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a LANGE medical book
CURRENT
Diagnosis & Treatment
Pediatrics
TWEN TY- THIRD ED ITIO N
Edited by
William W. Hay, Jr., MD Robin R. Deterding, MD
Professor, Department of Pediatrics Professor, Department of Pediatrics
Section of Neonatology and Chief, Section of Pediatric Pulmonary Medicine
Division of Perinatal Medicine University of Colorado School of Medicine and
University of Colorado School of Medicine and Children’s Children’s Hospital Colorado
Hospital Colorado
Medical Director, Breathing Institute
Myron J. Levin, MD Children’s Hospital Colorado
Professor, Departments of Pediatrics and Medicine Mark J. Abzug, MD
Section of Pediatric Infectious Diseases Professor, Department of Pediatrics
University of Colorado School of Medicine and Section of Pediatric Infectious Diseases
Children’s Hospital Colorado
Associate Vice Chair for Academic Affairs,
Department of Pediatrics
University of Colorado School of Medicine and
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
CURRENT Diagnosis & Treatment: Pediatrics, Twenty-Third Edition
Copyright © 2016 by McGraw-Hill Education. All rights reserved. Printed in the United States of America. Except as permitted
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Previous editions copyright © 2014, 2012, 2011, 2009, 2007, 2003, 2001 by The McGraw-Hill Companies, Inc., and copyright
© 1999, 1997, 1995, 1991, 1987 by Appleton & Lange.
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Contents
Authors xix Gastrointestinal Bleeding 55
Preface xxvii Gastroesophageal Reflux 55
Selected Highlighted Topics in the Infections in the Newborn Infant 56
23rd Edition of CDT-P xxix Bacterial Infections 56
Fungal Sepsis 59
1. Advancing the Quality Congenital Infections 60
& Safety of Care 1 Perinatally Acquired Infections 61
Hematologic Disorders in the Newborn Infant 63
Daniel Hyman, MD, MMM Bleeding Disorders 63
Current Context 1 Anemia 64
Strategies & Models for Quality Polycythemia 65
Improvement (Qi) 4 Renal Disorders in the Newborn Infant 65
Principles of Patient Safety Renal Failure 66
(Incident Reporting, Just Culture, Urinary Tract Anomalies 66
Disclosure, FMEA, RCA, Reliability, Renal Vein Thrombosis 66
Checklists) 7 Neurologic Problems in the Newborn Infant 67
Seizures 67
2. The Newborn Infant 10 Hypotonia 68
Intracranial Hemorrhage 68
Danielle Smith, MD Metabolic Disorders in the Newborn Infant 68
Theresa R. Grover, MD Hyperglycemia 68
The Neonatal History 10 Hypocalcemia 69
Assessment of Growth & Gestational Age 10 Inborn Errors of Metabolism 69
Examination at Birth 13 Quality Assessment & Improvement
Examination in the Nursery 14 in the Newborn Nursery And NICU 70
Care of the Well Neonate 16
Feeding the Well Neonate 17 3. Child Development & Behavior 71
Early Discharge of the Newborn Infant 17
Hearing Screening 18 Edward Goldson, MD
Common Problems in the Term Newborn 19 Ann Reynolds, MD
Neonatal Jaundice 19 Normal Development 71
Hypoglycemia 26 The First 2 Years 71
Respiratory Distress in the Term Newborn Infant 28 Ages 2–4 Years 78
Heart Murmurs 30 Early School Years: Ages 5–7 Years 78
Birth Trauma 30 Middle Childhood: Ages 7–11 Years 79
Infants of Mothers Who Abuse Drugs 31 Behavioral & Developmental Variations 79
Neonatal Intensive Care 34 Normality & Temperament 79
Perinatal Resuscitation 34 Enuresis & Encopresis 80
The Preterm Infant 39 Enuresis 80
The Late Preterm Infant 49 Encopresis 81
Cardiac Problems in the Newborn Infant 50 Common Developmental Concerns 82
Structural Heart Disease 50 Colic 82
Persistent Pulmonary Hypertension 51 Feeding Disorders in Infants & Young Children 83
Arrhythmias 51 Sleep Disorders 85
Gastrointestinal & Abdominal Surgical Temper Tantrums & Breath-Holding Spells 87
Conditions in the Newborn Infant 52 Well-Child Surveillance & Screening 89
Esophageal Atresia & Tracheoesophageal Fistula 52 Developmental Disorders 89
Intestinal Obstruction 52 Attention-Deficit/Hyperactivity Disorder 91
Abdominal Wall Defects 54 Autism Spectrum Disorders 93
Diaphragmatic Hernia 54 Intellectual Disability 96
iii
iv
▲ Co n t en t s
Specific Forms of Intellectual Disability & 6. Eating Disorders 159

Associated Treatment Issues 98
References 99 Eric J. Sigel, MD
Etiology 159
4. Adolescence 101 Incidence 160
Predisposing Factors & Clinical Profiles 160
Molly J. Richards, MD Anorexia Nervosa 160
David W. Kaplan, MD, MPH Bulimia Nervosa 166
Amy E. Sass, MD, MPH Binge-Eating Disorder 168
Demography 101 Avoidant/Restrictive Food
Mortality Data 101 Intake Disorder 169
Morbidity Data 101 Prognosis 169
Delivery of Health Services 102 Resources for Practioners & Families 170
Guidelines for Adolescent Preventive Services 103
Relating to the Adolescent Patient 103 7. Child & Adolescent Psychiatric
The Setting 103 Disorders & Psychosocial Aspects
Confidentiality 103 of Pediatrics 171
The Structure of the Visit 103
Growth & Development 109 Kimberly Kelsay, MD
Puberty 109 Adam Burstein, DO
Physical Growth 111 Ayelet Talmi, PhD
Sexual Maturation 111 Models of Care Encompassing Mental
Psychosocial Development 112 Health in the Primary Care Setting 172
Behavior & Psychological Health 114 Prevention, Early Identification,
Psychophysiologic Symptoms & & Developmental Context 173
Conversion Reactions 114 Lifestyle Recommendations 174
Depression 116 Identification & Assessment During
Adolescent Suicide 117 Health Maintenance Visits 174
Substance Abuse 118 Other Pediatric Care Settings 182
Eating Disorders 118 Consultation-Liaison Psychiatry 182
Overweight & Obesity 118 Chronic Illness in the Pediatric Population 183
School Avoidance 120 Pediatric Terminal Illness 183
School Failure 120 Psychiatric Disorders
Breast Disorders 121 of Childhood & Adolescence 185
Breast Masses 121 Anxiety Disorders 187
Nipple Discharge & Galactorrhea 123 Attention-Deficit/Hyperactivity Disorder 197
Gynecomastia 124 Mood Disorders 200
Gynecologic Disorders in Adolescence 125 Suicide in Children & Adolescents 206
Physiology of Menstruation 125 Conduct Disorders 208
Pelvic Examination 125 High-Risk Patients and Homicide 209
Menstrual Disorders 127 Somatoform Disorders 210
Contraception 135 Adjustment Disorders 212
Pregnancy 142 Psychotic Disorders 212
Other Psychiatric Conditions 215
5. Adolescent Substance Abuse 145
8. Child Abuse & Neglect 216
Paritosh Kaul, MD
Scope of the Problem 145 Antonia Chiesa, MD
Morbidity Data 150 Andrew P. Sirotnak, MD
Predicting the Progression From Use to Abuse 151 Prevention 217
Evaluation of Substance Abuse 152 Clinical Findings 217
Treatment & Referral 155 Differential Diagnosis 223
Prevention 157 Treatment 223
References 158 Prognosis 224
Co n t en t s
▲ v
9. Ambulatory & Office Pediatrics 225 Pertussis Vaccination

(Adolescents & Adults) 275
Meghan Treitz, MD Human Papillomavirus Vaccination 275
Maya Bunik, MD, MSPH Vaccinations for Special Situations 276
David Fox, MD Rabies Vaccination 276
Pediatric History 225 Typhoid Fever Vaccination 278
Pediatric Physical Examination 226 Japanese Encephalitis Vaccination 278
Health Supervision Visits 228 Tuberculosis Vaccination 279
Developmental & Behavioral Assessment 228 Yellow Fever Vaccination 279
Growth Parameters 231 Passive Prophylaxis 280
Blood Pressure 232
Vision & Hearing Screening 233 11. Normal Childhood Nutrition &
Anticipatory Guidance 237 Its Disorders 281
Nutrition Counseling 239
Counseling About Television & Matthew A. Haemer, MD, MPH
Other Media 239 Laura E. Primak, RD, CNSD
Immunizations 240 Nancy F. Krebs, MD, MS
Acute-Care Visits 240 Nutritional Requirements 281
Prenatal Visits 241 Nutrition & Growth 281
Sports Physicals 241 Energy 281
Chronic Disease Management 241 Protein 282
Medical Home 242 Lipids 283
Mental & Behavioral Health 242 Carbohydrates 284
Telephone Management & Major Minerals 285
Web-Based Information 243 Trace Elements 285
Advocacy & Community Pediatrics 243 Vitamins 285
Common General Pediatric Issues 244 Infant Feeding 285
Fever 244 Breast-Feeding 285
Growth Deficiency 246 Special Dietary Products for Infants 294
Nutrition for Children 2 Years & Older 296
10. Immunization 248 Pediatric Undernutrition 297
Pediatric Overweight & Obesity 298
Matthew F. Daley, MD
Nutrition Support 301
Sean T. O’Leary, MD, MPH
Enteral 301
Ann-Christine Nyquist, MD, MSPH
Parenteral Nutrition 302
Standards for Pediatric Immunization Practices 249 Nutrient Requirements & Delivery 303
Routine Childhood & Adolescent
Immunization Schedules 250 12. Emergencies & Injuries 308
Vaccine Safety 250
Vaccination in Special Circumstances 255 Kevin P. Carney, MD
Hepatitis B Vaccination 256 Kelley Roswell, MD
Rotavirus Vaccination 258 Introduction to Pediatric Emergencies & Injuries 308
Diphtheria-Tetanus-Acellular Pertussis Initial Approach to the Acutely
Vaccination 260 Ill Infant or Child 308
Haemophilus Influenzae Type B Vaccination 262 The ABCs of Resuscitation 308
Pneumococcal Vaccination 263 Management of Shock 313
Poliomyelitis Vaccination 265 Summary of Initial Approach to the
Influenza Vaccination 266 Acutely Ill Infant or Child 314
Measles, Mumps, & Emergency Pediatric Drugs 314
Rubella Vaccination 268 Approach to the Pediatric Trauma Patient 315
Varicella Vaccination 270 Mechanism of Injury 315
Hepatitis A Vaccination 272 Initial Assessment & Management 315
Meningococcal Vaccination 273 Primary Survey 315
Tetanus-Reduced Diphtheria-Acellular Secondary Survey 318
vi
▲ Co n t en t s
Head Injury 320 Hydrocarbons (Benzene, Charcoal

Burns 322 Lighter Fluid, Gasoline, Kerosene,
Thermal Burns 322 Petroleum Distillates, Turpentine) 347
Electrical Burns 324 Ibuprofen 347
Disorders Due to Extremes of Environment 325 Insect Stings (Bee, Wasp, & Hornet) 348
Heat-Related Illnesses & Heat Stroke 325 Insecticides 348
Hypothermia 325 Iron 349
Submersion Injuries 327 Lead 350
Lacerations 328 Magnets 350
Animal & Human Bites 328 Mushrooms 350
Dog Bites 328 Nitrites, Nitrates, Aniline, Pentachlorophenol,
Cat Bites 329 & Dinitrophenol 351
Human Bites 329 Opioids & Opiates 351
Pain Management & Procedural Sedation 330 Oral Hypoglycemics (Sulfonylureas, Metformin) 352
Antipsychotics (Typical & Atypical) 353
13. Poisoning 331 Plants 353
Psychotropic Drugs 353
Richard C. Dart, MD, PhD Salicylates 355
Barry H. Rumack, MD Scorpion Stings 356
George Sam Wang, MD
Serotonin Reuptake Inhibitors 356
Pharmacologic Principles of Toxicology 331 Snakebite 356
Preventing Childhood Poisonings 332 Soaps & Detergents 357
General Treatment of Poisoning 332 Spider Bites 358
Initial Telephone Contact 332 Vitamins 358
Initial Emergency Department Contact 335 Warfarin (Coumadin) & Other Oral
Definitive Therapy of Poisoning 335 Anticoagulants 358
Management of Specific Common
Poisonings 336 14. Critical Care 360
Acetaminophen (Paracetamol) 336 Todd C. Carpenter, MD
Alcohol, Ethyl (Ethanol) 338
Amy Clevenger, MD, PhD
Amphetamines & Related Drugs
Angela S. Czaja, MD, MSc
(Methamphetamine, Mdma) 339
Eva N. Grayck, MD
Anesthetics, Local 339
Cameron F. Gunville, DO
Antihistamines & Cough & Cold Preparations 340
Leslie Ridall, DO
Arsenic 341
Carleen Zebuhr, MD
Barbiturates & Benzodiazepines 341
Belladonna Alkaloids Introduction 360
(Atropine, Jimsonweed, Potato Leaves, Respiratory Critical Care 360
Scopolamine, Stramonium) 341 Acute Respiratory Failure 360
b-Blockers & Calcium Channel Blockers 342 Conventional Mechanical Ventilation 364
Carbon Monoxide 342 Major Respiratory Diseases in the Pediatric ICU 368
Caustics 342 Acute Respiratory Distress Syndrome 368
Central a 2-Adrenergic Agonist 343 Status Asthmaticus 371
Cocaine 343 Cardiovascular Critical Care 374
Cosmetics & Related Products 344 Shock 374
Cyclic Antidepressants 344 Sepsis 377
Digitalis & Other Cardiac Glycosides 345 Neurocritical Care 381
Diphenoxylate With Atropine (Lomotil) & Traumatic Brain Injury 381
Loperamide (Imodium) 345 Hypoxic-Ischemic Encephalopathy 385
Disinfectants & Deodorizers 345 Acute Kidney Injury & Renal
Disk-Shaped “Button” Batteries 346 Replacement Therapy 385
Ethylene Glycol & Methanol 346 Fluid Management & Nutritional Support
γ-Hydroxybutyrate, γ-Butyrolactone, of the Critically Ill Child 387
Butanediol, Flunitrazepam, & Ketamine 347 Sedation & Analgesia in the Pediatric ICU 389
Co n t en t s
▲ vii
End-of-Life Care & Death in the PICU 393 Pupils 421

Quality Improvement Initiatives in the PICU 396 Alignment & Motility Evaluation 422
Ophthalmoscopic Examination 423
15. Skin 397 Ocular Trauma 424
Ocular Foreign Bodies 424
Joseph G. Morelli, MD Corneal Abrasion 425
Lori D. Prok, MD Intraocular Foreign Bodies &
General Principles 397 Perforating Ocular Injuries 425
Diagnosis of Skin Disorders 397 Blunt Orbital Trauma 426
Treatment of Skin Disorders 397 Lacerations 427
Disorders of the Skin in Newborns 399 Burns 427
Transient Diseases in Newborns 399 Hyphema 428
Pigment Cell Birthmarks, Nevi, Abusive Head Trauma &
& Melanoma 400 Nonaccidental Trauma 429
Melanocytic NEVI 401 Prevention of Ocular Injuries 429
Vascular Birthmarks 401 Disorders of the Ocular Structures 430
Epidermal Birthmarks 402 Diseases of the Eyelids 430
Connective Tissue Birthmarks Viral Eyelid Disease 431
(Juvenile Elastoma, Collagenoma) 403 Miscellaneous Eyelid Infections 431
Hereditary Skin Disorders 403 Eyelid Ptosis 432
Common Skin Diseases in Infants, Children, Horner Syndrome 432
& Adolescents 404 Eyelid Tics 433
Acne 404 Disorders of the Nasolacrimal System 433
Bacterial Infections of the Skin 406 Nasolacrimal Duct Obstruction 433
Fungal Infections of the Skin 407 Congenital Dacryocystocele 434
Viral Infections of the Skin 408 Dacryocystitis 435
Virus-Induced Tumors 409 Diseases of the Conjunctiva 435
Insect Infestations 410 Ophthalmia Neonatorum 435
Dermatitis (Eczema) 410 Bacterial Conjunctivitis 436
Common Skin Tumors 413 Viral Conjunctivitis 437
Papulosquamous Eruptions 414 Allergic Conjunctivitis 437
Hair Loss (Alopecia) 415 Mucocutaneous Diseases 438
Reactive Erythemas 416 Disorders of the Iris 439
Miscellaneous Skin Disorders Seen Iris Coloboma 439
in Pediatric Practice 416 Aniridia 440
Albinism 440
16. Eye 418 Miscellaneous Iris Conditions 441
Glaucoma 441
Rebecca Sands Braverman, MD Uveitis 441
Common Nonspecific Signs & Symptoms 418 Anterior Uveitis/Iridocyclitis/Iritis 441
Red Eye 418 Posterior Uveitis 442
Tearing 418 Intermediate Uveitis 443
Discharge 418 Ocular Manifestations of AIDS 443
Pain & Foreign Body Sensation 418 Disorders of the Cornea 444
Photophobia 418 Cloudy Cornea 444
Leukocoria 418 Viral Keratitis 444
Refractive Errors 419 Corneal Ulcers 445
Myopia (Nearsightedness) 419 Disorders of the Lens 446
Hyperopia (Farsightedness) 420 Cataracts 446
Astigmatism 420 Dislocated Lenses/Ectopia Lentis 446
Ophthalmic Examination 420 Disorders of the Retina 447
History 420 Retinal Hemorrhages in the Newborn 447
Visual Acuity 420 Retinopathy of Prematurity 447
External Examination 421 Retinoblastoma 448
viii
▲ Co n t en t s
Retinal Detachment 449 The Throat & Oral Cavity 489

