of dysmorphology and syndrome identification
• application of molecular diagnosis
• common presentations of inborn errors of metabolism
• embryological basis of malformation
• environmental factors in fetal development

9.2. SKILLS

• construction and interpretation of a pedigree
• ability to provide genetic counselling to a family / individual with a known genetic or inherited disorder, or referral to appropriate source

9.3. PROBLEMS

• the dysmorphic child
• exposure to a possible teratogen
• approaches to and initial investigations of suspected inherited metabolic diseases
• common genetic syndromes (e.g. Down syndrome, Turner syndrome, Fragile-X)
9. RENAL and GENITOURINARY SYSTEM

10.1. KNOWLEDGE

• normal and abnormal development of the genitourinary tract including the external genitalia
• clinical presentation of acute and chronic glomerular diseases and tubular disorders
• indications for, advantages and risks of investigative techniques: IVP, voiding cystourethrograms, renal scan, renal ultrasound, urodynamics, renal angiography, renin studies and renal biopsy
• pathophysiology of renal failure
• indications and complications of dialysis and renal transplantation
• renal transplantation
• fluid and electrolyte requirements in normal and abnormal states
• normal mechanisms of acid-base balance
• indications for and interpretations of renal function tests

10.2. SKILLS

• interpret common abnormalities seen on urine microscopy

10.3. PROBLEMS

• enuresis
• incontinence
• disorders of the male and female external genitalia
• pathophysiology of alterations in morphology or quantity of formed elements in the blood
• principles underlying transfusion and hypertransfusion of blood and blood products
• pathophysiology of neoplasms including the acute leukemias
• characteristics and principles of investigation of the acute leukemias and common tumours of childhood
• social, familial and personal effects of childhood cancer
• techniques for safe administration of chemotherapy
• common side effects of chemotherapy and radiotherapy and their management
• management of the immunocompromised oncology patient
• late effects of cancer therapy
• principles of palliative care
• indications for and interpretation of common hematological tests

11.2. SKILLS

• counselling families faced with life-threatening illness/chronic childhood illness

11.3. PROBLEMS

• pallor / anemia
• bleeding
• purpura and petechiae
• lymphadenopathy
• cytopenia
• hepatosplenomegaly
• indications and complications of splenectomy
• acute complications of hemoglobinopathies and red cell disorders
11. INFECTIOUS DISEASES

12.1. KNOWLEDGE

• characteristics, epidemiology and pathogenicity of common infectious agents and conditions
• mechanisms of infection and host defense
• pharmacology of anti-microbial agents and interpretation of sensitivity tests for antibiotics
• antimicrobial resistance
• control of communicable diseases, including: prevention and immunization
• prevention of congenital and perinatal infections
• nosocomial infections and infection control

12.2. SKILLS

• tuberculin skin testing - perform and interpret
• procurement of appropriate specimens for diagnosis of infections

12.3. PROBLEMS

• common infectious diseases (viral bacterial, fungal, parasitic, protozoan infections)
• infection in the immunocompromised host
• fever without focus
• fever of unknown origin
• perinatal / congenital infections
• HIV Infection
• occult bacteremia
• life-threatening infection
• infectious issues relating to travel and immigration
12. NEONATAL / PERINATAL MEDICINE

13.1. KNOWLEDGE

• fetal growth, development and physiology including the role of the placenta
• aspects of pregnancy, labour and delivery which affect the neonate
• effect of maternal systemic disease on the fetus and newborn
• demographic, medical and psychosocial factors which influence perinatal mortality and morbidity (the high-risk pregnancy)
• process of neonatal adaptation to extrauterine life
• neonatal growth, nutrition, metabolic problems, feeding problems
• aspects of drug therapy unique to the newborn
• general principles of care of the newborn: skin, warmth, feeding
• problems encountered in the follow-up of the high-risk neonate
• newborn screening

13.2. SKILLS

• neonatal resuscitation and stabilization of critically ill newborn
• initial assessment of the newborn, including APGAR score and gestational age
• recognition of the seriously ill newborn
• management of conventional mechanical ventilation and its complications

