Fernando A. Ferrer, MD, FACS, FAAP, provides guidance for parents on managing their child’s pediatric urological care. He discusses the importance of monitoring urological conditions in children, and the team-based approach to patient care at Mount Sinai, which includes access to a broad range of specialists. He describes the breadth of resources for patients and their families, including social workers, child psychologists, and translation services. He also discusses the steps Mount Sinai is taking to ensure a safe environment for pediatric patients during COVID-19. My name is Fernando for our, um, pediatric urologists by training professor of pediatric urology at the Icahn School of Medicine. Um, at Mount Sana. Well, you know, the reality is, in pediatric urology, we there are a lot of conditions that we follow over a period of time. That period of time could be years. In some cases, that period of time can be a lifetime. And the serial observations important because things can change. Andi. Important milestones can be missed. Yeah, it's a particular concern. Now with cove, it because of the limitations in access and concern that people have that they play really close attention to their follow up appointments s so we can monitor their Children properly and as necessary intervene if appropriate. Yeah, it depends a little bit on the condition. Um, right. So kids that have conditions that potentially harm their kidneys, um, kids that have conditions that, um, potentially could evolve. Thio cancer states, um, Children that air getting, um, recurrent infections in the urinary tract. Um, Children under observation for obstruction or blockage in the urinary tract. These air, all conditions that really mandate that follow up, be consistent, and, um not interrupted. You know, the reality is my advice for parents is that give us a call and talk to us about their child's condition, and we can help them plan appropriate. Follow up the reality. The fact that matter is that we have really some extraordinary measures in place for patient safety in our in our outpatient clinics. We're not using our waiting rooms at all, for example, so when you come off the elevator, you're greeted, and essentially you're taken to the room where you'll be seen by the physician. All staff are wearing face masks for protection. We ask the patients and, um, their guardians do the same. Um, our hygiene standards are very, very strict at this point in time, so I think it's a safe place. Andi. I certainly think that the risk benefit is in the favor of coming in for your visit as opposed toe, leaving your child's condition. Unfollowed. Oh, there are a variety again. It's a little bit depending on the patient's condition, but I'll go through some of them with you, for for patients that have major reconstructive operations which we know could be stressful in taxing for the families we have a variety of services that we can provide to make the interface and experience better. Yeah, that stems all the way from experience Translator services for families that come from abroad. Thio qualified social workers, child psychologists Um, hospitalists, um that specialized in taking care of the broader medical problems a child might have outside through the neurologic condition for those Children that have unique conditions, we have some very close partnerships formed with our endocrinologist for Children that have endocrine logic disorders. Right to my mind comes a child whom I saw I thought needed endocrinology evaluation. I called the endocrinologist. They saw the family right away and literally within weeks that anthropologists and I met with the family. So all of the support services air here, Another very important support service for us is nephrology. And we have a very close relationship with that program. So whether you're being seen for kidney failure, kidney injury or kidney stones, we have collaborative programs for them. Um, that those patients that that essentially they get the benefit of both doctors, both points of view and a collaborative team management. Yeah, my my philosophy on pain control kids, is there shouldn't be pain s Oh, this is really a question that comes to mind most in the post surgical setting, right, And that really starts in the operating room. Our pediatric anesthesiologists are actually experts at all of the different strategies to reduce post operative pain in Children, whether that be specialized blocks or epidural catheters. As a matter of fact, I do a lot of academic work. I'm writing an article right now with one of our pediatric anesthesiologist about the best ways to manage pain in Children. In the postoperative phase, we transition from pediatric anesthesiologist to hospitalist team Andi. I see you doctors and the Pain Management team, which is a separate team that rounds specifically focused on managing the child's pain. Um, there are a variety of techniques that we use. They involve medications, some narcotics, some non narcotic. We try to avoid narcotics if we can. With Children are big issues anxiety. And quite frankly, we're fairly adept at managing anxiety. And kids are child life services. Um is an incredible arm of our enterprise. Uh, that's there to support families, whether it be distraction of the Children, entertaining the Children, understanding what the child's needs are. That team is also there to interface with the family, and they're very helpful in helping us sort out what's paying what's anxiety and which is the best way to go and managing it. So a couple of things, Um, my career focus has been mostly on major reconstructive surgery for conditions, um, like severe hyperspeed. Ius, um, bladder, extra fee, episcopate, ius coequal extra fee. Um, since I've been here these last couple of months, we've done several of the major reconstructions for these conditions, which is something that did not happen here at Mount Sinai before. Um, simply because we just the faculty was missing a person who