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Netters pediatrics


The ultimate Netter
Collection is back!
Netter’s timeless work, now arranged
and informed by modern text and
radiologic imaging!
The long-awaited update of The Netter Collection of Medical
Illustrations, also known as the CIBA “green books,” is now
becoming a reality! Master artist-physician, Carlos Machado,
and other top medical illustrators have teamed-up with
medical experts to make the classic Netter “green books” a
reliable and effective current-day reference.
s Apply a visual approach—with the classic Netter art, updated
illustrations, and modern imaging-- to normal and abnormal body
function and the clinical presentation of the patient.
s Clearly see the connection between basic and clinical sciences
with an integrated overview of each body system.
s Get a quick understanding of complex topics through a concise
text-atlas format that provides a context bridge between general and
specialized medicine.


ORDER YOURS TODAY!

Learn more about the series at www.NetterReference.com/greenbooks

AS/MA
10-GCRJO-0300


Atlas of Human Anatomy, 5th Edition
W
!
E
N
N ITIO Professional Edition
ED

Frank H. Netter, MD

May 2010. 978-1-4377-0970-4.

The Netter Atlas is your authoritative guide to the human body–through versatile print
and online resources. The new 5th Edition features a stronger clinical focus than ever
before, including an online image bank of some of Netter’s classic anatomy and pathology
illustrations, diagnostic imaging examples, and videos from Netter’s 3-D Interactive Anatomy.

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mynetter.com

1-800-545-2522


Netter’s

Pediatrics

EDITORS

ASSOCIATE EDITORS

Fellow, Division of Pediatric Emergency
Medicine
The Children’s Hospital of Philadelphia
Instructor, Department of Pediatrics
The University of Pennsylvania School
of Medicine
Philadelphia, Pennsylvania

Fellow, Division of Pediatric Emergency
Medicine
The Children’s Hospital of Philadelphia
Instructor, Department of Pediatrics
The University of Pennsylvania School
of Medicine
Philadelphia, Pennsylvania

TODD A. FLORIN, MD

STEPHEN LUDWIG, MD

Senior Advisor for Medical Education
John H. and Hortense Cassell Jensen Endowed
Chair
The Children’s Hospital of Philadelphia
Professor of Pediatrics and Emergency Medicine
The University of Pennsylvania School
of Medicine
Philadelphia, Pennsylvania

PAUL L. ARONSON, MD

HEIDI C. WERNER, MD
Fellow, Division of Emergency Medicine
Children’s Hospital Boston
Instructor of Pediatrics
Harvard Medical School
Boston, Massachusetts

Illustrations by Frank H. Netter, MD
CONTRIBUTING ILLUSTRATORS

Carlos A. G. Machado, MD
John A. Craig, MD
James A. Perkins, MS, MFA
Tiffany S. DaVanzo, MA, CMI
Anita Impagliazzo, MA, CMI

ERRNVPHGLFRVRUJ

www.drmyothethan.blogspot.com


1600 John F. Kennedy Blvd.
Ste 1800
Philadelphia, PA 19103-2899

NETTER’S PEDIATRICS

ISBN: 978-1-4377-1155-4

Copyright © 2011 by Saunders, an imprint of Elsevier Inc.
No part of this publication may be reproduced or transmitted in any form or by any means, electronic
or mechanical, including photocopying, recording, or any information storage and retrieval system,
without permission in writing from the publisher. Details on how to seek permission, further
information about the Publisher’s permissions policies and our arrangements with organizations such as
the Copyright Clearance Center and the Copyright Licensing Agency, can be found at our website:
www.elsevier.com/permissions.
Permissions for Netter Art figures may be sought directly from Elsevier’s Health Science Licensing
Department in Philadelphia PA, USA: phone 1-800-523-1649, ext. 3276 or (215) 239-3276; or email
H.Licensing@elsevier.com.
This book and the individual contributions contained in it are protected under copyright by the
Publisher (other than as may be noted herein).

Notices
Knowledge and best practice in this field are constantly changing. As new research and experience
broaden our understanding, changes in research methods, professional practices, or medical
treatment may become necessary.
Practitioners and researchers must always rely on their own experience and knowledge in
evaluating and using any information, methods, compounds, or experiments described herein. In
using such information or methods they should be mindful of their own safety and the safety of
others, including parties for whom they have a professional responsibility.
With respect to any drug or pharmaceutical products identified, readers are advised to check the
most current information provided (i) on procedures featured or (ii) by the manufacturer of each
product to be administered, to verify the recommended dose or formula, the method and duration
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experience and knowledge of their patients, to make diagnoses, to determine dosages and the best
treatment for each individual patient, and to take all appropriate safety precautions.
To the fullest extent of the law, neither the Publisher nor the authors, contributors, or editors,
assume any liability for any injury and/or damage to persons or property as a matter of products
liability, negligence or otherwise, or from any use or operation of any methods, products,
instructions, or ideas contained in the material herein.
ISBN: 978-1-4377-1155-4

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Developmental Editor: Marybeth Thiel
Editorial Assistant: Chris Hazle-Cary
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About the Editors

Stephen Ludwig, MD, is Senior Advisor for Medical Education and Senior Attending Physician at The Children’s Hospital
of Philadelphia, Department of Pediatrics. He is the Chairman
of the Graduate Medical Education Committee and Designated
Institutional Official. Dr. Ludwig holds the John H. and
Hortense Cassell Jensen Endowed Chair. In addition, he is
a Professor of Pediatrics and Emergency Medicine at The
University of Pennsylvania School of Medicine.
Dr. Ludwig is a past president of the Academic Pediatric
Association (APA) and a member of the Board of Directors, as
well as a founding member of the Pediatric Emergency Medicine Special Interest Group. He is a member of the International Society of Child Abuse and Neglect. Dr. Ludwig is a
founding member of the Ray Helfer Society. Currently, he
serves as Chairman of the Residency Review Committee (RRC)
for Pediatrics of the Accreditation Council for Graduate Medical
Education (ACGME). He has been a member of the Board of
Directors of the American Board of Pediatrics and was Chair of
the Program Directors Committee until 2009. He has received
many awards from The University of Pennsylvania, Association
of Pediatric Program Directors (APPD), and APA. He was
elected to the Institute of Medicine in 1998. Recently, Dr.
Ludwig has been selected by the Board of Directors of the
Federation of Pediatric Organizations as the recipient of the
2010 Joseph W. St. Geme, Jr. Leadership Award.
Dr. Ludwig has over 150 publications to his credit and serves
on several editorial boards. He is Co-Editor in Chief of Pediatric
Emergency Care. He is the Editor of the Textbook of Pediatric
Emergency Medicine, now in its sixth edition.
Dr. Ludwig received his medical degree from Temple University School of Medicine and completed his pediatric internship and residency at the Children’s Hospital National Medical
Center in Washington, DC. He holds board certification in
General Pediatrics and certificate 001 in Pediatric Emergency
Medicine from the American Board of Pediatrics.
Todd A. Florin, MD, is currently a senior fellow in Pediatric
Emergency Medicine at The Children’s Hospital of Philadelphia. Dr. Florin graduated from the University of Rochester
with a bachelor of arts in music with a vocal performance
and conducting focus and received his medical degree from
the University of Rochester School of Medicine and Dentistry.

He was a resident in Pediatrics from 2005-2008 and Chief
Resident from 2008-2009 at The Children’s Hospital of Philadelphia. In addition to his fellowship training, he is currently
pursuing his masters of science in clinical epidemiology at
the Center for Clinical Epidemiology and Biostatistics at The
University of Pennsylvania School of Medicine. Dr. Florin is
the recipient of a Young Investigator Award from the Academic
Pediatric Association and a grant from the Loan Repayment
Program of the National Institutes of Health. After completing
fellowship, Dr. Florin intends to pursue an academic career
combining clinical pediatric emergency medicine, medical
education, and research in pediatric acute care epidemiology.
He continues to be an active singer and conductor and has
just completed his eighth summer season as a principal con�
ductor with the College Light Opera Company in Falmouth,
Massachusetts.
Paul L. Aronson, MD, received his bachelor of arts in
drama from Duke University and his medical degree from
New York University. He completed his residency and chief
residency in pediatrics at The Children’s Hospital of Philadelphia, at which he is currently a fellow in pediatric emergency
medicine. His main academic interest is in medical education
with a particular focus on evidence-based medicine. He is the
recipient of the senior resident and fellow teaching awards from
the residency program at The Children’s Hospital of Philadelphia. He lives in Philadelphia with his wonderful wife, Jenny (a
fifth grade teacher), and their two loving cats, Emma and Duke.
He would especially like to thank his parents for their support
and for teaching him that true success is measured by character
and a happy family.
Heidi C. Werner, MD, is currently a senior fellow in
Pediatric Emergency Medicine at The Children’s Hospital
Boston. Dr. Werner graduated from Princeton University with
a bachelor of arts in molecular biology and received her medical
degree from Columbia College of Physicians and Surgeons. She
was a resident in pediatrics from 2005-2008 and Chief Resident
from 2008-2009 at The Children’s Hospital of Philadelphia.
After fellowship training, Dr. Werner intends to pursue an academic career combining clinical pediatric emergency medicine,
medical education ,and research in pediatric bedside emergency
ultrasound.