13.3. PROBLEMS

• respiratory distress
• prematurity
• cyanosis
• bronchopulmonary dysplasia
• jaundice
• retinopathy of prematurity
• intrauterine growth retardation
• seizures
• asphyxia
• floppy infant
• sepsis
• feeding difficulties / vomiting
• metabolic abnormalities including: hypoglycemia, hypo / hypercalcemia
• intraventricular hemorrhage
• surgical problems of the newborn
• anemia, hypovolemia, polycythemia
• bleeding
• apnea
• drug withdrawal
• congenital anomalies
13. NEUROMUSCULAR SYSTEM

14.1. KNOWLEDGE

• basic embryology, neuroanatomy and neurophysiology of the central nervous system, congenital malformations and common pediatric neurologic problems
• indications for, appropriate use of, and risks/complications of the following investigations:

• Lumbar puncture
• EEG
• Evoked potentials
• nerve conduction studies and electromyography
• skull and spine x-rays
• ultrasound scan of the head and spine
• CT scan
• MRI
• Radionuclide scan of the head and spine
• interpretation of CSF anaylsis
• pharmacology of drugs used in neurologic and neuromuscular problems

14.2 SKILLS (included in other sections)

14.3. PROBLEMS

• congenital malformations of the nervous system including the skull
• neurocutaneous syndromes
• developmental regression
• cerebral palsy
• seizures and sudden loss of consciousness
• breath-holding spells
• headaches
• raised intracranial pressure
• head trauma and sequelae
• cerebrovascular diseases including intracranial hemorrhage and strokes
• weakness and paralysis
• parasthesias
• disorders of peripheral nerves
• tics
• nystagmus, dizziness and vertigo
• ataxia
14. NUTRITION

15.1. KNOWLEDGE

• recommended nutritional requirements during infancy, childhood and adolescence
• effect of disease states on nutritional requirements
• infant feeding
• health implications of restricted diets, fad diets, diets determined by custom or socioeconomic situation
• indications for, physiological basis of and complications of parenteral and enteral nutrition

15.2. SKILLS

• prescribe and manage parenteral and enteral nutrition

15.3. PROBLEMS

• failure to thrive
• feeding disorders
• obesity
• nutritional deficiencies
• nutritional excesses
15. OPHTHALMOLOGY

16.1. KNOWLEDGE

• basic anatomy, embryology and physiology of the eye, ocular muscles and visual pathways
• etiology, classification of visual defects in children
• screening procedures for vision
• congenital abnormalities of the eye and ocular muscles
• acquired abnormalities of the eye
• ocular manifestations of systemic diseases

16.2. SKILLS

• measure visual acuity by use of standard visual acuity charts

16.3. PROBLEMS

• congenital blindness
• cataracts / leukocoria
• the red eye
• anisocoria
• proptosis
• ptosis
• strabismus / amblyopia
• abnormal acuity
• papilloedema
• heterochromia of the iris
• nasolacrimal duct obstruction
16. MUSCULOSKELETAL SYSTEM / RHEUMATOLOGY

17.1. KNOWLEDGE

• anatomy, structure and function of bone, joint and connective tissues in normal and abnormal
• physiology of normal bone growth and function
• recognition of non-inflammatory connective tissue diseases, e.g. Marfan's syndrome, Ehlers Danlos syndrome
• mechanisms of immune responses in rheumatic disease
• indications for, and interpretation of laboratory tests on blood and synovial fluid
• principles and applications of physical and occupational therapy for musculoskeletal diseases
• pharmacology of common anti-inflammatory drugs, corticosteroids and immunosuppressive drugs
• effects of chronic rheumatic diseases on physical growth and social development
• common radiographic abnormalities in musculoskeletal diseases