Diabetic Retinopathy 449 Acute Stomatitis 489
Diseases of the Optic Nerve 450 Pharyngitis 489
Optic Neuropathy 450 Peritonsillar Cellulitis or Abscess (Quinsy) 492
Optic Nerve Hypoplasia 451 Retropharyngeal Abscess 493
Papilledema 451 Ludwig Angina 493
Optic Neuritis 452 Acute Cervical Adenitis 493
Optic Atrophy 452 Snoring, Mouth Breathing,
Diseases of the Orbit 453 & Upper Airway Obstruction 494
Periorbital & Orbital Cellulitis 453 Tonsillectomy & Adenoidectomy 496
Craniofacial Anomalies 453 Disorders of the Lips 497
Orbital Tumors 454 Disorders of the Tongue 498
Nystagmus 455 Halitosis 498
Amblyopia 455 Salivary Gland Disorders 498
Strabismus 456 Congenital Oral Malformations 498
Unexplained Decreased Vision in Infants &
Children 458 19. Respiratory Tract & Mediastinum 500
Learning Disabilities & Dyslexia 458
Monica J. Federico, MD
Christopher D. Baker, MD
17. Oral Medicine & Dentistry 459
Emily M. Deboer, MD
Ulrich Klein, DMD, DDS, MS Ann C. Halbower, MD
Issues in Pediatric Oral Health 459 Oren Kupfer, MD
Dental Caries 460 Stacey L. Martiniano, MD
Oral Examination of the Newborn & Infant 463 Scott D. Sagel, MD
Eruption of the Teeth 465 Paul Stillwell, MD
Periodontal Disease 466 Edith T. Zemanick, MD
Dental Emergencies 467 Michelle Caraballo, MD
Antibiotics in Pediatric Dentistry 468 Stephen Hawkins, MD, DO
Special Patient Populations 468 Respiratory Tract 500
Orthodontic Referral 469 Growth & Development 500
Diagnostic AIDS 501
18. Ear, Nose, &Throat 470 Physical Examination of the
Respiratory Tract 501
Patricia J. Yoon, MD Pulmonary Function Tests 501
Melissa A. Scholes, MD Assessment of Oxygenation & Ventilation 502
Norman R. Friedman, MD Diagnosis of Respiratory Tract Infections 504
The Ear 470 Imaging of the Respiratory Tract 505
Infections of the Ear 470 Laryngoscopy & Bronchoscopy 506
Acute Trauma to the Middle Ear 480 General Therapy for Pediatric Lung Diseases 506
Cerumen Impaction & Ear Canal Oxygen Therapy 506
Foreign Body 480 Inhalation of Medications 507
Auricular Hematoma 480 Airway Clearance Therapy 508
Congenital Ear Malformations 480 Avoidance of Environmental Hazards 508
Identification & Management of Hearing Loss 481 Disorders of the Conducting Airways 508
The Nose & Paranasal Sinuses 483 Laryngomalacia & Congenital Disorders
Acute Viral Rhinitis 483 of the Extrathoracic Airway 509
Rhinosinusitis 485 Laryngomalacia 509
Choanal Atresia 487 Other Causes of Congenital Extrathoracic
Recurrent Rhinitis 487 Obstruction 509
Epistaxis 488 Acquired Disorders of the Extrathoracic Airway 510
Nasal Infection 488 Foreign Body Aspiration in the
Nasal Trauma 488 Extrathoracic Airway 510
Foreign Bodies in the Nose 489 Croup Syndromes 511
Co n t en t s
▲ ix
Vocal Cord Paralysis 513 Sleep-Disordered Breathing 544

Subglottic Stenosis 513 Obstructive & Central Sleep Apnea 545
Congenital Causes of Intrathoracic Apparent Life-Threatening Events 546
Airway Obstruction 514 Sudden Unexpected Infant Death
Malacia of Airways 514 and Sudden Infant Death Syndrome 548
Vascular Rings and Slings 515
Bronchogenic Cysts 515 20. Cardiovascular Diseases 550
Acquired Causes of Intrathoracic Airway
Obstruction 516 Pei-Ni Jone, MD
Foreign Body Aspiration in the Intrathoracic Jeffrey R. Darst, MD
Airway 516 Kathryn K. Collins, MD
Disorders of Mucociliary Clearance 517 Shelley D. Miyamoto, MD
Cystic Fibrosis 517 Diagnostic Evaluation 550
Primary Ciliary Dyskinesia 518 History 550
Bronchiectasis 519 Physical Examination 550
Bronchiolitis Obliterans 520 Electrocardiography 553
Congenital Malformations of the Chest Radiograph 555
Lung Parenchyma 521 Echocardiography 556
Pulmonary Agenesis & Hypoplasia 521 Magnetic Resonance Imaging 557
Pulmonary Sequestration 522 Cardiopulmonary Stress Testing 557
Congenital Lobar Emphysema 522 Arterial Blood Gases 557
Congenital Pulmonary Airway Malformation Cardiac Catheterization &
(Cystic Adenomatoid Malformation) 523 Angiocardiography 557
Acquired Abnormalities of the Lung Parenchyma 524 Perinatal & Neonatal Circulation 559
Bronchopulmonary Dysplasia 524 Heart Failure 560
Community-Acquired Bacterial Pneumonia 526 Genetic Basis of Congenital Heart Disease 562
Parapneumonic Effusion & Empyema 527 Acyanotic Congenital Heart Disease 562
Atypical Pneumonias 528 Defects in Septation 562
Viral Pneumonia 528 Patent (Persistent) Ductus Arteriosus 567
Bronchiolitis 530 Right-Sided Obstructive Lesions 568
Mycoplasma Pneumonia 531 Left-Sided Lesions 571
Aspiration Pneumonia 531 Diseases of the Aorta 575
Pneumonia in the Coronary Artery Abnormalities 576
Immunocompromised Host 532 Cyanotic Congenital Heart Disease 577
Lung Abscess 534 Tetralogy of Fallot 577
Children’s Interstitial Lung Pulmonary Atresia with Ventricular
Disease Syndrome 535 Septal Defect 578
Hypersensitivitiy Pneumonitis 536 Pulmonary Atresia with Intact Ventricular
Diseases of the Pulmonary Circulation 537 Septum 579
Pulmonary Hemorrhage 537 Tricuspid Atresia 580
Pulmonary Embolism 539 Hypoplastic Left Heart Syndrome 581
Pulmonary Edema 539 Transposition of the Great Arteries 582
Congenital Pulmonary Lymphangiectasia 540 Total Anomalous Pulmonary
Disorders of the Chest Wall 540 Venous Return 584
Scoliosis 540 Truncus Arteriosus 585
Pectus Carinatum 541 Quality Improvement in
Pectus Excavatum 541 Congenital Heart Disease 586
Neuromuscular Disorders 541 Acquired Heart Disease 587
Disorders of the Pleura & Pleural Cavity 542 Rheumatic Fever 587
Hemothorax 542 Kawasaki Disease 589
Chylothorax 542 Infective Endocarditis 590
Pneumothorax & Related Air Leak Syndromes 543 Pericarditis 591
Mediastinum 544 Cardiomyopathy 592
Mediastinal Masses 544 Myocarditis 595
x
▲ Co n t en t s
Preventive Cardiology 596 Congenital Anorectal Anomalies 631

Hypertension 596 Clostridium Difficile Infection in Children 631
Atherosclerosis & Dyslipidemias 596 Disorders of the Peritoneal Cavity 633
Chest Pain 597 Peritonitis 633
Cardiac Transplantation 597 Chylous Ascites 633
Quality Improvement for Pediatric Gastrointestinal Tumors & Malignancies 634
Heart Transplantation 599 Juvenile Polyps 634
Pulmonary Hypertension 599 Cancers of the Esophagus, Small Bowel,
Disorders of Rate & Rhythm 600 & Colon 635
Disorders of the Sinus Node 600 Mesenteric Cysts 636
Premature Beats 601 Intestinal Hemangiomas and Vascular
Supraventricular Tachycardia 603 Malformations 636
Ventricular Tachycardia 606 Major Gastrointestinal Symptoms & Signs 636
Long QT Syndrome 607 Acute Diarrhea 636
Sudden Death 607 Chronic Diarrhea 637
Disorders of Atrioventricular Conduction 607 Gastrointestinal Bleeding 639
Syncope (Fainting) 610 Vomiting 642
Abdominal Pain 643
21. Gastrointestinal Tract 611 Acute Abdomen 645
Malabsorption Syndromes 645
Edward Hoffenberg, MD Inflammatory Bowel Disease 649
Glenn T. Furuta, MD
Gregg Kobak, MD 22. Liver & Pancreas 653
Edwin Liu, MD
Jason Soden, MD Ronald J. Sokol, MD, FAASLD
Robert Kramer, MD Michael R. Narkewicz, MD
David Brumbaugh, MD Shikha S. Sundaram, MD, MSCI
Disorders of the Esophagus 611 Cara L. Mack, MD
Gastroesophageal Reflux & GERD 611 Liver Disorders 653
Eosinophilic Esophagitis 613 Neonatal Cholestatic Jaundice 653
Caustic Burns of the Esophagus 615 Intrahepatic Cholestasis 653
Foreign Bodies in the Alimentary Tract 616 Extrahepatic Neonatal Cholestasis 661
Disorders of the Stomach & Duodenum 617 Other Neonatal Hyperbilirubinemic
Hiatal Hernia 617 Conditions (Noncholestatic
Pyloric Stenosis 618 Nonhemolytic) 663
Gastric & Duodenal Ulcer 619 Hepatitis A 666
Congenital Diaphragmatic Hernia 620 Hepatitis B 668
Congenital Duodenal Obstruction 621 Hepatitis C 670
Disorders of the Small Intestine 622 Hepatitis D (Delta Agent) 671
Intestinal Atresia & Stenosis 622 Hepatitis E 671
Intestinal Malrotation 622 Other Hepatitis Viruses 671
Short Bowel Syndrome 623 Acute Liver Failure 672
Intussusception 624 Autoimmune Hepatitis 673
Inguinal Hernia 625 Nonalcoholic Fatty Liver Disease 675
Umbilical Hernia 626 a 1-Antitrypsin Deficiency Liver Disease 676
Patent Omphalomesenteric Duct 626 Wilson Disease (Hepatolenticular
Meckel Diverticulum 626 Degeneration) 677
Acute Appendicitis 627 Drug-Induced Liver Disease 679
Duplications of the Gastrointestinal Tract 627 Cirrhosis 679
Disorders of the Colon 628 Portal Hypertension 681
Congenital Aganglionic Megacolon Biliary Tract Disease 683
(Hirschsprung Disease) 628 Pyogenic & Amebic Liver Abscess 688
Constipation 629 Liver Tumors 689
Anal Fissure 630 Liver Transplantation 690
Co n t en t s
▲ xi
Pancreatic Disorders 691 Focal Segmental Glomerulosclerosis 719

Acute Pancreatitis 691 Membranous Nephropathy
Chronic Pancreatitis 692 (Membranous Glomerulonephritis) 719
Gastrointestinal & Hepatobiliary Diseases of the Renal Vessels 720
Manifestations of Cystic Fibrosis 693 Renal Vein Thrombosis 720
Syndromes With Pancreatic Exocrine Renal Arterial Disease 720
Insufficiency 697 Hemolytic-Uremic Syndrome 720
Isolated Exocrine Pancreatic Renal Failure 721
Enzyme Defect 697 Acute Kidney Injury 721
Pancreatic Tumors 697 Chronic Renal Failure 724
References 698 Hypertension 725
Inherited or Developmental Defects
23. Fluid, Electrolyte, & Acid-Base Disorders of the Kidneys 727
&Therapy 699 Disorders of the Renal Tubules 727
Cystinosis 729
Douglas M. Ford, MD Oculocerebrorenal Syndrome
Melisha G. Hanna, MD, MS (Lowe Syndrome) 730
Regulation of Body Fluids, Hypokalemic Alkalosis (Bartter Syndrome,
Electrolytes, & Tonicity 699 Gitelman Syndrome, & Liddle Syndrome) 730
Acid-Base Balance 700 Nephrogenic Diabetes Insipidus (NDI) 730
Fluid & Electrolyte Management 701 Nephrolithiasis 731
Dehydration 702 Urinary Tract Infections 732
Hyponatremia 704 QA/QI in Pediatric Nephrology 733
Hypernatremia 705
Potassium Disorders 706 25. Neurologic & Muscular
Acid-Base Disturbances 707 Disorders 735
Metabolic Acidosis 707
Metabolic Alkalosis 708 Sita Kedia, MD, MPH
Respiratory Acidosis 708 Kelly Knupp, MD
Respiratory Alkalosis 708 Teri L. Schreiner, MD, MPH
Michele L. Yang, MD
24. Kidney & Urinary Tract 710 Jeremy Toler, MD
Paul G. Moe, MD
Melissa A. Cadnapaphornchai, MD Neurologic Assessment & Neurodiagnostics 735
Gary M. Lum, MD History & Examination 735
Evaluation of the Kidney & Urinary Tract 710 Diagnostic Testing 735
History 710 Pediatric Neuroradiologic Procedures 737
Physical Examination 710 Disorders Affecting the Nervous System
Laboratory Evaluation of Renal Function 710 in Infants & Children 741
Laboratory Evaluation of Immunologic Altered States of Consciousness 741
Function 714 Seizure Disorders (Epilepsies) 744
Radiographic Evaluation 714 Sleep Disorders 758
Renal Biopsy 714 Headaches 759
Congenital Anomalies of the Urinary Tract 714 Pseudotumor Cerebri
Renal Parenchymal Anomalies 714 (Idiopathic Intracranial Hypertension) 762
Distal Urinary Tract Anomalies 715 Cerebrovascular Disease 764
Hematuria & Glomerular Disease 716 Congenital Malformations of the
Microhematuria 716 Nervous System 767
Glomerulonephritis 716 Abnormal Head Size 770
Tubulointerstitial Disease 718 Neurocutaneous Dysplasias 772
Acute Interstitial Nephritis 718 Central Nervous System
Proteinuria & Renal Disease 718 Degenerative Disorders of
Congenital Nephrosis 718 Infancy & Childhood 777
Idiopathic Nephrotic Syndrome of Childhood 718 Ataxias of Childhood 777
xii
▲ Co n t en t s
Acute Ataxias of Childhood 777 Trauma 828

