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Birth to 24 months: Boys
Length-for-age and Weight-for-age percentiles

98
95
85
75
50
25
10
5
2

98
95

90

75

50

25

10
5
2

Published by the Centers for Disease Control and Prevention, November 1, 2009
SOURCE: WHO Child Growth Standards (http://www.who.int/childgrowth/en)

• Figure 1 (1) Birth to 24 months: boys’ length-for-age and weight-for-age percentiles. (2) Birth to
24 months: boys’ head circumference-for-age and weight-for-length percentiles. (Published by the
Centers for Disease Control and Prevention, November 1, 2009. From WHO Child Growth Standards.
Available at www.cdc.gov/growthcharts.) (3) 2 to 20 years old: boys’ stature-for-age and weight-for-age
percentiles. (4) 2 to 20 years old: boys’ body mass index-for-age percentiles. (From the National Center
for Health Statistics in collaboration with the National Center for Chronic Disease Prevention and Health
Promotion, 2000.)
 Birth to 24 months: Girls
Birth to 24 months: Girls Head circumference-for-age and NAME
Length-for-age and Weight-for-age percentiles Weight-for-length percentiles RECORD #

Birth
in cm cm in H
E
A
52 52
D
20 20
50 98 50 C
98 95 I
95 90 R
90 H 19 19
48 75 48 C
75 E U
50 50
A M
25 D 18 46 25 46 18 F
10 10 E
5 5 R
2 C 44 2 44 E
I 17 17 N
R C
C 42
24 E
U 52
16 23
M 40 50
F 22 48
E
15 38 21 46
98 R 98
E 95 20 44
95 N 36 90 42
14 19
90
C
E 75
18 40
34
50 38
75 13 17
36
32 25 16
10 34
50 15
12 5
30 2 32
14
25 30 W
28 13 28 E
10 I
5 26 12 12 26 G
2 11 11
24 24 H
22 10 10 22 T
20 9 9 20
18 8 8 18
16 7 7
16
W
E 14 14
6 6
I 12
14 12
G 5 5
10 kg lb
H 4 LENGTH
T 8
64 66 68 70 72 74 76 78 80 82 84 86 88 90 92 94 96 98100102104106108 110 cm
6 3
26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 in
4 2
Date Age Weight Length Head Circ. Comment
2 1
lb kg
cm 46 48 50 52 54 56 58 60 62
in 18 19 20 21 22 23 24
Published by the Centers for Disease Control and Prevention, November 1, 2009 Published by the Centers for Disease Control and Prevention, November 1, 2009
SOURCE: WHO Child Growth Standards (http://www.who.int/childgrowth/en) SOURCE: WHO Child Growth Standards (http://www.who.int/childgrowth/en)

• Figure 2 (1) Birth to 24 months: girls’ length-for-age and weight-for-age percentiles. (2) Birth to
24 months: girls’ head circumference-for-age and weight-for-length percentiles. (Published by the Centers
for Disease Control and Prevention, November 1, 2009. From WHO Child Growth Standards. Available
at www.cdc.gov/growthcharts.) (3) 2 to 20 years old: girls’ stature-for-age and weight-for-age percentiles.
(4) 2 to 20 years old: girls’ body mass index-for-age percentiles. (From the National Center for Health
Statistics in collaboration with the National Center for Chronic Disease Prevention and Health Promotion,
2000.)
 BOYS GIRLS

• Figure 3 (1) Birth to 18 years old: boys’ head circumference percentiles. (2) Birth to 18 years old: girls’
head circumference percentiles. (From Nellhaus G: Head circumference from birth to eighteen years.
Practical composite international and interracial graphs, Pediatrics 41:106–114, 1968.)

• Figure 4(1) Boys preterm infant (2) Girls preterm infant (From Fenton TR, Kim JH: A systematic review
and meta-analysis to revise the Fenton growth chart for preterm infants, BMC Pediatrics 13:59, 2013.)
Pediatric Primary Care
Sixth Edition