17.2. SKILLS

• interpret bone X-rays for fractures

17.3. PROBLEMS

• congenital abnormalities
• joint and limb pain
• common fractures, dislocations or injuries
• joint deformities
• septic arthritis and osteomyelitis
• common gait disorders (limp, torsional and angular deformities of lower limbs)
• scoliosis
• acute / chronic arthritis
• systemic rheumatologic diseases, e.g. systemic lupus erythematosis, juvenile rheumatoid arthritis
17. OTOLARYNGOLOGY

18.1. KNOWLEDGE

• embryology, anatomy and pathophysiology of the ear, nose, throat and upper airway
• assessment of hearing
• indications and limitations of diagnostic imaging of the upper airway
• normal and abnormal dentition

18.2. SKILLS

• perform curettage under direct vision of the ear
• interpretation of the tympanogram
• interpretation of upper airway soft tissue X-rays

18.3. COMMON PROBLEMS

• hearing loss
• congenital deformities of ear
• otitis media / otitis externa
• mastoiditis
• epistaxis
• nasal obstruction
• sinusitis
• nasal polyps
• tonsillitis and complications
• retropharyngeal abscess
• cleft lip and palate
• hoarseness and stridor
• voice abnormalities
• upper airway abnormalities
• congenital and acquired neck masses
• facial swelling / asymmetry
• dental caries
18. RESPIRATORY SYSTEM

19.1. KNOWLEDGE

• embryology, anatomy and pathophysiology of lower airways, lung, diaphragm and chest
• control of respiration
• pharmacology of drugs used in respiratory diseases
• role of: chest X-ray, bronchoscopy, lung biopsy, lung scintigraphy, sleep studies, apnea monitors, pulmonary function studies, sweat test, fluoroscopy, and CT scan of the chest

19.2. SKILLS

• interpretation of pulmonary function tests
• demonstrate use of various devices: e.g. spacers, peak flow meters, metered dose inhalers
• interpretation of chest X-rays

19.3. PROBLEMS

• cough, acute and chronic
• hemoptysis
• dyspnea
• wheezing
• mediastinal and intrathoracic masses
• asthma
• cystic fibrosis
• pneumothorax
• pleural effusions
• adult respiratory distress syndrome
19. SKIN AND ALLIED TISSUES

20.1. KNOWLEDGE

• anatomy and pathophysiology of the skin, hair, nails and mucous membranes
• pigmentary, inflammatory and immune responses of the skin
• pharmacology of commonly used dermatologic medications
• indications for skin biopsy

20.2. SKILLS (included in other sections)

20.3. PROBLEMS

• acne
• eczema and other dermatitides
• infections of the skin
• vesiculobullous eruptions
• papulosquamous eruptions
• alopecia
• pigmentary and vascular disorders of the skin
20. MENTAL HEALTH

21.1. KNOWLEDGE

• pharmacology of psychotropic and anti-depressant medications
• availability of and access to community-based mental health resources
• biological, psychosocial and socioeconomic factors affecting mental health
• indications for hospitalization

21.2. SKILLS

• recognition of the impact of family function on the mental health of the child
• ability to distinguish between organic and non-organic causes of Psychiatric dysfunction

21.3. PROBLEMS

• mood disorders / depression
• anxiety
• conduct disorders, oppositional defiant behaviour
• violent behaviour
• family dynamics and psychological adjustment to family stress
• personality traits
• psychoses
• attempted suicide
• emotional abuse
• adjustment to life stresses
• obsessive compulsive disorders
21. SURGERY

22.1. KNOWLEDGE

• preoperative assessment
• indications for appropriate surgical referrals
• perioperative management, including: fluids, steroids, antibiotics
• principles of peri- and post-operative management, including pain management

22.2. SKILLS (included in other sections)

22.3. PROBLEMS

• hernias
• bowel obstruction
• the acute abdomen
• appendicitis
• acute scrotal pain
• abscess

CONTENT AND ORGANIZATION OF THE RESIDENCY PROGRAM:

There must be an organized program of rotations and other educational experiences, both mandatory and elective, designed to provide each resident with the opportunity to fulfill the educational requirements and achieve competence in the specialty.

