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THE COURAGE TO ADVOCATE: A CLINICIAN'S CALL TO ACTION -- Katherine C McKenzie, M.D., FACP

Question 1: What are some unique characteristics that make clinicians strong advocates?

Choose one:
A.   Expertise
B.   Experience
C.   Stature in society
D.   All of the above

Correct Answer: D. All of the above

Explanation: Clinicians can be powerful advocates based on their professional expertise, clinical experience, and the stature they have in society.

Reference: Law M, Leung P, Veinot P, Miller D, Mylopoulos M. A Qualitative Study of the Experiences and Factors That Led Physicians to Be Lifelong Health Advocates. Academic Medicine. 2016;91(10):1392-1397. PMID: 27438157
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THE COURAGE TO ADVOCATE: A CLINICIAN'S CALL TO ACTION -- Katherine C McKenzie, M.D., FACP

Question 2: Which of the following best describes physician advocacy?

Choose one:
A.   Limiting physician involvement to direct patient care and avoiding public health issues
B.   Using medical expertise and clinical experience to promote changes that improve the health and well-being of patients and communities
C.   Participating only in political campaigns related to healthcare
D.   Speaking publicly only when representing a professional society

Correct Answer: B. Using medical expertise and clinical experience to promote changes that improve the health and well-being of patients and communities

Explanation: Physician advocacy extends beyond the examination room and includes efforts to address social, economic, environmental, educational, and policy factors that affect health. Physicians are uniquely positioned to advocate because they combine scientific expertise, clinical experience, and firsthand knowledge of factors influencing patient outcomes.

Reference: Earnest MA, Wong SL, Federico SG. Physician Advocacy: What Is It and How Do We Do It? Academic Medicine. 2010;85(1):63-67.
American Medical Association. Declaration of Professional Responsibility: Medicine's Social Contract with Humanity.
American Board of Internal Medicine. Medical Professionalism in the New Millennium: A Physician Charter.
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What’s All the Buzz? Vector Borne Diseases in San Diego County -- Seema Shah, M.D., MPH

Question 3: A community pediatrician is counseling a family before travel to an area with endemic dengue transmission. Which prevention strategy is most effective for reducing the risk of dengue infection?

Choose one:
A.   Avoiding contact with wild rodents
B.   Preventing mosquito bites and eliminating standing water near the home
C.   Receiving routine antibiotic prophylaxis before travel
D.   Avoiding consumption of raw fruits

Correct Answer: B. Preventing mosquito bites and eliminating standing water near the home

Explanation: Dengue is transmitted by Aedes mosquitoes, which breed in small collections of standing water and are increasingly established throughout San Diego County. Prevention focuses on reducing mosquito exposure through personal protective measures and eliminating mosquito breeding sites around homes and communities. Vector control efforts are a critical component of dengue prevention.

References: Pescador Ruschel MA, Panda PK, Farmer A. Dengue Fever. StatPearls Publishing; 2026. PMID: 28613483.
Montenegro-Quiñonez CA, Louis VR, Horstick O, et al. Interventions against Aedes/dengue at the household level: a systematic review and meta-analysis. EBioMedicine. 2023;93:104660.
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What’s All the Buzz? Vector Borne Diseases in San Diego County -- Seema Shah, M.D., MPH

Question 4: Which strategy is most effective for preventing dengue transmission at the community level?

Choose one:
A.   Routine antibiotic prophylaxis
B.   Elimination of standing water and mosquito control measures
C.   Annual chest radiography
D.   Tick avoidance measures

Correct Answer: B. Elimination of standing water and mosquito control measures

Explanation: Aedes mosquitoes breed in small collections of standing water. Removing breeding sites and implementing vector control measures are key strategies for reducing dengue transmission. The presentation emphasized surveillance, mosquito control, and environmental management as major public health interventions.

