CURRENT Diagnosis & Treatment

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 a LANGE medical book

CURRENT
Diagnosis & Treatment
Pediatrics
TWENTY-FOURTH EDITION

Edited by
William W. Hay, Jr., MD
Professor, Department of Pediatrics
Section of Neonatology and
Division of Perinatal Medicine
University of Colorado School of Medicine
and Children’s Hospital Colorado
Myron J. Levin, MD
Professor, Departments of Pediatrics and Medicine
Section of Pediatric Infectious Diseases
University of Colorado School of Medicine
and Children’s Hospital Colorado
Robin R. Deterding, MD
Professor, Department of Pediatrics
Chief, Section of Pediatric Pulmonary Medicine
University of Colorado School of Medicine and
Children’s Hospital Colorado
Medical Director, Breathing Institute Children’s
Hospital Colorado
Mark J. Abzug, MD
Professor, Department of Pediatrics
Section of Pediatric Infectious Diseases
Associate Vice Chair for Academic Affairs,
Department of Pediatrics
University of Colorado School of Medicine and
Children’s Hospital Colorado

and Associate Authors

The Department of Pediatrics at the University of Colorado School of Medicine

is affiliated with Children’s Hospital Colorado.

New York Chicago San Francisco Athens London Madrid Mexico City Milan
New Delhi Singapore Sydney Toronto

Hay_FM_pi-xxxii.indd 1 30/03/18 11:40 AM

Copyright © 2018 by McGraw-Hill Education. All rights reserved. Except as permitted under the United States Copyright Act of
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 Contents
Authors xix Esophageal Atresia & Tracheoesophageal
Preface xxix Fistula 48
Selected Highlighted Topics in the Intestinal Obstruction 49
24th Edition of CDT-P xxxi Abdominal Wall Defects 50
Diaphragmatic Hernia 51
1. Advancing the Quality Gastrointestinal Bleeding 51
& Safety of Care 1 Gastroesophageal Reflux 51
Infections in the Newborn Infant 52
Daniel Hyman, MD Bacterial Infections 52
Introduction 1 Fungal Sepsis 55
Current Context 1 Congenital Infections 56
Strategies & Models for Perinatally Acquired Infections 58
Quality Improvement (QI) 4 Hematologic Disorders in the Newborn Infant 59
Principles of Patient Safety Bleeding Disorders 59
(Incident Reporting, Just Culture, Anemia 60
Disclosure, FMEA, RCA, Polycythemia 61
Reliability, Checklists) 7 Renal Disorders in the Newborn Infant 62
Renal Failure 62
2. The Newborn Infant 10 Urinary Tract Anomalies 62
Renal Vein Thrombosis 63
Danielle Smith, MD Neurologic Problems in the Newborn Infant 63
Theresa Grover, MD Seizures 63
Introduction 10 Intracranial Hemorrhage 64
The Neonatal History 10 Metabolic Disorders in the Newborn Infant 65
Assessment of Growth & Gestational Age 10 Hyperglycemia 65
Examination at Birth 12 Hypocalcemia 65
Examination in the Nursery 13 Inborn Errors of Metabolism 66
Care of the Well Neonate 15 Quality Assessment & Improvement
Feeding the Well Neonate 15 in the Newborn Nursery & NICU 66
Early Discharge of the Newborn Infant 17
Hearing Screening 18 3. Child Development & Behavior 67
Common Problems in the Term Newborn 18
Neonatal Jaundice 18 Edward Goldson, MD
Hypoglycemia 25 Ann Reynolds, MD
Respiratory Distress in the Term Introduction 67
Newborn Infant 26 Normal Development 67
Heart Murmurs 28 The First 2 Years 67
Birth Trauma 28 Ages 2–4 Years 73
Infants of Mothers Who Abuse Drugs 29 Early School Years: Ages 5–7 Years 74
Multiple Births 31 Middle Childhood: Ages 7–11 Years 74
Neonatal Intensive Care 32 Behavioral & Developmental Variations 74
Perinatal Resuscitation 32 Normality & Temperament 74
The Preterm Infant 36 Enuresis & Encopresis 75
The Late Preterm Infant 45 Enuresis 75
Cardiac Problems in the Newborn Infant 46 Encopresis 76
Structural Heart Disease 46 Common Developmental Concerns 77
Persistent Pulmonary Hypertension 47 Colic 77
Arrhythmias 48 Feeding Disorders in Infants &
Gastrointestinal & Abdominal Surgical Young Children 79
Conditions in the Newborn Infant 48 Sleep Disorders 80
iii

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 iv Contents

Parasomnias 81 Predicting the Progression from

Insomnia 81 use to Abuse 148
Sleep-Disordered Breathing 82 Evaluation of Substance Abuse 149
Restless Legs Syndrome & Periodic Treatment & Referral 152
Limb Movement Disorder 82 Prevention 154
Temper Tantrums & Breath-Holding Spells 83 References 155
Well-Child Surveillance & Screening 85
Developmental Disorders 85 6. Eating Disorders 156
Attention-Deficit/Hyperactivity Disorder 87
Autism Spectrum Disorders 89 Eric J. Sigel, MD
Intellectual Disability 93 Introduction 156
Specific Forms of Intellectual Disability & Etiology 156
Associated Treatment Issues 95 Incidence 157
References 97 Predisposing Factors & Clinical Profiles 157
Anorexia Nervosa 157
4. Adolescence 98 Bulimia Nervosa 163
Binge-Eating Disorder 165
Amy E. Sass, MD, MPH Avoidant/Restrictive Food Intake Disorder 166
Molly J. Richards, MD Prognosis, Quality Assessment,
Introduction 98 & Outcomes Metrics 166
Epidemiology 98 Resources for Practitioners & Families 167
Mortality Data 98
Morbidity Data 98 7. Child & Adolescent Psychiatric
Providing a Medical Home for Adolescents 99 Disorders & Psychosocial Aspects
Relating to the Adolescent Patient 100 of Pediatrics 168
The Structure of the Visit 101
Guidelines for Adolescent Preventive Services 107 Adam Burstein, DO
Adolescent Screening 107 Kimberly Kelsay, MD
Promoting Healthy Behaviors 108 Ayelet Talmi, PhD
Transition to Adult Care 112 Introduction 168
Growth & Development 114 Models of Care Encompassing
Puberty 114 Behavioral Health in the
Physical Growth 114 Primary Care Setting 169
Sexual Maturation 114 Prevention, Early Identification, &
Psychosocial Development 115 Developmental Context 170
Adolescent Gynecology & Lifestyle Recommendations 171
Reproductive Health 117 Identification & Assessment During Health
Breast Examination 117 Supervision Visits 171
Breast Masses 118 Psychiatric Disorders of Childhood
Nipple Discharge & Galactorrhea 119 & Adolescence 180
Gynecomastia 120 Anxiety Disorders 181
Gynecologic Disorders in Adolescence 122 Obsessive-Compulsive & Related Disorders 189
Contraception 132 Attention-Deficit/Hyperactivity Disorder 192
Pregnancy 139 Mood Disorders 196
Suicide in Children & Adolescents 202
5. Adolescent Substance Abuse 142 Disruptive, Impulse-Control
& Conduct Disorders 204
Paritosh Kaul, MD High-Risk Patients & Homicide 205
Scope of the Problem 142 Somatic Symptom & Related Disorders 207
Morbidity Data 147 Adjustment Disorders 209
Psychotic Disorders 209
Other Psychiatric Conditions 212

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 Contents v

8. Child Abuse & Neglect 213 Vaccination in Special Circumstances 254

Hepatitis B Vaccination 255
Antonia Chiesa, MD Rotavirus Vaccination 258
Andrew P. Sirotnak, MD Diphtheria-Tetanus-Acellular
Introduction 213 Pertussis Vaccination 259
Prevention 214 Haemophilus Influenzae Type B
Clinical Findings 214 Vaccination 261
Differential Diagnosis 220 Pneumococcal Vaccination 262
Treatment 220 Poliomyelitis Vaccination 264
Prognosis 221 Influenza Vaccination 265
Measles, Mumps, & Rubella Vaccination 266
9. Ambulatory & Office Pediatrics 222 Varicella Vaccination 268
Hepatitis A Vaccination 270
Meghan Treitz, MD
Meningococcal Vaccination 271
Daniel Nicklas, MD
Tetanus-Reduced Diphtheria-Acellular
Maya Bunik, MD, MSPH
Pertussis Vaccination
David Fox, MD
(Adolescents & Adults) 273
Introduction 222 Human Papillomavirus Vaccination 273
Pediatric History 222 Vaccinations for Special Situations 274
Pediatric Physical Examination 224 Rabies Vaccination 274
Health Supervision Visits 225 Typhoid Fever Vaccination 276
Developmental & Behavioral Assessment 225 Cholera Vaccination 277
Growth Parameters 228 Japanese Encephalitis Vaccination 277
Blood Pressure 229 Tuberculosis Vaccination 277
Vision & Hearing Screening 230 Yellow Fever Vaccination 278
Anticipatory Guidance 234 Passive Prophylaxis 278
Nutrition Counseling 235
Counseling About Television & 11. Normal Childhood Nutrition
Other Media 236 & Its Disorders 280
Immunizations 237
Acute-Care Visits 237 Matthew A. Haemer, MD, MPH
Prenatal Visits 238 Laura E. Primak, RD, CNSD
Sports Physicals 238 Nancy F. Krebs, MD, MS
Chronic Disease Management 238 Nutritional Requirements 280
Medical Home 239 Nutrition & Growth 280
Mental & Behavioral Health 239 Energy 280
Telephone Management & Web-Based Protein 281
Information 240 Lipids 282
Advocacy & Community Pediatrics 240 Carbohydrates 283
Common General Pediatric Issues 241 Major Minerals 284
Fever 241 Trace Elements 284
Growth Deficiency 243 Vitamins 284
Infant Feeding 288
10. Immunization 245 Breast-Feeding 288
Special Dietary Products for Infants 295
Matthew F. Daley, MD
Nutrition for Children 2 Years & Older 296
Sean T. O’Leary, MD, MPH
Pediatric Undernutrition 297
Ann-Christine Nyquist, MD, MSPH
Pediatric Overweight & Obesity 298
Standards for Pediatric Immunization Nutrition Support 302
Practices 246 Enteral 302
Routine Childhood & Adolescent Immunization Parenteral Nutrition 303
Schedules 247 Nutrient Requirements & Delivery 304
Vaccine Safety 247

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 vi Contents

12. Emergencies & Injuries 309 Barbiturates & Benzodiazepines 342

Belladonna Alkaloids (Atropine, Jimsonweed,
Kevin P. Carney, MD Potato Leaves, Scopolamine, Stramonium) 342
Kelley Roswell, MD b-Blockers & Calcium Channel Blockers 343
Introduction to Pediatric Carbon Monoxide 343
Emergencies & Injuries 309 Caustics 344
Initial Approach to the Acutely Ill Central a2-Adrenergic Agonist 344
Infant or Child 309 Cocaine 345
The ABCs of Resuscitation 310 Cosmetics & Related Products 345
Management of Shock 314 Cyclic Antidepressants 345
Summary of Initial Approach to the Digitalis & Other Cardiac Glycosides 346
Acutely Ill Infant or Child 315 Diphenoxylate with Atropine
Emergency Pediatric Drugs 316 (Lomotil) & Loperamide (Imodium) 346
Approach to the Pediatric Trauma Patient 316 Disinfectants & Deodorizers 347
Mechanism of Injury 317 Disk-Shaped “Button” Batteries 347
Initial Assessment & Management 317 Ethylene Glycol & Methanol 348
Primary Survey 317 g-Hydroxybutyrate, g-Butyrolactone,
Secondary Survey 319 Butanediol, Flunitrazepam, & Ketamine 348
Head Injury 321 Hydrocarbons (Benzene, Charcoal
Burns 323 Lighter Fluid, Gasoline, Kerosene,
Thermal Burns 323 Petroleum Distillates, Turpentine) 349
Electrical Burns 325 Ibuprofen 349
Disorders due to Extremes of Environment 326 Insect Stings (Bee, Wasp, & Hornet) 349
Heat-Related Illnesses & Heat Stroke 326 Insecticides 349
Hypothermia 326 Iron 350
Submersion Injuries 327 Lead 351
Lacerations 328 Magnets 352
Animal & Human Bites 329 Marijuana 352
Dog Bites 329 Mushrooms 352
Cat Bites 330 Nitrites, Nitrates, Aniline,
Human Bites 330 Pentachlorophenol, & Dinitrophenol 353
Pain Management & Procedural Sedation 330 Opioids & Opiates 353
Oral Anti-Diabetics
13. Poisoning 332 (Sulfonylureas, Metformin) 354
Antipsychotics (Typical & Atypical) 355
Richard C. Dart, MD, PhD
Plants 355
Barry H. Rumack, MD
Psychotropic Drugs 355
George Sam Wang, MD
Salicylates 357
Introduction 332 Scorpion Stings 358
Pharmacologic Principles of Toxicology 332 Serotonin Reuptake Inhibitors 358
Preventing Childhood Poisonings 333 Snakebite 358
General Treatment of Poisoning 333 Soaps & Detergents 359
Initial Telephone Contact 333 Spider Bites 360
Initial Emergency Department Contact 336 Vitamins 360
Definitive Therapy of Poisoning 336 Warfarin (Coumadin) & Newer Oral
Management of Specific Common Poisonings 337 Anticoagulants (NOAC) 361
Acetaminophen (Paracetamol) 337
Alcohol, Ethyl (Ethanol) 339
Amphetamines & Related Drugs
(Stimulants, Methamphetamine, MDMA) 340
Anesthetics, Local 340
Antihistamines & Cough & Cold
Preparations 341

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 Contents vii

14. Critical Care 362 Fungal Infections of the Skin 409

Viral Infections of the Skin 410
Todd C. Carpenter, MD Virus-Induced Tumors 411
Amy Clevenger, MD, PhD Insect Infestations 412
Angela S. Czaja, MD, MSc Dermatitis (Eczema) 412
Eva N. Grayck, MD Common Skin Tumors 415
Cameron F. Gunville, DO Papulosquamous Eruptions 416
Leslie Ridall, DO Hair Loss (Alopecia) 417
Carleen Zebuhr, MD Reactive Erythemas 418
Introduction 362 Miscellaneous Skin Disorders Seen
Respiratory Critical Care 362 in Pediatric Practice 418
Acute Respiratory Failure 362
Conventional Mechanical Ventilation 366 16. Eye 420
Other Modes of Respiratory Support 369
Major Respiratory Diseases in the Jennifer Lee Jung, MD
Pediatric ICU 370 Rebecca Sands Braverman, MD
Acute Respiratory Distress Syndrome 370 Introduction 420
Status Asthmaticus 373 Common Nonspecific Signs & Symptoms 420
Cardiovascular Critical Care 376 Red Eye 420
Shock 376 Tearing 420
Sepsis 379 Discharge 420
Neurocritical Care 383 Pain & Foreign Body Sensation 420
Traumatic Brain Injury 383 Photophobia 420
Hypoxic-Ischemic Encephalopathy 387 Leukocoria 421
Acute Kidney Injury & Renal Replacement Refractive Errors 421
Therapy 388 Myopia (Nearsightedness) 422
Fluid Management & Nutritional Support Hyperopia (Farsightedness) 422
of the Critically Ill Child 389 Astigmatism 422
Sedation & Analgesia in the Pediatric ICU 391 Ophthalmic Examination 422
End-of-Life Care & Death in the PICU 395 History 422
Quality Improvement Initiatives Visual Acuity 422
in the PICU 398 External Examination 423
Pupils 424
15. Skin 399 Alignment & Motility Evaluation 424
Ophthalmoscopic Examination 425
Lori D. Prok, MD Ocular Trauma 426
Carla X. Torres-Zegarra, MD Ocular Foreign Bodies 426
General Principles 399 Corneal Abrasion 427
Diagnosis of Skin Disorders 399 Intraocular Foreign Bodies & Perforating
Treatment of Skin Disorders 399 Ocular Injuries 428
Disorders of the Skin in Newborns 401 Blunt Orbital Trauma 429
Transient Diseases in Newborns 401 Lacerations 429
Pigment Cell Birthmarks, Nevi, Burns 430
& Melanoma 402 Hyphema 431
Melanocytic Nevi 402 Abusive Head Trauma & Nonaccidental
Vascular Birthmarks 403 Trauma 432
Epidermal Birthmarks 404 Prevention of Ocular Injuries 432
Connective Tissue Birthmarks Disorders of the Ocular Structures 433
(Juvenile Elastoma, Collagenoma) 404 Diseases of the Eyelids 433
Hereditary Skin Disorders 405 Viral Eyelid Disease 434
Common Skin Diseases in Infants, Miscellaneous Eyelid Infections 435
Children, & Adolescents 406 Eyelid Ptosis 435
Acne 406 Horner Syndrome 436
Bacterial Infections of the Skin 408 Eyelid Tics 437

