CORE CURRICULUM IN PAEDIATRICS FOR MEDICAL

UNDERGRADUATES

2018 UNIVERSITY GRANTS COMMISSION

Sri Lanka

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Core Curriculum in Paediatrics for Medical Undergraduates

Contents Core Curriculum in Paediatrics for Medical Undergraduates .............................................................. 1

Curriculum development ................................................................................................................... 2

Committee Members..................................................................................................................... 2

The process ....................................................................................................................................... 3

Introduction ...................................................................................................................................... 3

General objectives in formulating core curriculum in Paediatrics ....................................................... 4

Aims of the undergraduate paediatric teaching programme .......................................................... 5

Intended learning outcomes of the paediatric training programme ............................................... 6

Compulsory Clinical Appointments ................................................................................................. 10

Introductory clinical appointment................................................................................................ 10

First paediatric appointment ....................................................................................................... 12

Second paediatric appointment ................................................................................................... 15

Final clinical (Professorial) appointment in paediatrics ................................................................. 19

Assessments in paediatrics .............................................................................................................. 22

Theory component ...................................................................................................................... 23

Multiple choice questions paper .............................................................................................. 23

Recommended blueprint for MCQs .......................................................................................... 23

Structured essay question paper .............................................................................................. 24

Clinical component ...................................................................................................................... 24

Selection of examiners ............................................................................................................. 24

Pairing of examiners ................................................................................................................ 25

Long Cases ............................................................................................................................... 25

Short Cases .............................................................................................................................. 25

Appendix i ................................................................................................................................... 26

Appendix ii .................................................................................................................................. 28

Appendix iii: ................................................................................................................................ 28

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Curriculum development The following academic experts from the medical faculties of all state universities of Sri Lanka were appointed by the Standing Committee on Medicine and Dental Sciences of the University Grants Commission, to formulate the Paediatric Core Curriculum.

Coordinator Dr. S. T. Kudagammana

Committee Members

• University of Peradeniya, Sri Lanka Prof. Asiri Abeyagunawardena Dr. S. T. Kudagammana

• University of Colombo, Sri Lanka Prof Pujitha Wickramasinghe Dr. Jithangi Wanigasinghe

• University of Jaffna, Sri Lanka Dr. Githanjali Sathyadas

Dr. Niruba Umasankar

• University of Ruhuna, Sri Lanka Prof. U. K. Jayantha

Prof. Vasantha Devasiri

• University of Kelaniya, Sri Lanka Prof. Shaman Rajindrajith

Dr. Chamilka Jayasinghe

• University of Sri Jayewardenepura, Sri Lanka Prof. Dulani Gunasekera

Dr. Guwani Liyanage

• Eastern University, Sri Lanka Dr. Angela Arulpragasam

• Rajarata University of Sri Lanka Dr. Anurudda Padeniya

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The process The Committee met three times at the Faculty of Medicine, University of Peradeniya to

formulate the Core Curriculum of Paediatrics. Thereafter, fine tuning was done through email

communications among the committee members. The document was finalized at the last of

the meetings at the same venue.

Introduction There are eight state medical schools training medical students in Sri Lanka. They become

eligible to enter the medical school based on their performance at the GCE Advance Level

Examination. The duration of the medical undergraduate course is approximately 5 years.

Based on their performance at the final MBBS examination, the students are placed in the all

island merit list. Subsequent appointments (internship and first post-internship) are based on

this merit order. After the successful completion of the internship appointment, they are

eligible for permanent employment under the Ministry of Health, Sri Lanka. Thus, it is

important to provide a uniform format for training and assessment of students in all faculties

to match the bench mark document for medical degrees in SL.

By the end of the paediatric training programme the student is expected to transform into a

self-motivated medical professional with regards to paediatrics by consolidating the

competencies acquired during the introductory, first and second paediatric appointments.

Additional competencies the graduate should acquire are soft skills including communication,

leadership, management, team work, advising on parenting, role of family in patient

management, relationship with the staff, administration, professionalism, personal

management skills and accountability.

The graduates with the MBBS degree should be able to provide the best possible care to

children and adolescents of Sri Lanka. The committee has formulated a core curriculum

document enabling these students across all faculties, to achieve the desired objective.