Reference: Montenegro-Quiñonez CA, et al. Interventions against Aedes/dengue at the household level: a systematic review and meta-analysis. EBioMedicine. 2023.
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Trust, Transparency, and the Vaccine Schedule: Then and Now -- Pia S. Pannaraj, M.D., MPH

Question 5: A 15-month-old male presents with fever, runny nose, and cough. After 2 days, he began with a rash that started on his face and then spread to his head, trunk, arms and legs. He returned from Vietnam 1 week ago where he had spent the last 4 months visiting relatives. A throat swab is positive for measles by RT-PCR. Which statement best describes "immune amnesia" caused by measles infection?

Choose one:
A.   Measles permanently destroys all immune cells, leaving a person unable to fight infections
B.   Measles can erase part of the immune system's memory of previous infections, making a person more susceptible to other diseases after recovery
C.   Measles causes the immune system to attack the brain, leading to memory loss
D.   Measles strengthens immune memory by increasing the number of memory B cells

Correct Answer: B. Measles can erase part of the immune system's memory of previous infections, making a person more susceptible to other diseases after recovery

Explanation: Measles infection can cause immune amnesia, a phenomenon in which the virus destroys 11-73% of memory B and T cells that were generated from previous infections or vaccinations. As a result, individuals may lose some of their existing immune protection and become more vulnerable to other infectious diseases for months or even years after recovering from measles. Memory is re-learned by new exposures.

Reference: N Engl J Med 2025;393:2447-245.
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Trust, Transparency, and the Vaccine Schedule: Then and Now -- Pia S. Pannaraj, M.D., MPH

Question 6: Why does the American Academy of Pediatrics (AAP) recommend routine COVID-19 vaccination for children younger than 2 years of age, while making it risk-based or with shared clinical decision making for older children?

Choose one:
A.   Children under 2 years are at higher risk of hospitalization and severe COVID-19 outcomes, whereas most healthy older children have lower risk and may use shared decision-making with their clinician
B.   Because children under 2 years are the primary source of COVID-19 transmission in the community
C.   Because natural infection does not produce any immunity against COVID-19 in the younger age group
D.   The vaccine is less effective in children older than 2 years

Correct Answer: A. Children under 2 years are at higher risk of hospitalization and severe COVID-19 outcomes, whereas most healthy older children have lower risk and may use shared decision-making with their clinician

Explanation: The AAP recommends routine COVID-19 vaccination for children under 2 years because infants and young children experience higher rates of severe COVID-19 illness, hospitalization, and complications compared to other pediatric age groups. COVID-19 vaccines have been demonstrated to be safe and effective in protecting against serious outcomes of SARS-CoV-2 infection, including post-acute sequelae (PASC) and multisystem inflammatory syndrome in children (MIS-C). Unlike older children and adolescents, infants and toddlers cannot mask, distance, or otherwise mitigate exposure independently, making vaccination a critical layer of direct protection.

Reference: Pediatrics (2025) 156 (5): e2025073924
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Personalized Medicine in Very Early Onset IBD: Evaluation and Therapeutic Strategies -- Judith Kelsen, M.D.

Question 7: Genetic defects in children with VEO-IBD can involve:

Choose one:
A.   epithelial barrier function
B.   innate immune response
C.   adaptive response
D.   none of the above
E.   all of the above

Correct Answer: E. Defects in all arms of host defense can be involved in VEO-IBD

Explanation: Defects in all arms of host defense can be involved in VEO- IBD. Defects in both innate and adaptive immunity, such as neutrophils, T cell and B lymphocytes and macrophages, can result in the phenotype of VEO-IBD. Also, non-lymphohematopoietic defects with primary defects in enterocytes can also lead to IBD-like manifestations.