The content and organization of each accredited program in pediatrics must be consistent with the specialty training requirements.

In addition to offering the components noted in the specialty training requirements all accredited programs in pediatrics must offer community-based learning experiences.

Residents must be provided with increasing individual professional responsibility, under appropriate supervision, according to their level of training, ability, and experience.

RESOURCES:There must be sufficient resources including teaching faculty, the number and variety of patients, physical and technical resources, as well as the supporting facilities and services necessary to provide the opportunity for all residents in the program to achieve the educational objectives and receive full training as defined by the specialty training requirements in pediatrics.

In those cases where a university has sufficient resources to provide most of the training in pediatrics but lacks one or more essential elements, the program may still be accredited provided that formal arrangements have been made to send residents to another accredited residency program for periods of appropriate prescribed training.

1. Teaching Faculty

There must be a sufficient number of qualified teaching staff to supervise the residents and provide teaching in the basic and clinical sciences related to pediatrics.

2. Number and Variety of Patients

The number and variety of patients available for teaching under each of the following headings must be sufficient to meet the educational needs of the residents:

1. General Pediatrics

The program must provide an adequate volume of patients to give experience in the diagnosis and management of the wide variety of clinical problems seen in pediatric practice. These should include multi-system diseases, single system diseases, and generalized presentations. In addition to assuming an appropriate responsibility for the care of patients, residents should take part in providing a consultative service as an important feature of their training.

2. Clinical Subspecialties

Adequate numbers of patients and qualified staff must be available for the teaching of residents in the specialized areas of pediatric medicine.

3. Neonatal Pediatrics

Newborn nurseries and intensive care units, under the direction of qualified pediatricians, must be available. The volume of patients and the organization of these units must be such as to ensure full training in the clinical and technical skills associated with the management of normal and special-care newborn infants.

4. Acute Care Pediatrics

Pediatric critical care and emergency care experiences, under the direction of qualified specialists, must be available. The volume of patients and the organization of these experiences must be such as to ensure full training in the clinical and technical skills associated with the management of such patients.

3. Clinical Services Specific to Pediatrics

Clinical training must be based on adequate resources to ensure full training for each resident in all branches of pediatrics. The description of the integrated program should specify how the responsibility for each of the components of the program is shared by the participating institutions and the counterpart divisions in the department of medicine, or by secondment to other institutions.

Learning environments must include experiences that facilitate the acquisition of knowledge, skills, and attitudes relating to aspects of age, gender, culture, ethnicity, and disability appropriate to pediatrics.

1. In-Patient

Pediatric services participating in the program may be organized into one or more formal clinical teaching units, each with an adequate number of patients available for teaching and administered by a chief-of-service to whom the senior resident is directly responsible.

2. Ambulatory

In-patient and out-patient teaching services should be integrated so far as possible, in order to provide continuity of observation of patients both in and out of hospital. Organized clinics or other ambulatory care facilities must be available to provide opportunities for pre-admission investigation and post-discharge follow-up of general pediatric patients as well as those falling under the various subspecialties. Coordination of out-patient consultation services with those of surgical and psychiatric clinics is highly desirable.

3. Consultation

Throughout the program, the resident must be provided with opportunities to develop skills as a consultant to other pediatricians and to other health care professionals.

4. Community Learning Experiences

Community experiences must be available which provide a learning environment with appropriate supervision and evaluation based on rotation specific objectives. This assumes administrative support and linkages with the program.

5. Intensive Care Units

An organized clinical and teaching experience in pediatric critical care medicine, preferably in a pediatric intensive care unit, is required.

6. Emergency Department

There must be systematic supervision of residents to ensure expertise in the initial management of all types of emergencies involving infants and children, including accidents, poisoning and violence. The organization of the emergency department must be such as to ensure that residents in pediatrics obtain experience in initial patient assessment in addition to acting as consultants.

4. Supporting Services — Clinical, Diagnostic, Technical

There must be appropriate liaison with teaching services in anatomical pathology, anesthesia, diagnostic radiology, obstetrics and gynecology, psychiatry and surgery.