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General objectives in formulating core curriculum in Paediatrics The purpose of undergraduate paediatric training is to prepare the medical students for

internship in paediatrics, to prepare them to practice paediatrics as a skillful and safe doctor

subsequently and to motivate them to be lifelong learners. The clinical training in paediatrics

is designed to help them to acquire adequate knowledge, achieve clinical skills to diagnose

and treat the most common problems and to develop necessary skills required in the

management and follow up of children, including emergencies.

Unique components in paediatrics include growth and development, nutrition, immunization,

parenting, perinatal care, adolescent care, non-accidental injuries, care by proxy and school

related issues.

The aims of the curriculum should comply with the aims of the MBBS course as a whole, which

is given below.

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Aims of the undergraduate paediatric teaching programme To provide the desired knowledge, skills and attitudes to practice as a first contact doctor

and lay the foundation for further learning in relation to child and adolescent health.

The graduate should,

1. possess an attitude towards medicine that is both scientific and humane and have the

characteristics of high ethical standards required for professional life.

2. possesses knowledge, skills and attitudes that will enable the holistic management of

medical problems affecting individuals and community.

3. be able to deal appropriately with all paediatric emergencies utilizing the facilities

available.

4. be aware of the limitations of knowledge and skills and be prepared to seek help when

necessary.

5. be able to work in a team and provide leadership in activities related to health.

6. be able to provide medico-legal services to the judicial system of the country.

7. be able to assess evidence both as to its reliability and relevance and appreciate that

conclusions are reached by logical deductions.

8. be able to continue self-directed learning and contribute towards progress of

medical sciences.

9. demonstrate knowledge of the interaction between man and the environment and

their responsibility in promoting a healthy environment.

10. be able to communicate effectively with fellow practitioners, patients and their

families, other professionals and public.

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Intended learning outcomes of the paediatric training programme On successful completion of the paediatric program, students should be able to achieve the

following ILOs.

These are listed under ten major headings.

1. Patient care

2. Knowledge for practice

3. Practice based learning and improvement

4. Communication and inter-personal skills

5. Professionalism

6. Health care systems based practice

7. Inter- personal collaboration

8. Personal and professional development

9. Promoting health and preventing disease in the community

10. Assisting the legal system in the administration of justice

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Under each of the 10 headings mentioned above the student should be able to,

1. Contribute to the promotion of health, preventive health, and to provide patient-

centered care that is compassionate, appropriate and effective for the prevention and

management of health problems in the paediatric age group in the community, within

the family.

2. Demonstrate knowledge of established and evolving biomedical, clinical,

epidemiological and social-behavioral sciences, as well as the application of this

knowledge to patient care in the paediatric age group.

3. Demonstrate the ability to improve patient care based on scientific evidence,

constant self-evaluation and reflective life-long learning.

4. Demonstrate interpersonal communication and collaborative skills that result in the

effective exchange of information and collaborations with the community, patients,

their families, and health professionals.

5. Demonstrate the ability to carry out responsibilities in a professional and ethical

manner.

6. Demonstrate as a first contact doctor, an awareness of and responsiveness to the

larger context and system of health care, as well as the ability to effectively utilize

resources in the system to provide optimal health care.

7. Demonstrate the ability to engage in an inter professional team in a manner that

optimizes safe, effective patient- and population-centered care.

8. Demonstrate the qualities required to sustain lifelong personal and professional

growth.

9. Provide appropriate medico-legal services pertaining to the paediatric age group

where required.

10. Demonstrate the ability to carry out administrative and managerial functions within

the health care system.

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The paediatric training programme involves delivery of knowledge, imparting skills and

attitudes through a variety of educational methods. These include lectures, small group

discussions and ward teaching sessions.

The topics are given in appendix 1.

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The students undergo the following clinical appointments.

The compulsory paediatric clinical appointments and duration

• Introductory clinical appointment Minimum of 1 week

• First paediatric clinical appointment 3-4 weeks

• Second paediatric clinical appointment 3- 4 weeks

• Final clinical (Professorial) appointment minimum of 8 weeks

The trainee should undergo a minimum of 1 week of introductory paediatric appointment

and a minimum of 8 weeks of paediatric clinical training before becoming eligible to

undergo the final clinical (professorial) paediatric appointment.