Congenital Causes of Chronic & Traumatic Subluxations & Dislocations 829
Episodic Ataxias 783 Fractures 830
Intermittent/Episodic Ataxias 783 Infections of the Bones & Joints 832
Progressive Ataxias 784 Vascular Lesions & Avascular
Extrapyramidal Disorders 786 Necrosis (Osteochondroses) 835
Cerebral Palsy 789 Neoplasia of the Musculoskeletal System 836
Infections & Inflammatory Disorders Miscellaneous Diseases of Bone & Joint 838
of the Central Nervous System 790 Fibrous Dysplasia 838
Bacterial Meningitis 791 Bone Cysts, Baker Cyst, & Ganglions 839
Brain Abscess 792 Quality Assurance/Improvement
Viral Infections 793 Initiatives in Orthopedics 839
Encephalopathy of Human
Immunodeficiency Virus Infection 793 27. Sports Medicine 840
Other Infections 793
Noninfectious Inflammatory Disorders Katherine S. Dahab, MD, FAAP, CAQSM
of the Central Nervous System 794 Kyle B. Nagle, MD, MPH, FAAP, CAQSM
Other Parainfectious Encephalopathies 795 Rachel A. Coel, MD, PhD, FAAP, CAQSM
Multiple Sclerosis 795 Quynh B. Hoang, MD, FAAP, CAQSM
Syndromes Presenting as Acute Armando Vidal, MD
Flaccid Weakness 796 Basic Principles 840
Disorders of Childhood Affecting Muscles 799 Fitness & Conditioning 840
Benign Acute Childhood Myositis 807 Sports Nutrition 841
Myasthenic Syndromes 807 Preparticipation Physical Evaluation 841
Peripheral Nerve Palsies 809 Rehabilitation of Sports Injuries 849
Chronic Polyneuropathy 810 Common Sports Medicine
Miscellaneous Neuromuscular Disorders 811 Issues & Injuries 855
Floppy Infant Syndrome 811 Infectious Diseases 855
Web Resources 813 Head & Neck Injuries 855
Spine Injuries 858
26. Orthopedics 815 Shoulder Injuries 859
Elbow Injuries 861
Mark A. Erickson, MD, MMM Jason Rhodes, MD, MS Hand & Wrist Injuries 863
Cameron Niswander, BA Hip Injuries 864
Disturbances of Prenatal Origin 815 Knee Injuries 867
Congenital Amputations Foot & Ankle Injuries 870
& Limb Deficiencies 815 Prevention 872
Deformities of the Extremities 816
Common Foot Problems 816 28. Rehabilitation Medicine 873
Genu Varum & Genu Valgum 818
Tibial Torsion & Femoral Anteversion 819 Pamela E. Wilson, MD Gerald H. Clayton, PhD
Developmental Dysplasia of the Hip Joint 819 Pediatric Brain Injury 873
Slipped Capital Femoral Epiphysis 821 Spinal Cord Injury 876
Common Spine Conditions 821 Brachial Plexus Lesions 878
Torticollis 821 Common Rehabilitation Problems 879
Scoliosis 822 Quality Assurance/Improvement
Kyphosis 823 Initiatives in Rehabilitation
Inflammatory Conditions 824 Medicine 881
Arthritis and Tenosynovitis 824
Syndromes with Musculoskeletal 29. Rheumatic Diseases 882
Involvement 824
Arthrogryposis Multiplex Congenita Jennifer B. Soep, MD
(Amyoplasia Congenita) 824 Juvenile Idiopathic Arthritis 882
Neurologic Disorders Involving Systemic Lupus Erythematosus 885
the Musculoskeletal System 827 Dermatomyositis 887
Co n t en t s
▲ xiii
Vasculitis 888 Pretransfusion Testing 938

Raynaud Phenomenon 889 Transfusion Practice 938
Noninflammatory Pain Syndromes 889 References 944
30. Hematologic Disorders 891 31. Neoplastic Disease 945

Daniel R. Ambruso, MD Doug K. Graham, MD, PhD
Rachelle Nuss, MD John A. Craddock, MD
Michael Wang, MD Ralph R. Quinones, MD
Normal Hematologic Values 891 Amy K. Keating, MD
Bone Marrow Failure 891 Kelly Maloney, MD
Constitutional Aplastic Anemia Nicholas K. Foreman, MD, MRCP
(Fanconi Anemia) 891 Roger H. Giller, MD
Acquired Aplastic Anemia 892 Brian S. Greffe, MD
Anemias 893 Major Pediatric Neoplastic Diseases 945
Approach to the Child With Anemia 893 Acute Lymphoblastic Leukemia 945
Pure Red Cell Aplasia 895 Acute Myeloid Leukemia 948
Nutritional Anemias 897 Myeloproliferative Diseases 951
Anemia of Chronic Disorders 899 Brain Tumors 952
Congenital Hemolytic Anemias: Lymphomas & Lymphoproliferative
Red Cell Membrane Defects 900 Disorders 956
Congenital Hemolytic Anemias: Neuroblastoma 961
Hemoglobinopathies 901 Wilms Tumor (Nephroblastoma) 963
Congenital Hemolytic Anemias: Bone Tumors 965
Disorders of Red Cell Metabolism 908 Rhabdomyosarcoma 967
Acquired Hemolytic Anemia 910 Retinoblastoma 968
Polycythemia & Methemoglobinemia 912 Hepatic Tumors 969
Congenital Erythrocytosis Langerhans Cell Histiocytosis 970
(Familial Polycythemia) 912 Hematopoietic Stem Cell Transplant 971
Secondary Polycythemia 912 General Considerations 971
Methemoglobinemia 913 Late Effects of Pediatric Cancer Therapy 974
Disorders of Leukocytes 913 Growth Complications 974
Neutropenia 913 Endocrine Complications 974
Neutrophilia 915 Cardiopulmonary Complications 975
Disorders of Neutrophil Function 915 Renal Complications 975
Lymphocytosis 917 Neuropsychological Complications 975
Eosinophilia 918 Second Malignancies 975
Bleeding Disorders 918
Abnormalities of Platelet Number 32. Pain Management & Pediatric
or Function 919 Palliative & End-of-Life Care 977
Inherited Bleeding Disorders 924
Von Willebrand Disease 928 Brian Greffe, MD
Acquired Bleeding Disorders 929 Jeffrey L. Galinkin, MD, FAAP
Vascular Abnormalities Associated Nancy A. King, MSN, RN, CPNP
with Bleeding 931 Pain Assessment 977
Thrombotic Disorders 932 Acute Pain 977
Splenic Abnormalities 935 Chronic Pain Management 979
Splenomegaly & Hypersplenism 935 Pediatric Palliative & End-of-Life Care 981
Asplenia & Splenectomy 935 Introduction 981
Transfusion Medicine 936 Children Who May Benefit from
Donor Screening & Blood Processing: Palliative Care Interventions 982
Risk Management 936 Pain Management in Pediatric Palliative Care 982
Storage & Preservation of Blood Quality-of-Life Adjuncts & Symptom
& Blood Components 938 Management in Pediatric Palliative Care 982
xiv
▲ Co n t en t s
Psychosocial Aspects of Disorders of Calcium &

Pediatric Palliative Care 984 Phosphorus Metabolism 1022
Children’s Concept of Death 984 Hypocalcemic Disorders 1022
Spiritual & Cultural Support 984 Pseudohypoparathyroidism
Withdrawal of Medical Life Support 984 (Resistance To Parathyroid
Advance Care Planning 986 Hormone Action) 1026
Hypercalcemic States 1026
33. Immunodeficiency 988 Familial Hypocalciuric Hypercalcemia
(Familial Benign Hypercalcemia) 1028
Jordan K. Abbott, MD Hypervitaminosis D 1028
Pia J. Hauk, MD Idiopathic Hypercalcemia of Infancy
Immunodeficiency Evaluation: (Williams Syndrome) 1028
Primary Considerations 988 Immobilization Hypercalcemia 1028
Severe Combined Hypophosphatasia 1028
Immunodeficiency Diseases 992 Gonads (Ovaries & Testes) 1029
Antibody Deficiency Syndromes 995 Development 1029
Other Combined Disorders of Sexual Development 1029
Immunodeficiency Disorders 998 Abnormalities in Female Pubertal
Phagocyte Disorders 1001 Development & Ovarian Function 1031
Complement Deficiencies 1002 Abnormalities in Male Pubertal
Other Well-Defined Development & Testicular Function 1034
Immunodeficiency Syndromes 1003 Adrenal Cortex 1036
Genetic Syndromes Adrenocortical Insufficiency
Associated with Immunodeficiency 1005 (Adrenal Crisis, Addison Disease) 1037
Congenital Adrenal Hyperplasias 1039
34. Endocrine Disorders 1007 Adrenocortical Hyperfunction
(Cushing Disease, Cushing Syndrome) 1041
Megan Moriarty Kelsey, MD, MS
Primary Hyperaldosteronism 1042
Jennifer M. Barker, MD
Uses of Glucocorticoids &
Sarah Bartz, MD
Adrenocorticotropic Hormone in
Christine M. Chan, MD
Treatment of Nonendocrine Diseases 1042
Michael S. Kappy, MD, PhD
Adrenal Medulla Pheochromocytoma 1044
Sharon H. Travers, MD
Philip S. Zeitler, MD, PhD
35. Diabetes Mellitus 1045
General Concepts 1007
Hormone Types 1007 Marian Rewers, MD, PhD
Feedback Control of H. Peter Chase, MD
Hormone Secretion 1007 General Considerations 1045
Disturbances of Growth 1008
Target Height & Skeletal Maturation 1009 36. Inborn Errors of Metabolism 1054
Short Stature 1009
Tall Stature 1015 Janet A. Thomas, MD
Disorders of the Posterior Pituitary Gland 1016 Johan L.K. Van Hove, MD, PhD, MBA
Arginine Vasopressin Diagnosis 1054
(Antidiuretic Hormone) Physiology 1016 Suspecting Inborn Errors 1054
Central Diabetes Insipidus 1016 Laboratory Studies 1055
Thyroid Gland 1017 Common Clinical Situations 1055
Fetal Development of the Thyroid 1017 Management of Metabolic Emergencies 1056
Physiology 1017 Newborn Screening 1056
Hypothyroidism (Congenital & Disorders of Carbohydrate Metabolism 1057
Acquired) 1017 Glycogen Storage Diseases 1057
Thyroiditis 1019 Galactosemia 1058
Hyperthyroidism 1020 Hereditary Fructose Intolerance 1059
Thyroid Cancer 1021 Disorders of Energy Metabolism 1059
Co n t en t s
▲ xv
Disorders of Amino Acid Metabolism 1061 Autosomal Recessive Disorders 1101

Disorders of the Urea Cycle 1061 X-Linked Disorders 1103
Phenylketonuria & the Nonmendelian Disorders 1104
Hyperphenylalaninemias 1062 Disorders of Imprinting 1104
Hereditary Tyrosinemia 1063 Disorders Associated with Anticipation 1104
Maple Syrup Urine Disease Mitochondrial Disorders 1105
(Branched-Chain Ketoaciduria) 1064 Disorders of Multifactorial Inheritance 1106
Homocystinuria 1065 Cleft Lip & Cleft Palate 1106
Nonketotic Hyperglycinemia 1065 Neural Tube Defects 1107
Organic Acidemias 1066 Common Recognizable Disorders
Propionic & Methylmalonic Acidemia with Variable or Unknown Cause 1108
(Ketotic Hyperglycinemias) 1066 Genetic Evaluation of the Child with
Carboxylase Deficiency 1068 Developmental Disabilities 1110
Glutaric Acidemia Type I 1068 Perinatal Genetics 1111
Disorders of Fatty Acid Oxidation & Carnitine 1069 Teratogens 1111
Fatty Acid Oxidation Disorders 1069 Assisted Reproduction 1112
Carnitine 1070 Prenatal Diagnosis 1112
Purine Metabolism Disorders 1070
Lysosomal Diseases 1071 38. Allergic Disorders 1114
Peroxisomal Diseases 1075
Congenital Disorders of Glycosylation 1076 Ronina A. Covar, MD
Smith-Lemli-Opitz Syndrome & David M. Fleischer, MD
Disorders of Cholesterol Synthesis 1076 Christine Cho, MD
Disorders of Neurotransmitter Metabolism 1077 Mark Boguniewicz, MD
Creatine Synthesis Disorders 1078 Asthma 1114
Quality Initiatives in the Field of Allergic Rhinoconjunctivitis 1131
Metabolic Disease 1078 Atopic Dermatitis 1135
Urticaria & Angioedema 1139
37. Genetics & Dysmorphology 1080 Anaphylaxis 1141
Adverse Reactions to Drugs & Biologicals 1143
Margarita Sifuentes Saenz, MD Food Allergy 1147
Naomi J.L. Meeks, MD Insect Allergy 1148
Anne Chun-Hui Tsai, MD, MSc
Ellen R. Elias, MD 39. Antimicrobial Therapy 1150
Foundations of Genetic Diagnosis 1080
Cytogenetics 1080 Sarah K. Parker, MD
Molecular Genetics 1085 John W. Ogle, MD
Principles of Inherited Human Disorders 1086 Principles of Antimicrobial Therapy 1150
Mendelian Inheritance 1086 Antimicrobial Stewardship 1151
Multifactorial Inheritance 1090 Antimicrobial Susceptibility Testing 1158
Nonmendelian Inheritance 1090 Alteration of Dose & Measurement
Family History & Pedigree 1092 of Blood Levels 1159
Dysmorphology & Human Embryology 1092 The Use of New Antimicrobial Agents 1159
Mechanisms 1092 Prophylactic Antimicrobial Agents 1160
Clinical Dysmorphology 1093 Initial Empiric Antimicrobial Choices
Chromosomal Disorders: Abnormal Number 1095 for Selected Conditions 1161
Trisomies 1095 Specific Antimicrobial Agents 1163
Sex Chromosome Abnormalities 1096 Penicillins 1163
Chromosomal Abnormalities: Glycopeptide Agents 1164
Abnormal Structure 1097 Oxazolidinones 1165
Chromosome Deletion Disorders 1097 Cephalosporins 1165
Contiguous Gene Disorders 1098 Aztreonam 1166
Mendelian Disorders 1099 Carbapenems 1166
Autosomal Dominant Disorders 1099 Macrolides & Azalides 1166
xvi
▲ Co n t en t s
Clindamycin 1167 41. Human Immunodeficiency

