0:00:00.0 Professor Walden: Alright, guys. Hello, welcome. Hello, NP collective. I am very excited to have Dr. Rhonda Conner-Warren with us today. This is a treat, guys. So we needed someone who specializes in pediatrics, and of course we went out and we found that for you. So Dr. Warren is an assistant professor in the health programs at Michigan State University College of Nursing. She’s been a nurse for 30 years, and she’s currently a pediatric nurse practitioner. She’s currently practicing at Ingham County Health Department, the Willow Health Center, but she’s had some past practice of course at the DMC school-based health centers at James Campbell and Redford High School.
0:00:45.5 Professor Walden: She is teaching undergrad and graduate level teaching, and she’s had a lot of service. Just to name a few, COVID Immunization Task Force Coordinator, Focus: HOPE Detroit, the Corner Health Center and Perfecting Church ERT. So we are so excited to have you, Dr Wa… I call you Dr. Warren, but I also call you Dr. Rhonda in my head. So, thank you for showing up and doing this talk with us. We’re excited.
0:01:15.5 Dr. Rhonda Conner-Warren: Well, I wanna thank you for inviting me to come to talk about… I always tell people, this is who I am, and this is what I do. And the goal for me is to help us all to become better at what we do and serving our populations, as well as growing one another. So again, I thank you for this opportunity to speak to your group.
0:01:33.9 Professor Walden: Absolutely.
0:01:35.0 Dr. Rhonda Conner-Warren: And to be a part of this magnificent experience.
0:01:36.0 Professor Walden: Thank you. We’re excited. So, guys, she’s going to take over, as always. She’s gonna be talking to us, and of course she’s gonna go into it a little bit more, but about pediatric assessments, which I know some of us are very, very nervous about, when it comes to the kids, but this is what she does and she’s gonna make us feel a little bit more comfortable with it. So, take it away.
0:01:57.8 Dr. Rhonda Conner-Warren: Alrighty. So once again, just a reiteration of who I am so that you can understand how I became who I am. I’ve always been a pediatric nurse, even after when I was in nursing school and when I graduated at Children’s Hospital of Michigan, and that’s one of the places that I became a nurse practitioner. But one of the things that was really important to me during that time period was the fact that we sent children home who were considered high risk from the hospital, who would stay for years, and then recognize the need that there is a need to have advanced practice nurses. So I went back to Children’s Hospital in the Sickle Cell Center, as well as did school-based health centers, as well as, now I’m at Michigan State, at Ingham County Health Department. I’m also a Health Ecology fellow. And the reason why this is important is, I went there to look at it and talk about those environmental issues, that advocacy, those laws, and speaking to legislatures regarding the health of children in their community. I currently teach community and population health. I am a daughter, a mother, a grandmother, a aunty, and a golfer, and a cousin, and I thank you once again, to let you know that all these things make me who I am.
0:03:16.1 Dr. Rhonda Conner-Warren: So we have objectives. Any time we teach something, you always have an objective. You have an objective when you go in a room to provide the best care, to describe to the patient what their diagnosis might be. So in this case we’re gonna define issues of diversity, equity, inclusivity in the Family Medical Home and pediatric care. We’re gonna describe advanced practice physical assessment in the pediatric population, specifically primary care. And we’re gonna discuss some of the common challenges in performing the physical examination that many of you go, “Oh, the baby’s crying.” Well, number one, if the baby’s crying, we know that there’s air exchanging. If the baby’s crying, we also know that they’re responsive and that they’re alert. Crying is not a bad thing. And then we’re gonna discuss some common billing metrics that you would be evaluated by, as well as your insurance companies would be looking for. And also we’re gonna be talking about precepting tips for that pediatric rotation or the pediatric nurse practitioner student that you might encounter.
0:04:18.7 Dr. Rhonda Conner-Warren: So, number one, in terms of diversity, equity, inclusivity, the goal is to ensure that all children have a medical home. That may be a FQH, that may be private, that may be a community clinic, that may be a mobile unit, but the goal is for every child to have a medical home. That way we have history, that way we have dialogue, that way we are aware of the community resources that our families and our children need.
0:04:48.2 Dr. Rhonda Conner-Warren: So I belong to the National Association of Pediatric Nurse Practitioners. This is our professional organization for pediatric nurse practitioners, and once again, it talks about child health equity, that every child deserves fair and just health opportunities. While child health equity has got us significant attention due to the COVID-19 pandemic, the National Association of Pediatric Nurse Practitioners has always been committed to delivering the same high quality, evidence-based pediatric healthcare to all children, regardless of their social-economic background, their race, their citizenship status or sexual orientation.
0:05:29.9 Dr. Rhonda Conner-Warren: The Family Medical Home has also been defined by the American Academy of Pediatrics, and once again when we talk about professional groups, this is how they impact us. So, again, we are all in relationship. We need to be identifying children with diagnosed developmental disorders as children with special healthcare needs and managing their care as a chronic condition. We’re gonna do that in pediatrics, they’re gonna see a specialist, but they should be coming back to their Family Medical Home. We’re gonna be coordinating with specialists about additional evaluation that the children may need. They may start off at a early age and may no longer need them down the line. However, in pediatrics, usually at least an annual visit every year or every two years is important if you ever had a consultation outside of that area until they say their case is closed. And part of that evaluation, you’re gonna get feedback. You’re gonna get feedback from your early childhood providers, who can monitor and screen the children in the early childhood setting for early childhood programs that may be in your community and should be in your community. And one of them is Head Start, or the Early On program.
0:06:40.3 Dr. Rhonda Conner-Warren: Let’s talk about advanced pediatric physical assessment. What I wanna establish here with you all today is the overall process, ’cause there’s a whole lot more to come. Let’s start by taking the history. It requires communication, and that’s not just words. It requires you to have a body language that says, “I’m welcoming.” It requires you to lean into that conversation, requires you to smile, even in the mask. It also is important to understand cultural terms. And by cultural terms, I’m not talking about black and white, I am talking about maybe you have a grandmother, a great-grandmother who’s caring for the child, what terms does she or he use to communicate the issues of their child? We’re talking about the fact that I recently had a examination with a young lady who had a black eye, but she didn’t come in for that, she came in for a STI check. So in my inquiry, even though I had a student who came in and got this history, I said, “Hmm, seems like something’s wrong with your eye.” Her response in terms of that history was all in text language. I got tickled with my own self and said, “I’m sorry, I’m still on Line 1 trying to translate that, and so you’re gonna have to wait for me to catch up a little bit.”