vi  SECTION XV╇ •â•‡ Infectious Disease

About the Artists

Frank H. Netter, MD
Frank Netter was born in 1906, in New York City. He
studied art at the Art Student’s League and the National
Academy of Design before entering medical school at New
York University, where he received his MD degree in 1931.
During his student years, Dr. Netter’s notebook sketches
attracted the attention of the medical faculty and other physicians, allowing him to augment his income by illustrating
articles and textbooks. He continued illustrating as a sideline
after establishing a surgical practice in 1933, but he ultimately
opted to give up his practice in favor of a full-time commitment to art. After service in the United States Army during
World War II, Dr. Netter began his long collaboration
with the CIBA Pharmaceutical Company (now Novartis
Pharmaceuticals). This 45-year partnership resulted in the
production of the extraordinary collection of medical art
so familiar to physicians and other medical professionals
worldwide.
In 2005, Elsevier, Inc., purchased the Netter Collection and
all publications from Icon Learning Systems. There are now
over 50 publications featuring the art of Dr. Netter available
through Elsevier, Inc. (in the US: www.us.elsevierhealth.com/
Netter and outside the US: www.elsevierhealth.com).
Dr. Netter’s works are among the finest examples of the use
of illustration in the teaching of medical concepts. The 13-book
Netter Collection of Medical Illustrations, which includes the
greater part of the more than 20,000 paintings created by Dr.
Netter, became and remains one of the most famous medical
works ever published. The Netter Atlas of Human Anatomy, first
published in 1989, presents the anatomical paintings from the
Netter Collection. Now translated into 16 languages, it is the

anatomy atlas of choice among medical and health professions
students the world over.
The Netter illustrations are appreciated not only for their
aesthetic qualities, but, more important, for their intellectual
content. As Dr. Netter wrote in 1949, “… clarification of a
subject is the aim and goal of illustration. No matter how beautifully painted, how delicately and subtly rendered a subject may
be, it is of little value as a medical illustration if it does not serve
to make clear some medical point.” Dr. Netter’s planning, conception, point of view, and approach are what inform his paintings and what makes them so intellectually valuable.
Frank H. Netter, MD, physician and artist, died in 1991.
Learn more about the physician-artist whose work has inspired
the Netter Reference collection: http://www.netterimages.com/
artist/netter.htm.
Carlos A. G. Machado, MD
Carlos Machado was chosen by Novartis to be Dr. Netter’s successor. He continues to be the main artist who contributes to
the Netter collection of medical illustrations.
Self-taught in medical illustration, cardiologist Carlos
Machado has contributed meticulous updates to some of Dr.
Netter’s original plates and has created many paintings of his
own in the style of Netter as an extension of the Netter collection. Dr. Machado’s photorealistic expertise and his keen insight
into the physician/patient relationship informs his vivid and
unforgettable visual style. His dedication to researching each
topic and subject he paints places him among the premier
medical illustrators at work today.
Learn more about his background and see more of his art at:
http://www.netterimages.com/artist/machado.htm.


Preface

This book serves as a tribute to medical education and mentoring in all its forms. It spans a cycle of mentoring that began for
me more than 40 years ago. It underscores the value of the
mentoring process from that time to today.
More than 40 years ago, as a medical student, I relied on the
masterful work of Frank Netter. In every sense he seemed like
a helpful sage mentor. Learning from other standard textbooks
was certainly possible, but the Netter drawings took me by the
hand, opened my mind to anatomy, physiology, pathogenesis,
and clinical signs and symptoms in a very personal way. Gray’s
Anatomy Textbook had all the detail, but studying it felt almost
austere, untouchable. Frank Netter was warm and welcoming
the way any good mentor establishes a positive learning environment. Dr. Netter and those who followed him taught entire
generations of physicians through the 1960s, 1970s, and 1980s.
The old adage that a picture is worth a thousand words was
multiplied many times over by a Netter illustration. When
offered the opportunity to co-edit this book, which might help
to recirculate the Netter illustrations, it was my immediate reaction to sign on. Our hope was that these illustrations would be
available to touch the lives of the next generations of pediatric
trainees.
However, this volume had other mentoring dimensions as
well. First was the opportunity to work with three outstanding
chief residents, Todd Florin, MD, the co-editor, and Paul
Aronson, MD, and Heidi Werner, MD, the two associate
editors. Having worked with them over three years of pediatric
residency at The Children’s Hospital of Philadelphia and during
one additional year as chief residents, the choice to continue our
collaboration was a mentor’s dream. It was a chance to produce

something of enduring value as a team. Although all of our
careers have moved forward in new directions, this was a chance
to hold on to a certain chemistry we shared. This is the first
major textbook that will bear their names, but you will hear their
names often in the future, as I am certain they will be leaders
in pediatrics. This may be their first book, but I assure you it
will not be their last.
When formulating our concepts of the book, we decided to
make it a mentoring project in itself. All of the chapters were
written by more-junior faculty, fellows, and residents. Each was
supervised by a section editor who helped these young but talented authors get their chapters written, edited, and into print.
For some authors this represents their first major publication.
For many there were lessons learned along the way. For all
there was a chance to build a relationship with a more senior
section editor. To these section editors we owe a great debt of
gratitude.
With all the technologic advances in medicine and our deepening understanding of the basis of diseases and therapeutics,
we are all still benefiting from the time-worn traditions of medicine. Netter’s Pediatrics showed us the way. Senior faculty working
one on one with more-junior people. Mentoring — the apprenticeship model — still at the heart of our academic process.
Our hope is that this volume will aid you in the care of children. We hope these words and drawings will bring the subject
matter alive and help you derive as much practice knowledge
and pleasure from using Netter’s Pediatrics as we experienced in
bringing it to you.
Stephen Ludwig, MD
Philadelphia, 2011


viii  SECTION XV╇ •â•‡ Infectious Disease

Dedication

To my families—
The one at home and the one at work.
I am ever grateful to both.
SL
To
My patients, you are my greatest educators
My teachers, you are my inspiration
My parents, you are my foundation
My wife, Kemper, you are my rock
TAF
To my beautiful and very patient best friend and wife, Jenny.
You make me a better person, and everything I do is possible
because of your love and support.
To my family and family-in-law, I am truly grateful for your love
and generosity.
To my many teachers, mentors, and colleagues at The
Children’s Hospital of Philadelphia, from whom I have
learned so much.
To my patients, who have ultimately taught me everything I
know in pediatrics. It is a true privilege to be a pediatrician.
PLA
To my husband, my parents, and my children for their loving
support.
HCW


Acknowledgments

This is a book of “firsts.” The first time that Frank Netter’s drawings of pediatric illness have been brought together in a single
volume. The first time that many of the young residents and
fellows represented in this book have written a book chapter. For
Dr. Ludwig, the first time that he has collaborated on such a large
project with three of his chief residents. For Drs. Florin, Aronson,
and Werner, the first time they are editing a textbook. “Firsts” are
exciting—they create an atmosphere of adventure, passion, cautious anticipation. They also require significant effort and time,
often beyond the hours and days of the typical workweek. As a
result, many people not directly listed in the pages that follow had
a tremendous impact on the successful production of this book.
We would first like to thank all of the contributing authors
and section editors from The Children’s Hospital of Philadelphia and The University of Pennsylvania School of Medicine.
All of the first authors are residents and fellows at the early
stages of their pediatric careers whose passion, intellect, and
dedication shine through in the pages that follow. Without their
hard work, Netter’s Pediatrics could not exist. We would also like
to especially thank the faculty members at our institution that
served as section editors for this book. These physicians have
shown a clear and dedicated commitment to mentorship through
their contributions and hard work in guiding these young
authors through the process of writing this book.
Our patients and their parents provide continuous inspiration and motivation. We thank you all for the privilege to care
for you and your children and for being our most valued teachers. It is primarily our patients that motivate us to produce a
volume to teach the current and next generation of pediatric
health care providers.