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 viii Contents

Disorders of the Nasolacrimal System 437 17. Oral Medicine & Dentistry 466
Nasolacrimal Duct Obstruction 437
Congenital Dacryocystocele 438 Ulrich Klein, DMD, DDS, MS
Dacryocystitis 438 Roopa P. Gandhi, BDS, MSD
Diseases of the Conjunctiva 439 Camille V. Gannam, DMD, MS
Ophthalmia Neonatorum 439 Issues in Pediatric Oral Health 466
Bacterial Conjunctivitis 440 Oral Examination of Children 467
Viral Conjunctivitis 440 Eruption of the Teeth 469
Allergic Conjunctivitis 441 Dental Caries 471
Mucocutaneous Diseases 442 Periodontal Disease 473
Disorders of the Iris 443 Dental Emergencies 474
Iris Coloboma 443 Special Patient Populations 475
Aniridia 444 Orthodontic Referral 477
Albinism 444
Miscellaneous Iris Conditions 445 18. Ear, Nose, & Throat 478
Glaucoma 445
Patricia J. Yoon, MD
Uveitis 445
Melissa A. Scholes, MD
Anterior Uveitis/Iridocyclitis/Iritis 446
Norman R. Friedman, MD
Posterior Uveitis 446
Intermediate Uveitis 447 The Ear 478
Disorders of the Cornea 448 Infections of the Ear 478
Cloudy Cornea 448 Acute Trauma to the Middle Ear 488
Viral Keratitis 448 Ear Canal Foreign Body &
Corneal Ulcers 449 Cerumen Impaction 488
Disorders of the Lens 450 Auricular Hematoma 489
Cataracts 450 Congenital Ear Malformations 489
Dislocated Lenses/Ectopia Lentis 450 Identification & Management of
Disorders of the Retina 451 Hearing Loss 489
Retinal Hemorrhages in the Newborn 451 The Nose & Paranasal Sinuses 492
Retinopathy of Prematurity 451 Acute Viral Rhinitis 492
Retinoblastoma 452 Rhinosinusitis 493
Retinal Detachment 453 Choanal Atresia 495
Diabetic Retinopathy 454 Recurrent Rhinitis 495
Diseases of the Optic Nerve 454 Epistaxis 496
Optic Neuropathy 454 Nasal Infection 497
Optic Nerve Hypoplasia 455 Nasal Trauma 497
Papilledema 456 Foreign Bodies in the Nose 497
Optic Neuritis 457 The Throat & Oral Cavity 497
Optic Atrophy 458 Acute Stomatitis 497
Diseases of the Orbit 458 Pharyngitis 498
Periorbital & Orbital Cellulitis 458 Peritonsillar Cellulitis or Abscess (Quinsy) 501
Craniofacial Anomalies 459 Retropharyngeal Abscess 501
Orbital Tumors 459 Ludwig Angina 501
Nystagmus 460 Acute Cervical Adenitis 502
Amblyopia 461 Snoring, Mouth Breathing, & Upper Airway
Strabismus 462 Obstruction 503
Unexplained Decreased Vision Tonsillectomy & Adenoidectomy 505
in Infants & Children 464 Disorders of the Lips 506
Learning Disabilities & Dyslexia 464 Disorders of the Tongue 506
Halitosis 506
Salivary Gland Disorders 507
Congenital Oral Malformations 507

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 Contents ix

19. Respiratory Tract & Mediastinum 509 Congenital Malformations

of the Lung Parenchyma 529
Monica J. Federico, MD Pulmonary Agenesis & Hypoplasia 529
Christopher D. Baker, MD Pulmonary Sequestration 530
Emily M. Deboer, MD Congenital Lobar Overinflation 531
Ann C. Halbower, MD Congenital Pulmonary Airway Malformation
Oren Kupfer, MD (Cystic Adenomatoid Malformation) 532
Stacey L. Martiniano, MD Acquired Abnormalities of the Lung
Scott D. Sagel, MD Parenchyma 533
Paul Stillwell, MD Bronchopulmonary Dysplasia 533
Edith T. Zemanick, MD Community-Acquired Bacterial Pneumonia 534
Michelle Caraballo, MD Parapneumonic Effusion & Empyema 536
Stephen Hawkins, MD, DO Atypical Pneumonias 537
Respiratory Tract 509 Viral Pneumonia 537
Growth & Development 509 Bronchiolitis 538
Diagnostic Aids 510 Mycoplasma Pneumonia 539
Physical Examination of the Aspiration Pneumonia 540
Respiratory Tract 510 Pneumonia in the Immunocompromised
Pulmonary Function Tests 510 Host 541
Assessment of Oxygenation & Ventilation 511 Lung Abscess 542
Diagnosis of Respiratory Tract Infections 512 Bronchiolitis Obliterans 543
Imaging of the Respiratory Tract 514 Children’s Interstitial Lung Disease
Laryngoscopy & Bronchoscopy 515 Syndrome 544
General Therapy for Pediatric Lung Diseases 515 Hypersensitivity Pneumonitis 545
Oxygen Therapy 515 Diseases of the Pulmonary Circulation 546
Inhalation of Medications 516 Pulmonary Hemorrhage 546
Airway Clearance Therapy 516 Pulmonary Embolism 548
Avoidance of Environmental Hazards 517 Pulmonary Edema 549
Disorders of the Conducting Airways 517 Congenital Pulmonary Lymphangiectasia 549
Laryngomalacia & Congenital Disorders Disorders of the Chest Wall 550
of the Extrathoracic Airway 518 Scoliosis 550
Laryngomalacia 518 Pectus Carinatum 550
Other Causes of Congenital Extrathoracic Pectus Excavatum 550
Obstruction 518 Neuromuscular Disorders & Lung Disease 551
Acquired Disorders of the Disorders of the Pleura & Pleural Cavity 551
Extrathoracic Airway 519 Hemothorax 552
Foreign Body Aspiration in the Chylothorax 552
Extrathoracic Airway 519 Pneumothorax & Related Air Leak
Croup Syndromes 520 Syndromes 552
Vocal Fold Immobility 522 Mediastinum 553
Subglottic Stenosis 522 Mediastinal Masses 553
Congenital Causes of Intrathoracic Airway Sleep-Disordered Breathing 554
Obstruction 523 Obstructive & Central Sleep Apnea 554
Malacia of Airways 523 Apparent Life-Threatening Events 555
Vascular Rings & Slings 524 Sudden Unexpected Infant Death &
Bronchogenic Cysts 524 Sudden Infant Death Syndrome 558
Acquired Causes of Intrathoracic Quality Assessment & Outcomes Metrics 559
Airway Obstruction 525
Foreign Body Aspiration in the
Intrathoracic Airway 525
Disorders of Mucociliary Clearance 525
Cystic Fibrosis 526
Primary Ciliary Dyskinesia 527
Bronchiectasis 528

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 x Contents

20. Cardiovascular Diseases 561 Cardiac Transplantation 611

Quality Improvement for Pediatric Heart
Pei-Ni Jone, MD Transplantation 612
Johannes VonAlvensleben, MD Pulmonary Hypertension 613
Dale Burkett, MD Disorders of Rate & Rhythm 614
Jeffrey R. Darst, MD Disorders of the Sinus Node 614
Kathryn K. Collins, MD Premature Beats 615
Shelley D. Miyamoto, MD Supraventricular Tachycardia 616
Introduction 561 Ventricular Tachycardia 620
Diagnostic Evaluation 561 Long QT Syndrome 621
History 561 Sudden Death 621
Physical Examination 561 Disorders of Atrioventricular Conduction 621
Electrocardiography 564 Syncope (Fainting) 623
Chest Radiograph 566 Introduction 623
Echocardiography 567 Diagnostic Evaluation 624
Magnetic Resonance Imaging 568 Vasovagal/Neurocardiogenic Syncope 624
Cardiopulmonary Stress Testing 568
Arterial Blood Gases 568 21. Gastrointestinal Tract 626
Cardiac Catheterization & Angiocardiography 569
Perinatal & Neonatal Circulation 570 Edward J. Hoffenberg, MD
Heart Failure 571 Glenn T. Furuta, MD
Genetic Basis of Congenital Heart Disease 573 Gregory Kobak, MD
Acyanotic Congenital Heart Disease 574 Thomas Walker, MD
Defects in Septation 574 Jason Soden, MD
Patent (Persistent) Ductus Arteriosus 578 Robert E. Kramer, MD
Right-Sided Obstructive Lesions 580 David Brumbaugh, MD
Left-Sided Lesions 582 Disorders of the Esophagus 626
Diseases of the Aorta 586 Gastroesophageal Reflux & GERD 626
Coronary Artery Abnormalities 587 Eosinophilic Esophagitis 628
Cyanotic Congenital Heart Disease 588 Achalasia of the Esophagus 629
Tetralogy of Fallot 588 Caustic Burns of the Esophagus 630
Pulmonary Atresia with Ventricular Foreign Bodies in the Alimentary Tract 631
Septal Defect 590 Disorders of the Stomach & Duodenum 633
Pulmonary Atresia with Intact Hiatal Hernia 633
Ventricular Septum 590 Pyloric Stenosis 633
Tricuspid Atresia 592 Gastric & Duodenal Ulcer 634
Hypoplastic Left Heart Syndrome 593 Congenital Diaphragmatic Hernia 635
Transposition of the Great Arteries 594 Congenital Duodenal Obstruction 636
Total Anomalous Pulmonary Disorders of the Small Intestine 637
Venous Return 596 Intestinal Atresia & Stenosis 637
Truncus Arteriosus 597 Intestinal Malrotation 638
Quality Improvement in Congenital Short Bowel Syndrome 638
Heart Disease 598 Intussusception 640
Acquired Heart Disease 599 Inguinal Hernia 640
Rheumatic Fever 599 Umbilical Hernia 641
Kawasaki Disease 601 Patent Omphalomesenteric Duct 641
Infective Endocarditis 602 Meckel Diverticulum 641
Pericarditis 604 Acute Appendicitis 642
Cardiomyopathy 605 Duplications of the Gastrointestinal Tract 643
Myocarditis 608 Disorders of the Colon 643
Preventive Cardiology 609 Congenital Aganglionic Megacolon
Hypertension 609 (Hirschsprung Disease) 643
Atherosclerosis & Dyslipidemias 609 Constipation 644
Chest Pain 610 Anal Fissure 646

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 Contents xi

Congenital Anorectal Anomalies 646 Pancreatic Disorders 708

Clostridium Difficile Infection in Children 647 Acute Pancreatitis 708
Disorders of the Peritoneal Cavity 648 Chronic Pancreatitis 710
Peritonitis 648 Gastrointestinal & Hepatobiliary
Chylous Ascites 648 Manifestations of Cystic Fibrosis 711
Gastrointestinal Tumors & Malignancies 649 Syndromes with Pancreatic
Juvenile Polyps 649 Exocrine Insufficiency 711
Cancers of the Esophagus, Small Isolated Exocrine Pancreatic
Bowel, & Colon 651 Enzyme Defect 714
Mesenteric Cysts 651 Pancreatic Tumors 714
Intestinal Hemangiomas & References 715
Vascular Malformations 651
Major Gastrointestinal Symptoms & Signs 652 23. Fluid, Electrolyte, & Acid-Base
Acute Diarrhea 652 Disorders & Therapy 716
Chronic Diarrhea 653
Gastrointestinal Bleeding 655 Melisha G. Hanna, MD, MS
Vomiting 658 Margret Bock, MD, MS
Abdominal Pain 660 Regulation of Body Fluids, Electrolytes,
Acute Abdomen 661 & Tonicity 716
Malabsorption Syndromes 661 Acid-Base Balance 717
Inflammatory Bowel Disease 665 Fluid & Electrolyte Management 717
Dehydration 719
22. Liver & Pancreas 669 Hyponatremia 721
Hypernatremia 722
Ronald J Sokol, MD, FAASLD Potassium Disorders 722
Michael R. Narkewicz, MD Acid-Base Disturbances 724
Shikha S Sundaram, MD, MSCI Metabolic Acidosis 724
Cara L. Mack, MD Metabolic Alkalosis 725
Liver Disorders 669 Respiratory Acidosis 725
Neonatal Cholestatic Jaundice 669 Respiratory Alkalosis 725
Intrahepatic Cholestasis 669
Extrahepatic Neonatal Cholestasis 678 24. Kidney & Urinary Tract 726
Other Neonatal Hyperbilirubinemic
Conditions (Noncholestatic Melissa A. Cadnapaphornchai, MD
Nonhemolytic) 680 Gary M. Lum, MD
Hepatitis A 683 Evaluation of the Kidney & Urinary Tract 726
Hepatitis B 685 History 726
Hepatitis C 687 Physical Examination 726
Hepatitis D (Delta Agent) 688 Laboratory Evaluation of Renal Function 726
Hepatitis E 688 Laboratory Evaluation of Immunologic
Other Hepatitis Viruses 688 Function 730
Acute Liver Failure 689 Radiographic Evaluation 730
Autoimmune Hepatitis 690 Renal Biopsy 730
Nonalcoholic Fatty Liver Disease 692 Congenital Anomalies of the Urinary Tract 730
a1-Antitrypsin Deficiency Liver Disease 693 Renal Parenchymal Anomalies 730
Wilson Disease (Hepatolenticular Distal Urinary Tract Anomalies 731
Degeneration) 694 Hematuria & Glomerular Disease 732
Drug-Induced Liver Disease 696 Microhematuria 732
Cirrhosis 696 Glomerulonephritis 732
Portal Hypertension 698 Tubulointerstitial Disease 734
Biliary Tract Disease 701 Acute Interstitial Nephritis 734
Pyogenic & Amebic Liver Abscess 705 Proteinuria & Renal Disease 734
Liver Tumors 706 Congenital Nephrosis (Finnish Type) 735
Liver Transplantation 708