References:
Glocker EO, Kotlarz D, Boztug K, et al. Inflammatory bowel disease and mutations affecting the interleukin-10 receptor. N Engl J Med 2009;361:2033-45.
Uhlig HH, Schwerd T, Koletzko S, et al. The diagnostic approach to monogenic very early onset inflammatory bowel disease. Gastroenterology 2014;147:990-1007
Kelsen JR, North American Society for Pediatric Gastroenterology, Hepatology, and Nutrition Position Paper on the Evaluation and Management for Patients With Very Early-onset Inflammatory Bowel Disease, J Pediatr Gastroenterol Nutr. 2020 Mar;70(3):389-403

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Personalized Medicine in Very Early Onset IBD: Evaluation and Therapeutic Strategies -- Judith Kelsen, M.D.

Question 8: Patients with VEO-IBD can have histologic findings that include:

Choose one:
A.   Apoptosis
B.   Intraepithelial Lymphocytes
C.   Neutrophilic
D.   Eosinophils
E.   All of the above

Correct Answer: E. All of the above

Explanation: The setting of VEO-IBD is one of the circumstances in which a true partnership with the pathologist is required. There are specific features which are useful and can be clues to a monogenic form of VEO-IBD. In general, eosinophilic infiltrates are more common in VEO-IBD compared to older onset IBD. The same is true for increased apoptosis. One of the features that should be specifically sought is villous blunting or villous atrophy with a lymphocytic infiltrate. This can be seen in celiac disease, however, it is a strong indication of some of the T cell dysregulation disorders beyond celiac disease.

References:
Conrad, Wilkins, Kelsen, Distinct Histopathological Features at Diagnosis of Very Early Onset Inflammatory Bowel Disease, Journal of Crohn's and Colitis, 2019, 615–625
Boyle B, Collins MH, Wang Z, et al.; PROTECT Study Group. Histologic correlates of clinical and endoscopic severity in children newly diagnosed with ulcerative colitis. Am J Surg Pathol 2017;41:1491–8
Daniels JA, Lederman HM, Maitra A, Montgomery EA. Gastrointestinal tract pathology in patients with common variable immunodeficiency [CVID]: a clinicopathologic study and review. Am J Surg Pathol 2007;31:1800–12.

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Pediatric Long COVID: What the Data Show — and What Families Tell Us -- Kyung (Kay) Rhee, M.D., MSc, MA & Kelan Tantisira, M.D., M.P.H.

Question 9: What is NOT needed to qualify for a Long COVID diagnosis?

Choose one:
A.   Loss of smell
B.   Fever
C.   Rash
D.   Serology or proof of infection

Correct Answer: D. Serology or proof of infection

Explanation: Current pediatric Long COVID definitions do not require laboratory confirmation or positive antibody testing. A diagnosis can be made in individuals with a history of probable or confirmed SARS-CoV-2 infection who develop persistent symptoms that cannot be explained by another diagnosis.

Reference: World Health Organization. A Clinical Case Definition for Post COVID-19 Condition in Children and Adolescents by Expert Consensus. Geneva: World Health Organization; 2023.

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Pediatric Long COVID: What the Data Show — and What Families Tell Us -- Kyung (Kay) Rhee, M.D., MSc, MA & Kelan Tantisira, M.D., M.P.H.

Question 10: What are some of the defining symptoms and characteristics of Long COVID?

Choose one:
A.   Symptoms can persist for several months
B.   Symptoms can relapse and remit over time
C.   Symptoms can only occur after a severe SARS-CoV-2 infection
D.   Symptom clusters can vary across the age range
E.   All of the above
F.   A, B, and D

Correct answer: F. A, B, and D

Explanation: At this time, since there are no confirmatory laboratory tests, the WHO, CDC, and NICE have broadly defined Long COVID as having signs and symptoms, or conditions that develop, persist, or relapse over time after a SARS-CoV-2 infection. Some patients may not realize that they were infected with SARS-CoV-2 or had a very mild infection. However, the subsequent symptoms can last months or even years after the initial infection has resolved. Some of the most common symptoms included fatigue, muscle/joint pain, trouble with memory, headaches, skin rashes, GI complaints, and persistent cough, but can vary across the lifespan.