• A minimum of one week of neonatology is recommended during the final clinical

(professorial) paediatric appointment.

Other subspecialties that the student may be exposed to are paediatric cardiology,

paediatric neurology, paediatric rheumatology, paediatric nephrology, paediatric

haematology, paediatric surgery and paediatric dermatology.

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Compulsory Clinical Appointments

Introductory clinical appointment

1. Supervisor Respective consultants 2. Duration Minimum of one week 3. Work period Minimum 4 hours a day

At the end of the introductory Paediatric appointment a student should be able to

• develop the skill of interacting with a sick child confidently and communicating with

parents (talk and console).

• appreciate and respond to the needs of the child and the mother, and to build up a

friendly but professional relationship with both the child and the parents.

• develop the skill of obtaining a “system based” basic clinical history from the

caregiver including;

• Patient identification data and demographic data

• Presenting complaint

• History of the presenting complaint (important positives and negatives are not

expected)

• Past medical and surgical history

• Systemic inquiry

• Birth history

• Immunization history

• Development history

• Dietary history

• Family history

• Drug and allergic history

• Social history – economic and education levels of family members, housing

conditions, access to health care facilities, effect of disease on parents and

siblings, parents’ understanding of the disease and outcome

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• show the ability of responding to the problems related to the impact of illness and

hospitalization on the child and the family unit.

• develop the basic skill of examining children of different ages starting from the

neonatal period onwards and differentiate normal from abnormal regarding the

following aspects,

• General examination

• Anthropometry

• Cardiovascular system

• Respiratory system

• Abdominal examination

• Introduction to development assessment

• familiarize with regards to the different areas of the Child Health Development

Record (CHDR) to

• identify the importance of each area and the process of documentation in the

CHDR

• apply universal precautions:

Demonstrate 5 step hand washing technique. • comprehend ward procedures:

Describe the function of the bed head ticket

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First paediatric appointment

1. Supervisor Respective consultants of the unit 2. Duration 3 - 4 weeks 3. Usual time 8 am -12 noon

4. Additional time Students are expected to come early enough to be ready for the consultant`s ward round

5. Assessment Formative assessment at the end of the appointment

The student is expected to consolidate the competencies acquired during the introductory

paediatric appointment while developing other competencies given below.

At the end of the first paediatric clinical appointment a student should be able to;

1. obtain important positive and negative findings in a comprehensive “system

based” clinical history and reach a diagnosis or differential diagnoses

Students are expected to expand on the system based history learnt during their introductory

appointment.

2. demonstrate the basic skills of examination of the following systems learnt during

the introductory paediatric appointment

• General examination

• Cardiovascular system

• Respiratory system

• Abdominal examination

• Neurological examination – motor system and cranial nerves examination

3. demonstrate basic skills of neonatal examination

4. perform growth assessment and interpret using growth charts

5. identify four areas in developmental assessment and show the ability of doing a

basic developmental assessment in children.

6. perform a dietary assessment and to make a basic assessment of breast feeding.

7. describe how to perform practical procedures in a safe manner

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8. demonstrate basic skills of paediatric prescribing by;

describing the pharmacological basis of treatment prescribed.

demonstrating the ability of using a paediatric formulary correctly.

9. develop basic skills and acquire knowledge in matters related to safeguarding

children by

• appreciating the effects of family composition, socio-economic factors and

poverty on child health.

• familiarising with issues related to child protection.

• identifying the organisations involved in maternal and child health.

10. demonstrate the correct technique of performing,

• Pulse oximetry

• Positioning the child with respiratory distress / shock

• Oxygen administration – nasal prong / head box / mask

• Nebulization

• Collection of a mid-stream urine sample

• Urine ward test for protein / reducing substances

11. demonstrate basic life support skills with an understanding the basic concept of life

support.

12. demonstrate skills in the identification and management of common paediatric

emergencies.

• Anaphylaxis

• Acute exacerbation of asthma

• Stridor

• Dehydration

• Dengue haemorrhagic fever

• Circulatory collapse

• Convulsions

• Choking

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• Poisoning

• Snake bite

Students are expected to attend the casualty admissions in addition to the usual working

hours.