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Idiopathic Nephrotic Syndrome Acute Ataxias of Childhood 794

of Childhood 735 Chronic & Episodic Ataxias 797
Focal Segmental Glomerulosclerosis 736 Movement Disorders 797
Membranous Nephropathy Cerebral Palsy 800
(Membranous Glomerulonephritis) 736 Infections & Inflammatory Disorders
Diseases of the Renal Vessels 736 of the Central Nervous System 801
Renal Vein Thrombosis 736 Bacterial Meningitis 802
Renal Arterial Disease 737 Brain Abscess 803
Hemolytic-Uremic Syndrome 737 Viral Infections 804
Renal Failure 738 Encephalopathy of Human
Acute Kidney Injury 738 Immunodeficiency Virus Infection 804
Chronic Renal Failure 741 Other Infections 805
Hypertension 742 Noninfectious Inflammatory Disorders
Inherited or Developmental of the Central Nervous System 805
Defects of the Kidneys 745 Multiple Sclerosis 806
Disorders of the Renal Tubules 746 Syndromes Presenting as Acute
Cystinosis 746 Flaccid Weakness 807
Oculocerebrorenal Syndrome Disorders of Childhood Affecting Muscles 810
(Lowe Syndrome) 747 Benign Acute Childhood Myositis 817
Hypokalemic Alkalosis (Bartter Syndrome, Myasthenic Syndromes 817
Gitelman Syndrome, & Liddle Syndrome) 747 Peripheral Nerve Palsies 819
Nephrogenic Diabetes Insipidus (NDI) 747 Chronic Polyneuropathy 820
Nephrolithiasis 748 Miscellaneous Neuromuscular Disorders 821
Urinary Tract Infections 749 Floppy Infant Syndrome 821
QA/QI in Pediatric Nephrology 750
26. Orthopedics 824
25. Neurologic & Muscular Disorders 752
Jason Rhodes, MD, MS
Teri L. Schreiner, MD, MPH Mark A. Erickson, MD, MMM
Michele L. Yang, MD Alex Tagawa, BS
Jan A. Martin, MD Cameron Niswander, BA
Ricka Messer, MD, PhD Disturbances of Prenatal Origin 824
Scott Demarest, MD Congenital Amputations &
Diana Walleigh, MD Limb Deficiencies 824
Neurologic Assessment & Neurodiagnostics 752 Deformities of the Extremities 825
History & Examination 752 Common Foot Problems 825
Diagnostic Testing 752 Genu Varum & Genu Valgum 827
Pediatric Neuroradiologic Procedures 754 Tibial Torsion & Femoral Anteversion 828
Disorders Affecting the Nervous System Developmental Dysplasia of the Hip Joint 828
in Infants & Children 758 Slipped Capital Femoral Epiphysis 830
Altered States of Consciousness (Coma) 758 Common Spine Conditions 831
Seizures & Epilepsy 761 Torticollis 831
Sleep Disorders 773 Scoliosis 832
Headaches 774 Kyphosis 832
Pseudotumor Cerebri (Idiopathic Inflammatory Conditions 833
Intracranial Hypertension) 777 Arthritis & Tenosynovitis 833
Cerebrovascular Disease 779 Syndromes with Musculoskeletal Involvement 834
Congenital Malformations of the Arthrogryposis Multiplex Congenita
Nervous System 782 (Amyoplasia Congenita) 834
Abnormal Head Size 785 Klippel-Feil Syndrome 834
Neurocutaneous Dysplasias 787 Neurologic Disorders Involving the
Central Nervous System Degenerative Musculoskeletal System 836
Disorders of Infancy & Childhood 794 Trauma 837
Ataxias of Childhood 794 Traumatic Subluxations & Dislocations 839

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 Contents xiii

Fractures 840 30. Hematologic Disorders 898

Infections of the Bones & Joints 842
Vascular Lesions & Avascular Necrosis Daniel R. Ambruso, MD
(Osteochondroses) 845 Rachelle Nuss, MD
Neoplasia of the Musculoskeletal System 846 Michael Wang, MD
Miscellaneous Diseases of Bone & Joint 848 Normal Hematologic Values 898
Fibrous Dysplasia 848 Bone Marrow Failure 898
Bone Cysts, Baker Cyst, & Ganglions 849 Constitutional Aplastic Anemia
Quality Assurance/Improvement Initiatives (Fanconi Anemia) 898
in Orthopedics 849 Acquired Aplastic Anemia 900
Anemias 901
27. Sports Medicine 850 Approach to the Child with Anemia 901
Pure Red Cell Aplasia 903
Katherine S. Dahab, MD, FAAP, CAQSM Nutritional Anemias 904
Kyle B. Nagle, MD, MPH, FAAP, CAQSM Anemia of Chronic Disorders 906
Armando Vidal, MD Congenital Hemolytic Anemias:
Basic Principles 850 Red Cell Membrane Defects 907
Fitness & Conditioning 850 Congenital Hemolytic Anemias:
Sports Nutrition 851 Hemoglobinopathies 909
Preparticipation Physical Evaluation 851 Congenital Hemolytic Anemias:
Rehabilitation of Sports Injuries 859 Disorders of Red Cell Metabolism 916
Common Sports Medicine Issues & Injuries 860 Acquired Hemolytic Anemia 917
Infectious Diseases 860 Polycythemia & Methemoglobinemia 919
Head & Neck Injuries 860 Methemoglobinemia 920
Spine Injuries 864 Disorders of Leukocytes 920
Shoulder Injuries 865 Neutropenia 920
Elbow Injuries 867 Neutrophilia 922
Hand & Wrist Injuries 869 Disorders of Neutrophil Function 923
Hip Injuries 871 Lymphocytosis 925
Knee Injuries 873 Eosinophilia 925
Foot & Ankle Injuries 877 Bleeding Disorders 925
Prevention 878 Abnormalities of Platelet Number
or Function 927
28. Rehabilitation Medicine 880 Inherited Bleeding Disorders 931
Von Willebrand Disease 935
Gerald H. Clayton, PhD Acquired Bleeding Disorders 936
Pamela E. Wilson, MD Vascular Abnormalities Associated
Pediatric Brain Injury 880 with Bleeding 938
Spinal Cord Injury 883 Thrombotic Disorders 939
Brachial Plexus Lesions & Splenic Abnormalities 943
Typical Features 885 Splenomegaly & Hypersplenism 943
Common Rehabilitation Problems 886 Asplenia & Splenectomy 943
Quality Assurance/Improvement Transfusion Medicine 944
Initiatives in Rehabilitation Medicine 888 Donor Screening & Blood Processing:
Risk Management 944
29. Rheumatic Diseases 889 Storage & Preservation of Blood & Blood
Components 944
Jennifer B. Soep, MD
Pretransfusion Testing 945
Juvenile Idiopathic Arthritis 889 Transfusion Practice 949
Systemic Lupus Erythematosus 892 References 952
Dermatomyositis 894
Vasculitis 895
Raynaud Phenomenon 896
Noninflammatory Pain Syndromes 896

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 xiv Contents

31. Neoplastic Disease 953 Children’s Concept of Death 992

Spiritual & Cultural Support 993
John A. Craddock, MD Withdrawal of Medical Life Support 994
Ralph R. Quinones, MD Advance Care Planning 994
Amy K. Keating, MD References 996
Kelly Maloney, MD
Jean M. Mulcahy Levy, MD 33. Immunodeficiency 997
Roger H. Giller, MD
Brian S. Greffe, MD Jordan K. Abbott, MD
Anna Franklin, MD Pia J. Hauk, MD
Timothy Garrington, MD Immunodeficiency Evaluation: Primary
Major Pediatric Neoplastic Diseases 953 Considerations 997
Acute Lymphoblastic Leukemia 953 Severe Combined Immunodeficiency
Acute Myeloid Leukemia 957 Diseases 1001
Myeloproliferative Diseases 959 SCID Classification 1002
Brain Tumors 961 Other Combined Immunodeficiencies 1004
Lymphomas & Lymphoproliferative Antibody Deficiency Syndromes 1006
Disorders 965 Phagocyte Disorders 1010
Neuroblastoma 970 Deficiencies of the Innate Immune System 1011
Wilms Tumor (Nephroblastoma) 972 Immunodeficiency Diseases
Bone Tumors 974 That Present with Autoimmunity 1013
Rhabdomyosarcoma 976 Immunodeficiency Diseases
Retinoblastoma 977 That Overlap with Allergy 1014
Hepatic Tumors 978
Langerhans Cell Histiocytosis 980 34. Endocrine Disorders 1016
Hematopoietic Stem Cell Transplant 981
General Considerations 981 Sarah Bartz, MD
Late Effects of Pediatric Cancer Therapy 983 Jennifer M. Barker, MD
Growth Complications 983 Michael S. Kappy, MD, PhD
Endocrine Complications 983 Megan Moriarty Kelsey, MD, MS
Cardiopulmonary Complications 984 Sharon H. Travers, MD
Renal Complications 984 Philip S. Zeitler, MD, PhD
Neuropsychological Complications 984 General Concepts 1016
Second Malignancies 985 Hormone Types 1016
Feedback Control of Hormone Secretion 1016
32. Pain Management & Pediatric Disturbances of Growth 1017
Palliative & End-of-Life Care 986 Target Height & Skeletal Maturation 1018
Short Stature 1018
Brian S. Greffe, MD Tall Stature 1024
Jeffrey L. Galinkin, MD, FAAP Disorders of the Posterior Pituitary Gland 1025
Nancy A. King, MSN, RN, CPNP Arginine Vasopressin
Introduction 986 (Antidiuretic Hormone) Physiology 1025
Pain Assessment 986 Central Diabetes Insipidus 1025
Acute Pain 986 Thyroid Gland 1026
Chronic Pain Management 989 Fetal Development of the Thyroid 1026
Pediatric Palliative & End-of-Life Care 991 Physiology 1026
Introduction 991 Hypothyroidism (Congenital & Acquired) 1027
Children Who May Benefit from Palliative Thyroiditis 1028
Care Interventions 991 Hyperthyroidism 1029
Pain Management in Pediatric Palliative Care 992 Thyroid Cancer 1031
Quality-of-Life Adjuncts & Symptom Disorders of Calcium & Phosphorus
Management in Pediatric Palliative Care 992 Metabolism 1031
Psychosocial Aspects of Pediatric Hypocalcemic Disorders 1031
Palliative Care 992

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 Contents xv

Pseudohypoparathyroidism 36. Inborn Errors of Metabolism 1065

(Resistance to Parathyroid
Hormone Action) 1035 Janet A. Thomas, MD
Hypercalcemic States 1035 Johan L.K. Van Hove, MD, PhD, MBA
Familial Hypocalciuric Hypercalcemia Peter R. Baker II, MD
(Familial Benign Hypercalcemia) 1037 Introduction 1065
Hypervitaminosis D 1037 Diagnosis 1065
Idiopathic Hypercalcemia of Suspecting Inborn Errors 1065
Infancy (Williams Syndrome) 1037 Laboratory Studies 1066
Immobilization Hypercalcemia 1037 Common Clinical Situations 1066
Hypophosphatasia 1037 Management of Metabolic Emergencies 1067
Gonads (Ovaries & Testes) 1037 Newborn Screening 1067
Development 1037 Disorders of Carbohydrate Metabolism 1068
Disorders of Sexual Development 1038 Glycogen Storage Diseases 1068
Abnormalities in Female Pubertal Galactosemia 1069
Development & Ovarian Function 1040 Hereditary Fructose Intolerance 1070
Abnormalities in Male Pubertal Disorders of Energy Metabolism 1071
Development & Testicular Function 1043 Disorders of Amino Acid Metabolism 1073
Adrenal Cortex 1045 Disorders of the Urea Cycle 1073
Adrenocortical Insufficiency Phenylketonuria & the
(Adrenal Crisis, Addison Disease) 1046 Hyperphenylalaninemias 1074
Congenital Adrenal Hyperplasias 1048 Hereditary Tyrosinemia 1076
Adrenocortical Hyperfunction Maple Syrup Urine Disease
(Cushing Disease, Cushing Syndrome) 1050 (Branched-Chain Ketoaciduria) 1077
Primary Hyperaldosteronism 1051 Homocystinuria 1077
Uses of Glucocorticoids & Adrenocorticotropic Nonketotic Hyperglycinemia 1078
Hormone in Treatment of Organic Acidemias 1079
Nonendocrine Diseases 1051 Propionic & Methylmalonic
Adrenal Medulla Pheochromocytoma 1053 Acidemia (Ketotic Hyperglycinemias) 1079
Carboxylase Deficiency 1081
35. Diabetes Mellitus 1054 Glutaric Acidemia Type I 1081
Disorders of Fatty Acid O ­ xidation
Brigitte I. Frohnert, MD, PhD & Carnitine 1082
H. Peter Chase, MD Fatty Acid Oxidation Disorders 1082
Marian Rewers, MD, PhD Carnitine 1083
General Considerations 1054 Purine Metabolism Disorders 1083
Pathogenesis 1055 Lysosomal Diseases 1084
Prevention 1055 Peroxisomal Diseases 1087
Clinical Findings 1055 Congenital Disorders of Glycosylation 1088
Differential Diagnosis 1056 Smith-Lemli-Opitz Syndrome & D ­ isorders
Complications 1056 of Cholesterol Synthesis 1089
Associated Autoimmune Diseases in Disorders of Brain Specific M ­ etabolism:
Type 1 Diabetes 1059 Neurotransmitters, Synthesis
Associated Conditions with Type 2 of Amino Acids & Sphingolipids 1090
Diabetes 1060 Creatine Synthesis Disorders 1091
Treatment 1060 Quality Initiatives in the Field of
Quality Assessment (QA) & Outcomes Metabolic Disease 1092
Metrics 1064
Prognosis 1064
References 1064

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 xvi Contents

37. Genetics & Dysmorphology 1093 Urticaria & Angioedema 1152

Anaphylaxis 1154
Naomi J.L. Meeks, MD Adverse Reactions to Drugs & Biologicals 1156
Margarita Saenz, MD Food Allergy 1159
Anne Chun-Hui Tsai, MD, MSc Insect Allergy 1161
Ellen R. Elias, MD
Foundations of Genetic Diagnosis 1093 39. Antimicrobial Therapy 1163
Cytogenetics 1093
Molecular Genetics 1098 Sarah K. Parker, MD
Principles of Inherited Human Disorders 1099 Jason Child, PharmD
Mendelian Inheritance 1099 Justin Searns, MD
Multifactorial Inheritance 1102 John W. Ogle, MD
Nonmendelian Inheritance 1103 Principles of Antimicrobial Therapy 1163
Family History & Pedigree 1104 Susceptibility Testing & Drug Dosing
Dysmorphology & Human Embryology 1105 Properties 1163
Mechanisms 1105 Pharmacodynamic Concepts 1164
Clinical Dysmorphology 1106 Use of Antimicrobial Agents to
Chromosomal Disorders: Prevent Disease 1165
Abnormal Number 1107 Concepts for Judicious Use of
Trisomies 1107 Antimicrobials 1165
Sex Chromosome Abnormalities 1108 Choice of Antimicrobial Agents 1167
Chromosomal Abnormalities: Specific Antimicrobial Agents 1167
Abnormal Structure 1109 b-Lactam Antibiotics
Chromosome Deletion Disorders 1109 (Step 1, Figure 39–2) 1167
Contiguous Gene Disorders 1109 b-Lactam: Penicillins 1175
Mendelian Disorders 1110 b-Lactam: Cephems 1181
Autosomal Dominant Disorders 1110 b-Lactam: Monobactams 1181
Autosomal Recessive Disorders 1113 b-Lactam: Carbapenems 1181
X-Linked Disorders 1114 Glycopeptide Agents (Step 2, Figure 39–2) 1182
Nonmendelian Disorders 1115 Daptomycin (Step 4, Figure 39–2) 1182
Disorders of Imprinting 1115 Trimethoprim/Sulfamethoxazole
Disorders Associated with Anticipation 1116 (Step 5, Figure 39–2) 1182
Disorders of Multifactorial Inheritance 1116 Metronidazole (Step 6, Figure 39–2) 1183
Cleft Lip & Cleft Palate 1117 Macrolides (Step 6, Figure 39–2) 1183
Neural Tube Defects 1118 Lincosamides (Step 6, Figure 39–2) 1183
Common Recognizable Disorders Oxazolidinones (Step 6, Figure 39–2) 1184
with Variable or Unknown Cause 1119 Tetracyclines (Step 6, Figure 39–2) 1184
Genetic Evaluation of the Child Aminoglycosides (Step 6, Figure 39–2) 1184
with Developmental Disabilities 1120 Rifamycins (Step 7, Figure 39–2) 1185
Perinatal Genetics 1122 Fluoroquinolones (Step 8, Figure 39–2) 1185
Teratogens 1122 References 1185
Assisted Reproduction 1122
Prenatal Diagnosis 1123 40. Infections: Viral & Rickettsial 1187
Myron J. Levin, MD
38. Allergic Disorders 1124 Daniel Olson,
Ronina A. Covar, MD Edwin J. Asturias, MD
David M. Fleischer, MD Adriana Weinberg, MD
Christine Cho, MD Viral Infections 1187
Mark Boguniewicz, MD Respiratory Infections 1187
Introduction 1124 Viruses Causing the Common Cold 1187
Asthma 1124 Infections due to Adenoviruses 1190
Allergic Rhinoconjunctivitis 1143
Atopic Dermatitis 1148