Many of the beautiful images in this book were drawn by
Frank Netter. However, many images needed to be edited, and
some new images were drawn from scratch. We would like to
thank all of the artists that contributed to this book: Jim Perkins,
Tiffany DaVanzo, Anita Impagliazzo, and the DragonFly Media
Group. “A picture is worth a thousand words,” and these talented artists were incredible in their ability to bring concepts to
life through their beautiful artwork.
Special thanks go to our editorial team at Elsevier—Anne
Lenehan Woodcock, Elyse O’Grady, and especially Marybeth
Thiel—who were instrumental in guiding us through the production of this first edition of Netter’s Pediatrics. Their encouragement and guidance were critical in the process of writing and
editing the book.
Special recognition goes to Ms. Carolyn Trojan, whose
extraordinary organizational skills and commitment were vital
in producing a new multi-authored textbook.
Finally, we would like to extend our most emphatic thanks
to our families, without whom a project of this scope would not
be possible. Without their tremendous love and support, our
work would lack meaning. First, we would like to acknowledge
our spouses—Kemper Florin, Zella Ludwig, Jenny Shieh, and
Howard Horn—whose patience, encouragement, support, and
love make everything possible. Second, thanks to our children
and grandchildren—Susannah Ludwig and Mike Poppleton,
Elisa Ludwig and Jesse Pires, Aubrey Ludwig and Jared Ellman,
Jack Ellis Poppleton, and Archer and Ella Hornâ•›—â•›who challenge us and inspire us to remember the truly important things
in life. Finally, thanks to our parents who gave us the foundation
to become who we are today.


x  Editors

Editors

Todd A. Florin, MD
Fellow, Division of Pediatric Emergency Medicine
The Children’s Hospital of Philadelphia
Instructor, Department of Pediatrics
The University of Pennsylvania School of Medicine
Philadelphia, Pennsylvania
Stephen Ludwig, MD
Senior Advisor for Medical Education
John H. and Hortense Cassell Jensen Endowed Chair
The Children’s Hospital of Philadelphia
Professor of Pediatrics and Emergency Medicine
The University of Pennsylvania School of Medicine
Philadelphia, Pennsylvania
Paul L. Aronson, MD
Fellow, Division of Pediatric Emergency Medicine
The Children’s Hospital of Philadelphia
Instructor, Department of Pediatrics
The University of Pennsylvania School of Medicine
Philadelphia, Pennsylvania
Heidi C. Werner, MD
Fellow, Division of Emergency Medicine
Children’s Hospital Boston
Instructor of Pediatrics
Harvard Medical School
Boston, Massachusetts
Section Editors
Louis M. Bell, MD
Associate Chair for Clinical Activities
Department of Pediatrics
The Patrick S. Pasquariello, Jr, MD Endowed Chair in
Pediatrics
Chief, Division of General Pediatrics
The Children’s Hospital of Philadelphia
Professor of Pediatrics
The University of Pennsylvania School of Medicine
Philadelphia, Pennsylvania
Mercedes M. Blackstone, MD
Attending Physician
Division of Emergency Medicine
The Children’s Hospital of Philadelphia
Assistant Professor of Clinical Pediatrics
The University of Pennsylvania School of Medicine
Philadelphia, Pennsylvania

Terri Brown-Whitehorn, MD
Attending Physician
Division of Allergy and Immunology
The Children’s Hospital of Philadelphia
Assistant Professor of Clinical Pediatrics
The University of Pennsylvania School of Medicine
Philadelphia, Pennsylvania
James M. Callahan, MD
Director, Medical Education
Division of Emergency Medicine
The Children’s Hospital of Philadelphia
Associate Professor of Clinical Pediatrics
The University of Pennsylvania School of Medicine
Philadelphia, Pennsylvania
Matthew A. Deardorff, MD, PhD
Attending Physician
The Children’s Hospital of Philadelphia
Assistant Professor of Pediatrics
The University of Pennsylvania School of Medicine
Philadelphia, Pennsylvania
Richard S. Finkel, MD
Director, Neuromuscular Program
Division of Neurology
The Children’s Hospital of Philadelphia
Clinical Professor in Neurology and Pediatrics
The University of Pennsylvania School of Medicine
Philadelphia, Pennsylvania
Joshua R. Friedman, MD, PhD
Attending Physician
Division of Gastroenterology, Hepatology, and Nutrition
The Children’s Hospital of Philadelphia
Assistant Professor of Pediatrics
The University of Pennsylvania School of Medicine
Philadelphia, Pennsylvania
Rose C. Graham, MD, MSCE
Attending Physician
Mission Children’s Specialists
Pediatric Gastroenterology
Asheville, North Carolina
Fred Henretig, MD
Attending Physician
Division of Pediatric Emergency Medicine
The Children’s Hospital of Philadelphia
Professor of Pediatrics
The University of Pennsylvania School of Medicine
Philadelphia, Pennsylvania


Editors  xi

Leslie S. Kersun, MD
Attending Physician
Division of Oncology
The Children’s Hospital of Philadelphia
Assistant Professor of Clinical Pediatrics
The University of Pennsylvania School of Medicine
Philadelphia, Pennsylvania

Howard B. Panitch, MD
Director of Clinical Programs
Division of Pulmonary Medicine
The Children’s Hospital of Philadelphia
Professor of Pediatrics
The University of Pennsylvania School of Medicine
Philadelphia, Pennsylvania

Jason Y. Kim, MD, MSCE
Attending Physician
Division of Infectious Diseases
The Children’s Hospital of Philadelphia
Assistant Professor of Clinical Pediatrics
The University of Pennsylvania School of Medicine
Philadelphia, Pennsylvania

Beth Rezet, MD
Attending Physician
Division of General Pediatrics
The Children’s Hospital of Philadelphia
Clinical Associate Professor of Pediatrics
The University of Pennsylvania School of Medicine
Philadelphia, Pennsylvania

Sara B. Kinsman, MD, PhD
Attending Physician
Division of Adolescent Medicine
The Children’s Hospital of Philadelphia
Assistant Professor of Clinical Pediatrics
The University of Pennsylvania School of Medicine
Philadelphia, Pennsylvania

James R. Treat, MD
Attending Physician, Dermatology
Division of General Pediatrics
The Children’s Hospital of Philadelphia
Assistant Professor of Clinical Pediatrics
The University of Pennsylvania School of Medicine
Philadelphia, Pennsylvania

Michael A. Levine, MD, FAAP, FACP
Division Chief
Division of Endocrinology and Diabetes
The Children’s Hospital of Philadelphia
Professor of Pediatrics
The University of Pennsylvania School of Medicine
Philadelphia, Pennsylvania

Paul M. Weinberg, MD
Senior Cardiologist
Director, Fellowship Training Program in Pediatric
Cardiology
The Children’s Hospital of Philadelphia
Professor of Pediatrics and Pediatric Pathology and
Laboratory Medicine
The University of Pennsylvania School of Medicine
Philadelphia, Pennsylvania

Christina L. Master, MD
Associate Pediatric Residency Program Director
The Children’s Hospital of Philadelphia
Associate Professor of Clinical Pediatrics
The University of Pennsylvania School of Medicine
Philadelphia, Pennsylvania
Kevin E. C. Meyers, MB BCh
Attending Physician
Division of Nephrology
The Children’s Hospital of Philadelphia
Associate Professor of Pediatrics
The University of Pennsylvania School of Medicine
Philadelphia, Pennsylvania
David A. Munson, MD
Attending Physician
Division of Neonatology
The Children’s Hospital of Philadelphia
Assistant Professor of Clinical Pediatrics
The University of Pennsylvania School of Medicine
Philadelphia, Pennsylvania

Pamela F. Weiss, MD, MSCE
Attending Physician
Division of Rheumatology
The Children’s Hospital of Philadelphia
Assistant Professor of Clinical Pediatrics
The University of Pennsylvania School of Medicine
Philadelphia, Pennsylvania
Char M. Witmer, MD
Attending Physician
Division of Hematology
The Children’s Hospital of Philadelphia
Assistant Professor of Pediatrics
The University of Pennsylvania School of Medicine
Philadelphia, Pennsylvania


xii  Contributors

Contributors

Saba Ahmad, MD
Fellow, Division of Neurology
The Children’s Hospital of Philadelphia
Philadelphia, Pennsylvania

Ulf H. Beier, MD
Fellow, Division of Nephrology
The Children’s Hospital of Philadelphia
Philadelphia, Pennsylvania

Craig A. Alter, MD
Attending Physician
Division of Endocrinology
The Children’s Hospital of Philadelphia
Associate Professor of Pediatrics
The University of Pennsylvania School of Medicine
Philadelphia, Pennsylvania