did that kind of work with had great outcomes for the kids that we've treated Well, we've had some kids come from abroad for this is Well, um, the other other things. Um, obviously, I can I practice general pediatric urology, but Mount Sinai did not actually have a well developed, um, neural urology or voiding dysfunction program, including your dynamics for Children. These air studies that air used to understand abnormalities and how Children's bladders work. Andi, I'm happy to say that at this point in time We have been up and running program with our nurse practitioner, Aaron Miller, Um, where we can perform your dynamic studies on Children on DWI, can perform euro flow studies and really evaluate the entire spectrum of Children's avoiding disorders. That's something that wasn't present before, and we've gotten that up and running in the last couple of months here. And the last thing that I would mention is we've also started down the path of treating Children with disorders of sexual development. These air Children again with congenital anomalies that these anomalies result in abnormalities of development of their genitalia and technologic abnormalities. Montana has a phenomenal endocrinology department that has a long history of taking care of these patients. I I think I also bring some expertise in the surgical management of these patients when surgery is necessary. Um, of course, we do that, uh, adhering to the current standards of a multi disciplinary team that involves genetics, um, endocrinology, psychology, psychiatry and urologic surgery. Um, well, I think a couple of things are are important. Obviously it depends a little bit on the age of the child. We have to adapt our strategies. But first of all, I try to focus on looking at the child, talking to the child, that engaging the child and developing a report with them. I think that's really important. I also make it very clear right from the get go. We don't provide shots or do painful procedures in the office at all. That sets up a bad paradigm. Onda. We see this oftentimes with Children that have had bad experiences and offices before, and they come in and they're very afraid and very anxious. So we don't do any of that in the office at all. On Guy. Make it very clear to the Children we don't rush them or rush the exam. We are very, very cognizant of the fact that these are young human beings and and deserve the respect that adults do. We ask their permission to do examination on DWI, explain to them what we're going to do with the exam if we order any studies. We have a team of people, whether it's our medical assistance or our nurse practitioner or myself that sits down and explains what the test is gonna be like S O, that they understand that they're no surprises. Honesty is very, very important when I'm dealing with Children. Obviously these same things have a remarkable effect of putting the parents cities as well because in some ways, the parents are patients to, and they're anxious about bringing their child to the doctor. So knowing having appropriate expectations of what's gonna happen and how it's gonna happen, I think puts the whole family of these. Well, as we mentioned before, I practice general urology and do things like fix hernias and undescended testicles and varicose seals and so on and so forth. Um, as with with, ah, fair amount of experience at this point in time Ah, lot of people recognize me from my ability to complex reconstructions. Um, particularly general reconstructions for hyperspace odious episode radius, um, the management of patients with bladder extra fee, whether its initial closure or the subsequent operations or the management in between, um, patients with posterior urethral valves that have chronic kidney disease also something that I have a fair amount of experience with. I've also done a fair amount of work also in the genital urinary cancers in Children. On day. Finally, I would say, um, you know, if you look at my writing on our major textbooks have, um, different chapter categories. I also write the chapter on antenatal urologic abnormalities. I've had a big interest in, um, seeing mothers of with Children that air yet unborn, but have been identified of having neurologic abnormalities. And I've seen several really complicated cases here where we've brought, um, genomics And, um, you know, DNA sequencing to bear Teoh be able to arrive at the right diagnosis. The resource is that we have here in Sinai, um, for advanced medical care are really phenomenal, including the use of fetal emery image Children very, very carefully before they're born. Eso those, I would say, are things that if you talk to folks, they would say that I have particular expertise in. But of course, I I manage the broad spectrum of pediatric urologic conditions as well. That's a source of great pleasure, but more importantly, for my patients, it's a source of off a knowledge. For me, it's an ability to keep up to speed with whatever it is that is being entertained is the best pathway for my patients conditions. So, for example, every year there's an international meeting of the American Urologic Association the society of pediatric urology is the sort of governing body for all, um, all things pediatric urology and all academic things. Pediatric urology. And I'm actually the chairman of the meeting for this upcoming meeting. So I arrange pick the speakers and, um, select the forum for discussion for the entire multi day meeting, which is really probably the biggest meeting of its kind in the world on international meeting. But it's a unbelievable opportunity for me to meet and learn folks. I've also held positions in the urologic oncology, um uh, group in Thea Society of Pediatric Urology, which I was on past president of of that group. And I've also served on various N. I H study sections on DNA, National Kidney Foundation study sections, and I've also reviewed for the National Academy of Sciences. And I enjoy doing editorial