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 Contents xvii

Influenza 1194 42. Infections: Bacterial & Spirochetal 1246

Parainfluenza (Croup) 1195
Respiratory Syncytial Virus Disease 1196 James Gaensbauer, MD, MScPH
Human Metapneumovirus Infection 1198 Yosuke Nomura, MD
Infections due to Enteroviruses John W. Ogle, MD
& Parechoviruses 1198 Marsha S. Anderson, MD
Acute Febrile Illness 1199 Bacterial Infections 1246
Respiratory Tract Illnesses 1199 Group A Streptococcal Infections 1246
Rashes (Including Hand-Foot-&- Group B Streptococcal Infections 1250
Mouth Disease) 1200 Streptococcal Infections with Organisms
Central Nervous System Illnesses 1200 Other than Group A or B 1253
Infections due to Herpesviruses 1203 Pneumococcal Infections 1254
Herpes Simplex Infections 1203 Staphylococcal Infections 1257
Varicella & Herpes Zoster 1206 Meningococcal Infections 1261
Roseola Infantum (Exanthem Subitum) 1208 Gonococcal Infections 1264
Cytomegalovirus Infections 1209 Botulism 1267
Infectious Mononucleosis Tetanus 1269
(Epstein-Barr Virus) 1212 Gas Gangrene 1270
Viral Infections Spread by Insect Vectors 1214 Diphtheria 1271
Encephalitis 1214 Infections due to Enterobacteriaceae 1273
Dengue 1218 Pseudomonas Infections 1275
Chikungunya 1219 Salmonella Gastroenteritis 1277
Zika 1220 Typhoid Fever & Paratyphoid Fever 1279
Colorado Tick Fever 1221 Shigellosis (Bacillary Dysentery) 1280
Other Major Viral Childhood Exanthems 1222 Cholera 1281
Erythema Infectiosum 1222 Campylobacter Infection 1283
Measles (Rubeola) 1223 Tularemia 1284
Rubella 1225 Plague 1285
Infections due to Other Viruses 1226 Haemophilus Influenzae Type B Infections 1287
Hantavirus Cardiopulmonary Syndrome 1226 Pertussis (Whooping Cough) 1289
Mumps 1227 Listeriosis 1291
Rabies 1228 Tuberculosis 1293
Rickettsial Infections & Q Fever 1229 Infections with Nontuberculous
Human Ehrlichiosis & Anaplasmosis 1230 Mycobacteria 1296
Rocky Mountain Spotted Fever 1231 Legionella Infection 1298
Endemic Typhus (Murine Typhus) 1231 Chlamydophila & Chlamydia Infections
Q Fever 1232 (Psittacosis, C Pneumoniae, &
C Trachomatis) 1299
41. Human Immunodeficiency Cat-Scratch Disease 1301
Virus Infection 1233 Spirochetal Infections 1302
Syphilis 1302
Elizabeth J. McFarland, MD Relapsing Fever 1305
Perinatally HIV-Exposed Infant 1235 Leptospirosis 1306
Adolescents with HIV Exposure 1236 Lyme Disease 1308
Progressive HIV Disease 1237
Treatment 1240
Prevention 1244
Quality Assurance & Outcome Metrics 1245

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 xviii Contents

43. Infections: Parasitic & Mycotic 1311 Vaginal Discharge 1364

Genital Ulcerations 1365
James Gaensbauer, MD, MScPH Genital Warts & Human Papillomavirus 1368
Kevin Messacar, MD Other Viral Infections 1370
Samuel R. Dominguez, MD, PhD Ectoparasitic Infections 1371
Myron J. Levin, MD References 1372
Parasitic Infections 1311
Protozoal Infections 1312 45. Travel Medicine 1373
Systemic Infections 1312
Gastrointestinal Infections 1319 Suchitra Rao, MBBS
Trichomoniasis 1324 Introduction 1373
Metazoal Infections 1325 Preparing Children & Infants
Nematode Infections 1325 for Travel 1373
Cestode Infections (Flukes) 1331 Vaccinations—Routine Childhood
Trematode Infections 1334 Vaccines Modified for Travel 1375
Mycotic Infections 1335 Vaccinations—Travel-Specific 1377
Pneumocystis & Other Opportunistic Traveler’s Diarrhea 1379
Fungal Infections 1346 Malaria Prophylaxis & Prevention 1380
Pneumocystis Jiroveci Infection 1348 Visits to Friends & Relatives (VFR)
in High-Risk Areas 1381
44. Sexually Transmitted Infections 1351 HIV & Sexually Transmitted Diseases 1381
Fever in the Returned Traveler 1384
Daniel H. Reirden, MD References 1388
Ann-Christine Nyquist, MD, MSPH
Adolescent Sexuality 1351 46. Chemistry & Hematology Reference
Risk Factors 1352 Intervals 1389
Prevention of Sexually
Transmitted Infections 1352 Jordana E. Hoppe, MD
Screening for Sexually Robert Snyder, MT (ASCP)
Transmitted Infections 1352 Frank J. Accurso, MD
Signs & Symptoms 1353 Georgette Siparsky, PhD
The Most Common Antibiotic- Challenges in Determining & Interpreting
Responsive Sexually Transmitted Pediatric Reference Intervals 1389
Infections 1353 Guidelines for Use of Data in a Reference
Chlamydia Trachomatis Infection 1353 Range Study 1389
Neisseria Gonorrhoeae Infection 1354 Statistical Computation of
The Spectrum of Signs & Symptoms of Reference Intervals 1390
Sexually Transmitted Infections 1360 Why Reference Intervals Vary 1391
Cervicitis 1360 Sensitivity & Specificity 1391
Pelvic Inflammatory Disease 1361 Pediatric Reference Intervals 1392
Urethritis 1362
Epididymitis 1363 Index 1405
Proctitis, Proctocolitis, & Enteritis 1363

Hay_FM_pi-xxxii.indd 18 30/03/18 11:40 AM

 Authors
Jordan K. Abbott, MD
Assistant Professor, Department of Pediatrics, University of
Colorado School of Medicine and Children’s Hospital
Colorado; Division of Pediatric Allergy, Asthma and Clinical
Immunology, National Jewish Health
Chapter 33: Immunodeficiency
Frank J. Accurso, MD
Professor, Department of Pediatrics, Section of Pediatric
Pulmonary Medicine, University of Colorado School of
Medicine and Children’s Hospital Colorado
Chapter 46: Chemistry & Hematology Reference Intervals
Daniel R. Ambruso, MD
Professor, Department of Pediatrics, Section of Pediatric
Hematology, Oncology, and Bone Marrow Transplant,
University of Colorado School of Medicine and Children’s
Hospital Colorado
Chapter 30: Hematologic Disorders
Marsha S. Anderson, MD
Professor, Department of Pediatrics, Section of
Pediatric Infectious Diseases, University of Colorado School
of Medicine and Children’s Hospital Colorado
Chapter 42: Infections: Bacterial & Spirochetal
Edwin J. Asturias, MD
Associate Professor, Departments of Pediatrics and
Epidemiology and Infectious Diseases, University of
Colorado School of Medicine; Associate Director, Center for
Global Health, Colorado School of Public Health
Chapter 40: Infections: Viral & Rickettsial
Christopher D. Baker, MD
Associate Professor, Department of Pediatrics, Section of
Pediatric Pulmonary Medicine, University of Colorado
School of Medicine and Children’s Hospital Colorado
Chapter 19: Respiratory Tract & Mediastinum
Peter R. Baker II, MD
Assistant Professor, Department of Pediatrics, Section of
Clinical Genetics and Metabolism, University of Colorado
School of Medicine and Children’s Hospital Colorado
Chapter 36: Inborn Errors of Metabolism
Jennifer M. Barker, MD
Associate Professor, Department of Pediatrics, Section of
Pediatric Endocrinology, University of Colorado School of
Medicine and Children’s Hospital Colorado
Chapter 34: Endocrine Disorders
xix
Hay_FM_pi-xxxii.indd 19
Sarah Bartz, MD
Assistant Professor, Department of Pediatrics, Section of
Pediatric Endocrinology, University of Colorado School of
Medicine and Children’s Hospital Colorado
Chapter 34: Endocrine Disorders
Margret Bock, MD, MS
Assistant Professor, Department of Pediatrics, Section of
Pediatric Nephrology, University of Colorado and Children’s
Hospital Colorado
Chapter 23: Fluid, Electrolyte, & Acid-Base Disorders & Therapy
Mark Boguniewicz, MD
Professor, Department of Pediatrics, University of Colorado
School of Medicine and Children’s Hospital Colorado;
Division of Pediatric Allergy, Asthma and Clinical
Immunology, National Jewish Health
Chapter 38: Allergic Disorders
Rebecca Sands Braverman, MD
Associate Professor, Department of Ophthalmology,
University of Colorado School of Medicine
Chapter 16: Eye
David Brumbaugh, MD
Associate Professor, Department of Pediatrics, Section of
Pediatric Gastroenterology Hepatology and Nutrition,
University of Colorado School of Medicine and Children’s
Hospital Colorado
Chapter 21: Gastrointestinal Tract
Maya Bunik, MD, MSPH
Professor, Department of Pediatrics, Section of General
Academic Pediatrics, Director of the Child Health Clinic,
University of Colorado Denver School of Medicine and
Children’s Hospital Colorado
Chapter 9: Ambulatory & Office Pediatrics
Dale Burkett, MD
Assistant Professor, Department of Pediatrics, Section of
Pediatric Cardiology, University of Colorado School of
Medicine and Children’s Hospital Colorado
Chapter 20: Cardiovascular Diseases
Adam Burstein, DO
Senior Clinical Instructor, Department of Child & Adolescent
Psychiatry, Psychiatry Resident Training Programs,
University of Colorado School of Medicine and Children’s
Hospital Colorado
Chapter 7: Child & Adolescent Psychiatric Disorders &
Psychosocial Aspects of Pediatrics
30/03/18 11:40 AM
 xx AUTHORS
Melissa A. Cadnapaphornchai, MD
Professor, Departments of Pediatrics and Medicine,
University of Colorado School of Medicine, Section of
Pediatric Nephrology, Director, Pediatric Continuous Renal
Replacement Therapy, Hemodialysis, and Peritoneal
Dialysis, The Kidney Center, Children’s Hospital Colorado
Chapter 24: Kidney & Urinary Tract
Michelle Caraballo, MD
Former Fellow, Department of Pediatrics, Section of Pediatric
Pulmonary Medicine, University of Colorado School of
Medicine and Children’s Hospital Colorado
Assistant Professor, Department of Pediatrics, Division of
Respiratory Medicine, University of Texas Southwestern
Medical Center
Chapter 19: Respiratory Tract & Mediastinum
Kevin P. Carney, MD
Assistant Professor, Department of Pediatrics, Section of
Emergency Medicine, University of Colorado School of
Medicine, Director of Quality Improvement, Children’s
Hospital Colorado
Chapter 12: Emergencies & Injuries
Todd C. Carpenter, MD
Associate Professor, Department of Pediatrics, Section of
Pediatric Critical Care Medicine, University of Colorado
School of Medicine and Children’s Hospital Colorado
Chapter 14: Critical Care
H. Peter Chase, MD
Professor, Department of Pediatrics, Clinical Director Emeritus,
Barbara Davis Center for Childhood Diabetes, University of
Colorado School of Medicine
Chapter 35: Diabetes Mellitus
Antonia Chiesa, MD
Associate Professor, Department of Pediatrics, Kempe Child
Protection Team, University of Colorado School of
Medicine, Children’s Hospital Colorado and Kempe
Center for the Prevention and Treatment of Child Abuse
and Neglect
Chapter 8: Child Abuse & Neglect
Jason Child, PharmD
Co-Director of Antimicrobial Stewardship, Infectious Disease
Clinical Specialist, Department of Pharmacy, University of
Colorado Skaggs School of Pharmacy and Pharmaceutical
Sciences and Children’s Hospital Colorado
Chapter 39: Antimicrobial Therapy
Christine Cho, MD
Assistant Professor, Department of Pediatrics, University
Colorado School of Medicine and Children’s Hospital
Colorado; Division of Allergy, Asthma and Clinical
Immunology, National Jewish Health
Chapter 38: Allergic Disorders
Hay_FM_pi-xxxii.indd 20
Gerald H. Clayton, PhD
Instructor, Department of Physical Medicine and
Rehabilitation, University of Colorado School of Medicine
and Children’s Hospital Colorado
Chapter 28: Rehabilitation Medicine
Amy Clevenger, MD, PhD
Assistant Professor, Department of Pediatrics, Section of
Pediatric Critical Care Medicine, University of Colorado
School of Medicine and Children’s Hospital Colorado
Chapter 14: Critical Care
Kathryn K. Collins, MD
Professor, Department of Pediatrics, Section of
Pediatric Cardiology, University of Colorado School of
Medicine and Children’s Hospital Colorado
Chapter 20: Cardiovascular Diseases
Ronina A. Covar, MD
Associate Professor, Department of Pediatrics, University of
Colorado School of Medicine and Children’s Hospital
Colorado; Division of Pediatric Allergy, Asthma and Clinical
Immunology, National Jewish Health
Chapter 38: Allergic Disorders
John A. Craddock, MD
Assistant Professor, Department of Pediatrics, Section of
Pediatric Hematology, Oncology, and Bone Marrow
Transplant, Center for Cancer and Blood Disorders,
University of Colorado School of Medicine and Children’s
Hospital Colorado
Chapter 31: Neoplastic Disease
Angela S. Czaja, MD, MSc
Associate Professor, Department of Pediatrics, Section of
Pediatric Critical Care Medicine, University of Colorado
School of Medicine and Children’s Hospital Colorado
Chapter 14: Critical Care
Katherine S. Dahab, MD, FAAP, CAQSM
Assistant Professor, Department of Orthopedics, Fellowship
Director, Pediatric Primary Care Sports Medicine
Fellowship, University of Colorado School of Medicine and
Children’s Hospital Colorado
Chapter 27: Sports Medicine
Matthew F. Daley, MD
Associate Professor, Department of Pediatrics, Section of
General Academic Pediatrics, University of Colorado School
of Medicine and Children’s Hospital Colorado
Chapter 10: Immunization
Jeffrey R. Darst, MD
Associate Professor, Department of Pediatrics, Section of
Pediatric Cardiology, University of Colorado School of
Medicine and Children’s Hospital Colorado
Chapter 20: Cardiovascular Diseases
30/03/18 11:40 AM