13. gain hands on experience in monitoring of patients using relevant charts.

14. identify the importance of ambulatory paediatrics in the management of the

following conditions:

• At risk babies

• Failure to thrive

• Obesity

• Urinary tract infection

• Congenital heart defects

• Asthma

• Anaemia

• Congenital hypothyroidism

• Nephrotic syndrome

• Epilepsy

15. develop and demonstrate effective communication skills in providing accurate

information to the patient and the family.

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Second paediatric appointment

1. Supervisor Respective consultants of the unit 2. Duration 3-4 weeks 3. Usual time 8 a.m-12 noon 4. Additional time Students are expected to come early enough to

be ready for consultant’s ward round 5. Assessment Should be held at the end of the appointment,

using a suitable method

The student is expected to consolidate the competencies acquired during the introductory and the first paediatric appointments while developing other competencies given below.

At the end of the second paediatric clinical appointment the student should be able to

1. demonstrate the skill of presenting a “problem based” (not a system based) history

with formulation of a problem list, analysis and arriving at a diagnosis / differential

diagnoses, formulate a summary and state a plan of management and formulate

discharge and follow up plans for patients.

2. demonstrate the competence in examination skills of the following systems

• General examination

• Cardiovascular system

• Respiratory system

• Abdominal examination

• Neurological examination –motor system, cranial nerves, higher functions

• Developmental examination

• Newborn examination

• Ear nose throat examination

3. demonstrate the skills of nutritional assessment and breast feeding assessment

4. participate in the management of the following common paediatric emergencies

• Acute respiratory distress

• Stridor

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• Dehydration

• Dengue haemorrhagic fever

• Circulatory collapse

• Convulsion

• Unconscious child

• Poisoning

• Snake bite

• Haematemesis

• Neonatal Emergencies (appendix ii)

Students are expected to attend the casualty admissions in addition to the usual working hours.

5. identify and manage the following conditions in an ambulatory paediatric setting.

• Urinary tract infection

• Nephrotic syndrome

• Asthma

• Epilepsy

• Cerebral palsy

• Arthritis

• Developmental delay

• Diabetes mellitus

• Heart disease

• Headache

• Constipation

• Enuresis

• Abdominal pain

6. demonstrate skills in performing simple ward procedures

• Measuring blood pressure in different age groups (infant / toddler / child)

and interpretation of the values using charts

• Simple laboratory techniques (at least one of each should be done)

In ward packed cell volume (PCV), capillary blood sugar (CBS), estimation of

urine protein and urine sugar.

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7. demonstrate communication in health education, getting consent for procedures.

8. discuss the importance of the following aspects in paediatric pharmacology.

Dispensing drugs including organizing the drug trolley, emergency tray

• Maintenance of drug charts

• Administration of drugs, challenges and ensuring compliance

• Prescription writing

• Storage of drugs and vaccines including the importance of cold chain

• Advise patients regarding drug interactions and side effects

9. demonstrate the ability to perform the following skills

• Keeping the neonate warm

• Normal new-born care

• Nursing the unconscious child

• Positioning the convulsing child

• Setting up an intravenous infusion

10. demonstrate accurate documentation in the following

• Request forms to pathology and radiology departments

• Request form for blood and blood products

• Transfer forms

• Medical certificate

• Death certificate

• Diagnosis cards

• Notification form

11. observe and describe procedures and investigations carried out in the Paediatric

ward giving emphasis to safe practice

• Blood culture

• Urine culture

• Intravenous and intramuscular injection

• Lumbar puncture

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• Blood gas estimation

• Blood transfusions

• Urinary catheterisation

• Mantoux test

• Radiological procedures (eg.- MCUG)

• Intercostal tube insertion

• Pleural aspirations

• Bone marrow biopsy

• Liver / Renal biopsy

• Exchange transfusions

• Collection and transport of clinical samples

12. demonstrate knowledge and competency in safe prescribing

• Be able to calculate drug doses accurately according to specific doses for weight

/ age / body surface area rationalise prescribing of antimicrobials and other

medication

• describe the pharmacokinetics and pharmacodynamics of commonly prescribed

drugs

13. recognize the problems of children in the community

• Deviations of development

• Learning difficulties

• Immunization failure

• Autism and behavioral disorders

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Final clinical (Professorial) appointment in paediatrics

1. Supervisor Academic Staff of University Paediatric Unit 2. Duration 8 weeks 3. Work time Full time, based on learning schedules 4. Prerequisite Satisfactory completion of all pre-professorial

appointments 5. Assessment method Continuous assessment and final examination

The student is expected to consolidate the competencies acquired during the introductory,

the first and second paediatric appointment while developing other competencies given

below.