0:08:07.6 Dr. Rhonda Conner-Warren: So that’s the kind of culture I’m talking about, the differences in language, even sign language to those children who might sign, and also understanding, for example emotional issues such as autism and what that means in terms of approach that your family can help you with. Tone is everything. The gentleness in the tone, it brings about comfort. A stern tone usually brings about fear. And so, again, this is why it’s important to understand that diversity and that equity and that inclusivity of communication, that it’s gonna take all of you to communicate.
0:08:47.7 Dr. Rhonda Conner-Warren: So let’s talk about the history. NPs, depending upon when you get the patient, if it’s a child that’s under your own, you should be asking the mom, if the mom is present, about the pregnancy and the birth. We wanna know did she have prenatal care? Did she have any chronic illnesses while she was pregnant? Did she have any infections? We wanna know about the birth. Was it normal? Was it normal vaginal birth? Did they have to do a C-section, because she was positive for beta strep, or maybe she had some active herpetic lesions? Or even if she didn’t have active herpetic lesions, why did she have to have a C-section? You know, mothers of color have a higher rate of C-section than mothers who don’t have. So this is important to know. Now, if we’re past a year, and maybe we’re at two years, the past medical history, what was it like? When they were born, did they start breathing right away? Have they gone in for their routine examinations at 2, 4, 6 and 8 and 10 months and 12 months?
0:09:46.4 Dr. Rhonda Conner-Warren: We wanna know about injuries, those that may have been intentional or unintentional. Many times you will have cases that are on what I call that border of foster care or in terms of children’s protective services. We wanna know if they’ve been in a hospital, and if so, what for and how long, if they’ve been in the ER, or if they’ve been in the urgent care. And because people get urgent care and the ER confused, we need to tease that out. In terms of social activities, we wanna know, yeah, what activities are they doing? Are they looking at TV all day? Are they on a iPad all day? Do they go to school? Is it in person? Is it online? Is it two days a week in person? Three days a week online? Do kids play? And if so, what does play time look like? What are they playing? We wanna know sleep. We wanna know where they sleep, how much they sleep, and what’s the sleep hygiene. It is important for a child to have a routine in order to get some rest. But we also know that sometimes sleep can occur, because they’re exhausted, they’ve been up for several nights due to various reasons. And sometimes the location might be sleeping in a tub, depending upon where they live.
0:11:02.4 Dr. Rhonda Conner-Warren: In terms of nutrition, we wanna know all the food groups. My students are not allowed to tell me, “Oh, they eat everything.” That is not sufficient. And the reason why is, we’re looking at nutritive value, we’re looking at potentially pica or the eating of non-nutritive substances. Depending upon where you live, are they drinking well water? Is it fluorinated water? We wanna know how much milk, ’cause if it’s too much milk… And people always say, Oh, they drink a lot of milk, that is something to be proud of. Yes and no, because if you’re drinking more milk, you’re probably not eating a lot, and children can be anemic because of it. Are they eating from all food groups? Maybe there’s some food avoidances, and this is where we find out they have some gut sensitivities. So whatever goes in, we wanna understand what comes out, what do the stools look like. But that’s under review of systems. But right now, it’s what are they eating? Is the family… And we’ve been in COVID a while now, are they in food pantries? Are they in the food line? Are they on the WIC program? Is food a scarcity? Especially when children aren’t going to school. And certain school systems do have food programs in which students take home food from their schools.
0:12:23.2 Dr. Rhonda Conner-Warren: The next thing we talk about is safety, safety in the home. Do you have a fire alarm? A smoke detector? Do they work? Did you take the battery out? Or has it been beeping so much that even families become alarm-fatigued? What about safety in the community? Is it safe to walk to school? Is it safe to play in the park? And nowadays, it is school. School used to be a safe haven, but with recent events, it is not. And so as difficult as it might be for us as adults as we have to do training with respect to violence in our workplace, so do the children. So again, it’s important to understand what the school’s evacuation plan looks like. But also, because we’re in an inclement weather season, hurricanes, floods, we need to have families establish an emergency evacuation plan to know where to meet up. And the other thing that I left out is the issue of personal safety, which means the following: People still try to snatch kids off the street, at a bus stop, if they’re walking by themselves, even if it’s two or three. And this when we have children who are at risk for human trafficking. So again, talking to our children about how not having the headphones on and the iPods in both ears, to look and to listen as you walk.
0:13:45.8 Dr. Rhonda Conner-Warren: Developmentally, we wanna know literally what is their cognitive level. Just because you are 6 months of age, if you were born pre-term, we should be correcting for actual age versus chronological age. Therefore, when we do an evaluation to determine are they growing on time, we would need to correct for that, and we might find that the child has exceeded our expectations. Language is everything, because you see, if you can’t hear, you’re more than likely not going to speak. If you have anything wrong with your tongue, with your jaw line, or maybe we had to put an NG tube, again, the tongue is a muscle, therefore they’re not learning to speak.
0:14:35.4 Dr. Rhonda Conner-Warren: We wanna look at fine motor and gross motor. Fine motor is using your hands to grasp and to pull, to hug mom’s face, to pull at things, to grab at things. Gross motor is the big swoop, trying to get stuff, trying to push, trying to stand. And in peds sometimes, is it there? And has it gone away? Is it starting? And can we maximize it with our referrals to specialized services?
0:15:07.8 Dr. Rhonda Conner-Warren: In terms of the family profile, the social history is important. For example, employment. Again, if a family member is not employed that was once employed, we’re talking about family stressors, we are talking about whether or not a child has health insurance, whether or not parents can afford their food. Talking about the home situation, will they have to move? Because most of the people I have talked to said their rent has increased anywhere up to from maybe $50 to $200 a month, causing them to not even be able to stay in the home that they may have lived in for several years, or the home has been sold. How about even just the home situation of, are you living in a trailer that’s not in a trailer park? Then you’re homeless. If you’re living with somebody else, another family member, you’re homeless. And that’s a hard thing to have, that’s probably hard to talk about. And when we’re talking about adolescents who are at high risk for being homeless, again, where are you staying? Are you safe? Are you staying under a bridge? Are you staying in a shelter? And more importantly, who’s looking for you? And who’s taking care of you?