Richard C. Dart, MD, PhD
Professor, Departments of Regulatory Compliance and
Emergency Medicine, University of Colorado School of
Medicine; Director, Rocky Mountain Poison and Drug
Center, Denver Health and Hospital Authority
Chapter 13: Poison
Emily M. Deboer, MD
Assistant Professor, Department of Pediatrics, Section of
Pediatric Pulmonary Medicine, University of Colorado
School of Medicine and Children’s Hospital Colorado
Chapter 19: Respiratory Tract & Mediastinum
Scott Demarest, MD
Assistant Professor, Department of Pediatrics, Neurology,
University of Colorado School of Medicine and Children’s
Hospital Colorado
Chapter 25: Neurologic & Muscular Disorders
Samuel R. Dominguez, MD, PhD
Associate Professor, Department of Pediatrics, Section of
Pediatric Infectious Diseases, University of Colorado School
of Medicine and Children’s Hospital Colorado
Chapter 43: Infections: Parasitic & Mycotic
Ellen R. Elias, MD
Professor, Departments of Pediatrics and Genetics, Director,
Special Care Clinic, University of Colorado School of
Medicine and Children’s Hospital Colorado
Chapter 37: Genetics & Dysmorphology
Mark A. Erickson, MD, MMM
Chairman, Department of Pediatric Orthopaedics, Professor
of Orthopaedic Surgery, Orthopedic Institute, University
of Colorado School of Medicine and Children’s Hospital
Colorado
Chapter 26: Orthopedics
Monica J. Federico, MD
Associate Professor, Department of Pediatrics, Section of
Pediatric Pulmonary Medicine, University of Colorado
School of Medicine and Children’s Hospital Colorado
Chapter 19: Respiratory Tract & Mediastinum
David M. Fleischer, MD
Associate Professor, Department of Pediatrics, University of
Colorado School of Medicine and Children’s Hospital
Colorado; Division of Pediatric Allergy, Asthma and Clinical
Immunology, National Jewish Health
Chapter 38: Allergic Disorders
David Fox, MD
Associate Professor, Department of Pediatrics, Section of
General Academic Pediatrics, University of Colorado School
of Medicine and Children’s Hospital Colorado
Chapter 9: Ambulatory & Office Pediatrics
Hay_FM_pi-xxxii.indd 21
AUTHORS xxi
Anna Franklin, MD
Associate Professor, Department of Pediatrics,
Section of Pediatric Hematology, Oncology, and
Bone Marrow Transplant, University of Colorado
School of Medicine and Children’s Hospital Colorado
Chapter 31: Neoplastic Disease
Norman R. Friedman, MD
Associate Professor, Departments of Otolaryngology &
Pediatrics, University of Colorado School of Medicine and
Children’s Hospital Colorado
Chapter 18: Ear, Nose, & Throat
Brigitte I. Frohnert, MD, PhD
Assistant Professor, Department of Pediatrics, Barbara Davis
Center for Childhood Diabetes, University of Colorado
School of Medicine
Chapter 35: Diabetes Mellitus
Glenn T. Furuta, MD
Professor, Department of Pediatrics, Section of
Gastroenterology, Hepatology and Nutrition, Attending
Physician, Digestive Health Institute; Director,
Gastrointestinal Eosinophil Disease Program, University
of Colorado School of Medicine and Children’s Hospital
Colorado
Chapter 21: Gastrointestinal Tract
James Gaensbauer, MD, MScPH
Assistant Professor, University of Colorado, Children’s
Hospital Colorado Center for Global Health, Colorado
School of Public Health Pavilion for Women and Children
Chapter 42: Infections: Bacterial & Spirochetal
Chapter 43: Infections: Parasitic & Mycotic
Jeffrey L. Galinkin, MD, FAAP
Professor, Department of Anesthesiology, University of
Colorado School of Medicine and Children’s
Hospital Colorado
Chapter 32: Pain Management & Pediatric Palliative &
End-of-Life Care
Roopa Gandhi, BDS, MSD
Assistant Professor, Residency Program Director, Department
of Pediatric Dentistry, University of Colorado School of
Dental Medicine and Children’s Hospital Colorado
Chapter 17: Oral Medicine & Dentistry
Camille Gannam, DMD, MS
Assistant Professor, Department of Pediatric Dentistry,
University of Colorado School of Dental Medicine and
Children’s Hospital Colorado
Chapter 17: Oral Medicine & Dentistry
30/03/18 11:40 AM
 xxii AUTHORS
Timothy Garrington, MD
Associate Professor, Department of Pediatrics, Section of
Pediatric Hematology, Oncology, and Bone Marrow
Transplant, University of Colorado School of Medicine and
Children’s Hospital Colorado
Chapter 31: Neoplastic Disease
Roger H. Giller, MD
Professor, Department of Pediatrics, Section of Pediatric
Hematology, Oncology, and Bone Marrow Transplant,
Director, Pediatric BMT Program, University of Colorado
School of Medicine and Children’s Hospital Colorado
Chapter 31: Neoplastic Disease
Edward Goldson, MD
Professor, Department of Pediatrics, Section of Developmental
Pediatrics, University of Colorado School of Medicine and
Children’s Hospital Colorado
Chapter 3: Child Development & Behavior
Eva N. Grayck, MD
Professor, Department of Pediatrics, Section of
Pediatric Critical Care Medicine, University of Colorado
School of Medicine and Children’s Hospital Colorado
Chapter 14: Critical Care
Brian S. Greffe, MD
Professor, Department of Pediatrics, Section of Pediatric
Hematology, Oncology, and Bone Marrow Transplant,
University of Colorado School of Medicine and Children’s
Hospital Colorado
Chapter 31: Neoplastic Disease
Chapter 32: Pain Management & Pediatric Palliative &
End-of-Life Care
Theresa Grover, MD
Associate Professor, Department of Pediatrics, Section of
Neonatology, University of Colorado School of Medicine
and Children’s Hospital Colorado
Chapter 2: The Newborn Infant
Cameron F. Gunville, DO
Assistant Professor, Department of Pediatrics, Section of
Pediatric Critical Care Medicine, University of Colorado
School of Medicine and Children’s Hospital
Chapter 14: Critical Care
Matthew A. Haemer, MD, MPH
Associate Professor, Department of Pediatrics, Section of
Pediatric Nutrition, University of Colorado School of
Medicine and Children’s Hospital Colorado
Chapter 11: Normal Childhood Nutrition & Its Disorders
Ann C. Halbower, MD
Professor, Department of Pediatrics, Section of Pediatric
Pulmonology, University of Colorado School of Medicine
and Children’s Hospital Colorado
Chapter 19: Respiratory Tract & Mediastinum
Hay_FM_pi-xxxii.indd 22
Melisha G. Hanna, MD, MS
Assistant Professor, Department of Pediatrics, Section of
Pediatric Nephrology, University of Colorado School of
Medicine and Children’s Hospital Colorado
Chapter 23: Fluid, Electrolyte, & Acid-Base Disorders & Therapy
Pia J. Hauk, MD
Associate Professor, Department of Pediatrics, University of
Colorado School of Medicine and National Jewish Health
Chapter 33: Immunodeficiency
Stephen Hawkins, MD, DO
Assistant Professor, Department of Pediatrics, Section of
Pediatric Pulmonary Medicine, University of Colorado
School of Medicine and Children’s Hospital Colorado
Chapter 19: Respiratory Tract & Mediastinum
Edward J. Hoffenberg, MD
Professor, Department of Pediatrics, Section of
Pediatric Gastroenterology, Hepatology and Nutrition,
University of Colorado School of Medicine and Children’s
Hospital Colorado
Chapter 21: Gastrointestinal Tract
Daniel Hyman, MD
Associate Professor, Department of Pediatrics, University of
Colorado School of Medicine, Chief Quality Officer,
Children’s Hospital Colorado
Chapter 1: Advancing the Quality & Safety of Care
Pei-Ni Jone, MD
Associate Professor, Department of Pediatrics, Section of
Pediatric Cardiology, Children’s Hospital Colorado and
University of Colorado School of Medicine
Chapter 20: Cardiovascular Diseases
Jennifer Lee Jung, MD
Assistant Professor, Department of Ophthalmology, University of
Colorado School of Medicine, Children’s Hospital Colorado
Chapter 16: Eye
Michael S. Kappy, MD, PhD
Professor, Department of Pediatrics, Section of Pediatric
Endocrinology, University of Colorado School of Medicine
and Children’s Hospital Colorado
Chapter 34: Endocrine Disorders
Paritosh Kaul, MD
Professor, Department of Pediatrics, Section of Adolescent
Medicine, University of Colorado School of Medicine,
Children’s Hospital Colorado, and Denver Health Medical
Center
Chapter 5: Adolescent Substance Abuse
30/03/18 11:40 AM

Amy K. Keating, MD
Associate Professor, Department of Pediatrics, Section of
Pediatric Hematology, Oncology, and Bone Marrow
Transplant, Center for Cancer and Blood Disorders,
University of Colorado School of Medicine and Children’s
Hospital Colorado
Chapter 31: Neoplastic Disease
Kimberly Kelsay, MD
Associate Professor, Department of Psychiatry and Behavioral
Sciences, University of Colorado School of Medicine and
Children’s Hospital Colorado
Chapter 7: Child & Adolescent Psychiatric Disorders &
Psychosocial Aspects of Pediatrics
Megan Moriarty Kelsey, MD, MS
Associate Professor, Department of Pediatrics, Section of
Pediatric Endocrinology, University of Colorado School of
Medicine and Children’s Hospital Colorado
Chapter 34: Endocrine Disorders
Nancy A. King, MSN, RN, CPNP
Inpatient Oncology Advanced Practice Nurse, Department of
Pediatrics, Section of Hematology, Oncology, and Bone
Marrow Transplant, University of Colorado School of
Medicine and Children’s Hospital Colorado
Chapter 32: Pain Management & Pediatric Palliative
& End-of-Life Care
Ulrich Klein, DMD, DDS, MS
Associate Professor and Chair, Department of Pediatric
Dentistry, Director of Pediatric Dentistry Residency
Program, University of Colorado School of Dental Medicine
and Children’s Hospital Colorado
Chapter 17: Oral Medicine & Dentistry
Gregory Kobak, MD
Senior Instructor, Department of Pediatrics, Section of
Pediatric Gastroenterology, Hepatology and Nutrition,
Digestive Health Institute, University of Colorado School of
Medicine and Children’s Hospital Colorado
Chapter 21: Gastrointestinal Tract
Robert E. Kramer, MD
Professor, Department of Pediatrics, Section of
Pediatric Gastroenterology, Hepatology and Nutrition,
University of Colorado School of Medicine and Children’s
Hospital Colorado
Chapter 21: Gastrointestinal Tract
Nancy F. Krebs, MD, MS
Professor, Department of Pediatrics, Section of Pediatric
Nutrition, University of Colorado School of Medicine and
Children’s Hospital Colorado
Chapter 11: Normal Childhood Nutrition & Its Disorders
Hay_FM_pi-xxxii.indd 23
AUTHORS xxiii
Oren Kupfer, MD
Assistant Professor, Department of Pediatrics, Section of
Pediatric Pulmonary Medicine, University of Colorado
School of Medicine and Children’s Hospital Colorado
Chapter 19: Respiratory Tract & Mediastinum
Myron J. Levin, MD
Professor, Departments of Pediatrics and Medicine,
Section of Pediatric Infectious Diseases, University
of Colorado School of Medicine and Children’s Hospital
Colorado
Chapter 40: Infections: Viral & Rickettsial
Chapter 43: Infections: Parasitic & Mycotic
Gary M. Lum, MD
Clinical Professor, Departments of Pediatrics and Medicine,
Section of Pediatric Nephrology, University of Colorado
School of Medicine and Children’s Hospital Colorado
Chapter 24: Kidney & Urinary Tract
Cara L. Mack, MD
Associate Professor, Department of Pediatrics, Section of
Pediatric Gastroenterology, Hepatology and Nutrition,
University of Colorado School of Medicine and Children’s
Hospital Colorado
Chapter 22: Liver & Pancreas
Kelly Maloney, MD
Professor, Department of Pediatrics, Section of
Pediatric Gastroenterology, Hepatology and Nutrition,
University of Colorado School of Medicine and Children’s
Hospital Colorado
Chapter 31: Neoplastic Disease
Jan A. Martin, MD
Assistant Professor, Department of Pediatrics, Section of
Neurology Genops, University of Colorado School of
Medicine and Children’s Hospital Colorado
Chapter 25: Neurologic & Muscular Disorders
Stacey L. Martiniano, MD
Assistant Professor, Department of Pediatrics, Section of
Pediatric Pulmonary Medicine, University of Colorado
School of Medicine and Children’s Hospital Colorado
Chapter 19: Respiratory Tract & Mediastinum
Elizabeth J. McFarland, MD
Professor, Department of Pediatrics, Section of Pediatric
Infectious Diseases, University of Colorado School of
Medicine and Children’s Hospital Colorado
Chapter 41: Human Immunodeficiency Virus Infection
Naomi J. L. Meeks, MD
Assistant Professor, Department of Pediatrics, Section of
Clinical Genetics and Metabolism, University of Colorado
School of Medicine
Chapter 37: Genetics & Dysmorphology
30/03/18 11:40 AM
 xxiv AUTHORS
Kevin Messacar, MD
Assistant Professor, Department of Pediatrics, Section of
Pediatric Infectious Diseases, University of Colorado School
of Medicine and Children’s Hospital Colorado
Chapter 43: Infections: Parasitic & Mycotic
Ricka Messer, MD, PhD
Assistant Professor, Department of Pediatrics, Neurology,
University of Colorado School of Medicine and Children’s
Hospital Colorado
Chapter 25: Neurologic & Muscular Disorders
Shelley D. Miyamoto, MD
Associate Professor, Department of Pediatrics, Section of
Pediatric Cardiology, University of Colorado School of
Medicine and Children’s Hospital Colorado
Chapter 20: Cardiovascular Diseases
Jean M. Mulcahy Levy, MD
Assistant Professor, Department of Pediatrics, Center for
Cancer and Blood Disorders, University of Colorado
Chapter 31: Neoplastic Disease
Kyle B. Nagle, MD, MPH, FAAP, CAQSM
Assistant Professor, Department of Orthopedics, University of
Colorado School of Medicine, Sports Medicine for Young
Athletes, Children’s Hospital of Colorado Orthopedics
Institute
Chapter 27: Sports Medicine
Michael R. Narkewicz, MD
Professor, Department of Pediatrics, Fellowship Program
Director, Section of Pediatric Gastroenterology,
Hepatology and Nutrition, Hewitt Andrews Chair in
Pediatric Liver Diseases, Medical Director, Pediatric Liver
Center and Liver Transplant Pediatric Services
Associate Clinical Director/Associate Dean for Pediatric
Clinical Affairs, University of Colorado School of Medicine
and Children’s Hospital Colorado
Chapter 22: Liver & Pancreas
Daniel Nicklas, MD
Assistant Professor of Pediatrics, Director of Primary Care
Education, Children’s Hospital Colorado Residency
Program, University of Colorado and Children’s Hospital
Colorado
Chapter 9: Ambulatory & Office Pediatrics
Cameron Niswander, BA
Third Year Medical Student
University of Colorado School of Medicine
Chapter 26: Orthopedics
Yosuke Nomura, MD
Pediatrician and Instructor of Pediatrics, Denver Health,
University of Colorado School of Medicine
Chapter 42: Infections: Bacterial & Spirochetal
Hay_FM_pi-xxxii.indd 24
Rachelle Nuss, MD
Professor, Department of Pediatrics, Section of Pediatric
Hematology, Oncology, and Bone Marrow Transplant;
Associate Director, Colorado Sickle Cell Treatment and
Research Center at University of Colorado School of
Medicine; Director Pediatric Sickle Cell Program, Center for
Cancer and Blood Disorders, Children’s Hospital Colorado
Chapter 30: Hematologic Disorders
Ann-Christine Nyquist, MD, MSPH
Professor, Department of Pediatrics, Section of Pediatric
Infectious Diseases, University of Colorado School of
Medicine and Children’s Hospital Colorado
Chapter 10: Immunization
Chapter 44: Sexually Transmitted Infections
Sean T. O’Leary, MD, MPH
Associate Professor, Department of Pediatrics, Section
of Pediatric Infectious Diseases, University of Colorado
School of Medicine and Children’s Hospital Colorado
Chapter 10: Immunization
John W. Ogle, MD
Professor and Vice Chairman Emeritus, Department of
Pediatrics, University of Colorado School of Medicine
Chapter 39: Antimicrobial Therapy
Chapter 42: Infections: Bacterial & Spirochetal
Sarah K. Parker, MD
Associate Professor, Department of Pediatrics, Section of
Pediatric Infectious Diseases, University of Colorado School
of Medicine and Children’s Hospital Colorado
Chapter 39: Antimicrobial Therapy
Laura E. Primak, RD, CNSD
Professional Research Assistant, Coordinator of Nutrition
Electives, Section of Pediatric Nutrition, University of
Colorado School of Medicine and Children’s Hospital
Colorado
Chapter 11: Normal Childhood Nutrition & Its Disorders
Lori D. Prok, MD
Associate Professor, Departments of Pediatrics and
Dermatology, Section of Pediatric Dermatology, University
of Colorado School of Medicine and Children’s Hospital
Colorado
Chapter 15: Skin
Ralph R. Quinones, MD
Clinical Professor, Department of Pediatrics, Section of
Pediatric Hematology, Oncology, and Bone Marrow
Transplant, Center for Cancer and Blood Disorders,
University of Colorado School of Medicine and Children’s
Hospital Colorado
Chapter 31: Neoplastic Disease
30/03/18 11:40 AM