work for various medical journals again. All of this, um I think really serves to make me a better doctor. Andi make it so when I interface with the patients, I I'm pretty familiar with everything that is available for their child's care, and I can speak to them off all of the different options, whether they're Onley present here or Onley president someplace overseas. I am usually aware of that. So it's been a wonderful thing for me. Is a practicing clinician to be participating in all these national organizations. I actually had a role in developing in my administrative capacity and developing the surgical protocols, Um, that that we use here in China and commenting on them. So at this point in time, I would say to you that the operating room maybe one of the safest places to be a reason being, um, all of our patients are screened for cove it about 48 to 72 hours prior to the procedure. So the patients that air coming through the door way know them to be very likely covert negative. That fact notwithstanding, all of the usual precautions air still in place, masking hand hygiene, social distancing, Um, all of those air still in place. So I think that the combination of adjusting our schedules eso that patients were not in contact with each other having separate waiting areas for families that are waiting to go to surgery where they can feel safe and that their socially distance and then a process whereby the Children are checked literally before they come in for surgery. I think provides for an environment that's very safe in the operating room is you know, the environment sterile. Um, and obviously the operating rooms, an environment where we have all of the latest air filtration devices. So from, uh, perspective of a place to be an operating rooms a very, very safe place to be, Um, in this time. Well, so I have to tell you something, I It's funny that you mentioned that because I've had several parents comment to me this week about the fact that I discussed this with them. You know, we take care of the child, but the child in the family or different or difficult to separate, and all of the precautions that you just mentioned are the cornerstones, uh, being safe in this time. I will tell you that I frequently have conversations with parents because sometimes when I walk in the room, they will take their mass down, and I stopped and I pause, and I say to them, You know, I really want you to be safe, and I really encourage you to keep your mask on at all. times. Even when I'm in the room, it's not rude. It's not in polite. I'm wearing a mask at all times, and I emphasize for them how important it is for them when they leave the building. Thio continue using the mass. Use the mask for their Children as appropriate. And also, I emphasize, for them the social distancing. Um, this is unfortunately, Cove in 19 seems to be far from over. It's not done with us yet, although we would like to be done with it. And I think that parents really need to adhere to these precautions, also encouraging the carrying A hand sanitizer with them so they can sanitize frequently when they're out in about. So I will tell you that I have done ah lot of telemedicine visits. Interestingly, we were getting going on a telemedicine project before Cove in 19 and I think that most parents described the experience is excellent. The interface on my chart is pretty seamless at this point in time. It functions very nicely for routine follow ups or even times when we're going to review X rays that have already been done. It's ah, wonderful venue. Some parents are also using it. If they're not sure if they need to see a pediatric urologist, they'll schedule a tele visit. And we'll use that time to do an initial visit to understand the nature of the problem and make a recommendation on follow up. Um, I think the parents were really appreciating that. I will also say that in some cases are postoperative visits. When is to look at a simple wound just to make sure it's healing properly? Look at the cosmetics of a wound. We're also doing those by telemedicine toe limit the amount of times that the families need to leave their home and come here particularly helpful for people that have multiple kids, as you can imagine, because childcare is that is a big problem today. So we have found that it has been a nen credibly powerful tool on the parents seem very happy with it. If if parents haven't tried it, I strongly recommend that they give it a try. You can call the pediatric urology office, and they will schedule an appointment with you whether you want it to be telemedicine or in person. Um, immediately. We have appointments. We've been working very, very hard to make sure that patients don't have to wait. So we are seeing patients within a week to two weeks of them calling, um, and requesting an appointment either by Tele or in person. We actually are also gonna be offering evening tele on some evenings. If that's easier for some parents. And we have always offered some Sunday morning appointments, We're gonna begin offering Saturday morning appointments to, uh so I think that these air always that families can get access to us on. We're trying to be as helpful as we can to families during this difficult time. Be safe. Listen to the to the recommendations. Um, a, you know, avoid crowds, comply with the mass requirements. Really? Keep up with your hand hygiene. I think if we all do that, it'll expedite our path, and then the other is we appreciate your trust. We're taking really significant measures to make sure this is a safe place for you to bring your child for care. Um, you know, I personally stand behind the measures being taken care of being applied in my office. I think that if you if you have a child that needs follow up don't shy away from it or or that needs to be seen. A new don't shy away from that. Contact us. Talk to us about it. I'm always happy to talk to patients on the phone myself, Um, toe help them work through their concerns.