Sulfonamides 1167 Virus Infection 1214
Tetracyclines 1167
Aminoglycosides 1168 Elizabeth J. McFarland, MD
Fluoroquinolones 1168 Perinatally HIV-Exposed Infant 1216
Metronidazole 1169 Acute Retroviral Syndrome 1217
Daptomycin 1169 Progressive HIV Disease 1218
References 1169 Prevention 1223
Quality Assurance and Outcome Metrics 1225
40. Infections: Viral & Rickettsial 1170
42. Infections: Bacterial & Spirochetal 1226
Myron J. Levin, MD
Edwin J. Asturias, MD John W. Ogle, MD
Adriana Weinberg, MD Marsha S. Anderson, MD
Viral Infections 1170 Bacterial Infections 1226
Respiratory Infections 1170 Group A Streptococcal Infections 1226
Viruses Causing the Common Cold 1170 Group B Streptococcal Infections 1230
Infections Due to Adenoviruses 1175 Streptococcal Infections with
Influenza 1176 Organisms other than
Parainfluenza (Croup) 1178 Group A or B 1233
Respiratory Syncytial Virus Disease 1178 Pneumococcal Infections 1234
Human Metapneumovirus Infection 1180 Staphylococcal Infections 1237
Infections Due to Enteroviruses and Meningococcal Infections 1242
Parechoviruses 1181 Gonococcal Infections 1244
Acute Febrile Illness 1181 Botulism 1247
Respiratory Tract Illnesses 1181 Tetanus 1249
Rashes (Including Hand-Foot-and-Mouth Gas Gangrene 1251
Disease) 1182 Diphtheria 1252
Central Nervous System Illnesses 1183 Infections Due to Enterobacteriaceae 1253
Infections Due to Herpesviruses 1185 Pseudomonas Infections 1256
Herpes Simplex Infections 1185 Salmonella Gastroenteritis 1257
Varicella & Herpes Zoster 1189 Typhoid Fever & Paratyphoid Fever 1259
Roseola Infantum (Exanthem Subitum) 1191 Shigellosis (Bacillary Dysentery) 1261
Cytomegalovirus Infections 1192 Cholera 1262
Infectious Mononucleosis Campylobacter Infection 1263
(Epstein-Barr Virus) 1195 Tularemia 1264
Viral Infections Spread by Insect Vectors 1197 Plague 1266
Encephalitis 1197 Haemophilus Influenzae Type B
Dengue 1201 Infections 1267
Colorado Tick Fever 1202 Pertussis (Whooping Cough) 1270
Other Major Viral Childhood Exanthems 1202 Listeriosis 1272
Erythema Infectiosum 1202 Tuberculosis 1273
Measles (Rubeola) 1204 Infections With Nontuberculous
Rubella 1205 Mycobacteria 1276
Infections Due to Other Viruses 1207 Legionella Infection 1278
Hantavirus Cardiopulmonary Chlamydophila Infections
Syndrome 1207 (Psittacosis [Ornithosis],
Mumps 1208 C Pneumoniae, & C Trachomatis) 1279
Rabies 1209 Cat-Scratch Disease 1281
Rickettsial Infections 1210 Spirochetal Infections 1282
Human Ehrlichiosis 1210 Syphilis 1282
Rocky Mountain Spotted Fever 1211 Relapsing Fever 1286
Endemic Typhus (Murine Typhus) 1212 Leptospirosis 1287
Q Fever 1213 Lyme Disease 1288
Co n t en t s
▲ xvii
43. Infections: Parasitic & Mycotic 1291 Proctitis, Proctocolitis, & Enteritis 1342
Vaginal Discharge 1343
Kevin Messacar, MD Genital Ulcerations 1344
Samuel R. Dominguez, MD, PhD Genital Warts & Human Papillomavirus 1348
Myron J. Levin, MD Other Viral Infections 1349
Parasitic Infections 1291 Ectoparasitic Infections 1351
Protozoal Infections 1294
Systemic Infections 1294 45. Travel Medicine 1352
Gastrointestinal Infections 1300
Trichomoniasis 1305 Suchitra Rao, MBBS
Metazoal Infections 1306 Sarah K. Parker, MD
Nematode Infections 1306 Introduction 1352
Cestode Infections (Flukes) 1312 Preparing Children and Infants
Trematode Infections 1314 for Travel 1352
Pneumocystis and Other Opportunistic Vaccinations—Routine Childhood
Fungal Infections 1326 Vaccines Modified for Travel 1354
Pneumocystis Jiroveci Infection 1328 Vaccinations—Travel-Specific 1356
Mycotic Infections 1316 Traveler’s Diarrhea 1358
Malaria Prophylaxis & Prevention 1359
44. Sexually Transmitted Infections 1330 Visits To Friends & Relatives (VFR)
in High-Risk Areas 1360
Daniel H. Reirden, MD HIV & Sexually Transmitted Diseases 1360
Ann-Christine Nyquist, MD, MSPH Fever in the Returned Traveler 1363
Adolescent Sexuality 1330 References 1366
Risk Factors 1331
Prevention of Sexually 46. Chemistry & Hematology Reference
Transmitted Infections 1331 Intervals 1367
Screening for Sexually
Transmitted Infections 1331 Frank J. Accurso, MD
Signs & Symptoms 1332 Georgette Siparsky, PhD
The Most Common Antibiotic-Responsive Challenges in Determining &
Sexually Transmitted Infections 1332 Interpreting Pediatric Reference Intervals 1367
Chlamydia Trachomatis Infection 1332 Guidelines for Use of Data in a
Neisseria Gonorrhoeae Infection 1333 Reference Range Study 1367
The Spectrum of Signs & Symptoms Statistical Computation of
of Sexually Transmitted Infections 1339 Reference Intervals 1368
Cervicitis 1339 Why Reference Intervals Vary 1369
Pelvic Inflammatory Disease 1340 Sensitivity & Specificity 1369
Urethritis 1341 Pediatric Reference Intervals 1370
Epididymitis 1342
Index 1383
Authors
Jordan K. Abbott, MD Mark Boguniewicz, MD
Assistant Professor, Department of Pediatrics, University Professor, Department of Pediatrics, University of Colorado
of Colorado School of Medicine and Children’s Hospital School of Medicine and Children’s Hospital Colorado;
Colorado; Division of Pediatric Allergy, Asthma and Clinical Division of Pediatric Allergy, Asthma and Clinical
Immunology, National Jewish Health Immunology, National Jewish Health
Chapter 33: Immunodeficiency Chapter 38: Allergic Disorders
Frank J. Accurso, MD Rebecca Sands Braverman, MD

Professor, Department of Pediatrics, Section of Pediatric Assistant Professor, Department of Ophthalmology, University
Pulmonary Medicine, University of Colorado School of of Colorado School of Medicine
Medicine and Children’s Hospital Colorado Chapter 16: Eye
Chapter 46: Chemistry & Hematology Reference Intervals
David Brumbaugh, MD
Daniel R. Ambruso, MD Assistant Professor, Department of Pediatrics, Section of
Professor, Department of Pediatrics, Section of Pediatric Pediatric Gastroenterology Hepatology and Nutrition,
Hematology, Oncology, and Bone Marrow Transplant, University of Colorado School of Medicine and Children’s
University of Colorado School of Medicine and Children’s Hospital Colorado
Hospital Colorado; Associate Medical Director, Belle Bonfils Chapter 21: Gastrointestinal Tract
Blood Center
Chapter 30: Hematologic Disorders Maya Bunik, MD, MSPH
Assistant Professor, Department of Pediatrics, Section of
Marsha S. Anderson, MD General Academic Pediatrics, Director of the Child Health
Associate Professor, Department of Pediatrics, Section of Clinic, University of Colorado Denver School of Medicine
Pediatric Infectious Diseases, University of Colorado School and Children’s Hospital Colorado
of Medicine and Children’s Hospital Colorado Chapter 9: Ambulatory & Office Pediatrics
Chapter 42: Infections: Bacterial & Spirochetal
Adam Burstein, DO
Edwin J. Asturias, MD Senior Clinical Instructor, Department of Child & Adolescent
Associate Professor, Departments of Pediatrics and Psychiatry, Psychiatry Resident Training Programs,
Epidemiology and Infectious Diseases, University of University of Colorado School of Medicine and Children’s
Colorado School of Medicine; Associate Director, Center for Hospital Colorado
Global Health, Colorado School of Public Health Chapter 7: Child & Adolescent Psychiatric Disorders &
Chapter 40: Infections: Viral & Rickettsial Psychosocial Aspects of Pediatrics
Christopher D. Baker, MD Melissa A. Cadnapaphornchai, MD

Assistant Professor, Department of Pediatrics, Section of Associate Professor, Departments of Pediatrics and Medicine,
Pediatric Pulmonary Medicine, University of Colorado University of Colorado School of Medicine, Section of
School of Medicine and Children’s Hospital Colorado Pediatric Nephrology, Director, Pediatric Continuous
Chapter 19: Respiratory Tract & Mediastinum Renal Replacement Therapy, Hemodialysis, and Peritoneal
Dialysis, The Kidney Center, Children’s Hospital Colorado
Jennifer M. Barker, MD Chapter 24: Kidney & Urinary Tract
Pediatric Endocrinology, University of Colorado School of Michelle Caraballo, MD
Medicine and Children’s Hospital Colorado Former Fellow, Department of Pediatrics, Section of Pediatric
Chapter 34: Endocrine Disorders Pulmonary Medicine, University of Colorado School of
Medicine and Children’s Hospital Colorado
Sarah Bartz, MD Assistant Professor, Department of Pediatrics, Division of
Assistant Professor, Department of Pediatrics, Section of Respiratory Medicine, University of Texas Southwestern
Pediatric Endocrinology, University of Colorado School of Medical Center
Medicine and Children’s Hospital Colorado Chapter 19: Respiratory Tract & Mediastinum
Chapter 34: Endocrine Disorders
xix
xx
▲ Au t h o r s
Kevin P. Carney, MD Kathryn K. Collins, MD

Assistant Professor, Department of Pediatrics, Section of Associate Professor, Department of Pediatrics, Section of
Emergency Medicine, University of Colorado School of Pediatric Cardiology, University of Colorado School of
Medicine, Director of Quality Improvement, Children’s Medicine and Children’s Hospital Colorado
Hospital Colorado Chapter 20: Cardiovascular Diseases
Chapter 12: Emergencies & Injuries
Ronina A. Covar, MD
Todd C. Carpenter, MD Associate Professor, Department of Pediatrics, University
Associate Professor, Department of Pediatrics, Section of of Colorado School of Medicine and Children’s Hospital
Pediatric Critical Care Medicine, University of Colorado Colorado; Division of Pediatric Allergy, Asthma and Clinical
School of Medicine and Children’s Hospital Colorado Immunology, National Jewish Health
Chapter 14: Critical Care Chapter 38: Allergic Disorders
Christine M. Chan, MD John A. Craddock, MD

Assistant Professor, Department of Pediatrics, Section of Assistant Professor, Department of Pediatrics, Section of
Pediatric Endocrinology, University of Colorado School of Pediatric Hematology, Oncology, and Bone Marrow
Medicine and Children’s Hospital Colorado Transplant, Center for Cancer and Blood Disorders,
Chapter 34: Endocrine Disorders University of Colorado School of Medicine and Children’s
Hospital Colorado
H. Peter Chase, MD Chapter 31: Neoplastic Disease
Professor, Department of Pediatrics, Clinical Director Emeritus,
Barbara Davis Center for Childhood Diabetes, University of Angela S. Czaja, MD, MSc
Colorado School of Medicine Assistant Professor, Department of Pediatrics, Section of
Chapter 35: Diabetes Mellitus Pediatric Critical Care Medicine, University of Colorado
School of Medicine and Children’s Hospital Colorado
Antonia Chiesa, MD Chapter 14: Critical Care
Senior Instructor, Department of Pediatrics, Kempe Child
Protection Team, University of Colorado School of Katherine S. Dahab, MD, FAAP, CAQSM
Medicine, Children’s Hospital Colorado and Kempe Center Assistant Professor, Department of Orthopedics, Fellowship
for the Prevention and Treatment of Child Abuse and Director, Pediatric Primary Care Sports Medicine
Neglect Fellowship, University of Colorado School of Medicine and
Chapter 8: Child Abuse & Neglect Children’s Hospital Colorado
Chapter 27: Sports Medicine
Christine Cho, MD
Assistant Professor, Department of Pediatrics, University Matthew F. Daley, MD
Colorado School of Medicine and Children’s Hospital Assistant Professor, Department of Pediatrics, Section of
Colorado; Division of Allergy, Asthma and Clinical General Academic Pediatrics, University of Colorado School
Immunology, National Jewish Health of Medicine and Children’s Hospital Colorado
Chapter 38: Allergic Disorders Chapter 10: Immunization
Gerald H. Clayton, PhD Jeffrey R. Darst, MD

Instructor, Department of Physical Medicine and Assistant Professor, Department of Pediatrics, Section of
Rehabilitation, University of Colorado School of Medicine Pediatric Cardiology, University of Colorado School of
and Children’s Hospital Colorado Medicine and Children’s Hospital Colorado
Chapter 28: Rehabilitation Medicine Chapter 20: Cardiovascular Diseases
Amy Clevenger, MD, PhD Richard C. Dart, MD, PhD

Assistant Professor, Department of Pediatrics, Section of Professor, Departments of Regulatory Compliance and
Pediatric Critical Care Medicine, University of Colorado Emergency Medicine, University of Colorado School of
School of Medicine and Children’s Hospital Colorado Medicine; Director, Rocky Mountain Poison and Drug
Chapter 14: Critical Care Center, Denver Health and Hospital Authority
Chapter 13: Poison
Rachel A. Coel, MD, PhD, FAAP, CAQSM
Assistant Professor, Department of Orthopedics, Co-Medical Emily M. Deboer, MD
Director, Sports Medicine Program, University of Colorado Instructor, Department of Pediatrics, Section of Pediatric
School of Medicine and Children’s Hospital Colorado Pulmonary Medicine, University of Colorado School of
Chapter 27: Sports Medicine Medicine and Children’s Hospital Colorado
Chapter 19: Respiratory Tract & Mediastinum
Au t h o r s
▲ xxi
Samuel R. Dominguez, MD, PhD Glenn T. Furuta, MD

Assistant Professor, Department of Pediatrics, Section of Professor, Department of Pediatrics, Section of Gastroenterology,
Pediatric Infectious Diseases, University of Colorado School Hepatology and Nutrition, Attending Physician, Digestive
of Medicine and Children’s Hospital Colorado Health Institute; Director, Gastrointestinal Eosinophil Disease
Chapter 43: Infections: Parasitic & Mycotic Program, University of Colorado School of Medicine and
Ellen R. Elias, MD Chapter 21: Gastrointestinal Tract
Professor, Departments of Pediatrics and Genetics, Director,
Special Care Clinic, University of Colorado School of Jeffrey L. Galinkin, MD, FAAP
Medicine and Children’s Hospital Colorado Associate Professor, Department of Anesthesiology, University
Chapter 37: Genetics & Dysmorphology of Colorado School of Medicine and Children’s Hospital
Colorado
Mark A. Erickson, MD, MMM Chapter 32: Pain Management & Pediatric Palliative & End-of-
Chairman, Department of Pediatric Orthopaedics, Associate Life Care
Professor of Orthopaedic Surgery, Orthopedic Institute,
University of Colorado School of Medicine and Children’s Roger H. Giller, MD
Hospital Colorado Professor, Department of Pediatrics, Section of Pediatric
Chapter 26: Orthopedics Hematology, Oncology, and Bone Marrow Transplant,
Director, Pediatric BMT Program, University of Colorado
Monica J. Federico, MD Chapter 31: Neoplastic Disease
Pediatric Pulmonary Medicine, University of Colorado Edward Goldson, MD
School of Medicine and Children’s Hospital Colorado Professor, Department of Pediatrics, Section of Developmental
Chapter 19: Respiratory Tract & Mediastinum Pediatrics, University of Colorado School of Medicine and
David M. Fleischer, MD Chapter 3: Child Development & Behavior
Assistant Professor, Department of Pediatrics, University
of Colorado School of Medicine and Children’s Hospital Douglas K. Graham, MD, PhD
Colorado; Division of Pediatric Allergy, Asthma and Clinical Formerly Professor, Departments of Pediatrics and
Immunology, National Jewish Health Immunology, Section of Pediatric Hematology, Oncology,
Chapter 38: Allergic Disorders and Bone Marrow Transplant, University of Colorado
Douglas M. Ford, MD Professor, Department of Pediatrics, Chief, Division of
Professor, Department of Pediatrics, Section of Pediatric Pediatric Hematology/Oncology/ BMT, Emory University
Nephrology, Director, Home Dialysis & Renal School of Medicine, Director and Daniel P. Amos Children’s
Transplantation, University of Colorado School of Medicine Chair, Alfac Cancer and Blood Disorders Center
and Children’s Hospital Colorado Chapter 31: Neoplastic Disease
Chapter 23: Fluid, Electrolyte, & Acid-Base Disorders & Therapy
Eva N. Grayck, MD
Nicholas K. Foreman, MD, MRCP Associate Professor, Department of Pediatrics, Section of
Professor, Department of Pediatrics, Section of Pediatric Pediatric Critical Care Medicine, University of Colorado
Hematology, Oncology, and Bone Marrow Transplant, School of Medicine and Children’s Hospital Colorado
Seebaum/Tschetter Chair of Neuro-Oncology, University Chapter 14: Critical Care
of Colorado School of Medicine and Children’s Hospital
Colorado Brian S. Greffe, MD
Chapter 31: Neoplastic Disease Professor, Department of Pediatrics, Section of Pediatric
Hematology, Oncology, and Bone Marrow Transplant,
David Fox, MD University of Colorado School of Medicine and Children’s
Assistant Professor, Section of General Academic Pediatrics, Hospital Colorado
University of Colorado School of Medicine and Children’s Chapter 31: Neoplastic Disease
Hospital Colorado Chapter 32: Pain Management & Pediatric Palliative & End-of-
Chapter 9: Ambulatory & Office Pediatrics Life Care
Norman R. Friedman, MD Theresa R. Grover, MD