0:16:20.3 Dr. Rhonda Conner-Warren: So again, when we’re talking about development, we’re talking about that personal development, that personality. Are they able to socialize? What are their words? What are their fine motors, their gross motors? Children are expressing their sexuality at an earlier age, whether they’re male or female, or non-binary, in terms of sexuality or just even sex period. When we have patients who may be refugees who have undergone the female circumcision, though it is illegal in the United States, it doesn’t make it illegal in the other countries. And what does that look like? Or are they sexually acting out? Which gives us an indication that something has happened to them. Remember, children are like clay, and we’re moulding them with their life experiences. And that’s called the Vygotsky Principle in terms of development. You are moulded by what you see, what you hear and what you do.
0:17:14.0 Dr. Rhonda Conner-Warren: Temperance. Some of us were mellow children, others of us were just busy bees as they call it, and others would get very upset when things didn’t go right. Well, depending upon how significant that temperance is, could be a strong indicator that there may be some cognitive and some psychological issues. And this is why it’s also important to understand the parent, because again, children mirror what they see. So if their parent is highly excitable or sometimes we have families who are the loud families, they talk very loud and very bold, well, that’s what the child is going to do.
0:17:47.7 Dr. Rhonda Conner-Warren: We wanna know what discipline method is a parent using. Is it physical? Is it verbal? Are you taking away something? Are you sitting down and explaining? And again, health habits. So what do you do to stay healthy? Do you go to the dentist? Do you get your eyes checked? Are you brushing your teeth? Are you washing your face? What soaps are you using? Are you teaching our adolescents about their health and how to take care of themselves? Are you doing cod liver oil all winter long? And right now, it is pollen in the air, so what are you doing in order to decrease that intake of pollen into your home or into their hair? So that again, we don’t have a child that’s sneezing all night long, who’s congested, and even if they are, what are we doing in the morning to help them to get better?
0:18:35.1 Dr. Rhonda Conner-Warren: Let’s talk about review of systems. The review of systems literally to me, starts with the front desk, so think about all your providers at the front. The front desk person is gonna see how the family acts. The medical assistant, nine times outta 10, is going to interact before you do. So in order to have a positive exam, you need this positive workforce. You need a workforce that can communicate with children and not be fearful of children. You need electronic medical record that is going to help you document the BMI in a percentage as well, and show you trends and hemoglobins and other growth factors. And number two, is the room safe? If you have equipment that may sit out all the time, it’s not a great thing and keep, we should be putting equipment away so that children aren’t playing with it. And a lot of times, they may set up a tray ready to go, just in case you have a GYN exam, but that’s not a good thing, those things need to be put away.
0:19:37.0 Dr. Rhonda Conner-Warren: When we talk about equipment… And we’re wearing masks nowadays and depending upon where you work at, the mask mandate is not going away any time soon. I wear a lab coat, and for me, it is an issue of having pockets. Sometimes I wear scrubs, ’cause I need pockets to put things in, such as the cell phone, such as the walkie talkie, the reflex hammer, the stethoscope. So have all the equipment you need present in the room, especially in Ps, ’cause once you leave the room, children think the exam is over with and doesn’t care. It doesn’t matter if they’re 8 days or 18-years-old, if you leave the room, they think things are over with. Washing the equipment in the presence of the patient and the family is also significant. And the reason why is, people wanna know that you’re clean. If you put it in your pocket, remember that your pocket is not a clean space.
0:20:28.6 Dr. Rhonda Conner-Warren: And in defense of COVID and influenza, and other viruses in the world, we need to make sure that your equipment is clean and that they see you clean it. After you’ve cleaned it, it’s pediatrics. So allow the child to touch it so that they know that they’re not gonna be harmed by it, how it feels, that it’s cold, that this is kind of nice. And sometimes, they also wanna examine you as well to see what you’re looking at, and again, that’s establishing that relationship. That’s that communication. And maybe they have a doll with them, so use the doll. Examine the doll, and you will find that you’ll have decreased stress and that the children will be more, like I say, amenable to the physical examination. But you just never know, but these are ways to use what you have in the room to have the best outcome in terms of the examination.
0:21:27.2 Dr. Rhonda Conner-Warren: So here’s our objective data. You gotta be the detective, and by that, I mean this, healthcare to me is like a mystery. I don’t know what I’m getting when I walk inside. I make no assumptions, whether the mother is 16 or mother is 60. Make no assumptions. Know what normal is for that age group, and if you have forgotten, there’s nothing wrong with having your own cheat sheets and looking it up. The next thing you need to be a detective about, in peds especially is, did the body part grow? Is it present? Because if it didn’t, then we need to try to get it fixed. I mean, the earlier we can fix something that still needs room to grow, such as a leg lump discrepancy or scoliosis, the better off the child will be down the road. So we wanna catch it early. For example, are the pupils even the same size? Are there two? So, never assume. If you have two of anything, you need to examine both.
0:22:31.6 Dr. Rhonda Conner-Warren: So who should be in the room? This discussion is significant nowadays because of the things that have happened in this world. Parent or caregiver, up until the age of 12 or 13, you need a parent or caregiver in the room. When it comes to asking the sensitive questions, I either recommend that you do that as the parent has left the room, or you do that or capture the young patient somewhere in between to ask them the real question. But the one thing that I say to patients all the time if they have a decent relationship with their parent or caregiver, they probably already know. So to sit here and to tell me what I want to hear is not going to help you. So for example, I don’t smoke, but I bake. Well, guess what, you’re smoking. If there’s a question of ducking, of the, “Who has custody?” then you want that person to bring in that documentation so you can copy it for the chart.
0:23:28.3 Dr. Rhonda Conner-Warren: So many times in peds we have the story of, “Well, this is my boyfriend’s son, and I’m bringing him in for a physical.” Well, that individual does not have consent for you to see them, so you should have a letter that says it’s okay from the father, you’re gonna take a verbal one and have somebody witness it on the phone, so call the parent to verify consent, ’cause what can happen is is that the other parent becomes very upset and potentially, very hostile because, “I didn’t give you permission to get the child checked.” And we also have these issues, especially when we’re talking about immunising children. One parent wants the immunisation and the other one doesn’t. So the question has to be who has the custody regarding the medical care of the child.