Reference: Gross RS, Thaweethai T, Kleinman LC, et al. Characterizing Long COVID in Children and Adolescents. JAMA. 2024;332(14):1174-1188.
https://www.who.int/europe/news-room/fact-sheets/item/post-covid-19-condition

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Wired to Adapt: Leveraging the Neurobiology of Youth Resilience -- Paven Lidstone, M.D., Ph.D.

Question 11: A 13-year-old girl is seen in clinic six months after surviving a serious motor vehicle accident. She reports occasional nightmares and anxiety when riding in cars but has returned to school, become closer with her family, and recently began volunteering with an organization that supports injured children. Which of the following statements best reflects the current understanding of post-traumatic stress disorder (PTSD) and post-traumatic growth (PTG)?

Choose one:
A.   The presence of PTSD symptoms excludes the possibility of post-traumatic growth.
B.   Post-traumatic growth occurs only after complete resolution of PTSD symptoms.
C.   PTSD and post-traumatic growth may coexist, with positive psychological changes developing despite ongoing distress.
D.   Individuals who experience post-traumatic growth are less likely to have experienced severe trauma.
E.   Post-traumatic growth indicates that the traumatic event had primarily beneficial effects.

Correct Answer: C. PTSD and post-traumatic growth may coexist, with positive psychological changes developing despite ongoing distress.

Explanation: Post-traumatic growth (PTG) refers to positive psychological changes that may emerge following highly challenging life experiences, including increased appreciation of life, stronger relationships, greater personal strength, and a renewed sense of purpose. Importantly, PTG is not mutually exclusive with PTSD. Individuals may continue to experience intrusive symptoms, avoidance, or hyperarousal while simultaneously reporting meaningful personal growth. Clinicians should avoid framing recovery as an either-or phenomenon and instead recognize that distress and growth can coexist throughout recovery.

Reference:
Richard Tedeschi, & Lawrence Calhoun. Posttraumatic Growth: Positive Changes in the Aftermath of Crisis. 1996.
Ann Masten. Ordinary Magic: Resilience in Development. Guilford Press; 2014.
Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, Text Revision (DSM-5-TR).

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Wired to Adapt: Leveraging the Neurobiology of Youth Resilience -- Paven Lidstone, M.D., Ph.D.

Question 12: A pediatrician is counseling the parents of a 9-year-old boy who recently experienced parental separation and significant school-related stress. The parents ask what single factor has the strongest evidence for promoting resilience following adversity. Based on current developmental neuroscience, which of the following is the BEST recommendation?

Choose one:
A.   Encourage the child to suppress discussion of stressful experiences to reduce emotional distress.
B.   Focus primarily on cognitive training exercises to improve executive functioning.
C.   Ensure the child develops a close, stable, and supportive relationship with at least one consistently caring adult.
D.   Minimize exposure to all future stressors whenever possible.
E.   Delay discussions about emotions until the child is older and better able to understand them.

Correct Answer: C. Ensure the child develops a close, stable, and supportive relationship with at least one consistently caring adult.

Explanation: The most consistently identified protective factor in resilience research is the presence of at least one stable, supportive, and responsive relationship with a caring adult. Such relationships buffer activation of the stress-response system, promote healthy neurodevelopment, strengthen emotional regulation, and foster adaptive coping. While cognitive skills, therapy, and environmental supports are important, the quality of supportive relationships remains the most robust predictor of positive developmental outcomes following adversity.

References: Ann Masten. Ordinary Magic: Resilience in Development. Guilford Press; 2014.
Jack P. Shonkoff, et al. The lifelong effects of early childhood adversity and toxic stress. Pediatrics. 2012;129(1):e232–e246.
Center on the Developing Child at Harvard University. From Best Practices to Breakthrough Impacts.

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National Breastfeeding Month: Strengthen What Works -- Michelle Leff, M.D., IBCLC, NABBLM-C, FAAP

Question 13: Who benefits from breastfeeding?