The following special facilities and services must be available and closely coordinated with the overall residency program:

o        an active psychiatric service with adequate arrangements for the training of pediatric residents in child psychiatry, under the supervision of qualified teaching staff;

• facilities for the study and management of behavioral problems in infants, children and adolescents;
• facilities for the comprehensive assessment and care of mentally and physically handicapped children;
• active obstetrical and pediatric surgical services, preferably in the same institutions as the general pediatric and neonatal teaching units;
• facilities and resources to provide an opportunity for all residents in the program to receive appropriate training in pediatric advanced life support.

Hospitals with a major role in the pediatrics program should also be engaged in medical undergraduate teaching.

ACADEMIC AND SCHOLARLY ASPECTS OF THE PROGRAM:

The academic and scholarly aspects of the program must be commensurate with the concept of a university postgraduate education. The quality of scholarship in the program will in part, be demonstrated by a spirit of enquiry during clinical discussions, rounds, and conferences. Scholarship implies an in-depth understanding of basic mechanisms of normal and abnormal states and the application of current knowledge to practice.

1. Organized Scholarly Activities

The program must include lectures and seminars, which may be interdisciplinary in nature, teaching rounds, special conferences, demonstrations at community centres, and journal clubs. The milieu of scholarship should be enhanced wherever possible by close association between residents and active investigators on the staff. Residents should be involved in clinical research and presentations at teaching rounds.

2. Basic and Clinical Sciences Relevant to Pediatrics

A coordinated educational program must be provided in pediatrics and associated fields. This should include definitive organized teaching in the basic sciences, and in the advanced clinical and scientific knowledge essential to an understanding of those areas of pediatrics outlined in the preceding sections. Special attention must be paid to instruction in genetics, growth and development, the provision of health care and the social aspects of pediatrics.

3. Biomedical Ethics

The academic program must ensure that residents gain an understanding of the basic principles and practice of biomedical ethics as it relates to pediatrics. The program must have a coordinated educational program in medical ethics.

4. Communication Skills

The program must ensure that residents learn effective communication skills for interacting with patients and their families, colleagues, co-workers from other disciplines and students. Clearly defined educational objectives for teaching these skills and mechanisms of formal assessment should be in place.

5. Patient Care Team

Residents must be given opportunities to develop effective skills in collaborating with all members of the patient care team.

6. Teaching Skills

Residents must be given opportunities to develop effective teaching skills by teaching junior colleagues and students, as well as through conference presentations, clinical and scientific reports, and patient education.

7. Management Skills

Residents must be given opportunities to develop skills in management as applied to pediatrics such as efficient practice and records management and the ethical use of health care resources. Residents should also be prepared for their role as a health care advocate.

8. Quality Assurance/Improvement

The program must provide residents with opportunities to gain an understanding of the principles and practice of quality assurance/improvement. Opportunities should be provided for residents to participate actively in such programs.

9. Research Opportunities for Residents

There must be a faculty member with the responsibility to facilitate the involvement of residents in research and other scholarly work. The academic program must provide the opportunity for residents to learn biostatistics and critical appraisal of research methodology and medical literature. Such teaching must include issues related to age, gender, culture, and ethnicity in research protocols and data presentation and discussion. Residents should be encouraged to participate in clinical research during the course of the residency program.

10. Faculty Research

A satisfactory level of research and scholarly activity must be maintained among the faculty identified with the program.

11. Life-Long Learning

All programs must promote development of skills in self-assessment and self-directed life-long learning. To promote this end, the program should provide opportunities for residents to attend conferences outside their own university.

SPECIALTY REQUIREMENTS:

Approved residency in paediatrics. 

PROGRAMS (WITH TRAINING REQUIREMENTS):

Diplomas(Dip):

Six months of approved residency training.

Doctor of Medicine(M.D):

Eighteen months of approved residency training.

Doctor of Philosophy(Ph.D):

Forty eight months(four years)of approved residency training.