Associate Professor, Departments of Otolaryngology & Associate Professor, Department of Pediatrics, Section of
Pediatrics, University of Colorado School of Medicine and Neonatology, University of Colorado School of Medicine
Children’s Hospital Colorado and Children’s Hospital Colorado
Chapter 18: Ear, Nose, & Throat Chapter 2: The Newborn Infant
xxii
▲ Au t h o r s
Cameron F. Gunville, DO David W. Kaplan, MD, MPH

Assistant Professor, Department of Pediatrics, Section of Professor, Department of Pediatrics, Head, Section of
Pediatric Critical Care Medicine, University of Colorado Adolescent Medicine, University of Colorado School of
School of Medicine and Children’s Hospital Medicine and Children’s Hospital Colorado
Chapter 14: Critical Care Chapter 4: Adolescence
Matthew A. Haemer, MD, MPH Michael S. Kappy, MD, PhD

Assistant Professor, Department of Pediatrics, Section of Professor, Department of Pediatrics, Section of Pediatric
Pediatric Nutrition, University of Colorado School of Endocrinology, University of Colorado School of Medicine
Medicine and Children’s Hospital Colorado and Children’s Hospital Colorado
Chapter 11: Normal Childhood Nutrition & Its Disorders Chapter 34: Endocrine Disorders
Ann C. Halbower, MD Paritosh Kaul, MD

Professor, Department of Pediatrics, Section of Pediatric Associate Professor, Department of Pediatrics, Section of
Pulmonology, University of Colorado School of Medicine Adolescent Medicine, University of Colorado School of
and Children’s Hospital Colorado Medicine, Children’s Hospital Colorado, and Denver Health
Chapter 19: Respiratory Tract & Mediastinum Medical Center
Chapter 5: Adolescent Substance Abuse
Melisha G. Hanna, MD, MS
Assistant Professor, Department of Pediatrics, Section of Amy K. Keating, MD
Pediatric Nephrology, University of Colorado School of Assistant Professor, Department of Pediatrics, Section of Pediatric
Medicine and Children’s Hospital Colorado Hematology, Oncology, and Bone Marrow Transplant, Center
Chapter 23: Fluid, Electrolyte, & Acid-Base Disorders & Therapy for Cancer and Blood Disorders, University of Colorado
Pia J. Hauk, MD Chapter 31: Neoplastic Disease
Assistant Professor, Department of Pediatrics, University of
Colorado School of Medicine and National Jewish Health Sita Kedia, MD MPH
Chapter 33: Immunodeficiency Assistant Professor, Departments of Pediatrics and Neurology,
Section of Pediatric Neurology, University of Colorado
Stephen Hawkins, MD, DO School of Medicine and Children’s Hospital Colorado
Fellow Instructor, Department of Pediatrics, Section of Chapter 25: Neurologic & Muscular Disorders
Pediatric Pulmonary Medicine, University of Colorado
School of Medicine and Children’s Hospital Colorado Kimberly Kelsay, MD
Chapter 19: Respiratory Tract & Mediastinum Associate Professor, Department of Psychiatry and Behavioral
Sciences, University of Colorado School of Medicine and
Quynh B. Hoang, MD, FAAP, CAQSM Children’s Hospital Colorado
Assistant Professor, Department of Orthopedics, Sports Chapter 7: Child & Adolescent Psychiatric Disorders &
Medicine Program, University of Colorado School of Psychosocial Aspects of Pediatrics
Chapter 27: Sports Medicine Megan Moriarty Kelsey, MD, MS
Instructor, Department of Pediatrics, Section of Pediatric
Edward J. Hoffenberg, MD Endocrinology, University of Colorado School of Medicine
Associate Professor, Department of Pediatrics, Section of and Children’s Hospital Colorado
Pediatric Gastroenterology, Hepatology and Nutrition, Chapter 34: Endocrine Disorders
University of Colorado School of Medicine and Children’s
Hospital Colorado Nancy A. King, MSN, RN, CPNP
Chapter 21: Gastrointestinal Tract Inpatient Oncology Advanced Practice Nurse, Department
of Pediatrics, Section of Hematology, Oncology, and Bone
Daniel Hyman, MD, MMM Marrow Transplant, University of Colorado School of
Associate Professor, Department of Pediatrics, University Medicine and Children’s Hospital Colorado
of Colorado School of Medicine, Chief Quality Officer, Chapter 32: Pain Management & Pediatric Palliative &
Children’s Hospital Colorado End-of-Life Care
Chapter 1: Advancing the Quality & Safety of Care
Ulrich Klein, DMD, DDS, MS
Pei-Ni Jone, MD Associate Professor and Chair, Department of Pediatric
Assistant Professor, Department of Pediatrics, Section of Dentistry, Director of Pediatric Dentistry Residency
Pediatric Cardiology, Children’s Hospital Colorado and Program, University of Colorado School of Dental Medicine
University of Colorado School of Medicine and Children’s Hospital Colorado
Chapter 20: Cardiovascular Diseases Chapter 17: Oral Medicine & Dentistry
Au t h o r s
▲ xxiii
Kelly Knupp, MD Kelly Maloney, MD

Senior Instructor, Departments of Pediatrics and Neurology, Assistant Professor, Department of Pediatrics, Section of
Section of Pediatric Neurology, University of Colorado Pediatric Gastroenterology, Hepatology and Nutrition,
School of Medicine and Children’s Hospital Colorado University of Colorado School of Medicine and Children’s
Chapter 25: Neurologic & Muscular Disorders Hospital Colorado
Chapter 31: Neoplastic Disease
Gregory Kobak, MD
Senior Instructor, Department of Pediatrics, Section of Stacey L. Martiniano, MD
Pediatric Gastroenterology, Hepatology and Nutrition, Assistant Professor, Department of Pediatrics, Section of
Digestive Health Institute, University of Colorado School of Pediatric Pulmonary Medicine, University of Colorado
Medicine and Children’s Hospital Colorado School of Medicine and Children’s Hospital Colorado
Chapter 21: Gastrointestinal Tract Chapter 19: Respiratory Tract & Mediastinum
Robert E. Kramer, MD Elizabeth J. McFarland, MD

Assistant Professor, Department of Pediatrics, Section of Professor, Department of Pediatrics, Section of Pediatric
Pediatric Gastroenterology, Hepatology and Nutrition, Infectious Diseases, University of Colorado School of
University of Colorado School of Medicine and Children’s Medicine and Children’s Hospital Colorado
Hospital Colorado Chapter 41: Human Immunodeficiency Virus Infection
Chapter 21: Gastrointestinal Tract
Naomi J. L. Meeks, MD
Nancy F. Krebs, MD, MS Assistant Professor, Department of Pediatrics, Section of
Professor, Department of Pediatrics, Section of Pediatric Clinical Genetics and Metabolism, University of Colorado
Nutrition, University of Colorado School of Medicine and School of Medicine
Children’s Hospital Colorado Chapter 37: Genetics & Dysmorphology
Chapter 11: Normal Childhood Nutrition & Its Disorders
Kevin Messacar, MD
Oren Kupfer, MD Fellow, Department of Pediatrics, Section of Pediatric
Fellow, Department of Pediatrics, Section of Pediatric Infectious Diseases, University of Colorado School of
Pulmonary Medicine, University of Colorado School of Medicine and Children’s Hospital Colorado
Medicine and Children’s Hospital Colorado Chapter 43: Infections: Parasitic & Mycotic
Shelley D. Miyamoto, MD
Myron J. Levin, MD Associate Professor, Department of Pediatrics, Section of
Professor, Departments of Pediatrics and Medicine, Section of Pediatric Cardiology, University of Colorado School of
Pediatric Infectious Diseases, University of Colorado School Medicine and Children’s Hospital Colorado
of Medicine and Children’s Hospital Colorado Chapter 20: Cardiovascular Diseases
Chapter 40: Infections: Viral & Rickettsial
Chapter 43: Infections: Parasitic & Mycotic Paul G. Moe, MD
Professor Emeritus, Departments of Pediatrics and Neurology,
Edwin Liu, MD Section of Pediatric Neurology, University of Colorado
Associate Professor, Department of Pediatrics, Section of School of Medicine and Children’s Hospital Colorado
Pediatric Gastroenterology, Hepatology and Nutrition, Chapter 25: Neurologic & Muscular Disorders
Digestive Health Institute, University of Colorado School of
Medicine and Children’s Hospital Colorado Joseph G. Morelli, MD
Chapter 21: Gastrointestinal Tract Professor, Departments of Dermatology and Pediatrics,
Section Head, Section of Pediatric Dermatology, University
Gary M. Lum, MD of Colorado School of Medicine and Children’s Hospital
Professor, Departments of Pediatrics and Medicine, Section Colorado
of Pediatric Nephrology, University of Colorado School of Chapter 15: Skin
Chapter 24: Kidney & Urinary Tract Kyle B. Nagle, MD, MPH, FAAP, CAQSM
Assistant Professor, Department of Orthopedics, University of
Cara L. Mack, MD Colorado School of Medicine, Sports Medicine for Young
Associate Professor, Department of Pediatrics, Section of Athletes, Children’s Hospital of Colorado Orthopedics
Pediatric Gastroenterology, Hepatology and Nutrition, Institute
University of Colorado School of Medicine and Children’s Chapter 27: Sports Medicine
Hospital Colorado
Chapter 22: Liver & Pancreas
xxiv
▲ Au t h o r s
Michael R. Narkewicz, MD Lori D. Prok, MD

Professor, Department of Pediatrics, Fellowship Program Director, Assistant Professor, Departments of Pediatrics and Dermatology,
Section of Pediatric Gastroenterology, Hepatology and Section of Pediatric Dermatology, University of Colorado
Nutrition, Hewitt Andrews Chair in Pediatric Liver Diseases, School of Medicine and Children’s Hospital Colorado
Medical Director, Pediatric Liver Center and Liver Transplant Chapter 15: Skin
Pediatric Services Associate Clinical Director/Associate Dean
for Pediatric Clinical Affairs, University of Colorado School of Ralph R. Quinones, MD
Medicine and Children’s Hospital Colorado Associate Professor, Department of Pediatrics, Section of
Chapter 22: Liver & Pancreas Pediatric Hematology, Oncology, and Bone Marrow
Transplant, Center for Cancer and Blood Disorders,
Cameron Niswander, BA University of Colorado School of Medicine and Children’s
First Year Medical Student, Department of Orthopedics, Hospital Colorado
University of Colorado School of Medicine and Children’s Chapter 31: Neoplastic Disease
Hospital Colorado
Chapter 26: Orthopedics Suchitra Rao, MBBS
Rachelle Nuss, MD Pediatric Infectious Disease, University of Colorado School
Professor, Department of Pediatrics, Section of Pediatric of Medicine and Children’s Hospital Colorado
Hematology, Oncology, and Bone Marrow Transplant; Chapter 45: Travel Medicine
Associate Director, Colorado Sickle Cell Treatment and
Research Center at University of Colorado School of
Medicine; Director Pediatric Sickle Cell Program, Center for Daniel H. Reirden, MD
Cancer and Blood Disorders, Children’s Hospital Colorado Associate Professor, Department of Pediatrics, Section of
Chapter 30: Hematologic Disorders Adolescent Medicine and Internal Medicine, Medical
Director, CHIP Youth Clinic, Director of Internal
Ann-Christine Nyquist, MD, MSPH Medicine – Pediatric Residency, University of Colorado
Professor, Department of Pediatrics, Section of Pediatric School of Medicine and Children’s Hospital Colorado
Infectious Diseases, University of Colorado School of Chapter 44: Sexually Transmitted Infections
Chapter 10: Immunization Marian Rewers, MD, PhD
Chapter 44: Sexually Transmitted Infections Professor, Department of Pediatrics, Clinical Director, Barbara
Davis Center for Childhood Diabetes, University of
Sean T. O’Leary, MD, MPH Colorado School of Medicine
Fellow, Department of Pediatrics, Section of Pediatric Chapter 35: Diabetes Mellitus
Infectious Diseases, University of Colorado School of
Medicine and Children’s Hospital Colorado Ann Reynolds, MD
Chapter 10: Immunization Associate Professor, Department of Pediatrics, Section of
Developmental Pediatrics, University of Colorado School
John W. Ogle, MD of Medicine; Director, The Child Development Unit,
Professor and Vice Chairman Emeritus, Department of Children’s Hospital Colorado
Pediatrics, University of Colorado School of Medicine Chapter 3: Child Development & Behavior
Chapter 39: Antimicrobial Therapy
Chapter 42: Infections: Bacterial & Spirochetal Molly J. Richards, MD
Sarah K. Parker, MD Adolescent Medicine, University of Colorado School of
Assistant Professor, Department of Pediatrics, Section of Medicine and Children’s Hospital Colorado
Pediatric Infectious Diseases, University of Colorado School Chapter 4: Adolescence
of Medicine and Children’s Hospital Colorado
Chapter 39: Antimicrobial Therapy Leslie Ridall, DO
Chapter 45: Travel Medicine Assistant Professor, Department of Pediatrics, Section of
Pediatric Critical Care Medicine, University of Colorado
Laura E. Primak, RD, CNSD School of Medicine and Children’s Hospital Colorado
Professional Research Assistant, Coordinator of Nutrition Chapter 14: Critical Care
Electives, Section of Pediatric Nutrition, University of Colorado
Chapter 11: Normal Childhood Nutrition & Its Disorders
Au t h o r s
▲ xxv
Jason Rhodes, MD, MS Georgette Siparsky, PhD

Assistant Professor, Departments of Mechanical and Materials Clinical Data Analyst II, Department of Clinical Informatics,
Engineering, Director, Cerebral Palsy Program, Orthopedics Children’s Hospital Colorado, and University of Colorado
Institute, University of Colorado School of Medicine and School of Medicine
Children’s Hospital Colorado Chapter 46: Chemistry & Hematology Reference Intervals
Chapter 26: Orthopedics
Andrew P. Sirotnak, MD
Kelley Roswell, MD Professor and Vice Chair for Faculty Affairs, Department of
Assistant Professor, Department of Pediatrics, Section of Pediatrics, Director, Child Protection Team, University of
Emergency Medicine, Co-Director Medical Student Colorado School of Medicine, Children’s Hospital Colorado
Emergency Care Clerkship, University of Colorado School Chapter 8: Child Abuse & Neglect
of Medicine and Children’s Hospital Colorado
Chapter 12: Emergencies & Injuries Danielle Smith, MD
Barry H. Rumack, MD Neonatology, University of Colorado School of Medicine
Clinical Professor, Department of Pediatrics, University of and Children’s Hospital Colorado
Colorado School of Medicine; Director Emeritus, Rocky Chapter 2: The Newborn Infant
Mountain Poison and Drug Center, Denver Health
Authority Jason Soden, MD
Chapter 13: Poison Assistant Professor, Department of Pediatrics, Section of
Pediatric Gastroenterology, Hepatology and Nutrition,
Margarita Sifuentes Saenz, MD University of Colorado School of Medicine and Children’s
Assistant Professor, Department of Pediatrics, Section of Hospital Colorado
Clinical Genetics and Metabolism, University of Colorado Chapter 21: Gastrointestinal Tract
Chapter 37: Genetics & Dysmorphology Jennifer B. Soep, MD
Scott D. Sagel, MD Pediatric Rheumatology, University of Colorado School of
Assistant Professor, Department of Pediatrics, Section of Medicine and Children’s Hospital Colorado
Pediatric Pulmonary Medicine, University of Colorado Chapter 29: Rheumatic Diseases
Chapter 19: Respiratory Tract & Mediastinum Ronald J. Sokol, MD, FAASLD
Professor and Vice Chair, Department of Pediatrics, Arnold
Amy E. Sass, MD, MPH Silverman MD Endowed Chair in Digestive Health; Head,
Assistant Professor, Department of Pediatrics, Section of Section of Pediatric Gastroenterology, Hepatology and
Adolescent Medicine, University of Colorado School of Nutrition and the Digestive Health Institute, University
Medicine and Children’s Hospital Colorado of Colorado School of Medicine and Children’s Hospital
Chapter 4: Adolescence Colorado; Director, Colorado Clinical and Translational
Sciences Institute and Assistant Vice Chancellor for Clinical
Melissa A. Scholes, MD and Translational Science, University of Colorado Denver
Assistant Professor, Department of Pediatric Otolaryngology, Chapter 22: Liver & Pancreas
University of Colorado School of Medicine and Children’s
Hospital Colorado Paul Stillwell, MD
Chapter 18: Ear, Nose, Throat Senior Instructor, Department of Pediatrics, Section of
Pediatric Pulmonary Medicine, University of Colorado
Teri L. Schreiner, MD, MPH School of Medicine and Children’s Hospital Colorado
Assistant Professor, Departments of Pediatrics and Neurology, Chapter 19: Respiratory Tract & Mediastinum
Section of Pediatric Neurology, University of Colorado
School of Medicine and Children’s Hospital Colorado Shikha S. Sundaram, MD, MSCI
Chapter 25: Neurologic & Muscular Disorders Assistant Professor, Department of Pediatrics, Section of
Pediatric Gastroenterology, Hepatology and Nutrition,
Eric J. Sigel, MD University of Colorado School of Medicine and Children’s
Associate Professor, Department of Pediatrics, Section of Hospital Colorado
Adolescent Medicine, University of Colorado School of Chapter 22: Liver & Pancreas
Chapter 6: Eating Disorders
xxvi
▲ Au t h o r s
Ayelet Talmi, PhD Michael Wang, MD