Choose one:
A.   Baby
B.   Mom
C.   Society
D.   All of the above

Correct Answer: D. All of the Above

Explanation: Benefits to baby include decreased infections. Benefits to mom include decreased rates of breast cancer. Benefits to society include fewer missed days of work and school.

References: Joan Younger Meek, Lawrence Noble; Technical Report: Breastfeeding and the Use of Human Milk. Pediatrics July 2022; 150 (1): e2022057989. 10.1542/peds.2022-057989
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National Breastfeeding Month: Strengthen What Works -- Michelle Leff, M.D., IBCLC, NABBLM-C, FAAP

Question 14: Which of the following statements about California law and breastfeeding support in birthing hospitals is correct?

Choose one:
A.   California law mandates that birthing hospitals provide breastfeeding support.
B.   California law recommends, but does not require, breastfeeding support in birthing hospitals.
C.   Only hospitals with Baby-Friendly designation are required to provide breastfeeding support.
D.   California law does not address breastfeeding support in birthing hospitals.

Correct Answer: A. California law mandates that birthing hospitals provide breastfeeding support.

Explanation: Effective January 1, 2025, California Health and Safety Code § 123367 requires general acute care hospitals that provide maternity services to implement the Baby-Friendly Hospital Initiative's Ten Steps to Successful Breastfeeding, or an equivalent evidence-based program. This requirement helps ensure breastfeeding support is available to birthing patients.

Reference: https://leginfo.legislature.ca.gov/faces/codes_displaySection.xhtml?lawCode=HSC§ionNum=123367
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Holding the Line: Defending Children’s Health Amid Policy, Workforce and Community Pressures -- Health Equity Grand Rounds

Question 15: General trust in medicine has done which of the following in the past 5 years.

Choose one:
A.   Increased
B.   Decreased
C.   Stayed the same

Correct answer: B. Decreased

Explanation: Studies show that general trust in medical providers and medicine has decreased especially in those between the ages of 18-25

Reference: Perlis RH, Ognyanova K, Uslu A, et al. Trust in Physicians and Hospitals During the COVID-19 Pandemic in a 50-State Survey of US Adults. JAMA Netw Open. 2024;7(7):e2424984. doi:10.1001/jamanetworkopen.2024.24984

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Holding the Line: Defending Children’s Health Amid Policy, Workforce and Community Pressures -- Health Equity Grand Rounds

Question 16: Which of the following is true regarding Vitamin K administration to infants at time of birth?

Choose one:
A.   The percentage of infants receiving vitamin K has increased in the past 10 years
B.   The percentage of infants receiving vitamin K has decreased in the past 10 years
C.   The percentage of infants receiving vitamin K has stayed the same in the past 10 years

Correct Answer: B. The percentage of infants receiving vitamin K has decreased in the past 10 years

Explanation: The percentage of newborns NOT receiving vitamin K at birth has nearly doubled since 2017

References: Scott K, Miller E, Culhane JF, Greenspan J, Handley SC, Lo JY, Knake LA, McKenney KM, Burris HH, Dysart K. Trends in Vitamin K Administration Among Infants. JAMA. 2026 Jan 20;335(3):272-274. doi: 10.1001/jama.2025.21460. Erratum in: JAMA. 2026 May 12;335(18):1640. doi: 10.1001/jama.2026.4634. PMID: 41359326; PMCID: PMC12687205.

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Tools for Frontline: Simple Ways Primary Care Pediatricians and Nursery Providers Can Catch Biliary Atresia (and Other Liver Diseases) Earlier -- Sonny Harpavat, M.D., Ph.D.

Question 17: What is the ideal age to identify and refer infants who may have biliary atresia?

Choose one:
A.   0-30 days of life
B.   31-60 days of life
C.   61-90 days of life
D.   91-120 days of life

Correct Answer: A. 0-30 days of life

Explanation: For infants with biliary atresia, earlier treatment with the Kasai portoenterostomy associates with the best chances of delaying or avoiding need for liver transplant. Conversely, treatment beyond 90 days of life is seldom helpful. One way to conceptualize this is by considering bile as toxic, which leads to more injury the longer it is retained in the liver.