0:24:22.0 Dr. Rhonda Conner-Warren: “Is the physical exam hard to tell?” Well, this is peds. The general answer is yes. However, it depends upon the age of the child and the child’s cognitive development. So here’s a discussion point, as the parent, where the child is most sensitive, most protected, never start with a painful aspects, such as earache or arm that hurts. It’s great to examine head to toe, but always remember it is least invasive to most invasive. So again, a ear check is an invasive check. Checking one’s mouth is invasive. You wanna slow that one down, and again, palpate, listen. That’s fine. Some children will have great fear or stranger anxiety. Some families have a history of a bad assessment, especially the child had ear pain, and you wanna work at your skills being smooth and being gentle by asking, “Now, which side do you want me to look at first? Oh, okay. You sure?”
0:25:30.4 Dr. Rhonda Conner-Warren: And the kids will tell you. That would decrease their discomfort. And then tell them what you’re going to do, even if it is a child who’s in foster care place, or has had physical violence, or some of my refugee patients, who have been violated and physically harmed. As long as you’re explaining and they have a support in the room, you have a better physical examination.
0:25:56.2 Dr. Rhonda Conner-Warren: So here are some of the screening recommendations. From American Academy of Pediatrics, we wanna see children regularly, so definitely at 2, 4 and 6 months of age, because we wanna keep check of their weight. We wanna be able to assess the growth and development. Remember, the growth and development is, meaning from head to tail. The child will first lift up their head when they have tummy time, they would turn their head, they’ll begin to push up and hold their head up for longer periods, and then they’ll let down. Anywhere between 3 and 4 months, they can push themselves over, and then by 5 or 6 months, they can push themselves all the way over. If these milestones are not met, that’s a good reason to bring them back more frequently when you see this occur. So again, make sure that you have tools that are available in your clinic so that you can do this examination.
0:26:57.7 Dr. Rhonda Conner-Warren: So again, they talk about additional screenings nowadays, and it really is not a standard. Now, doing a regular Well-Child check, you’re screening for autism. Autism spectrum disorder, the word spectrum is your clue, is that it can be broad and vast. It might be simply when you walk in the room, the child never looks at you and just looks down, and they may look up and they may look down, they may look past you and look at the door, even at 18 months. And at 24 months, maybe they’re now trying to walk, maybe they’re standing for short periods and maybe they’re holding on to mom and dad with a… This is just where I’m at, this is just what I do, and the parent goes, “Oh, I don’t mind holding them.”
0:27:50.3 Dr. Rhonda Conner-Warren: “Show me what they do.” I even ask parents nowadays, because of cell phones, “Can you record what they do so we can understand the behaviors that they might do in their normal environment they might be afraid to do in clinic?” Now, if your patient was pre-term, had low birth weight, or had a lead exposure, then we’re gonna screen more frequently. Why? Because if we screen early, we can get the consults to our specialists, whether it’s speech and language and hearing, and the Early On program, and they can make tremendous strides because the biggest growth in the child’s brain is from 0 to 4 years of age, and we wanna capture this as soon as possible.
0:28:36.7 Dr. Rhonda Conner-Warren: So any exam, on a physical examination, we want height, weight, temperature, respirations. We don’t do blood pressures in infants, but we do palpate pulses. The head circumference is significant because we wanna know if it’s too narrow, if we have what’s called funnel, this could require plastic surgery. BMI in peds is done in percentages up until the age of 19, and that’s really an issue for Medicaid billing. We have growth and development charts on the CDC, so in case you don’t take your laptop into the exam room… Sometimes I don’t… I can least show the parent where the child is in terms of growth and development.
0:29:16.2 Dr. Rhonda Conner-Warren: Helping them to understand your child is on their own trajectory is great. Showing them that their child is obese because adults are adult learners is significant, so if they’re greater than the 95th percentile, they’re severely obese even in childhood. So that line about, “Oh, they’re just fluffy, and I was a big child too,” that’s nice, but that’s not good because it’s leading to other issues in life. When you walk in, once again be the detective. Look. What do you see? Do you see the parent talking with the child? In a case one time where I walked through a clinic lobby, I saw a mother with a 9-month-old on her lap, or just sitting next to her, and she was very talkative to the 2-year-old male, but did not talk to the 9-month-old child. I asked the secretary, I said, “Am I seeing that correctly?” She said, “Yeah, I noticed that too. She doesn’t interact with the child.”
0:30:17.8 Dr. Rhonda Conner-Warren: That tells me a whole lot. Either the child is not interacting or the parent has some social and attachment issues, and we were right. The mother said, and I quote, “I wasn’t raised by my mother. I was abused by my mother, so I don’t understand how to parent a female child. I don’t wanna mess it up.” Well, at the same time, she wasn’t attaching to her. What are you hearing? Are you hearing someone who’s yelling at the child all the time, berating the adolescent all the time. Is the child clean? Is the child dressed appropriately? ‘Cause maybe they don’t have clothes. Maybe they don’t have access to water. Is the child talking or is the parent always interpreting? Because if the parent is, that tells us we got a speech and language problem, which could be a hearing problem, or this is just what the parent does and is not letting the child grow up. And once again, walking, the child should be trying to step, or if they’re eight years of age and you’re hearing, “They’re so clumsy, they’re tripping all the time,” is it a visual problem or is there a neurological issue, such as muscular dystrophy? These are all things we’re gonna talk about at a later date.
0:31:35.4 Dr. Rhonda Conner-Warren: So for your ear, for your H-E-E-N-T, remember, we want the shape, you want size if it’s still time to measure, we want hair distribution. Can you look at one’s eyes? Is the sclera white? Are the pupils accommodating? Are they round? What about the eyelids, are they swollen? Are there lashes? Maybe they are so nervous that they’re literally pulling their lashes out. The red light reflex is significant to chart in anyone who’s about to 5 years of age. There is a condition called retinoblastoma, and if we don’t have a red light reflex, and it can happen all the time in primary care, then we need to send them immediately to the emergency room and contact hematology, oncology or ophthalmology.
0:32:25.8 Dr. Rhonda Conner-Warren: Can you see the optic disc in a child or adolescent? It still should look like the orange sunset moon. Are the ears present? Are they the same size? Are they located just below here? And all you have to do is put a pencil there and they’ll think, “Oh, they’re growing right on my head.” No, I’m really checking to make sure those ears are located in the right place. Is there cerumen or wax in the ear? If there is no cerumen whatsoever, it’s cleaner than the china in your china cabinet, guess what? The parent is more than likely using a cotton-tipped applicator in cleaning it out. That can cause an external otitis medium. We wanna know how the membrane is. Is it flexible so we view the layer, so that we can see it move, ’cause it needs to move with sound waves.