Lauren A. Beslow, MD
Fellow, Division of Neurology
The Children’s Hospital of Philadelphia
Philadelphia, Pennsylvania

Brett R. Anderson, MD, MBA
Pediatric Resident
Department of Pediatrics
The Children’s Hospital of Philadelphia
Philadelphia, Pennsylvania
Marsha Ayzen, MD
Pediatric Resident
Department of Pediatrics
The Children’s Hospital of Philadelphia
Philadelphia, Pennsylvania
Rochelle Bagatell, MD
Attending Physician
Division of Oncology
The Children’s Hospital of Philadelphia
Associate Professor of Pediatrics
The University of Pennsylvania School of Medicine
Philadelphia, Pennsylvania
H. Jorge Baluarte, MD
Medical Director, Renal Transplant Program
Division of Nephrology
The Children’s Hospital of Philadelphia
Professor of Pediatrics
The University of Pennsylvania School of Medicine
Philadelphia, Pennsylvania
Vaneeta Bamba, MD
Attending Physician
Division of Endocrinology
The Children’s Hospital of Philadelphia
Assistant Professor of Clinical Pediatrics
The University of Pennsylvania School of Medicine
Philadelphia, Pennsylvania
David R. Bearden, MD
Child Neurology Fellow, Division of Neurology
The Children’s Hospital of Philadelphia
Philadelphia, Pennsylvania

Shazia Bhat, MD
Pediatric Resident
Department of Pediatrics
The Children’s Hospital of Philadelphia
Philadelphia, Pennsylvania
Christopher P. Bonafide, MD
Fellow, Division of General Pediatrics
The Children’s Hospital of Philadelphia
Philadelphia, Pennsylvania
Jill L. Brodsky, MD
Fellow, Division of Endocrinology and Diabetes
The Children’s Hospital of Philadelphia
Philadelphia, Pennsylvania
Naomi Brown, MD
Pediatric Resident
Department of Pediatrics
The Children’s Hospital of Philadelphia
Philadelphia, Pennsylvania
Jason B. Caboot, MD
Fellow, Division of Pulmonary Medicine
The Children’s Hospital of Philadelphia
Philadelphia, Pennsylvania
Andrew C. Calabria, MD
Fellow, Division of Endocrinology & Diabetes
The Children’s Hospital of Philadelphia
Philadelphia, Pennsylvania
Leslie Castelo-Soccio, MD, PhD
Fellow, Dermatology
Division of General Pediatrics
The Children’s Hospital of Philadelphia
Philadelphia, Pennsylvania
Ann Chahroudi, MD, PhD
Division of Infectious Diseases
Department of Pediatrics
Emory University School of Medicine
Atlanta, Georgia


Contributors  xiii

David Chao, MD
Fellow, Pediatric Emergency Medicine
The Children’s Hospital of Philadelphia
Philadelphia, Pennsylvania
Kathryn Chatfield, MD, PhD
Fellow, Division of Genetics
The Children’s Hospital of Philadelphia
Philadelphia, Pennsylvania
Lori A. Christ, MD
Pediatric Resident
Department of Pediatrics
The Children’s Hospital of Philadelphia
Philadelphia, Pennsylvania
Andrew Chu, MD
Fellow, Division of Gastroenterology, Hepatology, and
Nutrition
The Children’s Hospital of Philadelphia
Philadelphia, Pennsylvania
R. Thomas Collins II, MD
Fellow, Division of Cardiology
The Children’s Hospital of Philadelphia
Philadelphia, Pennsylvania
Lawrence Copelovitch, MD
Attending Physician
Division of Nephrology
The Children’s Hospital of Philadelphia
Assistant Professor of Clinical Pediatrics
The University of Pennsylvania School of Medicine
Philadelphia, Pennsylvania
Jennifer A. Danzig, MD
Fellow, Division of Endocrinology
The Children’s Hospital of Philadelphia
Philadelphia, Pennsylvania
Carrie Daymont, MD
Fellow, Division of General Pediatrics
The Children’s Hospital of Philadelphia
Philadelphia, Pennsylvania
Diva D. DeLeón, MD
Attending Physician
Division of Endocrinology and Diabetes
The Children’s Hospital of Philadelphia
Assistant Professor of Pediatrics
The University of Pennsylvania School of Medicine
Philadelphia, Pennsylvania
Michelle Denburg, MD
Fellow, Division of Nephrology
The Children’s Hospital of Philadelphia
Philadelphia, Pennsylvania

Melissa Desai, MD, MPH
Pediatric Resident
Department of Pediatrics
The Children’s Hospital of Philadelphia
Instructor in Pediatrics
The University of Pennsylvania School of Medicine
Philadelphia, Pennsylvania
Erin Pete Devon, MD
Pediatric Resident
Department of Pediatrics
The Children’s Hospital of Philadelphia
Philadelphia, Pennsylvania
Aaron Donoghue, MD, MSCE
Attending Physician
Divisions of Emergency Medicine and Critical Care
Assistant Professor of Pediatrics
The Children’s Hospital of Philadelphia
The University of Pennsylvania School of Medicine
Philadelphia, Pennsylvania
Nicholas Evageliou, MD
Attending Physician
Division of Hematology and Oncology
The Children’s Hospital of Philadelphia
Assistant Professor of Clinical Pediatrics
The University of Pennsylvania School of Medicine
Philadelphia, Pennsylvania
Mirna M. Farah, MD
Attending Physician
Division of Pediatric Emergency Medicine
The Children’s Hospital of Philadelphia
Associate Professor of Clinical Pediatrics
The University of Pennsylvania School of Medicine
Philadelphia, Pennsylvania
Kristen A. Feemster, MD, MPH, MSHP
Fellow, Division of Infectious Diseases
The Children’s Hospital of Philadelphia
Philadelphia, Pennsylvania
James Aaron Feinstein, MD
Pediatric Resident
Department of Pediatrics
The Children’s Hospital of Philadelphia
Philadelphia, Pennsylvania
Amy Feldman, MD
Chief Pediatric Resident
Department of Pediatrics
The Children’s Hospital of Philadelphia
Philadelphia, Pennsylvania
Ryan J. Felling, MD, PhD
Pediatric Neurology Resident
The Johns Hopkins Hospital
Baltimore, Maryland


xiv  Contributors

John J. Flibotte, MD
Pediatric Resident
Department of Pediatrics
The Children’s Hospital of Philadelphia
Philadelphia, Pennsylvania
Stephen G. Flynn, MD
Pediatric Resident
Department of Pediatrics
The Children’s Hospital of Philadelphia
Instructor in Pediatrics
The University of Pennsylvania School of Medicine
Philadelphia, Pennsylvania
Elizabeth E. Foglia, MD
Attending Physician
Division of General Pediatrics
The Children’s Hospital of Philadelphia
Philadelphia, Pennsylvania
Lisa Forbes, MD
Fellow, Division of Allergy and Immunology
The Children’s Hospital of Philadelphia
Philadelphia, Pennsylvania
Jackie P. D. Garrett, MD
Pediatric Resident
Department of Pediatrics
The Children’s Hospital of Philadelphia
Philadelphia, Pennsylvania
Laura Gober, MD
Fellow, Division of Allergy and Immunology
The Children’s Hospital of Philadelphia
Philadelphia, Pennsylvania
Michael D. Gober, MD, PhD
Resident Physician, Department of Dermatology
Hospital of The University of Pennsylvania
Philadelphia, Pennsylvania
Kelly C. Goldsmith, MD
Aflac Cancer Center and Blood Disorders Service
Children’s Healthcare of Atlanta
Assistant Professor
Emory University
Atlanta, Georgia
Monika Goyal, MD
Fellow, Division of Emergency Medicine
The Children’s Hospital of Philadelphia
Instructor, Department of Pediatrics
The University of Pennsylvania School of Medicine
Philadelphia, Pennsylvania
Abby Green, MD
Pediatric Resident
Department of Pediatrics
The Children’s Hospital of Philadelphia
Philadelphia, Pennsylvania