Suchitra Rao, MBBS
Assistant Professor, Department of Pediatrics, Section of
Pediatric Infectious Disease, University of Colorado School
of Medicine and Children’s Hospital Colorado
Chapter 45: Travel Medicine
Daniel H. Reirden, MD
Associate Professor, Department of Pediatrics, Section of
Adolescent Medicine and Internal Medicine, Medical
Director, CHIP Youth Clinic, Director of Internal
Medicine—Pediatric Residency, University of Colorado
School of Medicine and Children’s Hospital Colorado
Chapter 44: Sexually Transmitted Infections
Marian Rewers, MD, PhD
Professor, Department of Pediatrics, Clinical Director, Barbara
Davis Center for Childhood Diabetes, University of
Colorado School of Medicine
Chapter 35: Diabetes Mellitus
Ann Reynolds, MD
Associate Professor, Department of Pediatrics, Section of
Developmental Pediatrics, University of Colorado School of
Medicine; Director, The Child Development Unit, Children’s
Hospital Colorado
Chapter 3: Child Development & Behavior
Jason Rhodes, MD, MS
Associate Professor, Departments of Mechanical and Materials
Engineering, Director, Cerebral Palsy Program, Orthopedics
Institute, University of Colorado School of Medicine and
Children’s Hospital Colorado
Chapter 26: Orthopedics
Molly J. Richards, MD
Associate Professor, Department of Pediatrics, Section of
Adolescent Medicine, University of Colorado School of
Medicine and Children’s Hospital Colorado
Chapter 4: Adolescence
Leslie Ridall, DO
Assistant Professor, Department of Pediatrics, Section of
Pediatric Critical Care Medicine, University of Colorado
School of Medicine and Children’s Hospital Colorado
Chapter 14: Critical Care
Kelley Roswell, MD
Assistant Professor, Department of Pediatrics, Section of
Emergency Medicine, Co-Director Medical Student
Emergency Care Clerkship, University of Colorado School
of Medicine and Children’s Hospital Colorado
Chapter 12: Emergencies & Injuries
Barry H. Rumack, MD
Clinical Professor, Department of Pediatrics, University of
Colorado School of Medicine; Director Emeritus, Rocky
Mountain Poison and Drug Center, Denver Health
Authority
Chapter 13: Poison
Hay_FM_pi-xxxii.indd 25
AUTHORS xxv
Margarita Sifuentes Saenz, MD
Assistant Professor, Department of Pediatrics, Section of
Clinical Genetics and Metabolism, University of Colorado
School of Medicine and Children’s Hospital Colorado
Chapter 37: Genetics & Dysmorphology
Scott D. Sagel, MD
Professor, Department of Pediatrics, Section of
Pediatric Pulmonary Medicine, University of Colorado
School of Medicine and Children’s Hospital Colorado
Chapter 19: Respiratory Tract & Mediastinum
Amy E. Sass, MD, MPH
Associate Professor, Department of Pediatrics, Section of
Adolescent Medicine, University of Colorado School of
Medicine and Children’s Hospital Colorado
Chapter 4: Adolescence
Melissa A. Scholes, MD
Assistant Professor, Department of Pediatric Otolaryngology,
University of Colorado School of Medicine and Children’s
Hospital Colorado
Chapter 18: Ear, Nose, Throat
Teri L. Schreiner, MD, MPH
Associate Professor, Departments of Pediatrics and
Neurology, Section of Pediatric Neurology, University
of Colorado School of Medicine and Children’s Hospital
Colorado
Chapter 25: Neurologic & Muscular Disorders
Justin Searns, MD
Pediatric Infectious Diseases Fellow, Department of Pediatrics,
Section of Pediatric Infectious Diseases, University of
Colorado School of Medicine and Children’s
Hospital Colorado
Chapter 39: Antimicrobial Therapy
Eric J. Sigel, MD
Professor, Department of Pediatrics, Section of
Adolescent Medicine, University of Colorado School of
Medicine and Children’s Hospital Colorado
Chapter 6: Eating Disorders
Georgette Siparsky, PhD
Clinical Data Analyst II, Department of Clinical Informatics,
Children’s Hospital Colorado, and University of Colorado
School of Medicine
Chapter 46: Chemistry & Hematology Reference Intervals
Andrew P. Sirotnak, MD
Professor and Vice Chair for Faculty Affairs, Department of
Pediatrics, Director, Child Protection Team, University of
Colorado School of Medicine, Children’s Hospital Colorado
Chapter 8: Child Abuse & Neglect
30/03/18 11:40 AM
 xxvi AUTHORS
Danielle Smith, MD
Assistant Professor, Department of Pediatrics, Section of
Neonatology, University of Colorado School of Medicine
and Children’s Hospital Colorado
Chapter 2: The Newborn Infant
Robert Snyder, MT (ASCP)
Clinical Chemistry Supervisor, Department of Pathology and
Laboratory Medicine, University of Colorado, Children’s
Hospital Colorado
Chapter 46: Chemistry & Hematology Reference Intervals
Jason Soden, MD
Associate Professor, Department of Pediatrics, Section of
Pediatric Gastroenterology, Hepatology and Nutrition,
University of Colorado School of Medicine and Children’s
Hospital Colorado
Chapter 21: Gastrointestinal Tract
Jennifer B. Soep, MD
Associate Professor, Department of Pediatrics, Section of
Pediatric Rheumatology, University of Colorado School of
Medicine and Children’s Hospital Colorado
Chapter 29: Rheumatic Diseases
Ronald J. Sokol, MD, FAASLD
Professor and Vice Chair, Department of Pediatrics, Arnold
Silverman MD Endowed Chair in Digestive Health; Head,
Section of Pediatric Gastroenterology, Hepatology and
Nutrition and the Digestive Health Institute, University of
Colorado School of Medicine and Children’s Hospital
Colorado; Director, Colorado Clinical and Translational
Sciences Institute and Assistant Vice Chancellor for Clinical
and Translational Science, University of Colorado Denver
Chapter 22: Liver & Pancreas
Paul Stillwell, MD
Senior Instructor, Department of Pediatrics, Section of
Pediatric Pulmonary Medicine, University of Colorado
School of Medicine and Children’s Hospital Colorado
Chapter 19: Respiratory Tract & Mediastinum
Shikha S. Sundaram, MD, MSCI
Associate Professor, Department of Pediatrics, Section of
Pediatric Gastroenterology, Hepatology and Nutrition,
University of Colorado School of Medicine and Children’s
Hospital Colorado
Chapter 22: Liver & Pancreas
Alex Tagawa, BS
Research Assistant, Center for Gait and Movement Analysis,
Department of Pediatric Orthopedics, University
of Colorado School of Medicine and Children’s Hospital
Colorado
Chapter 26: Orthopedics
Hay_FM_pi-xxxii.indd 26
Ayelet Talmi, PhD
Assistant Professor, Departments of Psychiatry and Pediatrics,
Associate Director, Irving Harris Program in Child
Development and Infant Mental Health, University of
Colorado School of Medicine and Children’s Hospital
Colorado
Chapter 7: Child & Adolescent Psychiatric Disorders &
Psychosocial Aspects of Pediatrics
Janet A. Thomas, MD
Associate Professor, Department of Pediatrics, Section of
Clinical Genetics and Metabolism, Director—IMD Clinic,
University of Colorado School of Medicine and Children’s
Hospital Colorado
Chapter 36: Inborn Errors of Metabolism
Carla X. Torres-Zegarra, MD
Assistant Professor, Pediatric Dermatology Fellow, Pediatric
Dermatology, Department of Dermatology, University of
Colorado and Children’s Hospital Colorado
Chapter 15: Skin
Sharon H. Travers, MD
Associate Professor, Department of Pediatrics, Section of
Pediatric Endocrinology, University of Colorado School of
Medicine and Children’s Hospital Colorado
Chapter 34: Endocrine Disorders
Meghan Treitz, MD
Assistant Professor, Department of Pediatrics, Section of
General Academic Pediatrics, University of Colorado
Denver School of Medicine and Children’s Hospital
Colorado
Chapter 9: Ambulatory & Office Pediatrics
Anne Chun-Hui Tsai, MD, MSc
Professor, Department of Pediatrics, Section of
Pediatric Clinical Genetics and Metabolism, University
of Colorado School of Medicine and Children’s Hospital
Colorado
Chapter 37: Genetics & Dysmorphology
Johan L. K. Van Hove, MD, PhD, MBA
Professor, Department of Pediatrics, Head, Section of Clinical
Genetics and Metabolism, University of Colorado School of
Medicine and Children’s Hospital Colorado
Chapter 36: Inborn Errors of Metabolism
Armando Vidal, MD
Associate Professor, Department of Orthopedics—Sports
Medicine Program, University of Colorado School of
Medicine and Children’s Hospital Colorado
Chapter 27: Sports Medicine
30/03/18 11:40 AM

Johannes Von Alvensleben, MD
Assistant Professor, Department of Pediatrics, Section of
Pediatric Cardiology, University of Colorado School of
Medicine and Children’s Hospital Colorado
Chapter 20: Cardiovascular Diseases
Thomas Walker
Professor of Pediatrics, Section of Pediatric Gastroenterology,
Hepatology and Nutrition, Digestive Health Institute,
University of Colorado School of Medicine and Children’s
Hospital Colorado
Chapter 21: Gastrointestinal Tract
Diana Walleigh, MD
Assistant Professor, Department of Pediatrics, Neurology,
University of Colorado School of Medicine and Children’s
Hospital Colorado
Chapter 25: Neurologic & Muscular Disorders
George Sam Wang, MD
Assistant Professor, Department of Pediatrics, Section of
Emergency Medicine, Medical Toxicology, University of
Colorado School of Medicine and Children’s Hospital
Colorado
Chapter 13: Poison
Michael Wang, MD
Associate Professor, Department of Pediatrics, Section of
Pediatric Hematology, Oncology, and Bone Marrow
Transplant, Center for Cancer and Blood Disorders,
University of Colorado School of Medicine and Children’s
Hospital Colorado
Chapter 30: Hematologic Disorders
Adriana Weinberg, MD
Professor, Departments of Pediatrics and Medicine, Director of
Clinical Virology Laboratory, Section of Pediatric Infectious
Diseases, University of Colorado School of Medicine and
Children’s Hospital Colorado
Chapter 40: Infections: Viral & Rickettsial
Hay_FM_pi-xxxii.indd 27
Contents xxvii
Pamela E. Wilson, MD
Associate Professor, Department of Physical Medicine &
Rehabilitation Medicine, University of Colorado School of
Medicine and Children’s Hospital Colorado
Chapter 28: Rehabilitation Medicine
Michele L. Yang, MD
Assistant Professor, Departments of Pediatrics and Neurology,
Section of Child Neurology, University of Colorado School
of Medicine and Children’s Hospital Colorado
Chapter 25: Neurologic & Muscular Disorders
Patricia J. Yoon, MD
Associate Professor, Department of Otolaryngology, Associate
Director, Bill Daniels Center for Children’s Hearing,
University of Colorado School of Medicine and Children’s
Hospital Colorado
Chapter 18: Ear, Nose, & Throat
Carleen Zebuhr, MD
Assistant Professor, Department of Pediatrics, Section of
Pediatric Critical Care Medicine, University of Colorado
School of Medicine and Children’s Hospital Colorado
Chapter 14: Critical Care
Philip S. Zeitler, MD, PhD
Professor, Department of Pediatrics, Head, Section of Pediatric
Endocrinology, University of Colorado School of Medicine
and Children’s Hospital Colorado
Chapter 34: Endocrine Disorders
Edith T. Zemanick, MD
Associate Professor, Department of Pediatrics Section of
Pediatric Pulmonary Medicine, University of Colorado
School of Medicine and Children’s Hospital Colorado
Chapter 19: Respiratory Tract & Mediastinum
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"It is well for those who can, say that cheerfully, Betty."

"Well, now, I do feel cheerful, and I just hope I'm not like Ignorance in the
'Pilgrim.' Fred read me that book, and surely, next to the Bible, it comes
home to one. But I don't really think I'm like he, though I'm ignorant
enough. Not ignorant of my dear Saviour, though. I feel Him keeping me,
somehow."

"Ah, old friend, many a learned man might envy you. I came to talk to
you about Fred. Where is he?"

"Playing cricket on the green. Schoolmaster tells him he's getting too old
for school, and that he won't learn much by staying on. I sometimes wish
we could find his people. He's growing up—poor Fred!"