0:33:13.2 Dr. Rhonda Conner-Warren: We look at the nose, and kids are usually like this, “Ugh, you’re looking at my nose. That’s nasty.” Well, guess what? The nose is gonna tell us a whole lot. If it’s pale pink, it’s allergic. If it’s cherry red, we know it’s a virus. If there’s a lot of swelling, nine times out of 10, they’re also snoring. We wanna look at the throat. We wanna know if that trach is mid-line, so you’re looking head on. We wanna know whether or not that thyroid is in place. And if you move upward once again, you’re looking at the lips and its formation. Then you’re looking at gums or teeth. Are they coming in correctly, or are the teeth that are in, are they decayed because maybe they’re taking a bottle to bed at night? Maybe they’re drinking a lot of juice during the day. Or maybe we have some dental crowding, or in our adolescents, we do have a problem with wisdom teeth and that there’s just not enough room. Buccal mucosa is the mucosa inside the mouth, is it pink? Are there lesions? Does the tongue look like a map? It’s called a geographic tongue, that is caused by a virus. I can’t tell you which virus ’cause many viruses can cause this.
0:34:20.6 Dr. Rhonda Conner-Warren: We wanna know about tonsils. Tonsils are significant. They are lymph nodes that help with infection, but when they get so large that they are meeting in the back, and you can barely see the uvula, like you can see my face, when they get inflamed, they will close, and so the child will sound like this… If their adenoids are enlarged, and they may be subject to a lot of sore throats and a lot of ear infections. You wanna check the neck. You wanna check the posterior cervical chain, anterior chain, again, to see where these lymph nodes are and if there’s an infection. So with the ophthalmoscope, again, you can allow them to play with it, so that they can get an idea of what it’s like to look. The otoscope, again, you need to practice on your hand-holding. Many use a hammer technique such as this. It’s just one I use as well, but I also manage to grab the pinna so that if the child moves, I’m moving with the child’s head and I’m not causing any harm. If you decide to look in the child’s ear because you should, always look in the child’s here because I don’t wanna them coming back and saying, “Oh, I think they got an ear infection.” Just look automatically so that you know.
0:35:42.7 Dr. Rhonda Conner-Warren: You can move the tragus, which is a lot easier in a small child to look in because it’s kind of flat so if you pull it forward, you’ll be okay. But if the child’s having an ear infection, always ask, “Is it okay?” You wanna do an audiometer, especially when they’re getting ready to go to school, to determine whether or not they can hear, and if they can hear between 500 to 6000 hertz, at 25 decibels, they are in good shape and can continue on to school without us being concerned about a hearing loss. In terms of respiratory, we wanna know if there’s nasal flaring. We want to know if the shape of their chest is sufficient. There’s things called pectus cavatum… Excavatum, or pigeon chest. We always wanna note the rise and the fall of the chest. Is one side going up and the other side’s not?
0:36:43.5 Dr. Rhonda Conner-Warren: Here’s something that’s really significant in peds, do not miss the right middle lobe. If there’s a possibility that the child has swallowed something, had something in their mouth, whether it’s even peanuts or a coin, it more than likely may lodge there, just the way it breaks off the bronchus. Rales mean a lot of mucus. Could mean a nice pneumonia. Rhonchi could mean a nice asthma. Remember, rhonchi sounds like…
0:37:08.6 Dr. Rhonda Conner-Warren: And a wheeze is…
0:37:12.0 Dr. Rhonda Conner-Warren: Rales is more…
0:37:17.0 Dr. Rhonda Conner-Warren: And I encourage you to look at YouTube for these particular sounds so that you get used to them. You’ll have to be able to determine what’s the heart sound and what’s the lung sound. So it may take you a little longer. I encourage you to have the parent just to hold the child or tell the child, “Give mom a hug, give sister a hug,” and a lot of times they will, and you’ll get that, their arms expanded so that you can listen to their back. A paroxysmal cough is one that goes…
0:37:49.7 Dr. Rhonda Conner-Warren: And once again, could be a sign that you have an irritated airway. A barky or a seal-sounding cough is usually indicator of epiglottitis, so once again, do your reading to know which needs a cool mist, one which may respond to albuterol, and another one that may cause you to place the child in the emergency room, and give the emergency room a call first. But one of the things in terms of assessment, a child’s respiratory system is you’ve gotta make it a game. You can have them blow out a candle, you could have them blow out a feather, you could have them blow a cotton ball across the room ’cause they gotta take in a deep breath and then blow, so that you’ll get that lung sound that you richly deserve on a physical exam. Cardiac-wise, you gotta know your heart range for age. We want to know the rhythm that it’s regular, so if that whoosh is a murmur, and it might be what’s called a systolic ejection murmur.
0:38:53.7 Dr. Rhonda Conner-Warren: And that usually occurs in children with sickle cell anemia due to the low hemoglobin. We want peripheral pulses. Now, I promise you, they will check in the nursery, but once again, if there is the slightest chance of a coarctation of the aorta, you may find that their peripheral pulses are fainter on one side versus another. We want capillary refill, we wanna note the nail bed color, and just make a game of it. Oh, let me see your bronchials? So again, Let me squeeze your arms. Let me squeeze your wrists. Let me check your thighs. Let me check behind your knees. And then check your dorsal peds. So, remember, making a game of it using yourself as an entertainment piece with your voice and your actions will carry you a long way in the physical exam. And in terms of the gastrointestinal, oh, this is the toddler’s favorite exam. You’re gonna look and say, “Wow, you’ve been eating some stuff,” and then you wanna listen, and you wanna see that it’s nice and round, and you want to listen for those bowel sounds. They should have bowel sounds no less than every minute.
0:40:02.0 Dr. Rhonda Conner-Warren: And if they’re hyperactive, once again, you may wanna revisit your history, ’cause the physical exam is verified on history. So the parent might say, “They have at least six, seven stools a day.” And they’re one to two years old, their diet is changing, absolutely, but again, there may be some food sensitivity. We used to say, “Okay, well, I’m gonna feel your belly.” Well, the word, feel, has a bad connotation nowadays. So again, you may use the phrase, “I’m gonna place my hand on your stomach.” And you can allow the patient to say, “Okay.” “Show me your belly and show me where you want me to put my hand, ’cause I’ll check your belly.” And a lot of times the child will direct your hand as to where you’re gonna touch it, or they’ll put their hand on top of your hand, and once again, you can go through abdominal examination. You wanna look for… Umbilical hernias are the most popular in this age group. And again, we want to note liver and spleen size. And again, the rate of bowel sounds. And the pot belly is gonna stay at least until they’re about three years of age, when they start to thin out, they’re walking around and they have more muscle mass in this area.