References: Serinet et al. Pediatrics 2009 123:1280-6. PMID: 19403492

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Tools for Frontline: Simple Ways Primary Care Pediatricians and Nursery Providers Can Catch Biliary Atresia (and Other Liver Diseases) Earlier -- Sonny Harpavat, M.D., Ph.D.

Question 18: All infants with biliary atresia have:

Choose one:
A.   Jaundice
B.   Pale stools
C.   Elevated direct/conjugated bilirubin levels
D.   Elevated ALT levels

Correct Answer: C. Elevated direct/conjugated bilirubin levels

Explanation: All infants with biliary atresia have high direct/conjugated bilirubin levels, starting at birth. In contrast, in early stages of the disease, infants may not appear jaundiced. In addition, pale stools take time to develop, with only 82% of infants with biliary atresia having pale stools at 30 days of life. Similarly, ALT levels eventually rise in biliary atresia, but, in the first 30 days of life, ALT levels may be normal. Importantly, despite the lack of jaundice, normal stool color, and normal ALT, infants still have liver scarring as demonstrated by liver biopsies taken at early ages.

References: Harpavat et al. Pediatrics 2025 155:e2024070077. PMID: 39961332

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Tools for Frontline: Simple Ways Primary Care Pediatricians and Nursery Providers Can Catch Biliary Atresia (and Other Liver Diseases) Earlier -- Sonny Harpavat, M.D., Ph.D.

Question 19: What is the most important laboratory test identifying an infant who needs further testing for biliary atresia?

Choose one:
A.   GGT
B.   ALT
C.   Direct/conjugated bilirubin
D.   Total bilirubin

Correct Answer: C. Direct/conjugated bilirubin

Explanation: Primary care pediatricians do not need to order multiple tests to identify biliary atresia. This is because extra testing can be confusing and delay referrals. For example, in biliary atresia, GGT levels can vary from <200 IU to >800 IU, and ALT levels may be normal. Total bilirubin levels (and transcutaneous bilirubin measurements) do not provide any information relevant to liver disorders. Direct/conjugated bilirubin levels can be interpreted with the help of a pediatric hepatologist or with BiliScreen.org.

References: Fawaz et al. JPGN 2017 64:154-168. PMID: 27429428
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Tools for Frontline: Simple Ways Primary Care Pediatricians and Nursery Providers Can Catch Biliary Atresia (and Other Liver Diseases) Earlier -- Sonny Harpavat, M.D., Ph.D.

Question 20: Based on a recent American Academy of Pediatrics Clinical Report, PCPs should suspect biliary atresia in infants at the 2-4 week well-child visit based on which 3 findings:

Choose one:
A.   Spleen size, birthweight, prenatal history
B.   Eye color, stool color, first direct/conjugated bilirubin level
C.   Family history, phototherapy history, liver size
D.   Skin color, ultrasound results, hepatitis B immunization status

Correct Answer: B. Eye color, stool color, first direct/conjugated bilirubin level

Explanation: Primary care pediatricians at the 2-4 week well-child visit can use the following mnemonic, which rhymes when the last syllable is emphasized: “Step 1, step 2, step 3...Check Eyes, then Poop, then First Bili.” If any of these are concerning, they should check a direct/conjugated bilirubin level and interpret with BiliScreen.org. The other items are extraneous information, which can delay prompt referral. For example, the liver and spleen are usually of normal size, there is no association with family or prenatal history, and infants of all birthweights and gestational ages can be affected. Skin color can be difficult to assess, so the eyes are a more reliable place to assess jaundice. To avoid over-ordering tests, primary care providers do not need to order or interpret ultrasound exams before consulting pediatric GI/hepatology.

References: Harpavat et al. Pediatrics 2025 155:e2024070077. PMID: 39961332

Herbert Kimmons Summer Grand Rounds MOC Questionnaire