Adda Grimberg, MD
Scientific Director, Diagnostic and Research Growth Center
Division of Endocrinology and Diabetes
The Children’s Hospital of Philadelphia
Associate Professor of Pediatrics
The University of Pennsylvania School of Medicine
Philadelphia, Pennsylvania
Chad R. Haldeman-Englert, MD
Assistant Professor
Department of Pediatrics, Section of Medical Genetics
Wake Forest University School of Medicine
Winston-Salem, North Carolina
E. Kevin Hall, MD
Fellow, Heart Failure and Transplantation
Children’s Hospital Boston
Boston, Massachusetts
Fiona Healy, MD
Pulmonary Fellow, Division of Pulmonary Medicine
The Children’s Hospital of Philadelphia
Philadelphia, Pennsylvania
Jessica L. Hills, MD
Attending Physician
Division of General Pediatrics
The Children’s Hospital of Philadelphia
Clinical Assistant Professor of Pediatrics
The University of Pennsylvania School of Medicine
Philadelphia, Pennsylvania
Melissa A. Hofmann, MD
Pediatric Resident
Department of Pediatrics
The Children’s Hospital of Philadelphia
Philadelphia, Pennsylvania
Daniel B. Horton, MD
Pediatric Resident
Department of Pediatrics
The Children’s Hospital of Philadelphia
Philadelphia, Pennsylvania
Anna Hunter, MD
Fellow, Division of Gastroenterology, Hepatology, and
Nutrition
The Children’s Hospital of Philadelphia
Philadelphia, Pennsylvania
Elif E. Ince, MD
Fellow, Division of Neonatology
The Children’s Hospital of Philadelphia
Philadelphia, Pennsylvania
Reena Jethva, MD, MBA
Attending Physician
St. Christopher’s Hospital for Children
Assistant Professor
Drexel University College School of Medicine
Philadelphia, Pennsylvania


Contributors  xv

Anitha S. John, MD, PhD
Fellow, Adult Congenital Heart Disease
The Mayo Clinic
Rochester, Minnesota
Amanda Jones, MD
Pediatric Resident
Department of Pediatrics
The Children’s Hospital of Philadelphia
Philadelphia, Pennsylvania
Eden Kahle, MD
Pediatric Resident
Department of Pediatrics
The Children’s Hospital of Philadelphia
Instructor of Pediatrics
The University of Pennsylvania School of Medicine
Philadelphia, Pennsylvania
Jennifer M. Kalish, MD, PhD
Fellow, Division of Human Genetics
The Children’s Hospital of Philadelphia
Philadelphia, Pennsylvania
Melissa Kennedy, MD
Fellow, Division of Gastroenterology, Hepatology, and
Nutrition
The Children’s Hospital of Philadelphia
Philadelphia, Pennsylvania
Soorena Khojasteh, MD
Pediatric Resident
Department of Pediatrics
The Children’s Hospital of Philadelphia
Instructor of Pediatrics
The University of Pennsylvania School of Medicine
Philadelphia, Pennsylvania
Roy J. Kim, MD, MPH
Assistant Professor of Pediatrics
Department of Pediatrics
Division of Endocrinology
University of Texas Southwestern Medical Center
Dallas, Texas
Dorit Koren, MD
Attending Physician
Division of Endocrinology and Diabetes
The Children’s Hospital of Philadelphia
Clinical Associate
The University of Pennsylvania School of Medicine
Philadelphia, Pennsylvania
Matthew P. Kronman, MD
Divisions of Infectious Diseases and General Pediatrics
The Children’s Hospital of Philadelphia
Departments of Pediatrics and Epidemiology
The University of Pennsylvania School of Medicine
Philadelphia, Pennsylvania

David R. Langdon, MD
Clinical Director, Division of Endocrinology and Diabetes
The Children’s Hospital of Philadelphia
Clinical Associate Professor of Pediatrics
The University of Pennsylvania School of Medicine
Philadelphia, Pennsylvania
Christopher LaRosa, MD
Fellow, Division of Nephrology
The Children’s Hospital of Philadelphia
Philadelphia, Pennsylvania
Javier J. Lasa, MD
Fellow, Division of Cardiology
The Children’s Hospital of Philadelphia
Philadelphia, Pennsylvania
Lara Wine Lee, MD, PhD
Pediatric Resident
Department of Pediatrics
The Children’s Hospital of Philadelphia
Philadelphia, Pennsylvania
Melissa Leyva-Vega, MD
Fellow, Division of Gastroenterology, Hepatology, and
Nutrition
The Children’s Hospital of Philadelphia
Philadelphia, Pennsylvania
Scott M. Lieberman, MD, PhD
Fellow, Division of Rheumatology
The Children’s Hospital of Philadelphia
Philadelphia, Pennsylvania
Jessica Sparks Lilley, MD
Fellow, Pediatric Endocrinology
Vanderbilt University School of Medicine
Nashville, Tennessee
Julie M. Linton, MD
Pediatric Resident
Department of Pediatrics
The Children’s Hospital of Philadelphia
Philadelphia, Pennsylvania
Elizabeth Lowenthal, MD
Fellow, Division of General Pediatrics
The Children’s Hospital of Philadelphia
Philadelphia, Pennsylvania
Sheela N. Magge, MD, MSCE
Attending Physician
Division of Endocrinology and Diabetes
The Children’s Hospital of Philadelphia
Assistant Professor of Pediatrics
The University of Pennsylvania School of Medine
Philadelphia, Pennsylvania
Jennifer Mangino, MD
Fellow, Divisions of Hematology and Oncology
The Children’s Hospital of Philadelphia
Philadelphia, Pennsylvania


xvi  Contributors

Olivera Marsenic, MD
Pediatric Nephrologist
Assistant Professor of Pediatrics
Oklahoma University Health Sciences Center
Oklahoma City, Oklahoma
Pamela A. Mazzeo, MD
Pediatric Resident
Department of Pediatrics
The Children’s Hospital of Philadelphia
Instructor of Pediatrics
The University of Pennsylvania School of Medicine
Philadelphia, Pennsylvania
Jennifer L. McGuire, MD
Fellow, Division of Neurology
The Children’s Hospital of Philadelphia
Philadelphia, Pennsylvania
Paul McNally, MB, MRCPI
Consultant Respiratory Physician
Our Lady’s Children’s Hospital, Crumlin
Dublin, Ireland
Jane E. Minturn, MD, PhD
Attending Physician
Division of Oncology
The Children’s Hospital of Philadelphia
Assistant Professor of Pediatrics
The University of Pennsylvania School of Medicine
Philadelphia, Pennsylvania
Manoj K. Mittal, MD, MRCP (UK), FAAP
Attending Physician
Division of Emergency Medicine
Assistant Professor of Clinical Pediatrics
The University of Pennsylvania School of Medicine
Philadelphia, Pennsylvania
Melissa Mondello, MD
Pediatric Resident
Department of Pediatrics
The Children’s Hospital of Philadelphia
Philadelphia, Pennsylvania
Kathryn M. Murphy, RN, PhD
Associate Director, Diabetes Center for Children
Division of Endocrinology and Diabetes
The Children’s Hospital of Philadelphia
Philadelphia, Pennsylvania
Sage Myers, MD
Fellow, Division of Pediatric Emergency Medicine
The Children’s Hospital of Philadelphia
Philadelphia, Pennsylvania
Frances Nadel, MD, MSCE
Attending Physician
Division of Pediatric Emergency Medicine
The Children’s Hospital of Philadelphia
Associate Professor of Clinical Pediatrics
The University of Pennsylvania School of Medicine
Philadelphia, Pennsylvania

Kyle Nelson, MD, MPH
Attending Physician
Division of Pediatric Emergency Medicine
The Children’s Hospital of Philadelphia
Assistant Professor of Pediatrics
The University of Pennsylvania School of Medicine
Philadelphia, Pennsylvania
Gustavo Nino, MD
Fellow, Division of Pulmonary Medicine
The Children’s Hospital of Philadelphia
Philadelphia, Pennsylvania
Bettina Mucha-Le Ny, MD
Fellow, Division of Human Genetics
The Children’s Hospital of Philadelphia
Philadelphia, Pennsylvania
Michael L. O’Byrne, MD
Pediatric Resident
Department of Pediatrics
The Children’s Hospital of Philadelphia
Philadelphia, Pennsylvania
Vikash S. Oza, MD
Pediatric Resident
Department of Pediatrics
The Children’s Hospital of Philadelphia
Philadelphia, Pennsylvania
Andrew A. Palladino, MD
Attending Physician
Division of Endocrinology and Diabetes
The Children’s Hospital of Philadelphia
Assistant Professor of Pediatrics
The University of Pennsylvania School of Medicine
Philadelphia, Pennsylvania
Shefali Parikh, MD
Fellow, Division of Hematology and Oncology
The Children’s Hospital of Philadelphia
Philadelphia, Pennsylvania
Tara Petersen, MD
Chief Pediatric Resident
Department of Pediatrics
The Children’s Hospital of Philadelphia
Philadelphia, Pennsylvania
Amy L. Peterson, MD
Fellow, Division of Cardiology
The Children’s Hospital of Philadelphia
Philadelphia, Pennsylvania
Connie M. Piccone, MD
Fellow, Division of Hematology and Oncology
The Children’s Hospital of Philadelphia
Philadelphia, Pennsylvania