Editors

Catherine E. Burns, PhD, RN, Nancy Barber Starr, MS, APRN-BC

CPNP-PC, FAAN (PNP), CPNP-PC
Professor Emeritus Pediatric Nurse Practitioner
Primary Health Care Nurse Practitioner Specialty Advanced Pediatric Associates
School of Nursing Centennial, Colorado
Oregon Health & Science University
Portland, Oregon
Catherine G. Blosser, MPA:HA,
Ardys M. Dunn, PhD, RN, PNP RN, PNP
Associate Professor Emeritus Pediatric Nurse Practitioner, Retired
University of Portland School of Nursing Oak Grove, Oregon
Portland, Oregon;
Professor, Retired Dawn Lee Garzon, PhD, PNP-BC,
School of Nursing
Samuel Merritt College CPNP-PC, PMHS, FAANP
Oakland, California Teaching Professor and PNP Emphasis Area Coordinator
College of Nursing
Margaret A. Brady, PhD, RN, University of Missouri–St. Louis
St. Louis, Missouri
CPNP-PC
Professor Associate Editor
School of Nursing
California State University Long Beach
Long Beach, California; Nan M. Gaylord, PhD, RN, CPNP-PC
Co-Director, PNP Program
Associate Professor
School of Nursing
College of Nursing
Azusa Pacific University
University of Tennessee
Azusa, California
Knoxville, Tennessee
3251 Riverport Lane
St. Louis, Missouri 63043

PEDIATRIC PRIMARY CARE, SIXTH EDITION ISBN: 978-0-323-24338-4

Copyright © 2017 by Elsevier, Inc. All rights reserved.

No part of this publication may be reproduced or transmitted in any form or by any means, electronic or
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Notices

Knowledge and best practice in this field are constantly changing. As new research and experience broaden
our understanding, changes in research methods, professional practices, or medical treatment may become
necessary.
Practitioners and researchers must always rely on their own experience and knowledge in evaluating and
using any information, methods, compounds, or experiments described herein. In using such information or
methods they should be mindful of their own safety and the safety of others, including parties for whom they
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With respect to any drug or pharmaceutical products identified, readers are advised to check the most
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material herein.

Previous editions copyrighted 2013, 2009, 2004, 2000, 1996.

Library of Congress Cataloging-in-Publication Data

Names: Burns, Catherine E., editor.

Title: Pediatric primary care / editors, Catherine E. Burns [and 6 others].
Other titles: Pediatric primary care (Burns)
Description: Sixth edition. | St. Louis, Missouri : Elsevier, [2017] |
Includes bibliographical references and index.
Identifiers: LCCN 2015045933 | ISBN 9780323243384 (hardcover : alk. paper)
Subjects: | MESH: Pediatrics | Primary Health Care | United States
Classification: LCC RB145 | NLM WS 100 | DDC 618.92–dc23 LC record available at
http://lccn.loc.gov/2015045933

Executive Content Strategist: Lee Henderson

Content Development Manager: Billie Sharp
Content Development Specialist: Charlene Ketchum
Publishing Services Manager: Catherine Jackson
Senior Project Manager: Rachel E. McMullen
Design Direction: Brian Salisbury

Printed in China

Last digit is the print number: 9 8 7 6 5 4 3 2 1

Contributors

Michele E. Acker, MN, ARNP Joy S. Diamond, MS, CPNP

Pediatric Nurse Practitioner Pediatric Nurse Practitioner
Seattle Children’s Hospital Advanced Pediatric Associates
Seattle, Washington Children’s Hospital Colorado
Aurora, Colorado
Jan Bazner-Chandler, RN, MSN, CNS, CPNP
Assistant Professor, Nurse Practitioner Mary Ann Draye, MPH, APRN
Azusa Pacific University Assistant Professor, Emerita
Azusa, California DNP FNP Program
School of Nursing
Anita D. Berry, MSN, CNP, APN, PMHS University of Washington
Director, Healthy Steps for Young Children Program Seattle, Washington
Advocate Children’s Hospital
Downers Grove, Illinois Martha Driessnack, PhD, PPCNP-BC
Associate Professor
Jennifer Bevacqua, RN, MS, CPNP-AC, CPNP-PC Pediatric Nurse Practitioner Program
Pediatric Nurse Practitioner Oregon Health & Science University (OHSU) School of
Oregon Health & Science University (OHSU) Nursing
Portland, Oregon Portland, Oregon

Crisann Bowman-Harvey, CPNP, AC, PC, MSN Karen G. Duderstadt, PhD, RN, CPNP
Instructor Clinical Professor
University of Colorado Coordinator PNP Specialty
Aurora, Colorado Academic Coordinator of International Student Programs
and Special Studies
Donald L. Chi, DDS, PhD University of California San Francisco
Associate Professor School of Nursing
University of Washington, School of Dentistry, Department of Family Health Care Nursing
Department of Oral Health San Francisco, California
Seattle, Washington
Susan Filkins, MS, RD
Cynthia Marie Claytor, MSN, PNP, FNP Nutrition Consultant
Graduate Nursing Faculty Oregon Center for Children & Youth with Special Health
Azusa Pacific University Needs
Azusa California Oregon Health & Sciences University
Portland, Oregon
Sara D. DeGolier, RN, MS, CPNP
Pediatric Nurse Practitioner Leah G. Fitch, MSN, RN, CPNP
Department of Emergency Medicine Pediatric Nurse Practitioner
The Children’s Hospital Colorado and University of Providence Pediatrics, Carolinas HealthCare System
Colorado Denver Charlotte, North Carolina
Aurora, Colorado