0:41:10.5 Dr. Rhonda Conner-Warren: In terms of genitourinary for both male and female, are they developed? If the labia majora is not well developed in a female child, it may be that she has labial adhesions. We wanna make sure there’s no hernia in the area, and that the urethra placement is where it should be. In the male, it’s the same issue, is the placement appropriate? Is the penis present? Is the meatus in the middle? Or is it maybe under on the dorsi side? Where’s the meatus? What about a circumcision? And then the testicular development. Is it down on its sack? Or is it somewhere in the inguinal canal? Again, this is an offence that could cause you a visitation with a court system. Because if we don’t detect the testicle and it stays in there roughly til the age of 6 or 7, this young person has a higher risk for developing testicular cancer. And we don’t want that to happen as well as sterility, so make sure that you are charting it. In the adolescent population, they do have the right to refuse. I would say ask them, is anything different? Are there any bumps? Any growths? Any lesions? Whether it’s male or female, and chart accordingly. But on this exam, you need a chaperone and not just the parent.
0:42:49.0 Dr. Rhonda Conner-Warren: In terms of an infant in muscle skeletal system, which is our next system, we wanna know that those hips are developed well. ‘Cause many times out of 20 births, 20 out of 1000 births, you’ll have what’s called a hip dysplasia. Well, what happened is, is that sometimes there is a difference in the gluteal folds. When you look from behind, you take their diaper off, and you wanna make sure the gluteal folds and the thigh folds are kinda like a Christmas tree, they should line up. One should not be higher than the other, that’s an indicator that there is a hip displacement. You wanna do Barlow, you have to engage the hip, putting your fingers, your longer fingers right at that hip socket and press and then rotate out and press to see if you get a click. And the order linings, you’re gonna rotate out and around to see if you get a click or a click sound or a thud.
0:43:47.3 Dr. Rhonda Conner-Warren: And the reason being is, is that the hip femur head has not either totally developed or the hip socket itself is shallow, so we got slippage, and so this is why you’re going to get a click. These maneuvers are to be documented in anyone who is under a year old, and it is significant because it may self-correct by doing triple diapering within eight weeks, and it may not. Then… So therefore, we need to make sure this child goes on to ortho as soon as possible for further evaluation and x-ray.
0:45:19.6 Dr. Rhonda Conner-Warren: Neurologically, we’re talking about the mental status as well. How aware is the child? How much they interact with their environment is the beginning of understanding whether or not the child may indeed have autism. Watching the infant interact with the parent tells us about attachment. If we talk about an older child, can they follow directions? Can you sit on the exam table? And when people say, “Oh, they’re busy all the time,” remember to look at the parent. If the parent is up and down, and interjecting a lot in your physical examination or a lot in your history, it might be an indicator to ask the parent once again, “Have you been diagnosed with attention deficit? Or do you have a hard time following things or staying with activities?” And again, ask the older child and observe them, get a conversation going, what’s their favorite toy? What do you like to do? What do you plan on doing? And see if they can make sense while talking, in terms of telling a story.
0:45:31.2 Dr. Rhonda Conner-Warren: For example, I had a 5-year-old patient the other day, he didn’t know all the technical terms, but when I said, “Why are you here today?” He said, “Well, I need to know if I got in lead chips.” I said, ” Well, alright. Let’s talk about why you think you got lead chips.” And he was able to describe that the house next door to him was old, and it’s peeling paint and there’s chips all over the place. Now, he denied eating them, but again, we’re gonna talk about lead in another presentation. He’s certainly at risk from lead poison because of this. And again, you wanna observe the child’s interaction with the parent and with you. Sometimes we get a better interaction than what the parents do, because we’re calmer and we’re smoother.
0:46:18.3 Dr. Rhonda Conner-Warren: Here is the grey old acronym like, old Oloff sits on the top of the mountain. All these cranial nerves, I just bring back to you so that you can say, “Oh my God, not again, I thought I was done with this.” No, you’re not. It stays with you forever. And again, you can get most of these during the examination of the system. You’re doing them, you don’t always realize it, such as having a child smile, which is gonna tell you the facial nerve or the acoustic nerve, the whispering sound. Have a child stick their tongue out to say, ah, now stick your tongue out, you can get that. In terms of the Vegas nerve again, swallow. She gotta do that in order to check their thyroid. The accessory muscles, again checking the shoulder and the neck. Let me see. Can you make your touch or shoulder? Can you do like this? And that tells you something. And the hypoglossal nerve once again is responsible for the movement of the tongue, so if the speech is garbled is it because there is damage to this nerve? Remember you’re getting all these nerves when you examine your patient.
0:47:31.5 Dr. Rhonda Conner-Warren: In terms of motor, this is significant because we’re talking about motor function and balance. We wanna know can a child stand up to hold on to mom or hold on to the table. That’s great. Can they walk flatfooted, or are they walking on their tip toe? And if they’re like 3 years of age, can you walk on your tip toes in a straight line? Can you squeeze my fingers? Can you hop, skip or jump? It is amazing that from four to five, they can switch feet when they skip. And again, how far can you jump? Tells us about the balance. As the children get older, we’re talking about, can you follow doing these things? The squeezing and the reflexes. They think that’s pretty cool when you get their reflexes. A word of advice to you when you go to check lower extremities, kids can do one or two things, either like to do like this, or they like to do like this. If they do like this, they cannot guard against you getting those lower reflexes. And they think it’s pretty cool if you can pop them just right. So again, have them active, have them moving during this time and they will enjoy the examination.
0:48:49.0 Dr. Rhonda Conner-Warren: Just remember that once you get them up off the table, they think everything is done. The sensory exam is pretty interesting in that number one, you’re gonna do dull needles. I got news for you folks, most kids are not gonna hold still for that, so you’re going to use your reflex hammer, the pointier end and not the rubbery end or a tuning fork. Now you might be saying to yourself, well, kids don’t have strokes and yes they do, but they may have nerve damage just because of how they were born or a recent injury. And they didn’t wanna tell anyone because they thought they were gonna get into trouble. So they try to hide things. Remember, again, you need to check their arms and their legs. They need to be able to identify the sensation cause you can have nerve damage and you can also have something wrong in terms of hormones as well. But again, make it a game. Is it hot? Is it cold? Is it sharp? Is it dull? And may think this is wonderful and it makes it easier to examine.