Contributors  xvii

Sara E. Pinney, MD
Attending Physician
Division of Endocrinology
The Children’s Hospital of Philadelphia
Assistant Professor of Pediatrics
The University of Pennsylvania School of Medicine
Philadelphia, Pennsylvania

Esther Maria Sampayo, MD, MPH
Attending Physician
Division of Pediatric Emergency Medicine
The Children’s Hospital of Philadelphia
Assistant Professor of Pediatrics
The University of Pennsylvania School of Medicine
Philadelphia, Pennsylvania

Jill Posner, MD, MSCE
Attending Physician Pediatric Emergency Medicine
The Children’s Hospital of Philadelphia
Associate Professor of Clinical Pediatrics
The University of Pennsylvania School of Medicine
Philadelphia, Pennsylvania

Matthew G. Sampson, MD
Fellow, Division of Nephrology
The Children’s Hospital of Philadelphia
Clinical Instructor in Pediatrics
The University of Pennsylvania School of Medicine
Philadelphia, Pennsylvania

Kari R. Posner, MD
Fellow, Pediatric Emergency Medicine
The Children’s Hospital of Philadelphia
Philadelphia, Pennsylvania

Alisa B. Schiffman, DO
Fellow, Division of Endocrinology and Diabetes
The Children’s Hospital of Philadelphia
Philadelphia, Pennsylvania

Madhura Pradhan, MD
Attending Physician
Division of Nephrology
The Children’s Hospital of Philadelphia
Assistant Professor of Clinical Pediatrics
The University of Pennsylvania School of Medicine
Philadelphia, Pennsylvania

Dana Aronson Schinasi, MD
Fellow, Division of Pediatric Emergency Medicine
The Children’s Hospital of Philadelphia
Philadelphia, Pennsylvania

Ryan M. Raffaelli, MD
Fellow, Division of Nephrology
The Children’s Hospital of Philadelphia
Philadelphia, Pennsylvania
Homaira Rahimi, MD
Fellow, Division of Rheumatology
The Children’s Hospital of Philadelphia
Philadelphia, Pennsylvania
Kristin N. Ray, MD
Pediatric Resident
Department of Pediatrics
The Children’s Hospital of Philadelphia
Philadelphia, Pennsylvania
Susan R. Rheingold, MD
Attending Physician
Division of Oncology
The Children’s Hospital of Philadelphia
Assistant Professor of Pediatrics
The University of Pennsylvania School of Medicine
Philadelphia, Pennsylvania
Nicole Ryan, MD
Fellow, Division of Neurology
The Children’s Hospital of Philadelphia
Philadelphia, Pennsylvania
Benjamin A. Sahn, MD, MS
Pediatric Resident
Department of Pediatrics
The Children’s Hospital of Philadelphia
Philadelphia, Pennsylvania

Sandra Schwab, MD
Attending Physician
Division of Pediatric Emergency Medicine
The Children’s Hospital of Philadelphia
Assistant Professor of Clinical Pediatrics
The University of Pennsylvaina School of Medicine
Philadelphia, Pennsylvania
Halden F. Scott, MD
Fellow, Division of Pediatric Emergency Medicine
The Children’s Hospital of Philadelphia
Instructor in Pediatrics
The University of Pennsylvania School of Medicine
Philadelphia, Pennsylvania
Jeffrey A. Seiden, MD
Attending Physician
Division of Pediatric Emergency Medicine
The Children’s Hospital of Philadelphia
Assistant Professor of Clinical Pediatrics
The University of Pennsylvania School of Medicine
Philadelphia, Pennsylvania
Dana Sepe, MD
Fellow, Division of Oncology
The Children’s Hospital of Philadelphia
Philadelphia, Pennsylvania
Nilika B. Shah, MD
Pediatric Resident
Department of Pediatrics
The Children’s Hospital of Philadelphia
Philadelphia, Pennsylvania


xviii  Contributors

Rachana Shah, MD
Fellow, Division of Endocrinology and Diabetes
The Children’s Hospital of Philadelphia
Instructor of Pediatrics
The University of Pennsylvania School of Medicine
Philadelphia, Pennsylvania
Samir S. Shah, MD, MSCE
Attending Physician
Divisions of Infectious Diseases and General Pediatrics
The Children’s Hospital of Philadelphia
Assistant Professor of Pediatrics
The University of Pennsylvania School of Medicine
Philadelphia, Pennsylvania
Eric D. Shelov, MD
Pediatric Hospitalist
Division of General Pediatrics
The Children’s Hospital of Philadelphia
Clinical Associate
The University of Pennsylvania School of Medicine
Philadelphia, Pennsylvania
Angela J. Sievert, MD, MPH
Fellow, Division of Hematology and Oncology
The Children’s Hospital of Philadelphia
Instructor in Pediatrics
The University of Pennsylvania School of Medicine
Philadelphia, Pennsylvania
Sanjeev K. Swami, MD
Fellow, Division of Infectious Diseases
The Children’s Hospital of Philadelphia
Philadelphia, Pennsylvania
Christina Lynch Szperka, MD
Fellow, Division of Neurology
The Children’s Hospital of Philadelphia
Philadelphia, Pennsylvania
Kathryn S. Taub, MD
Fellow, Division of Neurology
The Children’s Hospital of Philadelphia
Philadelphia, Pennsylvania
Alexis Teplick, MD
Fellow, Division of Hematology and Oncology
The Children’s Hospital of Philadelphia
Philadelphia, Pennsylvania
Deepika Thacker, MD
Fellow, Division of Cardiology
The Children’s Hospital of Philadelphia
Philadelphia, Pennsylvania
Oana Tomescu, MD, PhD
Attending Physician
Craig Dalsimer Division of Adolescent Medicine
The Children’s Hospital of Philadelphia
Philadelphia, Pennsylvania

Howard Topol, MD
Pediatrics Resident
Department of Pediatrics
The Children’s Hospital of Philadelphia
Philadelphia, Pennsylvania
Shamir Tuchman, MD, MPH
Attending Physician
Division of Nephrology
The Children’s Hospital of Philadelphia
Philadelphia, Pennsylvania
Levon H. Utidjian, MD
Pediatric Resident
Department of Pediatrics
The Children’s Hospital of Philadelphia
Philadelphia, Pennsylvania
Carly R. Varela, MD
Fellow, Division of Oncology
The Children’s Hospital of Philadelphia
Philadelphia, Pennsylvania
Shirley D. Viteri, MD
Fellow, Department of Anesthesiology and Critical Care
Medicine
The Children’s Hospital of Philadelphia
Clinical Instructor
The University of Pennsylvania School of Medicine
Philadelphia, Pennsylvania
Amy T. Waldman, MD
Attending Physician
Division of Child Neurology
The Children’s Hospital of Philadelphia
Assistant Professor of Pediatrics
The University of Pennsylvania School of Medicine
Philadelphia, Pennsylvania
Elizabeth M. Wallis, MD
Pediatric Resident
Department of Pediatrics
The Children’s Hospital of Philadelphia
Instructor in Pediatrics
The University of Pennsylvania School of Medicine
Philadelphia, Pennsylvania
Daniel A. Weiser, MD
Fellow, Division of Hematology and Oncology
The Children’s Hospital of Philadelphia
Philadelphia, Pennsylvania
Jessica Wen, MD
Fellow, Division of Gastroenterology, Hepatology, and
Nutrition
The Children’s Hospital of Philadelphia
Philadelphia, Pennsylvania


Contributors  xix

Deborah Whitney, MD
Attending Physician
Division of General Pediatrics
The Children’s Hospital of Philadelphia
Clinical Assistant Professor of Pediatrics
The University of Pennsylvania School of Medicine
Philadelphia, Pennsylvania
Jennifer J. Wilkes, MD
Pediatric Resident
Department of Pediatrics
The Children’s Hospital of Philadelphia
Philadelphia, Pennsylvania
Kamillah Wood, MD
Pediatric Chief Resident
Department of Pediatrics
The Children’s Hospital of Philadelphia
Philadelphia, Pennsylvania