"That is just what I came to talk about, Betty. Dale spoke to me about
him. He thinks him very clever."

"About book cleverness, sir, I know naught, but he reads as well as any
clergyman; I'm told he's quite as good at writing and cyphering. But as to
hand cleverness, that I can speak to. There's nothing ever was done with
hands that he couldn't learn to do."

"Well, I want an assistant in the dispensary. Fred is rather young, but

Fletcher will not leave me at once, and I will teach the boy carefully. If he
turns out well, I will take care of his future. You'll be glad, I dare say, to
have a big fellow like him off your hands; you must find it hard to do for
him now."

"I don't, then," said Betty, shortly. "I'll find it harder to do without him.
But I won't stand in his way. I suppose you want to take him altogether—
to live in your house, maybe?"

"I did think of that. You see, my wife could teach him so much, and so
could I. But, to get the full benefit of this, he must be always at hand."

"Ay, ay, I understand. Well, I've had him a long time, and he's been as a
son to me, and a good son, too. I won't stand in his way."

"I see him coming now, Betty."

And in a moment more, Fred stood before them, having taken off his
straw hat to pay due respect to the doctor.

"Fred, my dear boy, here's good news for you," began Betty, briskly.
"Many a time have I taken a little fret, wondering what would become of
you when I die, and that can't be very far off, for I'm getting very old and
failed. Now, here's Dr. Wentworth offering you a good place with him,
where you'll get learning, and have work to do more suitable to you than
gardening. And I'm thankful to know it, Fred."

Fred looked from one to the other.

"I don't quite understand," he said, "but I'm much obliged to Dr.
Wentworth; he's always been very kind to me."

The doctor, who by this time had found a seat on the doorstep, began to
explain. Fred listened attentively. Then he looked at Betty, who forthwith
assumed what she intended for a pleased and encouraging smile. Fred
laughed, and for a healthy boy, he laughed but seldom.

FRED LISTENED ATTENTIVELY.

"Ah, Mrs. Betty, that won't do!" he said. "'Tis nine years, or more, since I
crept up to the door, half frozen and half starved, and asked you to come
to—to Frank. I remember all, Betty dear, though I never could talk of it.
Ever since then, you've kept me and cared for me, and nursed me and
borne with me, and—loved me. And now, doctor, she's not as strong as
she used to be, she couldn't live alone now, she couldn't keep up the
garden or the plants and slips without help, and she couldn't carry the
things home. I earn a little money, too, and what I earn is needed now.
I'm very grateful for your kind offer, but I can't leave her, and if I did,
every one would cry shame on me, and I should deserve it."

"Fred, I won't stand in your way. I shall do very well. I'll get my
grandchild, John's little Kate, to come and stay with me; I know they'll let
me have her. And suppose your own people find you by-and-by, won't
they be glad to find you something better than a working gardener? No,
no, boy; you must go."

Fred stood, looking far away over the fields. He seemed to be trying to
put some thought into words, for his lips moved from time to time. At
last, without looking at them, but still gazing away over the fields, he said
—

"I can remember her face. It was like Frank's, fair and loving. I think we
were well off once, but I don't remember. I seem just going to remember
sometimes, but it all dies off. Mrs. Betty, you know Kate is only ten, and a
little baby of a thing; even if she came, she could not do all that I do, and
the garden would run waste, and there would be no earnings coming in.
And if my mother—if it is my mother that I remember—I'm very sure that
she would be more sorry to find me an ungrateful brute than to find me a
gardener, or anything else. No, Dr. Wentworth, I cannot leave Mrs. Betty.
As she cared for me, so must I care for her now, and she has been a
mother to me all these years. But I'm not ungrateful to you, sir, and there
is nothing I should like better than to learn from you if it could be; but it
cannot."

"I would not say another word, my boy, if I did not see a way out of the
difficulty. I like you the better for being grateful and faithful to Betty, and
I was not aware how dependent she has become upon you. But I'll tell
you how it can be managed. Instead of coming to live with me, and
studying hard, you must go on living here, and only give me so many
hours a day, say from ten a.m. to six in the evening. This will give you
time for your gardening under Betty, and your wages will be better than
your chance earnings now. What do you say to this?"
"May I just run home for a few moments at about one, sir, to see that she
gets her dinner?"

"It is not far; yes, we will manage that. You shall have your dinner at our
luncheon-time, which will save Betty a good deal of cooking."

"Mrs. Betty, does this suit you?"

"That it do!" said Betty. "I won't deny that my heart sank to think of being
without you, Fred, and seeing my poor garden, that's all my living, going
to waste. I was thinking it meant the poorhouse."

"Yet you wanted me to believe you were delighted. Oh, Mrs. Betty, I'm
ashamed of you! I never can thank you enough, Dr. Wentworth, but I'll
serve you faithfully," said the boy, earnestly; and, kneeling down beside a
patch of annuals, he began tenderly to pick out minute weeds from
among the tiny plants.

"Thin 'em, Fred, thin 'em. You're always too shy of thinning. Leave each
plant standing by itself. Yes, that's more like. Doctor, come closer. I
wouldn't allow this, but that I don't think it will be for very long. I feel
very weak sometimes, and they're all doing well, and now that Fred's
provided for, I'm quite ready to go. What is it now, Fred?"

"I want to ask the doctor a question. Can you tell me, sir, what it will cost
to get a well-made wooden cross, with words cut on it and painted for
Frank? I've saved up a few shillings for it."

"I am going to town to-morrow, and I will order it for you; if it costs more
than you have saved, you must let me pay the rest, as my thanks to you
for all your care of our little grave. What shall I have carved on it?"

"Just this, sir. First, 'Frank' by itself, and then 'Tell muddie I took care of
Fred.' That's to go across the arms of it. And below the date, 'September
14, 18—.'"

"Why, Fred, I'd no idea you understood or remembered those words,"

cried Betty. "You know, doctor, that's what the little fellow said."

"Yes," said Fred, "I never forgot them. Frank died to save me; I can see
that now. We called her muddie. Some day, perhaps, among the people
who come to see our church and the churchyard, there may be some one
who knows her, who will know what the words mean. Some day, I shall
put a marble cross with the whole story on it, but this will do now."

Fred went back to his weeding, and Dr. Wentworth said to Betty—
"I never heard the boy speak so much before."

"Nor I, sir."

"And he can say Frank and Fred now, I perceive."

"Oh yes, sir; only if he is in a hurry, he slips back into the old way. Well,
Dr. Wentworth, I'm easy in my mind about the boy now."

"You may be, Betty. As far as I can, I will make him my care. He is a fine
fellow."

So, when the midsummer holidays began, Fred left school and began his
new work. The doctor began to teach him enough Latin to read the
prescriptions, or at least that was what he first intended, but the boy was
so eager to learn that the lessons did not stop there, nor was Latin the
only thing studied. Study was a delight to the silent, somewhat lonely boy,
and he made such progress that the good doctor was proud of his pupil.

And the cross was placed at the head of Frank's grave, but the doctor
persuaded Fred to allow him to give Frank's message in a slightly different
form. Thus—"His last words were a message to his mother, to tell her that
he had taken care of Fred."

For a little more than a year, this arrangement continued to work very
well. Fred became very useful to the doctor, and Betty had no reason to
feel neglected. Then the dear old woman began to fail more and more
rapidly, and Fred spent the greater part of his time with her, but it was
with the doctor's full consent.

One evening—it was now September, and Dr. Wentworth had told Fred
that old Betty could not last much longer—the boy was sitting beside the
bed on which she lay; not suffering, only, as she said herself, "dying, and
very slow about it." They had both been silent for some time, and when
she said suddenly, "Is there any one here but us two, Fred?" poor Fred
started, for his thoughts were far away.

"No, Betty. Mrs. Summers—" Betty's eldest daughter—"has gone home to

see after the children, and John and his wife are coming presently to stay
all night with you."

"Very good children they've always been to me, and I must tell their
father that, for he laid it on them to be good to me. But I'm glad of a
quiet half-hour with you, dear. Sometimes I think you're nearer my heart
than my own children. You're so young, I suppose that's it. It's just the
day, Fred, and very near the hour, when you came knocking, with your
little soft hand, at the door yonder. I think I'd like to die to-night. I'd like
to be able to say, 'Lord, I'm only a poor ignorant and hardworking woman,
and it was very little I ever could do, beyond earning my bread; but there
was one thing—the boy that was sent to me this very night many years
ago, I took him for Thy sake, and I wasn't bad to him.' I think I'd like to
say that."

"It is less than the truth, dear Mrs. Betty. You saved me from misery, and
made me as happy as one so parted from his own people, and with Frank
dead, could ever be. And you'll meet Frank."

"I'll tell him that you were worth saving," said the old woman, fondly.
"Now, my dear, just one word. I've no doubt you'll do well and prosper.
The doctor's fond of you, and he's a good man. But when you're a
gentleman, with learning, and money and all your heart can desire, don't
you forget what I say to you now: If you let those things fill your heart so
that you forget God, and never read the Bible, nor go to church, nor pray,
it would have been better for you if you had died there on my hearthstone
along with your little brother. Don't turn God's favour into a misfortune,
Fred. Mind, Frank's waiting for you in heaven. Do you know why I say all
this? Because I do fancy that, although the doctor and his wife are kind
and good, and will be true friends to you, yet you won't learn from them
such lessons as I'd have you put first of all. Don't forget God, Fred dear,
nor begin to have high thoughts of yourself, and forget that you're just a
sinner, and want the Saviour, and will never get to heaven any other way.
Will you remember, dear?"

"I will, Betty. God helping me, I will. Oh, dear Betty, how good you've
been to me!"

"And you to me. Ah, here's John and my good Deb. Go you, Fred, and get
a little rest. You're tired out, I know."

Before the day dawned, the simple, true-hearted old woman had breathed
her last. And none of her children or grandchildren mourned for her more
truly, nor half so long, as did the boy she had so lovingly befriended.
 CHAPTER XI.
MRS. RAYBURN'S LETTER.

FROM the time of Betty Giles' death, Fred lived altogether with the
Wentworths, and they eventually became so fond of him that he was like
a son to them both. He studied under Dr. Wentworth, at first only with a
view to becoming his assistant in the dispensary, but after a time with the
intention of becoming a doctor himself. Mr. Hewson, the curate, who had
been a very distinguished man in college, gave him lessons in various
branches of learning; in fact, Dr. Wentworth gave him every advantage
that he would have given to his own son had he lived.

Of course, as he grew up, the preparations for his profession took him
away frequently from what was now his home, and no one missed him
more than did Mrs. Wentworth, who had at one time quite shrunk from
the idea of having him to live with her.

With his studies and all concerning his profession we have nothing to do,
except with one event which took place in London.

Fred was now engaged in what is called "walking the hospitals" in London,
and was a very ardent and industrious student. One day, he heard that
there was to be a wonderful operation performed at a certain hospital by
one of the first surgeons of the day, and he was fortunate enough to get
leave to be present, though it was not one of the hospitals he generally
attended. When the affair was over, one of the junior doctors, who knew
him, took him through the wards.

In one of these, there was a woman who had come up from the country to
take a place as cook in an hotel, but had fallen ill, and been sent to this
hospital. Her name was Rayburn, and she came from Hemsborough.
The arrangements of this hospital were supposed to be almost perfect,
and the system of ventilation was quite new. Young Dr. Vernon was
explaining it to Fred, and consequently their progress through the ward
was slow. And if they had looked at the old woman in the corner of the
room, they would have seen that for some reason she was frightened—or,
at least, greatly excited—at the appearance of Fred Giles.

Fred, however, saw nothing of this; neither did Dr. Vernon; but when the
latter was going his rounds in the evening, No. 24 in the first ward was
found in a rather excited state.

"She's been quite odd all the afternoon, Dr. Vernon," said the nurse, "and
she was going on nicely before."

"I'm not worse," the woman said, "but I want to know, doctor, who was
the tall young man that went through the ward with you this morning?"

"A dark-haired fellow? His name is Giles, and he's the son—adopted son, I
believe—of a Dr. Giles—no, his name is not Giles—but a doctor
somewhere in the country. Why do you ask?"

"Oh, I have no reason, sir; only I'm a curious woman—always was. Thank
you, sir."

"Did you think you knew him?"

"Oh no; but he's like some one I knew once. I'm sleepy now—I'm much
better."

"Well, good night. Nurse, I don't think she's so well. Watch her carefully."

"Is the young man going to be a doctor, Dr. Vernon?" inquired the patient,
suddenly.

"Yes, and a very promising student he is."

"Has he—has he—a brother?" she asked in a low voice.

"I don't know. What interests you so much in this particular student, may
I ask?"

She laughed in an odd, constrained manner, and replied—

"Indeed, sir, you may ask much easier than I can answer. I have no
reason at all."
"Except that he is like some one you knew?"

"Just so, sir."

Mr. Vernon went away, this being the last bed he had to visit. Next day,
the patient was very much worse, and it was some days before she again
began to mend. When she was really recovering, Dr. Vernon spoke to her
about Fred Giles, but she declared that she remembered nothing about
him, and that she must have been dreaming. And in a day or two more,
she left the hospital.

Her history since the loss of the children can be told in a few words. She
was a long time under medical care, her mind not having recovered
completely from the effects of the attack she had at Kelmersdale. When at
last she was herself again, she went to Hemsborough, and found an
asylum with her sister-in-law. She heard from Lord Beaucourt of her
stepson's visit to England, and she guessed that he had discovered that
she had not been kind to the children. So she never wrote to him, though
in her misery—for she was a very miserable woman—she would have
given much to beg for his and Janet's forgiveness. She had lived
principally with her sister-in-law, who was not unkind; but sometimes she
quarrelled with her nieces, and then she would leave them and take a
place somewhere. But her health and her nerves were shattered, and she
always broke down before long, and returned to Hemsborough. She did so
now, when she left the hospital.

When she was again comfortably settled in her sister-in-law's house, she
wrote the following letter to Janet:

"MY DEAR JANET,

"If this ever comes to your hand, try to think less bad
of me than I deserve of you. I have suffered for my
unkindness, Heaven knows. I have been a wretched
woman. I hope you and Fred have not been as wretched as
I am, but I dare not think of what you must have felt.

"I would not venture to write now but for one thing. I
have always felt that there was a chance that the children
were not drowned in the Kelmer. And I think I saw one of
them, a tall, handsome young man, studying to be a
doctor. I could not think any one could be so like your
husband but little Fred, who was always so like him. But he
calls himself Frederick Giles, and when I was well and left
the hospital, I found out where he was lodging, and made
 what inquiry I could. He comes from a place near
Cirencester, called Edgestone, and he had gone home. I
could do no more, having no money but what would take
me home to my sister's house in Hemsborough. I am weak
and ill, more in mind than in body, and so the best thing I
can do is to tell you this, and if you tell me what to do, I
will do it. But I know that you and Fred will come home to
see for yourselves, if you can afford it.

"I am not long for this world. I suppose there is no use

in asking you two to forgive me; I cannot forgive myself. I
am a wretched woman, and have no hope. But if you find
the boys, perhaps you might forgive me. Fred Giles is the
adopted son of a doctor in Edgestone. That is all I know.

"LYDIA RAYBURN."