0:49:54.5 Dr. Rhonda Conner-Warren: Skin is probably the hardest for all of us unless you’re a dermatology fellow specialist. So I always tell people get a good derm book. And nowadays the pictures online are so wonderful that you’ll be able to get a good idea of what your patient has. We wanna know the condition of the skin. Number one, is it clean? Is it dry? Is it rough in certain areas? Hydration? If a patient has, not drinking a lot with skin tense. A infant is made of about 60% water, they’re just a football of water. So it’s easier for them to get dehydrated. They also will not make tears. What’s the color of the skin? Are they pale or are they dark? And is it a bronzy color which could be indicative of a liver problem. Are there lesions on the skin such as birthmarks or port wine stain, or spider Nevis, and a campus on the back of the throat or back of the neck where mothers usually say they just don’t wash their neck well which looks like a hyperpigmentation. When in fact they’re showing signs of possibly having diabetes type two at an early age.
0:50:57.3 Dr. Rhonda Conner-Warren: Hypopigmentation or loss of color might be indication of vitiligo. It could be an indication of other autoimmune disorders as well. Redness is usually many times in skin fold areas, but redness, if it’s on the child’s bottom or other areas could be an indicator that there may be some abuse of some kind. Acne, whether it’s cystic or blackheads or Whitehead or cones and dons, once again, location, location, location, and sometimes you’ll have a mixture. Is it truly acne or could it be psoriasis? So this is why a picture says a thousand words and take a good look. If a parent says this is worse, then always encourage your parents to take a picture with their cell phones that you can see when you treat it if things are getting better. Cause many times parents want it to go away, right away. The one time that as a pediatric nurse practitioner, I would send them rapidly to a dermatologist, of course, is if they are losing pigmentation in their face. Because this is a self conscious state and people have a tendency to say things. So if you have a growth on the face, or loss of pigmentation, or some redness send them to derm right away. Remember children are still in the growing stage. And when we use things that might have a story in them, they may lose some texture. They may lose some coloring in the skin, making things worse. So again, I want them evaluated right away by a specialist and then we can carry on from there.
0:52:56.1 Dr. Rhonda Conner-Warren: So now we’ve seen the patient, we’ve done a well-child preventative check, no any abnormal findings, but the original diagnosis and why they’re there is the well-child preventative check. It may be well-child preventative check with abnormal findings is your number one diagnosis and then you would indicate what those abnormal findings are, such as elevated BMI or BMI less than 5%, indicating that they are less than the weight to be expected. We’re gonna run labs, such as a CBC, you may run an H&H in the office, if you have the machine. Make sure that you do have a medical assistant who is comfortable doing this, ’cause many times, many medical assistants, if they don’t do peds, they really do not like doing the babies, and so then it becomes, “Oh, we’re gonna send them to the lab.” Well, I don’t know about your population, but if my population struggle to get to clinic, they usually don’t get to the lab, so the labs aren’t drawn. The labs may not get drawn unless the child is trying to go to school and they know that they need to have at least that hemoglobin and that Led drawn. If they’re going to wick, they’re gonna have the hemoglobin drawn.
0:54:08.5 Dr. Rhonda Conner-Warren: A basic panel is gonna tell us about liver, spleen and kidney function. A Led up into the age of 5 is usually covered by Medicaid, but if you have reason to suspect, such as the young man I saw, then again, the documentation needs to be there and I go ahead and do a peripheral one, so that we don’t have this discussion about, “How it could be an error in terms of how it’s processed.” A hemoglobin A1C, if your patient is obese, is imperative. Thyroid-stimulating hormone if your patient is obese, not gaining weight or has too much weight. A T 3-4, once again, to see if there’s something wrong with the thyroid and a lipid panel. You can go to American Academy of Pediatrics and they usually will identify any other additional labs, because of your concerns that you should draw, but this is standard labs that are drawn. We use that kind of tests for your analysis, unless we have reason to suspect that we do have some kidney disruption or dysfunction.
0:55:06.0 Dr. Rhonda Conner-Warren: Provide the prescriptions, but provide the parent with information regarding the prescriptions, if your electronic medical record can do that. And the reason why is you’ll be surprised how there is this lack of exchange between what is read and what is understood and I found more parents to have a reading receptive learning problem. And they usually say, “I’ve always had problems reading. I had problems in school and… Can you just tell me?” So I take a highlighter and I highlight and explain to them what I want them to do. And I love pharmacies nowadays, ’cause most pharmacists, I will say, “Please speak with the parent regardless so they understand where to put the cream, how to put the cream, so forth and so on, and what to look for.”
0:55:47.0 Dr. Rhonda Conner-Warren: In terms of other information, websites are good and apps are good. So my teenagers, especially, when it comes to menstrual cycles, I ask them to track it with an app. They can use any app they so desire and I usually encourage them to use a free app. If I have patients who are trying to monitor their weight, ’cause again, COVID, a lot of them gained 30 pounds, again, they can use whatever app they so desire. If I find that my patients are very anxious. The mom saying, “Oh, they’re sleeping in my bed, they just don’t sleep well.” Calm is a really great app that helps them relax or to help them to do yoga. So make sure you’re indicating the interventions and what you need them to do and you might need to do some with specificity. Explain to the parent why you’re sending them for a referral, such as, you’re starting to have… You have period for menses at 12 or 14, and all of a sudden they stop, but your lab results don’t indicate any change. Then it’s time to go off for additional diagnostic testing and explain why, and what the plan is, and many times the parents will follow up, if they understand the why you’re doing what you’re doing.
0:57:02.4 Dr. Rhonda Conner-Warren: The follow-up plans should also include your documentation when you want them to come back to clinic, and again, you wanna see them back so that you can explain what their labs are, what they’re looking like. And here lately most of our children in our clinic are vitamin D deficient, not decreased, but deficiency, severely, so we’re putting them all on vitamin D, and I encourage you to check that as well. This seems to be a nationwide problem.
0:57:26.9 Dr. Rhonda Conner-Warren: There are challenges in providing care and one of the challenges is physical placement and comfort of the child, so again, if you have a child who is very anxious, whether it’s an infant, a toddler or even a school aged child, there’s no problem with you examining them in a chair and not on the exam table. If it’s a toddler, you can examine them on the parents’ lap. Now an anxious parent, there are evidence-based information that you can find online that talks about how to hold your child when we’re doing procedures. The other thing is be knowledgeable about what we call Dr. Google, if they said they went to a site and it said A, B, and C, ask them to pull up the site, review the site. Show them how this is not what we would consider a reputable site because they’re not using evidence based information that it’s not backed by a scientific organization and that that’s their right to choose, but this is a site that we’re using, that we’re using evidence-based interventions and products so that we know what is the best.