Courtney J. Wusthoff, MD
Clinical Neurophysiology Fellow
Division of Neurology
The Children’s Hospital of Philadelphia
Philadelphia, Pennsylvania
Joyce Yang, MD
Pediatric Resident
Department of Pediatrics
The Children’s Hospital of Philadelphia
Philadelphia, Pennsylvania
Mark R. Zonfrillo, MD
Fellow, Division of Pediatric Emergency Medicine
The Children’s Hospital of Philadelphia
Philadelphia, Pennsylvania


xx  Contents

Contents

SECTION I

21 Approach to the Child with Primary
Immunodeficiency

CARE OF THE ACUTELY ILL CHILD
Fred Henretig and James M. Callahan

1 Resuscitation

2

David Chao and Frances Nadel

2 Shock

11
17
24
29
35

45

Sage Myers and James M. Callahan

9 Poisoning

62

25 Sports Medicine

151

SECTION V
RHEUMATOLOGIC DISORDERS
26 Chronic Arthritis

158

27 Juvenile Dermatomyositis

163

Naomi Brown and Pamela F. Weiss

67

Tara Petersen and Manoj K. Mittal

12 Child Abuse and Neglect

147

Julie M. Linton and Pamela F. Weiss

Stephen G. Flynn and Jeffrey A. Seiden

11 Apparent Life-Threatening Event and
Sudden Infant Death Syndrome

24 Disorders of the Neck and Spine

Pamela F. Weiss

56

Melissa Desai and Fred Henretig

10 Neurologic Emergencies

141

39

Todd A. Florin and Jill Posner

8 Injury and Trauma

23 Disorders of the Hip and Lower Extremity

Erin Pete Devon and Mercedes M. Blackstone

Halden F. Scott and Kyle Nelson

7 Burns

132

Mark R. Zonfrillo

Dana Aronson Schinasi and Sandra Schwab

6 Drowning

22 Common Fractures

Jessica Sparks Lilley and Mercedes M. Blackstone

Jennifer A. Danzig and Mirna M. Farah

5 The Acute Abdomen

BONE AND JOINT DISORDERS

Monika Goyal

Shirley D. Viteri and Esther Maria Sampayo

4 Diabetic Ketoacidosis

SECTION IV
Mercedes M. Blackstone

Kari R. Posner and Aaron Donoghue

3 Respiratory Distress

124

Lisa Forbes and Terri Brown-Whitehorn

72

Stephen Ludwig

28 Vasculitis

167

Homaira Rahimi and Pamela F. Weiss

29 Systemic Lupus Erythematosus

173

Christopher P. Bonafide and Pamela F. Weiss

30 Granulomatous Disease

178

Scott M. Lieberman and Pamela F. Weiss

SECTION II

SECTION VI

NUTRITION
Beth Rezet

13 Nutritional Requirements and Growth

82

Carrie Daymont and Beth Rezet

14 Malnutrition

88

Elizabeth Lowenthal and Beth Rezet

15 Obesity

93

Amanda Jones and Beth Rezet

16 Nutritional Deficiencies

97

Amanda Jones and Beth Rezet

17 Failure to Thrive

102

Carrie Daymont and Beth Rezet

DISORDERS OF THE HEAD, NECK, AND
UPPER AIRWAY
Christina L. Master

31 Otitis

186

Melissa A. Hofmann

32 Disorders of the Eye

192

Eden Kahle

33 Sinusitis

198

Pamela A. Mazzeo

34 Dentition and Common Oral Lesions

202

Pamela A. Mazzeo

35 Pharyngitis

207

Melissa Desai

SECTION III

36 Stridor

212

Soorena Khojasteh and Paul L. Aronson

ALLERGY AND IMMUNOLOGY
Terri Brown-Whitehorn

18 Anaphylaxis

108

SECTION VII

114

DISORDERS OF THE RESPIRATORY SYSTEM AND
LOWER AIRWAY

Jackie P. D. Garrett and Terri Brown-Whitehorn

19 Atopic Dermatitis

Howard B. Panitch

Christopher P. Bonafide and Terri Brown-Whitehorn

20 Urticaria and Angioedema
Laura Gober and Terri Brown-Whitehorn

119

37 Bronchiolitis and Wheezing
Gustavo Nino

218


Contents  xxi

38 Asthma

224

James Aaron Feinstein

39 Congenital Anomalies of the Lung

232

Fiona Healy

40 Pleural Effusions and Pneumothorax

239

Jason B. Caboot

41 Cystic Fibrosis

246

SECTION XI
DISORDERS OF THE RENAL AND UROLOGIC SYSTEMS
Kevin E. C. Meyers

61 Hematuria and Proteinuria
62 Glomerulonephritis

380

Matthew G. Sampson and Kevin E. C. Meyers

63 Nephrotic Syndrome

Paul McNally

372

Ryan M. Raffaelli and Madhura Pradhan

385

Michelle Denburg and Shamir Tuchman

SECTION VIII

64 Hemolytic-Uremic Syndromes
65 Acute and Chronic Renal Failure

Paul M. Weinberg

42 Development of the Cardiovascular System

252

Kristin N. Ray and Anitha S. John

43 Acyanotic Congenital Heart Disease

259

SECTION XII

278

DISORDERS OF THE ENDOCRINE SYSTEM

Javier J. Lasa

46 Heart Failure

285

E. Kevin Hall

47 Hypertension

289

Michael L. O’Byrne and R. Thomas Collins II

48 Syncope

294

Brett R. Anderson and Anitha S. John

49 Acute Rheumatic Fever and Rheumatic
Heart Disease

300

308
314

Daniel A. Weiser

321

Jennifer Mangino

326

Connie M. Piccone

331

Alexis Teplick

338
346

Dana Sepe and Leslie S. Kersun

351

Angela J. Sievert and Jane E. Minturn

355

Elizabeth M. Wallis and Nicholas Evageliou

59 Renal Neoplasms

360

Shefali Parikh and Rochelle Bagatell

442
450
457

Dorit Koren and Adda Grimberg

SECTION XIII
DISORDERS OF THE NERVOUS SYSTEM
Richard S. Finkel

74 Seizures

466

Nicole Ryan

75 Headache

471

Christina Lynch Szperka

76 Neurocutaneous Disorders

479
485
491

Amy T. Waldman

79 Stroke

495

David R. Bearden and Lauren A. Beslow

80 Spinal Cord Disorders

503

Saba Ahmad

81 Neuromuscular Disorders

508

Jennifer L. McGuire

SECTION XIV
ADOLESCENT MEDICINE
Sara B. Kinsman

Carly R. Varela and Kelly C. Goldsmith

60 Bone Neoplasms

71 Diabetes Mellitus

78 Demyelinating Diseases

Abby Green and Susan R. Rheingold

58 Neuroblastoma

436

Roy J. Kim and Rachana Shah

Courtney J. Wusthoff

Leslie S. Kersun

57 Brain Tumors

429

Jill L. Brodsky and Michael A. Levine

77 Cerebral Palsy

NEOPLASTIC DISORDERS

56 Lymphoma

69 Disorders of Calcium and Bone Metabolism

Kathryn S. Taub

SECTION X
55 Leukemia

422

Sara E. Pinney, Vaneeta Bamba, and Craig A. Alter

73 Disorders of Growth

Howard Topol

54 Disorders of Thrombosis and Hemostasis

68 Thyroid Disease

Andrew A. Palladino and Diva D. DeLeón

Char M. Witmer

53 Sickle Cell Disease

416

Andrew C. Calabria and David R. Langdon

72 Hypoglycemia

HEMATOLOGIC DISORDERS

52 Platelet Disorders

67 Puberty

Alisa B. Schiffman, Kathryn M. Murphy, and Sheela N. Magge

SECTION IX

51 Disorders of White Blood Cells

408

Michael A. Levine

70 Disorders of the Adrenal Gland

Deepika Thacker and Amy L. Peterson

50 Disorders of Red Blood Cells

66 Congenital Anomalies of the Kidney and
Urologic System

269

Michael L. O’Byrne and Anitha S. John

45 Arrhythmias

397

Olivera Marsenic and H. Jorge Baluarte

Ulf H. Beier and Lawrence Copelovitch

Marsha Ayzen and Anitha S. John

44 Cyanotic Congenital Heart Disease

390

Christopher LaRosa and Kevin E. C. Meyers

DISORDERS OF THE CARDIOVASCULAR SYSTEM

366

82 Substance Abuse
Daniel B. Horton and Sara B. Kinsman

518


xxii  Contents

83 Menstrual Disorders

522

Kamillah Wood and Sara B. Kinsman

84 Polycystic Ovarian Syndrome

526
528

Levon H. Utidjian and Sara B. Kinsman

SECTION XVII
DISORDERS OF THE DIGESTIVE SYSTEM
Rose C. Graham and Joshua R. Friedman