Assistant Professor, Departments of Psychiatry and Pediatrics, Assistant Professor, Department of Pediatrics, Section of
Associate Director, Irving Harris Program in Child Pediatric Hematology, Oncology, and Bone Marrow
Development and Infant Mental Health, University of Colorado Transplant, Center for Cancer and Blood Disorders,
School of Medicine and Children’s Hospital Colorado University of Colorado School of Medicine and Children’s
Chapter 7: Child & Adolescent Psychiatric Disorders & Hospital Colorado
Psychosocial Aspects of Pediatrics Chapter 30: Hematologic Disorders
Janet A. Thomas, MD Adriana Weinberg, MD

Assistant Professor, Department of Pediatrics, Section of Professor, Departments of Pediatrics and Medicine, Director of
Clinical Genetics and Metabolism, Director—IMD Clinic, Clinical Virology Laboratory, Section of Pediatric Infectious
University of Colorado School of Medicine and Children’s Diseases, University of Colorado School of Medicine and
Hospital Colorado Children’s Hospital Colorado
Chapter 36: Inborn Errors of Metabolism Chapter 40: Infections: Viral & Rickettsial
Jeremy Toler, MD Pamela E. Wilson, MD

Assistant Professor, Department of Pediatrics, Section of Child Associate Professor, Department of Physical Medicine &
Neurology, University of Colorado School of Medicine Rehabilitation Medicine, University of Colorado School of
Chapter 25: Neurologic & Muscular Disorders Medicine and Children’s Hospital Colorado
Chapter 28: Rehabilitation Medicine
Sharon H. Travers, MD
Associate Professor, Department of Pediatrics, Section of Michele L. Yang, MD
Pediatric Endocrinology, University of Colorado School of Senior Instructor, Departments of Pediatrics and Neurology,
Medicine and Children’s Hospital Colorado Section of Child Neurology, University of Colorado School
Chapter 34: Endocrine Disorders of Medicine and Children’s Hospital Colorado
Chapter 25: Neurologic & Muscular Disorders
Meghan Treitz, MD
Assistant Professor, Department of Pediatrics, Section of Patricia J. Yoon, MD
General Academic Pediatrics, University of Colorado Assistant Professor, Department of Otolaryngology, Associate
Denver School of Medicine and Children’s Hospital Director, Bill Daniels Center for Children’s Hearing,
Colorado University of Colorado School of Medicine and Children’s
Chapter 9: Ambulatory & Office Pediatrics Hospital Colorado
Chapter 18: Ear, Nose, & Throat
Anne Chun-Hui Tsai, MD, MSc
Associate Professor, Department of Pediatrics, Section of Pediatric Carleen Zebuhr, MD
Clinical Genetics and Metabolism, University of Colorado Assistant Professor, Department of Pediatrics, Section of
School of Medicine and Children’s Hospital Colorado Pediatric Critical Care Medicine, University of Colorado
Chapter 37: Genetics & Dysmorphology School of Medicine and Children’s Hospital Colorado
Chapter 14: Critical Care
Johan L. K. Van Hove, MD, PhD, MBA
Associate Professor, Department of Pediatrics, Head, Section of Philip S. Zeitler, MD, PhD
Clinical Genetics and Metabolism, University of Colorado Professor, Department of Pediatrics, Head, Section of Pediatric
School of Medicine and Children’s Hospital Colorado Endocrinology, University of Colorado School of Medicine
Chapter 36: Inborn Errors of Metabolism and Children’s Hospital Colorado
Chapter 34: Endocrine Disorders
Armando Vidal, MD
Assistant Professor, Department of Orthopedics - Sports Edith T. Zemanick, MD
Medicine Program, University of Colorado School of Assistant Professor, Department of Pediatrics Section of
Medicine and Children’s Hospital Colorado Pediatric Pulmonary Medicine, University of Colorado
Chapter 27: Sports Medicine School of Medicine and Children’s Hospital Colorado
George Sam Wang, MD
Emergency Medicine, Medical Toxicology, University of
Colorado School of Medicine and Children’s Hospital
Colorado
Chapter 13: Poison
Preface
The 23rd edition of Current Diagnosis & Treatment: Pediatrics (CDTP) features practical, up-to-date, well-referenced informa-
tion on the care of children from birth through infancy and adolescence. CDTP emphasizes the clinical aspects of pediatric care
while also covering important underlying principles. CDTP provides a guide to diagnosis, understanding, and treatment of the
medical problems of all pediatric patients in an easy-to-use and readable format.
INTENDED AUDIENCE
Like all Lange medical books, CDTP provides a concise, yet comprehensive source of current information. Students will find
CDTP an authoritative introduction to pediatrics and an excellent source for reference and review. CDTP provides excellent
coverage of The Council on Medical Student Education in Pediatrics (COMSEP) curriculum used in pediatric clerkships.
Residents in pediatrics (and other specialties) will appreciate the detailed descriptions of diseases as well as diagnostic and
therapeutic procedures. Pediatricians, family practitioners, nurses, nurse practitioners, physician assistants, and other health
care providers who work with infants, children, and adolescents will find CDTP a useful reference on management aspects of
pediatric medicine.
COVERAGE
Forty-six chapters cover a wide range of topics, including neonatal medicine, child development and behavior, emergency and
critical care medicine, and diagnosis and treatment of specific disorders according to major problems, etiologies, and organ
systems. A wealth of tables and figures provides quick access to important information, such as acute and critical care pro-
cedures in the delivery room, the office, the emergency room, and the critical care unit; anti-infective agents; drug dosages;
immunization schedules; differential diagnosis; and developmental disorders.
NEW TO THIS EDITION

The 23rd edition of CDTP has been revised comprehensively by the editors and contributing authors. A major effort involved
reducing the length of the book by 10% by condensing text into tables, eliminating wordy text, and updating references. New
references as well as up-to-date and useful websites have been added, permitting the reader to consult original material and
to go beyond the confines of the textbook. As editors and practicing pediatricians, we have tried to ensure that each chapter
reflects the needs and realities of day-to-day practice.
CHAPTERS WITH MAJOR REVISIONS INCLUDE:

3 Child Development & Behavior
6 Eating Disorders
7 Child & Adolescent Psychiatric Disorders & Psychosocial Aspects of Pediatrics
9 Ambulatory & Office Pediatrics
10 Immunization
14 Critical Care
15 Skin
17 Oral Medicine & Dentistry
19 Respiratory Tract & Mediastinum
21 Gastrointestinal Tract
22 Liver & Pancreas
23 Fluid, Electrolyte, & Acid Base Disorders
24 Kidney and Urinary Tract
xxvii
xxviii
▲ Pr ef ACe
25 Neurologic & Muscular Disorders

26 Orthopedics
31 Neoplastic Disease
32 Pain Management & Pediatric Palliative & End-of-Life Care
33 Immunodeficiency
37 Genetics & Dysmorphology
38 Allergic Disorders
41 Human Immunodeficiency Virus Infection
42 Infections: Bacterial & Spirochetal
43 Infections: Parasitic & Mycotic
CHAPTER REVISIONS
The 23 chapters that have been extensively revised, with new authors added in several cases, reflect the substantially updated
material in each of their areas of pediatric medicine. Especially important are updates to the chapters on immunizations, endo-
crinology, neurologic and muscular disorders, and critical care. The chapter on HIV includes current guidelines for prevention
and treatment of HIV and updates information on the new antiretroviral therapies that have become available. The chapter
on immunizations contains the most recently published recommendations, discusses the contraindications and precautions
relevant to special populations, and includes the new vaccines licensed since the last edition of this book. Chapters on skin,
immunodeficiency, and neoplastic disease are markedly updated with the latest information. All laboratory tables in Chapter 46
Pediatric Laboratory Medicine and Reference Ranges that includes reference ranges and reference intervals have been updated.
All other chapters are substantially revised and references have been updated. Nineteen new authors have contributed to these
revisions.
ACKNOWLEDGMENTS
The editors would like to thank Bonnie Savone for her expert assistance in managing the flow of manuscripts and materials
among the chapter authors, editors, and publishers. Her attention to detail was enormously helpful. The editors also would like
to thank Tia Brayman at Children’s Hospital Colorado who produced the cover photographs.
William W. Hay, Jr., MD

Myron J. Levin, MD
Robin R. Deterding, MD
Mark J. Abzug, MD
Aurora, Colorado
Selected Highlighted Topics in the
23rd Edition of CDT-P
The Newborn Infant chapter includes the new 2015 Neonatal Resuscitation Program (NRP) Guidelines for Neonatal
Resuscitation.
The Child Abuse & Neglect chapter includes the use of nucleic acid amplification tests to diagnose sexually transmitted
diseases in prepubertal children evaluated for sexual abuse.
The Immunization chapter includes new discussions about how HPV vaccination can prevent cancer, how a newer HPV
vaccine protects against additional HPV types, and new discussion about how most parents in the United States choose to
vaccinate their children (in 2013, < 1% of young children received no vaccines). Although parents’ concerns about vaccines
are on the rise, an increasing number of parents are choosing to delay or decline vaccination for their children.
The Poisoning chapter includes new recommendations for evaluation and treatment for common ingestions and exposures in
the pediatric population, including pharmaceuticals, household products, and designer drugs.
The Skin chapter includes the use of propranolol for infantile hemangiomas.
The Eye chapter describes how instrument-based vision screening is a novel means of detecting vision-threatening amblyo-
genic risk factors in preverbal, preliterate, and developmentally delayed children, and is endorsed by the American Academy
of Pediatrics.
The Oral Medicine & Dentistry chapter includes preventive dental treatment (fluoride varnish) by physicians for high-
risk populations.
The Respiratory Tract & Mediastinum chapter introduces the new cystic fibrosis drug, Orkambi.
The Cardiovascular Diseases chapter includes three–dimensional echocardiography as a new diagnostic addition to noninva-
sive evaluation of congenital heart disease.
The Gastrointestinal Tract chapter identifies the life-threatening impact of button batteries as startling and significant health
care problem.
The Liver & Pancreas chapter identifies two new oral therapies that are available for children with chronic hepatitis B: entecavir
for children 3 years or older and tenofovir for children 12 years or older.
The Hematologic Disorders chapter notes that hydroxyurea therapy is now recommended for all children with sickle cell
anemia or sickle β-thalassemia.
The Immunodeficiency chapter describes the use of genetic testing in the evaluation of children with immunodeficiency and
states of immune dysregulation.
The Endocrine Disorders chapter includes the use of recombinant alkaline phosphatase (asfotase alfa) for the treatment of
hypophosphatasia and how it has revolutionized therapy for this disorder.
The Genetics & Dysmorphology chapter includes information on microarray testing and whole exome sequencing.
The Antimicrobial Therapy chapter includes information on antimicrobial stewardship.
And many more!
xxix
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no related content on Scribd:
In this latter passage, he discloses the intellectual basis of his
criticism of science. He alleges against science its absorption in
abstractions. His consistent theme is that the important facts of
nature elude the scientific method. It is important therefore to ask,
what Wordsworth found in nature that failed to receive expression in
science. I ask this question in the interest of science itself; for one
main position in these lectures is a protest against the idea that the
abstractions of science are irreformable and unalterable. Now it is
emphatically not the case that Wordsworth hands over inorganic
matter to the mercy of science, and concentrates on the faith that in
the living organism there is some element that science cannot
analyse. Of course he recognises, what no one doubts, that in some
sense living things are different from lifeless things. But that is not
his main point. It is the brooding presence of the hills which haunts
him. His theme is nature in solido, that is to say, he dwells on that
mysterious presence of surrounding things, which imposes itself on
any separate element that we set up as an individual for its own
sake. He always grasps the whole of nature as involved in the
tonality of the particular instance. That is why he laughs with the
daffodils, and finds in the primrose “thoughts too deep for terms.”
Wordsworth’s greatest poem is, by far, the first book of The
Prelude. It is pervaded by this sense of the haunting presences of
nature. A series of magnificent passages, too long for quotation,
express this idea. Of course, Wordsworth is a poet writing a poem,
and is not concerned with dry philosophical statements. But it would
hardly be possible to express more clearly a feeling for nature, as
exhibiting entwined prehensive unities, each suffused with modal
presences of others:
“Ye Presences of Nature in the sky
And on the earth! Ye Visions of the hills!
And Souls of lonely places! can I think
A vulgar hope was yours when ye employed
Such ministry, when ye through many a year
Haunting me thus among my boyish sports,
On caves and trees, upon the woods and hills,
Impressed upon all forms the characters
Of danger or desire; and thus did make
The surface of the universal earth
With triumph and delight, with hope and fear,
Work like a sea?...”
In thus citing Wordsworth, the point which I wish to make is that

we forget how strained and paradoxical is the view of nature which
modern science imposes on our thoughts. Wordsworth, to the height
of genius, expresses the concrete facts of our apprehension, facts
which are distorted in the scientific analysis. Is it not possible that the
standardised concepts of science are only valid within narrow
limitations, perhaps too narrow for science itself?
Shelley’s attitude to science was at the opposite pole to that of
Wordsworth. He loved it, and is never tired of expressing in poetry
the thoughts which it suggests. It symbolises to him joy, and peace,
and illumination. What the hills were to the youth of Wordsworth, a
chemical laboratory was to Shelley. It is unfortunate that Shelley’s
literary critics have, in this respect, so little of Shelley in their own
mentality. They tend to treat as a casual oddity of Shelley’s nature
what was, in fact, part of the main structure of his mind, permeating
his poetry through and through. If Shelley had been born a hundred
years later, the twentieth century would have seen a Newton among
chemists.
For the sake of estimating the value of Shelley’s evidence it is
important to realise this absorption of his mind in scientific ideas. It
can be illustrated by lyric after lyric. I will choose one poem only, the
fourth act of his Prometheus Unbound. The Earth and the Moon
converse together in the language of accurate science. Physical
experiments guide his imagery. For example, the Earth’s
exclamation,
“The vaporous exultation not to be confined!”
is the poetic transcript of ‘the expansive force of gases,’ as it is

termed in books on science. Again, take the Earth’s stanza,
“I spin beneath my pyramid of night,