0:58:43.3 Dr. Rhonda Conner-Warren: Chaperone, who should and how? This is the rule that I have at our clinic. That number one, if you’re going to examine any one from the waist down, you need a chaperone, especially if they have to remove their underwear. The chaperone cannot be a medical student and it cannot be your nurse practitioner student. It has to be that medical assistant, it cannot be the front desk person unless they are a medical assistant, because the issue is where are your hands placed and are you touching the appropriate spot. If the parent says, “Oh, I don’t wanna chaperone.” Then you do have the ability to reiterate that the chaperone is also your protection and if you decide that you’re uncomfortable, because maybe the parent is acting not in a way that makes you feel comfortable, then you also have that right to say I can not examine your child without a chaperone. This is about your protection as well.
0:59:46.4 Dr. Rhonda Conner-Warren: The biggest question I get in clinic is, Am I gonna get a shot? Am I gonna get a shot? I get that coming in the door, I get that in the middle of the examination, I get it as soon as I ask a question about your immunizations, ’cause they know these big words. So again, I always talk about comfort hold and comfort positions. And so once again, you need to know those positions so that you can teach the parents. If you’re doing immunizations in your clinic, what you see here is called the buzzy. Some children might have to get three or four immunizations, and this is an evidence-based product that we’ve used in clinic to help them to tolerate getting the immunization, so that we’re not doing this fierce hug that really is holding them down against their will. That’s not the way to give an injection of any kind or to say the phrase, “Oh it’s just gonna hurt a little.” See, your version of hurting a little and my version is not the same, so keep that in mind. Say it’s gonna hurt. You may wanna demonstrate how it’s gonna hurt. It’s gonna feel like this. Meaning just pinching their skin. That makes a difference in their interpretation, and they’ll say, Oh, okay. And they might even say to you, “Okay, I need you hold me real, real tight. Real, real tight.” And in my case, I had a child tell me, “You hold too tight. Let me go.”
1:01:08.9 Dr. Rhonda Conner-Warren: So when it comes to building, once again, we talked about the well-child or the routine child check. Make sure that your front desk has identified this as a new or an established patient as those rates change, you must document your BMI. You should be documenting a psych mental health screening, and if your patient is smoking, smoking cessation, even if it’s the parent, and we’re talking about exercise or play time. Remember to sort by level of importance in terms of immunizations, always documenting if the parent says no risk versus benefit. And remember if there is visual screenings and audio screenings that your MA has documented that in the EHR and that you have signed off on those, so that everyone’s getting credit for what they do. If you have behavioral health counselors, then again, even if the screening shows that they’re growing on time, I still refer them to the behavioral health counselor, even though they’re not gonna get credit in terms of a visit, so that the family is aware that we are concerned about the whole patient, which is what the medical home is all about. Having the patient feel that they have a home and not just a place to come in and get a quick discipline. If you’re precepting a student, most students, unless they have children of their own, or even like teeds are quite anxious during this visit.
1:02:36.0 Dr. Rhonda Conner-Warren: So here are some of the things that we found to do in our clinic. Evaluate the student’s experience, their personal experience. Maybe they were a nanny in a previous lifetime, maybe they’re the oldest of 10 and babysat a lot. And their education, are they doing simulation with simulated mannequins, especially the Barlow’s and Orleans to understand how that click is going to feel. Are they using standardized simulation patients so they got a patient who’s in a well state who is gonna be very talkative and share with them, yeah I color, yeah I do this, I go to school, and not be intimidated themselves. Determine and define what the student’s strengths are at the start. You’re a great talker, you give great eye contact, you’ve got a great voice, you know how to just sit there and just listen, but also help them to control the conversation so they get the necessary data that they need and be clear about how much time you’re going to allow them to do this in. So when I first have a student in my clinic, they only get the history, that is all. And then I will come in, reevaluate the history and do the actual physical. I shadow them the first two times, and then after that, they need to do so. And one of the ways we encourage them to do so because they don’t have access to our agency EHR, is that we provide them with a physical assessment examination sheet that will contain information for the patient’s age or overall.
1:04:05.2 Professor Walden: Then another way that we also encourage our students that are being precepted is you need to read bright futures. And you need to go to the CDC to talk about issues of refugee care, STI care, go to the American Academy of Pediatrics and Nap Nap or the Society of Pediatric nurses to look at evidence-based interventions and actions. These things encompass everything that the student has done in previous clinicals, but now the focus is on peds. So when you say, “Well, how much do you drink in a day?” “Oh, I drink a lot,” I need to know what they’re drinking and exactly how much. Once again, if they’re drinking a lot of milk, I know my patients are at risk for being anemic, if they’re drinking a lot of juice, my patient may not be brushing their teeth well and is showing signs of tooth decay. And once again, when I say, what are you eating, the parent say, “Oh, we just eat just regular food.” The question becomes, what is the portion size when I have someone who’s greater than 95% or 50%. So here are some other resources. Once again, bright futures, healthy children’s.org, and there are screening tools on the CDC, encourage your students to take a look at those before they get started in their clinical area and hold them to it.
1:05:25.3 Dr. Rhonda Conner-Warren: Many times we’ll all get the question of well, what should I do, what should I do? If this is not your first clinical, they should have an idea of what they should do, help them to critically think, help them to clinically problem-solve what their next actions will be. As I’ve said to all my students, I’m not expecting you to have all the answers, but I need you to understand what is normal versus what you saw, and if you don’t know what it is, that’s fine, we’ll work it out, because we all have a collaborative and we’ve all had to make the call. The next time we’re gonna have a deeper dive into pediatric psych mental health screening. And the reason why is, is this early detection is significant. We’re gonna talk about the screening tools, diagnosis, supportive services, and just recently they talk about medications that they now have that once again are being specifically tested in the pediatric population. Many times in the psychotropic meds we use were not tested, and we didn’t know, but we have more data now. But once again, many parents don’t want anything that’s going to cause them to not grow or to not eat, ’cause that’s significant when you’re a parent. You want your child to rest well, you want your child to grow well, and you want your child to be well. Until I see you again, take care, and if you have any questions by all means, please let me know.