At the end of the final (professorial) paediatric clinical appointment a student should be

able to;

1. analyze problems in children and adolescents in a holistic manner. They should be

able to formulate a list of problems / differential diagnoses

2. formulate a plan of management.

3. formulate a discharge summary.

4. maintain complete medical documentation.

5. demonstrate adequate knowledge in the conditions mentioned in appendix I

6. deliver health promotional activities relevant to the following

• Breast feeding

• Immunisation

• Nutrition

• Growth monitoring

• Early childhood care and development

• Healthy life style

• Reproductive health

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7. analyse public health related issues pertaining to;

• Notification and prevention of communicable disease

• Child safety

• School health

• Malnutrition

• Teenage pregnancy

• Environment

8. demonstrate the ability to actively participate in

• Newborn resuscitation

• Newborn examination

• Managing newborn emergencies

• Neonatal screening

• Lactation management

The student should be competent to diagnose and manage the neonatal conditions

given in appendix III.

9. perform a pubertal assessment and attend to adolescent health issues.

10. get actively involved in the management of the following conditions including

emergencies

• Dengue haemorrhagic fever

• Cardiac arrest

• Shock

• Status epilepticus

• Status asthmaticus

• Child with impaired level of consciousness

• Hypertensive encephalopathy

• Acute renal failure

• Diabetic ketoacidosis

• Respiratory distress in the neonate

• Acute upper airway obstruction

• Cardiac arrhythmias

• Snake bite and poisoning

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11. prescribe rationally with special emphasis on

• Writing appropriate prescriptions

• Regular evaluation of drug charts

• Knowing the doses of emergency drugs

• Complying with the national guidelines for named diseases

12. adhere to national guidelines and circulars related to health care.

13. demonstrate competence in ward procedures:

• Admission and discharge process

• Medical documentation

• Transport within and out of hospital

• Liaison with other health care professionals

• Adverse event following immunisation

• Issuing death certificate / medical certificate

• Ordering an inquest

• Conducting a case conference

• Multi Disciplinary Team discussions / meetings

14. perform the following procedures

• Collection of blood for culture

• Collection of urine for culture

• Venepuncture

• Setting up an iv infusion / blood transfusion

• Peripheral blood glucose monitoring

15. demonstrate advanced paediatric and neonatal life support skills.

16. demonstrate professional skills in relation to

• Effective communication and team work

• Presentation skills

• team work among students

• reflective practice

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Assessments in paediatrics.

Composition of marks for the final assessment

a. Continuous assessment - 20% out of total 100 marks; of which 50% should be from

OSCE

b. Summative assessment

a. Theory (MCQ & SBR) 20% + SEQ 20% = 40% of final mark

b. Clinical 40% of final mark

(Continuous assessment will be considered only in the first attempt, for subsequent

attempts marks will be calculated for 80% & converted to 100%)

a. Continuous assessment

Should include Objective Structured Clinical Examination (OSCE) covering the

following areas with a minimum of 10 stations.

Recommended subjects / content areas for stations include the following.

Out of the 10 OSCEs a minimum of two stations should be dedicated to check

• Communication skills

• Procedural skills.

b. Summative assessment

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Theory component Multiple choice questions paper

Duration : 02 Hours

Single best answer (SBA) s : 30 questions

Multiple True False type (MTF) s : 20 questions

Recommended blueprint for MCQs

MCQ Minimum requirement in

each section

SBA Minimum requirement in

each section Neonatology 1 3

CVS 1 2

Respiratory 1 2 CNS 1 2 Genitourinary 1 1 Growth and development 1 2 GIT/Liver 1 2 Haematology 1 1 Breast feeding/nutrition 1 2 Infection 1 3 Pharmacology 1

Malignancy 1 1

Paediatric surgery 1 1 Rheumatology/ connective tissue disease 1 1

Genetics 1 Emergency paediatrics 1 2 Immunization 1 Dermatology 1 Poisoning 1 Endocrinology 1 1 Social paediatrics 1 1 Miscellaneous 2

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Structured essay question Paper

Duration of the paper : 03 hours

No of questions : 6 All questions carry equal marks. Following core areas should be included with adequate coverage of social paediatrics.