Which points into the heavens,—dreaming delight,
Murmuring victorious joy in my enchanted sleep;
As a youth lulled in love-dreams faintly sighing,
Under the shadow of his beauty lying,
Which round his rest a watch of light and warmth doth keep.”
This stanza could only have been written by someone with a

definite geometrical diagram before his inward eye—a diagram
which it has often been my business to demonstrate to mathematical
classes. As evidence, note especially the last line which gives
poetical imagery to the light surrounding night’s pyramid. This idea
could not occur to anyone without the diagram. But the whole poem
and other poems are permeated with touches of this kind.
Now the poet, so sympathetic with science, so absorbed in its
ideas, can simply make nothing of the doctrine of secondary qualities
which is fundamental to its concepts. For Shelley nature retains its
beauty and its colour. Shelley’s nature is in its essence a nature of
organisms, functioning with the full content of our perceptual
experience. We are so used to ignoring the implications of orthodox
scientific doctrine, that it is difficult to make evident the criticism upon
it which is thereby implied. If anybody could have treated it seriously,
Shelley would have done so.
Furthermore Shelley is entirely at one with Wordsworth as to the
interfusing of the Presence in nature. Here is the opening stanza of
his poem entitled Mont Blanc:
“The everlasting universe of Things
Flows through the Mind, and rolls its rapid waves,
Now dark—now glittering—now reflecting gloom—
Now lending splendour, where from secret springs
The source of human thought its tribute brings
Of waters,—with a sound but half its own,
Such as a feeble brook will oft assume
In the wild woods, among the Mountains lone,
Where waterfalls around it leap for ever,
Where woods and winds contend, and a vast river
Over its rocks ceaselessly bursts and raves.”
Shelley has written these lines with explicit reference to some form
of idealism, Kantian or Berkeleyan or Platonic. But however you
construe him, he is here an emphatic witness to a prehensive
unification as constituting the very being of nature.
Berkeley, Wordsworth, Shelley are representative of the intuitive
refusal seriously to accept the abstract materialism of science.
There is an interesting difference in the treatment of nature by
Wordsworth and by Shelley, which brings forward the exact
questions we have got to think about. Shelley thinks of nature as
changing, dissolving, transforming as it were at a fairy’s touch. The
leaves fly before the West Wind
“Like ghosts from an enchanter fleeing.”
In his poem The Cloud it is the transformations of water which

excite his imagination. The subject of the poem is the endless,
eternal, elusive change of things:
“I change but I cannot die.”
This is one aspect of nature, its elusive change: a change not

merely to be expressed by locomotion, but a change of inward
character. This is where Shelley places his emphasis, on the change
of what cannot die.
Wordsworth was born among hills; hills mostly barren of trees, and
thus showing the minimum of change with the seasons. He was
haunted by the enormous permanences of nature. For him change is
an incident which shoots across a background of endurance,
“Breaking the silence of the seas

Among the farthest Hebrides.”
Every scheme for the analysis of nature has to face these two
facts, change and endurance. There is yet a third fact to be placed
by it, eternality, I will call it. The mountain endures. But when after
ages it has been worn away, it has gone. If a replica arises, it is yet a
new mountain. A colour is eternal. It haunts time like a spirit. It
comes and it goes. But where it comes, it is the same colour. It
neither survives nor does it live. It appears when it is wanted. The
mountain has to time and space a different relation from that which
colour has. In the previous lecture, I was chiefly considering the
relation to space-time of things which, in my sense of the term, are
eternal. It was necessary to do so before we can pass to the
consideration of the things which endure.
Also we must recollect the basis of our procedure. I hold that
philosophy is the critic of abstractions. Its function is the double one,
first of harmonising them by assigning to them their right relative
status as abstractions, and secondly of completing them by direct
comparison with more concrete intuitions of the universe, and
thereby promoting the formation of more complete schemes of
thought. It is in respect to this comparison that the testimony of great
poets is of such importance. Their survival is evidence that they
express deep intuitions of mankind penetrating into what is universal
in concrete fact. Philosophy is not one among the sciences with its
own little scheme of abstractions which it works away at perfecting
and improving. It is the survey of sciences, with the special objects of
their harmony, and of their completion. It brings to this task, not only
the evidence of the separate sciences, but also its own appeal to
concrete experience. It confronts the sciences with concrete fact.
The literature of the nineteenth century, especially its English
poetic literature, is a witness to the discord between the aesthetic
intuitions of mankind and the mechanism of science. Shelley brings
vividly before us the elusiveness of the eternal objects of sense as
they haunt the change which infects underlying organisms.
Wordsworth is the poet of nature as being the field of enduring
permanences carrying within themselves a message of tremendous
significance. The eternal objects are also there for him,
“The light that never was, on sea or land.”
Both Shelley and Wordsworth emphatically bear witness that

nature cannot be divorced from its aesthetic values; and that these
values arise from the cumulation, in some sense, of the brooding
presence of the whole onto its various parts. Thus we gain from the
poets the doctrine that a philosophy of nature must concern itself at
least with these five notions: change, value, eternal objects,
endurance, organism, interfusion.
We see that the literary romantic movement at the beginning of the
nineteenth century, just as much as Berkeley’s philosophical
idealistic movement a hundred years earlier, refused to be confined
within the materialistic concepts of the orthodox scientific theory. We
know also that when in these lectures we come to the twentieth
century, we shall find a movement in science itself to reorganise its
concepts, driven thereto by its own intrinsic development.
It is, however, impossible to proceed until we have settled whether
this refashioning of ideas is to be carried out on an objectivist basis
or on a subjectivist basis. By a subjectivist basis I mean the belief
that the nature of our immediate experience is the outcome of the
perceptive peculiarities of the subject enjoying the experience. In
other words, I mean that for this theory what is perceived is not a
partial vision of a complex of things generally independent of that act
of cognition; but that it merely is the expression of the individual
peculiarities of the cognitive act. Accordingly what is common to the
multiplicity of cognitive acts is the ratiocination connected with them.
Thus, though there is a common world of thought associated with
our sense-perceptions, there is no common world to think about.
What we do think about is a common conceptual world applying
indifferently to our individual experiences which are strictly personal
to ourselves. Such a conceptual world will ultimately find its complete
expression in the equations of applied mathematics. This is the
extreme subjectivist position. There is of course the half-way house
of those who believe that our perceptual experience does tell us of a
common objective world; but that the things perceived are merely the
outcome for us of this world, and are not in themselves elements in
the common world itself.
Also there is the objectivist position. This creed is that the actual
elements perceived by our senses are in themselves the elements of
a common world; and that this world is a complex of things, including
indeed our acts of cognition, but transcending them. According to
this point of view the things experienced are to be distinguished from
our knowledge of them. So far as there is dependence, the things
pave the way for the cognition, rather than vice versa. But the point
is that the actual things experienced enter into a common world
which transcends knowledge, though it includes knowledge. The
intermediate subjectivists would hold that the things experienced
only indirectly enter into the common world by reason of their
dependence on the subject who is cognising. The objectivist holds
that the things experienced and the cognisant subject enter into the
common world on equal terms. In these lectures I am giving the
outline of what I consider to be the essentials of an objectivist
philosophy adapted to the requirement of science and to the
concrete experience of mankind. Apart from the detailed criticism of
the difficulties raised by subjectivism in any form, my broad reasons
for distrusting it are three in number. One reason arises from the
direct interrogation of our perceptive experience. It appears from this
interrogation that we are within a world of colours, sounds, and other
sense-objects, related in space and time to enduring objects such as
stones, trees, and human bodies. We seem to be ourselves
elements of this world in the same sense as are the other things
which we perceive. But the subjectivist, even the moderate
intermediate subjectivist, makes this world, as thus described,
depend on us, in a way which directly traverses our naïve
experience. I hold that the ultimate appeal is to naïve experience and
that is why I lay such stress on the evidence of poetry. My point is,
that in our sense-experience we know away from and beyond our
own personality; whereas the subjectivist holds that in such
experience we merely know about our own personality. Even the
intermediate subjectivist places our personality between the world
we know of and the common world which he admits. The world we
know of is for him the internal strain of our personality under the
stress of the common world which lies behind.
My second reason for distrusting subjectivism is based on the
particular content of experience. Our historical knowledge tells us of
ages in the past when, so far as we can see, no living being existed
on earth. Again it also tells us of countless star-systems, whose
detailed history remains beyond our ken. Consider even the moon
and the earth. What is going on within the interior of the earth, and
on the far side of the moon! Our perceptions lead us to infer that
there is something happening in the stars, something happening
within the earth, and something happening on the far side of the
moon. Also they tell us that in remote ages there were things
happening. But all these things which it appears certainly happened,
are either unknown in detail, or else are reconstructed by inferential
evidence. In the face of this content of our personal experience, it is
difficult to believe that the experienced world is an attribute of our
own personality. My third reason is based upon the instinct for
action. Just as sense-perception seems to give knowledge of what
lies beyond individuality, so action seems to issue in an instinct for
self-transcendence. The activity passes beyond self into the known
transcendent world. It is here that final ends are of importance. For it
is not activity urged from behind, which passes out into the veiled
world of the intermediate subjectivist. It is activity directed to
determinate ends in the known world; and yet it is activity
transcending self and it is activity within the known world. It follows
therefore that the world, as known, transcends the subject which is
cognisant of it.
The subjectivist position has been popular among those who have
been engaged in giving a philosophical interpretation to the recent
theories of relativity in physical science. The dependence of the
world of sense on the individual percipient seems an easy mode of
expressing the meanings involved. Of course, with the exception of
those who are content with themselves as forming the entire
universe, solitary amid nothing, everyone wants to struggle back to
some sort of objectivist position. I do not understand how a common
world of thought can be established in the absence of a common
world of sense. I will not argue this point in detail; but in the absence
of a transcendence of thought, or a transcendence of the world of
sense, it is difficult to see how the subjectivist is to divest himself of
his solitariness. Nor does the intermediate subjectivist appear to get
any help from his unknown world in the background.
The distinction between realism and idealism does not coincide
with that between objectivism and subjectivism. Both realists and
idealists can start from an objective standpoint. They may both agree
that the world disclosed in sense-perception is a common world,
transcending the individual percipient. But the objective idealist,
when he comes to analyse what the reality of this world involves,
finds that cognitive mentality is in some way inextricably concerned
in every detail. This position the realist denies. Accordingly these two
classes of objectivists do not part company till they have arrived at
the ultimate problem of metaphysics. There is a great deal which
they share in common. This is why, in my last lecture, I said that I
adopted a position of provisional realism.
In the past, the objectivist position has been distorted by the
supposed necessity of accepting the classical scientific materialism,
with its doctrine of simple location. This has necessitated the
doctrine of secondary and primary qualities. Thus the secondary
qualities, such as the sense-objects, are dealt with on subjectivist
principles. This is a half-hearted position which falls an easy prey to
subjectivist criticism.
If we are to include the secondary qualities in the common world, a
very drastic reorganisation of our fundamental concepts is
necessary. It is an evident fact of experience that our apprehensions
of the external world depend absolutely on the occurrences within
the human body. By playing appropriate tricks on the body a man
can be got to perceive, or not to perceive, almost anything. Some
people express themselves as though bodies, brains, and nerves
were the only real things in an entirely imaginary world. In other
words, they treat bodies on objectivist principles, and the rest of the
world on subjectivist principles. This will not do; especially, when we
remember that it is the experimenter’s perception of another
person’s body which is in question as evidence.
But we have to admit that the body is the organism whose states
regulate our cognisance of the world. The unity of the perceptual
field therefore must be a unity of bodily experience. In being aware
of the bodily experience, we must thereby be aware of aspects of the
whole spatio-temporal world as mirrored within the bodily life. This is
the solution of the problem which I gave in my last lecture. I will not
repeat myself now, except to remind you that my theory involves the
entire abandonment of the notion that simple location is the primary
way in which things are involved in space-time. In a certain sense,
everything is everywhere at all times. For every location involves an
aspect of itself in every other location. Thus every spatio-temporal
standpoint mirrors the world.
If you try to imagine this doctrine in terms of our conventional
views of space and time, which presuppose simple location, it is a
great paradox. But if you think of it in terms of our naïve experience,
it is a mere transcript of the obvious facts. You are in a certain place
perceiving things. Your perception takes place where you are, and is
entirely dependent on how your body is functioning. But this
functioning of the body in one place, exhibits for your cognisance an
aspect of the distant environment, fading away into the general
knowledge that there are things beyond. If this cognisance conveys
knowledge of a transcendent world, it must be because the event
which is the bodily life unifies in itself aspects of the universe.
This is a doctrine extremely consonant with the vivid expression of
personal experience which we find in the nature-poetry of
imaginative writers such as Wordsworth or Shelley. The brooding,
immediate presences of things are an obsession to Wordsworth.
What the theory does do is to edge cognitive mentality away from
being the necessary substratum of the unity of experience. That
unity is now placed in the unity of an event. Accompanying this unity,
there may or there may not be cognition.
At this point we come back to the great question which was posed
before us by our examination of the evidence afforded by the poetic
insight of Wordsworth and Shelley. This single question has
expanded into a group of questions. What are enduring things, as
distinguished from the eternal objects, such as colour and shape?
How are they possible? What is their status and meaning in the
universe? It comes to this: What is the status of the enduring stability
of the order of nature? There is the summary answer, which refers
nature to some greater reality standing behind it. This reality occurs
in the history of thought under many names, The Absolute, Brahma,
The Order of Heaven, God. The delineation of final metaphysical
truth is no part of this lecture. My point is that any summary
conclusion jumping from our conviction of the existence of such an
order of nature to the easy assumption that there is an ultimate
reality which, in some unexplained way, is to be appealed to for the
removal of perplexity, constitutes the great refusal of rationality to
assert its rights. We have to search whether nature does not in its
very being show itself as self-explanatory. By this I mean, that the
sheer statement, of what things are, may contain elements
explanatory of why things are. Such elements may be expected to
refer to depths beyond anything which we can grasp with a clear
apprehension. In a sense, all explanation must end in an ultimate
arbitrariness. My demand is, that the ultimate arbitrariness of matter
of fact from which our formulation starts should disclose the same
general principles of reality, which we dimly discern as stretching
away into regions beyond our explicit powers of discernment. Nature
exhibits itself as exemplifying a philosophy of the evolution of
organisms subject to determinate conditions. Examples of such
conditions are the dimensions of space, the laws of nature, the
determinate enduring entities, such as atoms and electrons, which
exemplify these laws. But the very nature of these entities, the very
nature of their spatiality and temporality, should exhibit the
arbitrariness of these conditions as the outcome of a wider evolution
beyond nature itself, and within which nature is but a limited mode.
One all-pervasive fact, inherent in the very character of what is
real is the transition of things, the passage one to another. This
passage is not a mere linear procession of discrete entities. However
we fix a determinate entity, there is always a narrower determination
of something which is presupposed in our first choice. Also there is
always a wider determination into which our first choice fades by
transition beyond itself. The general aspect of nature is that of
evolutionary expansiveness. These unities, which I call events, are
the emergence into actuality of something. How are we to
characterise the something which thus emerges? The name ‘event’
given to such a unity, draws attention to the inherent transitoriness,
combined with the actual unity. But this abstract word cannot be
sufficient to characterise what the fact of the reality of an event is in
itself. A moment’s thought shows us that no one idea can in itself be
sufficient. For every idea which finds its significance in each event
must represent something which contributes to what realisation is in
itself. Thus no one word can be adequate. But conversely, nothing
must be left out. Remembering the poetic rendering of our concrete
experience, we see at once that the element of value, of being
valuable, of having value, of being an end in itself, of being
something which is for its own sake, must not be omitted in any
account of an event as the most concrete actual something. ‘Value’
is the word I use for the intrinsic reality of an event. Value is an
element which permeates through and through the poetic view of
nature. We have only to transfer to the very texture of realisation in
itself that value which we recognise so readily in terms of human life.
This is the secret of Wordsworth’s worship of nature. Realization
therefore is in itself the attainment of value. But there is no such
thing as mere value. Value is the outcome of limitation. The definite
finite entity is the selected mode which is the shaping of attainment;
apart from such shaping into individual matter of fact there is no
attainment. The mere fusion of all that there is would be the
nonentity of indefiniteness. The salvation of reality is its obstinate,
irreducible, matter-of-fact entities, which are limited to be no other
than themselves. Neither science, nor art, nor creative action can
tear itself away from obstinate, irreducible, limited facts. The
endurance of things has its significance in the self-retention of that
which imposes itself as a definite attainment for its own sake. That
which endures is limited, obstructive, intolerant, infecting its
environment with its own aspects. But it is not self-sufficient. The
aspects of all things enter into its very nature. It is only itself as
drawing together into its own limitation the larger whole in which it
finds itself. Conversely it is only itself by lending its aspects to this
same environment in which it finds itself. The problem of evolution is
the development of enduring harmonies of enduring shapes of value,
which merge into higher attainments of things beyond themselves.
Aesthetic attainment is interwoven in the texture of realisation. The
endurance of an entity represents the attainment of a limited
aesthetic success, though if we look beyond it to its external effects,
it may represent an aesthetic failure. Even within itself, it may
represent the conflict between a lower success and a higher failure.
The conflict is the presage of disruption.
The further discussion of the nature of enduring objects and of the
conditions they require will be relevant to the consideration of the
doctrine of evolution which dominated the latter half of the nineteenth
century. The point which in this lecture I have endeavoured to make
clear is that the nature-poetry of the romantic revival was a protest
on behalf of the organic view of nature, and also a protest against
the exclusion of value from the essence of matter of fact. In this
aspect of it, the romantic movement may be conceived as a revival
of Berkeley’s protest which had been launched a hundred years
earlier. The romantic reaction was a protest on behalf of value.
CHAPTER VI
THE NINETEENTH CENTURY
My previous lecture was occupied with the comparison of the