In the years that had passed since the loss of the boys, Fred Rayburn had
quite lived down the prejudice against him which had prevented Gilbert
Gray from making him the first manager of the Royal Victoria Hotel in
Gattigo. But when the first manager gave up the situation, Fred was able
to take it; and the hotel had been most successful under him and Janet,
and had made both Gilbert Gray and Fred Rayburn rich and prosperous
men. The Rayburns now lived in a pretty house two or three miles from
Old Man's Ferry Farm, where Janet and her daughter had no more
arduous work to do than to keep house and see after their garden. Fred
drove into Gattigo every day, and the hotel still flourished without a rival.

The important letter was addressed to Old Man's Ferry Farm, and when it
arrived there, Gilbert and his wife, always glad to visit the Rayburns,
ordered their well-appointed phaeton, with its two pretty ponies, and
inquired if any of the young people would like to fill the back seat.

Several of the young people wanted to go, for cousin Lily was a general
favourite; and while the boys were arguing about their claims to the seat,
the two elder girls slipped quietly away to the stable and came round to
the door in possession of the places. Gil and Emile and the rest were
naturally very indignant, but the girls only smiled serenely, and were soon
bowling smoothly along the well-made road, very different from the rough
track by which Janet reached the farm on her first arrival.

"The Gables," as the Rayburns called their home, certainly deserved its
name. It had been added to by many hands, and in many styles, and how
many gables there were I should be afraid to conjecture. Janet and her
daughter had made a pretty garden close to the house; to be sure, it was
only a corner of a field well fenced with high palisades and wire netting,
but it was full of flowers in summer, and afforded as much pleasure to its
owners as any walled garden in the dear "old country." Lily and her
mother were at work among their flowers when the Grays drove up. Out
ran Lily, followed by Janet, who, however, remembered to shut the gate.

"You've come to stay all day, haven't you?" cried Lily, joyously.

She was a fair, bright-haired lassie, very like her mother and poor little
Frank.

"You must stay," she went on, "for father's in Gattigo, and won't be home
until dinner-time."

"Well, we can stay, Miss Apple-cheeks," said her uncle. "Janet, we've
brought you a letter. Who on earth can be so behind the times as to write
to you still at the Ferry Farm?"

"I don't know, but I'm glad of anything that brings you here. You and
Aimée don't take a holiday half often enough. Lily, call Karl to take the
ponies."

Karl having been found, the others all went into the house and had some
luncheon, after which Janet asked for her letter.

"I declare I had forgotten it!" said Gilbert. "Here it is."

"The Hemsborough postmark!" Janet said. "I don't know the hand. Who
can it be from? Oh, Gilbert, it is from Mrs. Rayburn!"

"Fred's mother—stepmother, I mean?"

They all crowded round Janet. Janet gave the letter to her brother.

"Somehow I can't see it," she said. "Read it aloud, Gilbert."

Which Gilbert did; and then they all looked at each other, not knowing
what to think.

Before any one spoke, a man appeared at the window, which opened like
a door, and, with a cry of "Gilbert and Aimée here! How lucky that I got
off so early!" He pushed the window wide and came in.
It was our old friend Fred Rayburn, and a very fine-looking man he had
become. And if ever a man had cause to give thanks for a good wife, Fred
Rayburn was that man. For, by the blessing of God, Janet's love for him,
and Janet's faith in him in spite of his follies, had made a man of him.

"Fred, Fred!" cried Janet. "Our boys—she has seen Fred—Mrs. Rayburn—
here is her letter; read it, and tell me may I believe it?"

Fred took the letter and read it. He looked at Janet and began to speak,
but turned back to the letter and read it again.

"Janet, when I was in England, Mrs. Rayburn was not quite in her right
mind. It may be so still."

"Do you think the letter shows that she is out of her mind?" Janet said.
"No, Fred, I don't think so. She says she is weak in mind and body, and I
suppose she was unable to make a thorough inquiry, but we must make
it."

"Certainly—of that, there can be no doubt. But do not build too much
upon it, Janet, my darling; I fear it was but too plain that our boys were
lost in the Kelmer."

"I have never been able to believe it; and, you see, Mrs. Rayburn has felt
the same. But what do you think of doing, Fred?"

"I shall go to England as soon as I can be ready, and go direct to this

place, Edgestone, near Cirencester. The truth must be easily ascertained
on the spot. My fear is that her conscience, poor soul, being so burthened,
she was startled by an accidental likeness—and the name being Frederick,
and the young man an adopted son."

"Yes," Gilbert Gray said, "and if the boys were alive all this time, why did
they never let you know? Frank was seven years old; he surely could have
told his name, and where you had lived, and then you would have heard.
Take my advice, Rayburn, and write to this young Giles."

"No, no—we must go," Janet said. "Fred, I am not often unreasonable, but
I cannot rest till we are on our way home. Give me this satisfaction, let us
go, and find out the truth together. We will take Lily too. Fred, you will
take us?"

"I will indeed, Janet. I wish you could feel how unlikely it is that there is
anything in what this wretched woman says, but I can quite understand
your longing to see for yourself. I have a few arrangements to make, of
course. Gilbert, you and Emile will see after the hotel, I am sure."

"I will do anything you like; but do remember how ill Janet was on the
voyage out. Even if you must go, rather than write—"

"No, no!" said Aimée. "They must go. It is but a poor little straw of a
hope, yet I feel that Janet must go. Only, dear, why take Lily? Leave her
with me."

"Ah, no! I cannot bear to part with her, Aimée. I never parted with my
boys but that once. Lily must come too."

Janet was ill enough on the voyage, but by no means as ill as she had
been when coming out. Fortunately, Lily proved a good sailor, and was
able to take care of her after the first day or so.

They had a good passage, and, on reaching England, at once went on to

Cirencester, where Janet was so worn out that Fred would not hear of
going on to Edgestone that evening.

Next day, she still seemed so weak that Fred proposed to go alone to
Edgestone, as she seemed unfit for any exertion. But for once Janet was
obstinate; she would go.

Edgestone was about fifteen miles from Cirencester, and no railways went
near it. Fred Rayburn hired a wagonette, and at about twelve o'clock they
set out.
 CHAPTER XII.
FRANK'S MESSAGE REACHES "MUDDIE."

AS the Rayburns drove out of town, a gentleman in a small trap passed

them, and just where the road to Edgestone joins the main road, they
overtook him. Something had gone wrong with his harness. Fred Rayburn
called out—

"Can we help you in any way, sir?"

And the other replied, "Thank you, but I've got it all right now."

Jumping into the trap, he drove on, soon passing the heavier vehicle
again. As he did so, he took off his hat to the occupants.

Little thought the Rayburns that this pleasant-looking man could have told
them about their boys very easily. As little thought Dr. Wentworth, as he
wondered what was bringing a trio of strangers to quiet Edgestone, that
they came to clear up the story that had baffled him so long, and to rob
him of his adopted son. Had he seen Fred Rayburn nearer, or had an
opportunity of conversing with him, the likeness both to young Fred and
to his cherished photograph would have struck him; but a magnificent
dark beard had altered the elder Fred a good deal, and the likeness
escaped the doctor's notice. He was soon out of sight.

The travellers reached Edgestone presently, and stopped at the little inn,
as the Cygnet called itself, though it really was only a decent kind of
public-house. Here they alighted, and told the driver to put up his horses
for a time.

"Can we have a private sitting-room?" Mr. Rayburn asked, looking

doubtfully round the parlour they had been requested to enter; it
possessed a strong smell of tobacco and a sanded floor.

"This is our only parlour, sir, and the Edgestone Club meets here most
evenings."

"Janet, you must stay here while I inquire where the doctor lives. It will
be better, dear; you look very tired, and this will spare you a little. I will
come back to you as soon as I find him."
Now that the truth must soon be known, poor Janet's hopes and courage
had deserted her. Till now she could not know soon enough. Now she
would gladly have put off certainty a little longer. It was all she could do
not to entreat her husband to wait a little, but she held her peace and
subsided into a very unpromising wooden armchair. Fred turned to the
mistress of the Cygnet, and said—

"Will you bring Mrs. Rayburn some tea as soon as possible?" He followed
her out of the room, shutting the door. "Stay, if you please. Can you tell
me where the doctor lives? You have not more than one, I suppose, in so
small a place?"

"I may say there's only one, though his son is well-nigh a doctor too, and
they do say he set Jerry Davidson's leg as handsome as possible, the
doctor being away at the time. He lives on the green, sir, the second
house from the church. I'll show you the green. Step this way, sir; you
can see it from our door, and the second house is Dr. Wentworth's."

"Wentworth! I thought his name was Giles?"

"Oh, that's his son—his adopted son, sir."

"Thank you. Well, come what may, we shall know soon—my poor Janet!"

Janet and Lily had some tea. The Cygnet knew a great deal more about
beer and punch than about tea, and consequently, it was not very
refreshing. Lily began to feel anxious about her mother, she looked so
pale.

"Mother dear," the girl said, "let us go out and get a little fresh air. We
need not go out of sight of the door, you know."

"It is very close indeed; I am half smothered," poor Janet said; and, more
to please Lily than because she hoped for relief, she tied her bonnet and
stood up. The busy landlady heard the door open, and came into the
passage.

"We are going to walk about a little," said Lily.

"Maybe you'd like to see the church, ladies? Sexton lives next door, and
will lend you the key of yonder little gate, just t'other side of the road; it
opens into the churchyard—the seminary, I believe, gentlefolk call it—and
it's a matter of general remark that our church and the churchyard are
very pretty; I've known people come from a distance to see them. I'll just
get you the key."
She rushed into the nearest cottage, and came out carrying a key. "Here
'tis, ma'am; and if you go up the steps you'll see, just before you, near
the top, two little graves, kept beautiful with flowers, and when you come
back, I'll tell you the story of them two graves, which is worth hearing, I
assure you, besides being true. Here's the key of the gate—the wicked
gate, sexton calls it, but it's a good gate enough, and handy when one
don't want to go round to the big one."

To stop the torrent of words, Janet took the key, and she and Lily crossed
the road.

"How she does chatter!" Lily said. "But we may as well go in, mother. It
will be quieter than out here, don't you think?"

"Yes, so it will. We can watch for your father well enough there."

Once inside the wicket, Janet would have been content to sit on the steps
which led up to the church, but she found that she could not see over the
wall; so they began to climb upwards. And the place was so pretty, and,
moreover, so unlike anything that Lily had ever seen, that they went on
and on, till they reached the top of the bank, and saw before them the
beautiful old church, with a wide, low porch; and between them and it a
number of graves. All were nicely kept, but two were quite beautiful,
covered completely with blue and white flowers, while the grass
surrounding them was like velvet. Round the white marble cross at the
head of one grave, a white clematis was trained so skilfully that the
inscription was not obscured. The other grave had a cross, but it was of
wood, and round it clung a rose-tree, with small crimson roses in great
profusion. But here, too, the growth was not allowed to interfere with the
inscription.

"Oh, mother, is not that lovely? What constant care some one must take
of these two graves—such little graves, too! These must be the two the
landlady spoke of; we must hear the story. I wonder why one has a
marble cross and the other only a wooden one?"

While Lily spoke, they were drawing nearer to the little graves, and now
the girl began to read aloud—

"'Charles William Wentworth, only child of Dr. Alexander Wentworth

and Lucy, his wife. Died April 3, 18—, aged seven years.'"
Suddenly her mother caught her by the arm, and said in a low, strange
voice—

"Lily! The other—look at it, read it!"

Lily was frightened, and she was more frightened when she saw her
mother's face. She looked at the wooden cross, and exclaimed—

"Oh, mother, what can it mean?"

"Read it to me; I may have read it wrong. Be quick, Lily, read it."

And Lily read—

"'Frank. Died September 14, 18—, aged about seven years.

He laid down his life to save his brother's. His last words
were a message to his mother, to tell her he had taken care of Fred.'"

"Oh, mother, mother, what does it mean?"

"That I have found one of my little boys," Janet said, and she trembled so
that Lily put her arms round her and tried to hold her up.

A step rang on the gravel, a young man came round the corner of the
church and stopped short on seeing strangers near the graves he came to
visit. Lily, though usually very shy, was so beside herself with fright, that
she called aloud to him—

"Please, please come here; mother is ill, and I am afraid she will fall!"

The stranger was at her side in a moment.

"Has she fainted? I'll carry her up to the seat in the porch, and run for
water."

But Janet had not fainted, and now she steadied herself, laid her hand on
his arm, and said—

"Tell me what this means, if you are Fred?" pointing to the wooden cross.

He looked at her earnestly. "Who are you?" he said. "Is my childish dream
come true at last? Oh, I can tell you what those words mean! My brother
lies there. We had wandered—I don't know where from. He was the elder,
and—he laid down his life to save mine."
"Then you are my little Fred, and I have found both my boys," said Janet.
"Child, don't you know me?"

"Is it true? Are you really my mother? But you are ill; don't try to speak.
Let me help you up to the porch; you can hardly stand."

He put his arm round her and guided her faltering steps to the porch,
followed by the distracted Lily, who felt as if walking in her sleep. In the
porch, there was a broad stone seat, on which Fred placed his mother; he
knelt beside her, and said—

"Is it true that you are really my mother?—the 'muddie' for whom Frank
and I fretted so—to find when we ran away? From whom we escaped, I
cannot remember. I only recall an angry, cruel face. For pity's sake, tell
me who you are."

"I am surely your mother, my son. You always called me 'muddie.' Come
here, Lily; this is your brother Fred. Why, where has the child gone?"

For Lily, having caught sight of her father and Dr. Wentworth at the door
of the Cygnet, had run down the steps to the gate, and across the road to
her father's side.

"Father," she cried, "we have found him! Mother and I, up there. Come, I
will show you the way."

"Lily, tell me—does my poor Janet know that Frank is dead?"

"I think she does. It was a little grave, all over flowers—and then he came
round the church. I did not quite understand, but mother did."

"It must have been the inscription that I told you of: she understood, no
doubt. Tell her the exact words were, 'Tell muddie that I took care of
Fred.' Mr. Rayburn, in finding Fred you've found a good and noble son; but
little Frank was a hero and a martyr, to my mind."

"He was his mother's son," was the answer.

Then they went up the steep steps, and found mother and son standing
by the flower-clad cross.

"Dr. Wentworth, I have found my mother!" cried Fred, hardly seeing that
the doctor was not alone in his agitation.

"Fred, I have found both our boys," said Janet, leaving her son and taking
her husband's arm; "and God has taken care of both of them."
 CHAPTER XIII.
"AS WE FORGIVE."

THE Wentworths contrived to find room for the Rayburns,

and begged of them to stay as long as they conveniently
could. Indeed, for some days Janet could hardly have
travelled, but she soon regained her usual health and quiet
cheerfulness. She and her husband, with Lily for their
companion, made Fred show them every spot connected
with the story of Frank's death, and his own life since then.
Betty Giles's cottage, the very spot on the road where the
child-hero at last stumbled and fell, were visited and
revisited. But the mystery as to how the children had so
quickly got so far away from Rugeley was never thoroughly
solved. Fred had no remembrance of the long railway
journey.

The Rayburns were the more inclined to linger at Edgestone

because they could not bring themselves to take Fred away
from the kind friends who had long regarded him as their
own son. But this difficulty was ended by a conversation
between Mrs. Wentworth and Janet, one day when the rest
had gone for a long walk, leaving them to keep each other
company. They talked of various matters for some time.
Then there was a short silence, broken by Mrs. Wentworth,
who said—

"Janet—I may call you Janet, may I not?—I want to ask

you, if you don't mind, what you mean to do about Fred?"

"Oh," said Janet, quickly, "he has not yet finished his
studies. There is a fine opening for a doctor in Gattigo, but