Neonatology, Emergency paediatrics, Growth / Nutrition/ Development- a part or whole question

Clinical component

Recommendations for fair conduct of the clinical component of final MBBS Examination.

1. The gap between theory component and the clinical component of the exam should

not exceed 6 weeks. Under the circumstances prevailing, the faculties could decide

which component they have first (either the clinical or theory).

2. Duration of the clinical exam should not extend to unduly long periods. The number

of days should not exceed the number of students in the batch divided by 20

(Considering that 20 students are examined in a day).

Selection of examiners

Examiners are selected from Board Certified paediatricians who are in active service in the

university, public sector or in the military who have been practicing as consultants for more

than 3 years. Paediatricians who have retired from the university system, public and military

can be appointed as examiners for a period of two years from retirement.

Examiners will have to declare their conflicts of interest by signing a document on each day

of the examination.

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Pairing of examiners

All attempts will be made to pair examiners considering the following criteria as far as possible.

Universityexaminers + Non-university examiners Internal examiners + External examiners Senior examiners + Junior examiners Male examiners + Female examiners

Long Cases

Both patients and examiners are selected by a system of drawing lots by students to reduce bias.

Students are given 40 minutes to spend with the patient and 5 minutes on their own before commencing the discussion.

- Discussion with examiners is for 20 minutes.

- It is advisable to have a structured marking scheme.

- Two examiners mark independently and agree on a consensus mark if there is a discrepancy of more than 15. Marks are given out of 100 given as a multiple of 5.

Short Cases

Each student will get two short cases. Time duration is 10 minutes per each case. (6 minutes for examination and 4 minutes for discussion)

Each case is assessed by a separate set of examiners.

Case selection for each student will vary according to the long case he/she has been tested on to prevent repetition of assessing the same system in the short cases as much as possible.

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Appendix I Well Baby Care

Abnormal Growth & Development

Infant Feeding

Nutrition

Failure to thrive

Screening for illnesses

Immunizations /EPI Schedule

Fluid Balance Fluids and Electrolytes

Acid base disorders and management

Paediatric Emergencies Basic Life Support

Advance Life Support

Respiratory emergencies

Cardiac Emergencies

CNS Emergencies

Dengue shock

Nephrology Urinary tract infections

Acute renal failure

Chronic renal failure

Nephritic syndrome

Nephrotic syndrome

A child with haematuria

Haematology A Child with anaemia

Haemolytic anaemias

Evaluation of a child with a bleeding disorder

Bleeding disorders

Coagulation disorders

Haematologycal malignancies

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Neurology Congenital malformations of CNS

Seizure disorders

Seizure disorders

Cerebral palsy

Floppy baby

CNS infections

Obesity

Endocrinology Hypothyroidism

Diabetes mellitus

Adrenal Disorders

Precocious puberty/Delayed puberty

Short stature and Pituitary disorders

Cardiology Congenital heart diseases

Musculoskeletal Disorders Rickets

Monoarthritis

Polyarthritis

GIT disorders Acute diarrhoea

Chronic diarrhoea

Constipation and Encopresis

Respiratory Diseases Upper Respiratory infections

Lower respiratory tract infections

Bronchial asthma and other allergic diseases

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Appendix II

Neonatal Emergencies

1. Preterm delivery

2. Neonatal respiratory distress

3. Neonatal convulsion

4. Septic baby

5. Neonatal jaundice

Appendix III

Neonatology

Newborn examination

Neonatal Jaundice

Prematurity and low birth weight

Respiratory distress in newborn

Neonatal Sepsis

Birth asphyxia & Neonatal convulsions

Gastrointestinal disorders of newborn

Haematological disorders of newborn

Suggested reading material

1. Illustrated text book of paediatrics by Tom Lissauer

2. Nelson Text Book of paediatrics

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