nature-poetry of the romantic movement in England with the
materialistic scientific philosophy inherited from the eighteenth
century. It noted the entire disagreement of the two movements of
thought. The lecture also continued the endeavour to outline an
objectivist philosophy, capable of bridging the gap between science
and that fundamental intuition of mankind which finds its expression
in poetry and its practical exemplification in the presuppositions of
daily life. As the nineteenth century passed on, the romantic
movement died down. It did not die away, but it lost its clear unity of
tidal stream, and dispersed itself into many estuaries as it coalesced
with other human interests. The faith of the century was derived from
three sources: one source was the romantic movement, showing
itself in religious revival, in art, and in political aspiration: another
source was the gathering advance of science which opened avenues
of thought: the third source was the advance in technology which
completely changed the conditions of human life.
Each of these springs of faith had its origin in the previous period.
The French Revolution itself was the first child of romanticism in the
form in which it tinged Rousseau. James Watt obtained his patent for
his steam-engine in 1769. The scientific advance was the glory of
France and of French influence, throughout the same century.
Also even during this earlier period, the streams interacted,
coalesced, and antagonised each other. But it was not until the
nineteenth century that the threefold movement came to that full
development and peculiar balance characteristic of the sixty years
following the battle of Waterloo.
What is peculiar and new to the century, differentiating it from all
its predecessors, is its technology. It was not merely the introduction
of some great isolated inventions. It is impossible not to feel that
something more than that was involved. For example, writing was a
greater invention than the steam-engine. But in tracing the
continuous history of the growth of writing we find an immense
difference from that of the steam-engine. We must, of course, put
aside minor and sporadic anticipations of both; and confine attention
to the periods of their effective elaboration. The scale of time is so
absolutely disparate. For the steam-engine, we may give about a
hundred years; for writing, the time period is of the order of a
thousand years. Further, when writing was finally popularised, the
world was not then expecting the next step in technology. The
process of change was slow, unconscious, and unexpected.
In the nineteenth century, the process became quick, conscious,
and expected. The earlier half of the century was the period in which
this new attitude to change was first established and enjoyed. It was
a peculiar period of hope, in the sense in which, sixty or seventy
years later, we can now detect a note of disillusionment, or at least of
anxiety.
The greatest invention of the nineteenth century was the invention
of the method of invention. A new method entered into life. In order
to understand our epoch, we can neglect all the details of change,
such as railways, telegraphs, radios, spinning machines, synthetic
dyes. We must concentrate on the method in itself; that is the real
novelty, which has broken up the foundations of the old civilisation.
The prophecy of Francis Bacon has now been fulfilled; and man,
who at times dreamt of himself as a little lower than the angels, has
submitted to become the servant and the minister of nature. It still
remains to be seen whether the same actor can play both parts.
The whole change has arisen from the new scientific information.
Science, conceived not so much in its principles as in its results, is
an obvious storehouse of ideas for utilisation. But, if we are to
understand what happened during the century, the analogy of a mine
is better than that of a storehouse. Also, it is a great mistake to think
that the bare scientific idea is the required invention, so that it has
only to be picked up and used. An intense period of imaginative
design lies between. One element in the new method is just the
discovery of how to set about bridging the gap between the scientific
ideas, and the ultimate product. It is a process of disciplined attack
upon one difficulty after another.
The possibilities of modern technology were first in practice
realised in England, by the energy of a prosperous middle class.
Accordingly, the industrial revolution started there. But the Germans
explicitly realised the methods by which the deeper veins in the mine
of science could be reached. They abolished haphazard methods of
scholarship. In their technological schools and universities progress
did not have to wait for the occasional genius, or the occasional
lucky thought. Their feats of scholarship during the nineteenth
century were the admiration of the world. This discipline of
knowledge applies beyond technology to pure science, and beyond
science to general scholarship. It represents the change from
amateurs to professionals.
There have always been people who devoted their lives to definite
regions of thought. In particular, lawyers and the clergy of the
Christian churches form obvious examples of such specialism. But
the full self-conscious realisation of the power of professionalism in
knowledge in all its departments, and of the way to produce the
professionals, and of the importance of knowledge to the advance of
technology, and of the methods by which abstract knowledge can be
connected with technology, and of the boundless possibilities of
technological advance,—the realisation of all these things was first
completely attained in the nineteenth century; and among the
various countries, chiefly in Germany.
In the past human life was lived in a bullock cart; in the future it will
be lived in an aeroplane; and the change of speed amounts to a
difference in quality.
The transformation of the field of knowledge, which has been thus
effected, has not been wholly a gain. At least, there are dangers
implicit in it, although the increase of efficiency is undeniable. The
discussion of various effects on social life arising from the new
situation is reserved for my last lecture. For the present it is sufficient
to note that this novel situation of disciplined progress is the setting
within which the thought of the century developed.
In the period considered four great novel ideas were introduced
into theoretical science. Of course, it is possible to show good cause
for increasing my list far beyond the number four. But I am keeping
to ideas which, if taken in their broadest signification, are vital to
modern attempts at reconstructing the foundations of physical
science.
Two of these ideas are antithetical, and I will consider them
together. We are not concerned with details, but with ultimate
influences on thought. One of the ideas is that of a field of physical
activity pervading all space, even where there is an apparent
vacuum. This notion had occurred to many people, under many
forms. We remember the medieval axiom, nature abhors a vacuum.
Also, Descartes’ vortices at one time, in the seventeenth century,
seemed as if established among scientific assumptions. Newton
believed that gravitation was caused by something happening in a
medium. But, on the whole, in the eighteenth century nothing was
made of any of these ideas. The passage of light was explained in
Newton’s fashion by the flight of minute corpuscles, which of course
left room for a vacuum. Mathematical physicists were far too busy
deducing the consequences of the theory of gravitation to bother
much about the causes; nor did they know where to look, if they had
troubled themselves over the question. There were speculations, but
their importance was not great. Accordingly, when the nineteenth
century opened, the notion of physical occurrences pervading all
space held no effective place in science. It was revived from two
sources. The undulatory theory of light triumphed, thanks to Thomas
Young and Fresnel. This demands that there shall be something
throughout space which can undulate. Accordingly, the ether was
produced, as a sort of all pervading subtle material. Again the theory
of electromagnetism finally, in Clerk Maxwell’s hands, assumed a
shape in which it demanded that there should be electromagnetic
occurrences throughout all space. Maxwell’s complete theory was
not shaped until the eighteen-seventies. But it had been prepared for
by many great men, Ampère, Oersted, Faraday. In accordance with
the current materialistic outlook, these electromagnetic occurrences
also required a material in which to happen. So again the ether was
requisitioned. Then Maxwell, as the immediate first-fruits of his
theory, demonstrated that the waves of light were merely waves of
his electromagnetic occurrences. Accordingly, the theory of
electromagnetism swallowed up the theory of light. It was a great
simplification, and no one doubts its truth. But it had one unfortunate
effect so far as materialism was concerned. For, whereas quite a
simple sort of elastic ether sufficed for light when taken by itself, the
electromagnetic ether has to be endowed with just those properties
necessary for the production of the electromagnetic occurrences. In
fact, it becomes a mere name for the material which is postulated to
underlie these occurrences. If you do not happen to hold the
metaphysical theory which makes you postulate such an ether, you
can discard it. For it has no independent vitality.
Thus in the seventies of the last century, some main physical
sciences were established on a basis which presupposed the idea of
continuity. On the other hand, the idea of atomicity had been
introduced by John Dalton, to complete Lavoisier’s work on the
foundation of chemistry. This is the second great notion. Ordinary
matter was conceived as atomic: electromagnetic effects were
conceived as arising from a continuous field.
There was no contradiction. In the first place, the notions are
antithetical; but, apart from special embodiments, are not logically
contradictory. Secondly, they were applied to different regions of
science, one to chemistry, and the other to electromagnetism. And,
as yet, there were but faint signs of coalescence between the two.
The notion of matter as atomic has a long history. Democritus and
Lucretius will at once occur to your minds. In speaking of these ideas
as novel, I merely mean relatively novel, having regard to the
settlement of ideas which formed the efficient basis of science
throughout the eighteenth century. In considering the history of
thought, it is necessary to distinguish the real stream, determining a
period, from ineffectual thoughts casually entertained. In the
eighteenth century every well-educated man read Lucretius, and
entertained ideas about atoms. But John Dalton made them efficient
in the stream of science; and in this function of efficiency atomicity
was a new idea.
The influence of atomicity was not limited to chemistry. The living
cell is to biology what the electron and the proton are to physics.
Apart from cells and from aggregates of cells there are no biological
phenomena. The cell theory was introduced into biology
contemporaneously with, and independently of, Dalton’s atomic
theory. The two theories are independent exemplifications of the
same idea of ‘atomism.’ The biological cell theory was a gradual
growth, and a mere list of dates and names illustrates the fact that
the biological sciences, as effective schemes of thought, are barely
one hundred years old. Bichât in 1801 elaborated a tissue theory:
Johannes Müller in 1835 described ‘cells’ and demonstrated facts
concerning their nature and relations: Schleiden in 1838 and
Schwann in 1839 finally established their fundamental character.
Thus by 1840 both biology and chemistry were established on an
atomic basis. The final triumph of atomism had to wait for the arrival
of electrons at the end of the century. The importance of the
imaginative background is illustrated by the fact that nearly half a
century after Dalton had done his work, another chemist, Louis
Pasteur, carried over these same ideas of atomicity still further into
the region of biology. The cell theory and Pasteur’s work were in
some respects more revolutionary than that of Dalton. For they
introduced the notion of organism into the world of minute beings.
There had been a tendency to treat the atom as an ultimate entity,
capable only of external relations. This attitude of mind was breaking
down under the influence of Mendeleef’s periodic law. But Pasteur
showed the decisive importance of the idea of organism at the stage
of infinitesimal magnitude. The astronomers had shown us how big
is the universe. The chemists and biologists teach us how small it is.
There is in modern scientific practice a famous standard of length. It
is rather small: to obtain it, you must divide a centimetre into one
hundred million parts, and take one of them. Pasteur’s organisms
are a good deal bigger than this length. In connection with atoms, we
now know that there are organisms for which such distances are
uncomfortably great.
The remaining pair of new ideas to be ascribed to this epoch are
both of them connected with the notion of transition or change. They
are the doctrine of the conservation of energy, and the doctrine of
evolution.
The doctrine of energy has to do with the notion of quantitative
permanence underlying change. The doctrine of evolution has to do
with the emergence of novel organisms as the outcome of change.
The theory of energy lies in the province of physics. The theory of
evolution lies mainly in the province of biology, although it had
previously been touched upon by Kant and Laplace in connection
with the formation of suns and planets.
The convergent effect of the new power for scientific advance,
which resulted from these four ideas, transformed the middle period
of the century into an orgy of scientific triumph. Clear-sighted men, of
the sort who are so clearly wrong, now proclaimed that the secrets of
the physical universe were finally disclosed. If only you ignored
everything which refused to come into line, your powers of
explanation were unlimited. On the other side, muddle-headed men
muddled themselves into the most indefensible positions. Learned
dogmatism, conjoined with ignorance of the crucial facts, suffered a
heavy defeat from the scientific advocates of new ways. Thus to the
excitement derived from technological revolution, there was now
added the excitement arising from the vistas disclosed by scientific
theory. Both the material and the spiritual bases of social life were in
process of transformation. When the century entered upon its last
quarter, its three sources of inspiration, the romantic, the
technological, and the scientific had done their work.
Then, almost suddenly, a pause occurred; and in its last twenty
years the century closed with one of the dullest stages of thought
since the time of the First Crusade. It was an echo of the eighteenth
century, lacking Voltaire and the reckless grace of the French
aristocrats. The period was efficient, dull, and half-hearted. It
celebrated the triumph of the professional man.
But looking backwards upon this time of pause, we can now
discern signs of change. In the first place, the modern conditions of
systematic research prevent absolute stagnation. In every branch of
science, there was effective progress, indeed rapid progress,
although it was confined somewhat strictly within the accepted ideas

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CURRENT Diagnosis and Treatment

Pediatrics 23rd Edition William W. Hay

CURRENT Diagnosis & Treatment Pediatrics 24th Edition

CURRENT Medical Diagnosis and Treatment 2023 (Current

CURRENT Medical Diagnosis and Treatment 2021 60th

(eBook PDF) CURRENT Medical Diagnosis and Treatment

Current Medical Diagnosis & Treatment 2019 58th Edition

CURRENT Medical Diagnosis and Treatment 2023 62nd

Current Diagnosis and Treatment Cardiology (5th

Current Diagnosis & Treatment Obstetrics & Gynecology,

and Associate Authors

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

This book was set in Minion Pro by Cenveo®Publisher Services.

This book is printed on acid-free paper.

International Edition ISBN 978-1-259-25125-2; MHID 1-259-25125-X

Specific Forms of Intellectual Disability & 6. Eating Disorders 159

9. Ambulatory & Office Pediatrics 225 Pertussis Vaccination

Head Injury 320 Hydrocarbons (Benzene, Charcoal

End-of-Life Care & Death in the PICU 393 Pupils 421

Retinal Detachment 449 The Throat & Oral Cavity 489

Vocal Cord Paralysis 513 Sleep-Disordered Breathing 544

Preventive Cardiology 596 Congenital Anorectal Anomalies 631

Pancreatic Disorders 691 Focal Segmental Glomerulosclerosis 719

Acute Ataxias of Childhood 777 Trauma 828

Vasculitis 888 Pretransfusion Testing 938

30. Hematologic Disorders 891 31. Neoplastic Disease 945

Psychosocial Aspects of Disorders of Calcium &

Disorders of Amino Acid Metabolism 1061 Autosomal Recessive Disorders 1101

Clindamycin 1167 41. Human Immunodeficiency

Frank J. Accurso, MD Rebecca Sands Braverman, MD

Christopher D. Baker, MD Melissa A. Cadnapaphornchai, MD

Kevin P. Carney, MD Kathryn K. Collins, MD

Christine M. Chan, MD John A. Craddock, MD

Gerald H. Clayton, PhD Jeffrey R. Darst, MD

Amy Clevenger, MD, PhD Richard C. Dart, MD, PhD

Samuel R. Dominguez, MD, PhD Glenn T. Furuta, MD

Norman R. Friedman, MD Theresa R. Grover, MD

Cameron F. Gunville, DO David W. Kaplan, MD, MPH

Matthew A. Haemer, MD, MPH Michael S. Kappy, MD, PhD

Ann C. Halbower, MD Paritosh Kaul, MD

Kelly Knupp, MD Kelly Maloney, MD

Robert E. Kramer, MD Elizabeth J. McFarland, MD

Michael R. Narkewicz, MD Lori D. Prok, MD

Jason Rhodes, MD, MS Georgette Siparsky, PhD

Ayelet Talmi, PhD Michael Wang, MD

Janet A. Thomas, MD Adriana Weinberg, MD

Jeremy Toler, MD Pamela E. Wilson, MD

NEW TO THIS EDITION

CHAPTERS WITH MAJOR REVISIONS INCLUDE:

25 Neurologic & Muscular Disorders

William W. Hay, Jr., MD

In thus citing Wordsworth, the point which I wish to make is that

“The vaporous exultation not to be confined!”

is the poetic transcript of ‘the expansive force of gases,’ as it is

“I spin beneath my pyramid of night,

This stanza could only have been written by someone with a

“Like ghosts from an enchanter fleeing.”

In his poem The Cloud it is the transformations of water which

“I change but I cannot die.”