iii
iv Contributors

Maxine Fookson, RN, MN, PNP Rita Marie John, EdD, DNP, CPNP, PMHS
Pediatric Nurse Practioner, School Based Health Program Associate Professor of Nursing at CUMC
Multnomah County Health Department PNP Program Director
Portland, Oregon Columbia University School of Nursing
New York, New York
Lauren Bell Gaylord, MSN, CPNP-PC
Pediatric Nurse Practitioner Veronica Kane, PhD, RN, MSN, CPNP
Etowah Pediatrics Clinical Assistant Professor, Coordinator—Pediatric
Rainbow City, Alabama Nursing Specialty
MGH Institute of Health Professions, School of Nursing
Teral Gerlt, MS, RN, WHCNP-E, PNP-R Boston, Massachusetts;
Instructor Pediatric Nurse Practioner, Pediatrics, Urgent Care
Oregon Health & Science University Harvard Vangard Medical Associates
School of Nursing Braintree, Massachusetts
Portland, Oregon
Julie Martchenke, RN, MSN, CPNP
Terea Giannetta, DNP, RN, CPNP, FAANP Pediatric Cardiology Nurse Practitioner
Associate Professor/Chief Nurse Practitioner Oregon Health & Science University
California State University, Fresno/Valley Children’s Portland, Oregon
Hospital
Fresno, California/Madera, California MiChelle McGarry, MSN, RN, CPNP, CUNP
Certified Pediatric and Urology Nurse Practitioner/
Denise A. Hall, BS, CMPE Program Director/Owner
Practice Administrator Pediatric Effective Elimination Program Clinic &
Advanced Pediatrics Associates Consulting, PC
Aurora, Colorado Highlands Ranch, Colorado

Anna Marie Hefner, PhD, RN, CPNP Peter M. Milgrom, DDS

Associate Professor Professor of Oral Health Sciences and Pediatric Dentistry,
Azusa Pacific University Adjunct Professor of Health Services,
Upland, California Director, Northwest Center to Reduce Oral Health
Disparities
Pamela J. Hellings, RN, PhD, CPNP-R University of Washington
Professor Emeritis Seattle, Washington
Oregon Health & Science University
Portland, Oregon Carole R. Myers, PhD, RN
Associate Professor-College of Nursing
Susan Hines, RN, MSN, CPNP University of Tennessee
Pediatric Nurse Practitioner Knoxville, Tennessee
Sleep Medicine
Children’s Hospital Colorado Jennifer Newcombe, MSN, PCNS-BC,
Aurora, Colorado CPNP-PC/AC
Nurse Practitioner, Pediatric Cardiothoracic Surgery
Sandra Daack-Hirsch, PhD, RN Loma Linda Children’s Hospital
Associate Professor Loma Linda, California
The University of Iowa, College of Nursing
Iowa City, Iowa Noelle Nurre, RN, MN, CPNP
Suspected Child Abuse and Neglect (SCAN) Nurse
Belinda James-Petersen, DNP, RN, CPNP Practitioner
Pediatric Nurse Practitioner-Gastroenterology Oregon Health and Science University Doernbecher
Children’s Specialty Group Children’s Hospital and CARES Northwest
Children’s Hospital of the Kings Daughters Portland, Oregon
Norfolk, Virginia
Catherine O’Keefe, DNP, CPNP-PC
Associate Professor/NP Curriculum Coordinator
Creighton University, College of Nursing
Omaha, Nebraska
 Contributors v

Gabrielle M. Petersen, MSN, CPNP Robert D. Steiner, MD

Medical Examiner Executive Director
Children’s Center Marshfield Clinic Research Foundation;
Oregon City, Oregon Professor of Pediatrics
University of Wisconsin
Ann M. Petersen-Smith, PhD, APRN, CPNP-PC, Marshfield, Wisconsin
CPNP-AC
Assistant Professor Ohnmar K. Tut, BDS, MPhil
University of Colorado Anschutz Medical Campus Adjunct Senior Research Fellow
College of Nursing; Griffith University;
Associate Clinical Professor Program Consultant Investigator
University of Colorado Anschutz Medical Campus HRSA Oral Health Workforce Activities—FSM
School of Medicine Brisbane, Queensland, Australia;
Section of Pediatric Emergency Medicine Affiliate Instructor
Aurora, Colorado University of Washington
Seattle, Washington
Michele L. Polfuss, PhD, RN, CPNP-AC/PC
Assistant Professor Becky J. Whittemore, MPH, MN, FNP-BC
University of Wisconsin–Milwaukee; Nurse Practitioner
Nurse Researcher Institute on Development and Disability
Children’s Hospital of Wisconsin Oregon Health & Sciences University
Milwaukee, Wisconsin Portland, Oregon