107 Disorders of the Esophagus

SECTION XV

108 Gastritis and Gastrointestinal Bleeding

532

109 Intestinal Obstruction and Malrotation

538

110 Inflammatory Bowel Disease

Elizabeth E. Foglia
Jessica L. Hills

88 Osteomyelitis and Other Bone and Joint
Infections

553

Kristen A. Feemster

90 Skin and Soft Tissue Infections

562

Eric D. Shelov

91 Pneumonia and Respiratory Infections

568

Matthew P. Kronman and Samir S. Shah

92 Infections of the Central Nervous System

575

690

Andrew Chu

698

Jessica Wen and Rose C. Graham

111 Diarrhea

547

Ann Chahroudi

89 Sexually Transmitted Infections

683

Andrew Chu

Jason Y. Kim and Louis M. Bell

87 Infections of the Head and Neck

676

Amy Feldman and Rose C. Graham

INFECTIOUS DISEASE

86 Fever of Unknown Origin

669

Shazia Bhat

Oana Tomescu and Sara B. Kinsman

85 Eating Disorders

106 Neonatal Resuscitation

704

Anna Hunter and Rose C. Graham

112 Constipation

711

Melissa Kennedy

113 Hernias

714

Benjamin A. Sahn and Rose C. Graham

114 Disorders of the Pancreas

719

Melissa Kennedy

115 Hepatobiliary Disease

723

Melissa Leyva-Vega

Sanjeev K. Swami

93 Infections of the Urinary Tract

584

Eric D. Shelov

94 Infections of the Cardiovascular System

590

Deborah Whitney

95 Human Immunodeficiency Virus

596

Elizabeth Lowenthal

96 Gastrointestinal Infections

602

Jennifer J. Wilkes

97 Viral Infections

609

Joyce Yang

98 Fungal Infections

617

Melissa Mondello and Jason Y. Kim

99 Parasitic Infections

623

SECTION XVIII
GENETIC AND METABOLIC DISORDERS
Matthew A. Deardorff

116 Principles of Human Genetics
117 Trisomy 21

740

Nilika B. Shah

118 Chromosomal Abnormalities

745

Bettina Mucha-Le Ny and Reena Jethva

119 Disorders of Sexual Development

752

Chad R. Haldeman-Englert and Jennifer M. Kalish

120 Genetic Syndromes

759

Jennifer M. Kalish and Chad R. Haldeman-Englert

121 Inborn Errors of Metabolism

Jennifer J. Wilkes and Jason Y. Kim

732

Kathryn Chatfield

770

Reena Jethva

SECTION XVI

SECTION XIX

NEONATAL MEDICINE

DERMATOLOGIC DISORDERS

David A. Munson

100 Hyperbilirubinemia

634

Kristin N. Ray

101 Disorders of the Nervous System

640

Ryan J. Felling and David A. Munson

102 Disorders of the Respiratory System

646

Lori A. Christ and David A. Munson

103 Disorders of the Gastrointestinal
System

652

Lori A. Christ

782

Lara Wine Lee

123 Vascular Disorders

787

Lara Wine Lee

124 Hyperpigmented Skin Disorders

792

125 Acne

798

Erin Pete Devon

658

126 Nevi

803

Leslie Castelo-Soccio and James R. Treat

Elif E. Ince

105 Neonatal Infections

122 Dermatologic Morphology

Vikash S. Oza

John J. Flibotte

104 Hematologic Disorders

James R. Treat

664

127 Nutritional Dermatoses
Michael D. Gober and James R. Treat

807


Fred Henretig and James M. Callahan

Care of the Acutely
Ill Child
1 Resuscitation
2 Shock
3 Respiratory Distress
4 Diabetic Ketoacidosis
5 The Acute Abdomen
6 Drowning
7 Burns
8 Injury and Trauma
9 Poisoning
10 Neurologic Emergencies
11 Apparent Life-Threatening Event and Sudden Infant
Death Syndrome
12 Child Abuse and Neglect

I


2  SECTION I╇ •â•‡ Care of the Acutely Ill Child

Resuscitation

1â•…

David Chao and Frances Nadel

C

ardiopulmonary resuscitation (CPR) is the series of emergency interventions provided to a person who appears dead
or in respiratory extremis, with the goal of restoring vital functions through optimization of cardiac output and tissue oxygen
delivery. The two main components are external cardiac massage
(chest compressions) and assisted respirations.
Most children who require CPR do not survive. Those who
do survive often have significant neurologic deficits from the
hypoxia and ischemia associated with the cardiopulmonary
arrest. However, some children do return to their premorbid
function. This may be related to recognition and treatment of
impending cardiorespiratory failure, early bystander CPR, or
rapid correction of the life-threatening event. It is difficult to
predict which patients will have a return of spontaneous circulation and ultimately survive. Therefore, high-quality CPR should
be begun immediately while more information is gathered to
guide therapy.
The incidence of out-of-hospital cardiopulmonary arrest is
difficult to ascertain from the current literature. However, data
from multicenter registries support many widely held beliefs
about pediatric out-of-hospital arrests. The incidence of nontraumatic, out-of-hospital cardiac arrest is highest for infants
(children younger than 1 year of age). The most common cause
in this age group is sudden infant death syndrome (SIDS). The
presenting rhythm is usually asystole, and survival to discharge
is rare (≈3%). For all other pediatric age groups, trauma is the
leading cause of death. Although asystole is the most common
arrest rhythm, ventricular tachycardia (VT) and ventricular
fibrillation (VF) do occur and are more common in older children, especially adolescents. Survival in patients with ventricular
dysrhythmias is higher than in patients with cardiopulmonary
arrest associated with rhythms that are not responsive to cardioversion or defibrillation, such as asystole and pulseless electrical
activity (PEA). For nontraumatic arrests, survival even for
older children remains low, about 9% in those older than 1 year
of age.

ETIOLOGY AND PATHOGENESIS
Cardiopulmonary arrest may result from many causes. Sepsis,
respiratory infection, pulmonary conditions, drowning, SIDS,
and injuries can lead to respiratory failure or shock. Without
effective intervention, cardiopulmonary failure (inadequate perfusion and ineffective or absent respiration) ensues. Most pediatric arrests occur after an initial respiratory arrest (rather than
circulatory failure) and if prolonged result in terminal rhythms
of bradycardia; PEA; and, finally, asystole. Patients in asystole
likely have experienced a significant hypoxic–ischemic insult.

CLINICAL PRESENTATION
The signs and symptoms of children requiring immediate resuscitation are typically the result of failure of the delivery of two

vital substrates—oxygen and glucose—to end organs (Table
1-1). Recognition of these manifestations through a physical
examination that focuses on airway, gas exchange, and cardiovascular stability allows for rapid resuscitation of those who have
failure of substrate delivery and identification of those at risk for
failure.

INITIAL ASSESSMENT
Evaluation of a critically ill or injured child should begin with
a general assessment. Physical examination clues help the provider
determine the extent of illness or injury (i.e., whether the condition is life threatening or not) and identify systems that require
closer attention during the remainder of the assessment. The
Pediatric Assessment Triangle of the Pediatric Advanced Life
Support (PALS) course outlines the following components of
the general assessment:
Appearance: muscle tone, interaction, consolability, look or
gaze, speech or cry
Work of breathing: increased work of breathing, decreased or
absent respiratory effort, or abnormal sounds
Circulation: abnormal skin color or bleeding
The initial assessment can be done without laying hands on
the patient and should take no more than several seconds. If the
patient’s condition is life threatening, additional support should
be recruited immediately. After these rapid initial impressions,
the clinician should aim to perform a swift yet careful primary
assessment.

PRIMARY ASSESSEMENT
The primary assessment evaluates and addresses vital functions
in a systematic way with priority to systems that are most crucial
for sustaining life. Conveniently, the components of the primary
assessment can be remembered as the “ABCDEs”—airway,
breathing, circulation, disability, and exposure and environment. If a
life-threatening abnormality is identified at any point, the aberration should be addressed before moving on in the assessment.
With the publication of new guidelines for cardiopulmonary
resuscitation in 2010, it has been recommended that the standard sequence of “ABC” be switched to “CAB” for patients who
need cardiopulmonary resuscitation. This recommendation is
based on the recognition that most cardiopulmonary arrests
occur in adults and that even in children and adolescents sudden
arrest is more likely to be due to a cardiac arrhythmia. Prompt
institution of cardiac compressions to provide artificial circulation is important to ensure the best possible outcome for individual patients. This is especially important in out-of-hospital
settings where early initiation of bystander CPR has been shown
to be one of the strongest predictors of survival and good
neurologic outcome. In medical settings the approach to resuscitation may be individualized based on the clinical scenario.


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