Ruth K. Rosenblum, DNP, RN, PNP-BC Elizabeth E. Willer, RN, MSN, CPNP
Assistant Professor, DNP Program Coordinator Pediatric Nurse Practitioner
San Jose State University Kaiser Permanente
San Jose, California Walnut Creek, California

Mary Rummell, MN, RN, CNS, CPNP, FAHA Teri Moser Woo, PhD, RN, ARNP, CNL, CPNP,
Clinical Nurse Specialist FAANP
The Knight Cardiovascular Institute, Cardiac Services Associate Professor
Oregon Health & Science University Associate Dean for Graduate Nursing Programs
Portland, Oregon Pacific Lutheran University
Tacoma, Washington
Susan K. Sanderson, DNP, APRN, FNP-BC
Pediatric Infectious Diseases Nurse Practitioner; Instructor Robert J. Yetman, MD
Department of Pediatrics Professor of Pediatrics
Division of Infectious Diseases Director, Division of Community and General Pediatrics
University of Utah School Of Medicine University of Texas–Houston Medical School
Salt Lake City, Utah UT Physicians Pediatrics—The Kid’s Place
Houston, Texas
Arlene Smaldone, PhD, CPNP, CDE
Associate Professor of Nursing at CUMC Yvonne K. Yousey, RN, CPNP, PhD
Associate Professor of Dental Behavioral Sciences (in Pediatric Nurse Practitioner
Dental Medicine) at CUMC Kids First Health Care
Assistant Dean, Scholarship and Research (School of Commerce City, Colorado
Nursing)
Columbia University
New York, New York

Isabelle Soulé, PhD, RN

Human Resources for Health Rwanda
University of Maryland
Baltimore, Maryland
 Reviewers

Reviewers

Jennifer P. D’Auria, PhD, RN, CPNP Judith W. Leonard, PNP-BC, MSN

Associate Professor Pediatric Nurse Practioner-Board Certified
The University of North Carolina–Chapel Hill School of Southern Orange County Pediatric Associates
Nursing Lake Forest, California
Chapel Hill, North Carolina
Ann Parsons, MN, PPCNP
Martha Driessnack, PhD, PPCNP-BC Nurse Practitioner
Associate Professor TEDI EAR Children’s Advocacy Center at East Carolina
Pediatric Nurse Practitioner Program University
Oregon Health & Science University (OHSU) School of Greenville, North Carolina
Nursing
Portland, Oregon Debra P. Shockey, DNP, APRN-BC, CPNP
Assistant Professor
Melissa J. Geist, EdD, PPCNP-BC, CNE Family and Community Health Nursing
Associate Professor of Nursing Virginia Commonwealth University School of Nursing
Whitson-Hester School of Nursing Richmond, Virginia
Tennessee Technological University
Cookeville, Tennessee Leigh Small, PhD, RN, CPNP-PC, FNAP, FAANP,
FAAN
Beverly P. Giordano, MS, RN, CPNP, PPCMHS Associate Professor and Chair
Pediatric Nurse Practitioner Department of Family and Community Health Nursing
Child Development/ADHD Clinic Virginia Commonwealth University
University of Florida School of Nursing
Gainesville, Florida Richmond, Virginia

Sunny Hallowell, PhD, PPCNP-BC, IBCLC

Pediatric Nurse Practitioner & Lactation Consultant
Research Fellow
Center for Health Outcomes and Policy Research
University of Pennsylvania School of Nursing
Philadelphia, Pennsylvania

vi
Preface
We are delighted to introduce the sixth edition of Pediatric
Primary Care. This book was first developed 20 years ago
as a resource for advanced practice nurses serving the
primary health care needs of infants, children, and adoles-
cents. Pediatric nurse practitioners (PNPs) and family nurse
practitioners (FNPs) are our primary audience. However,
physicians, physician assistants, and nurses who care for
children in a variety of settings also find the book to be a
valuable resource. The field of pediatric primary care has
also grown and changed since the first edition of this book.
The interdisciplinary Institute of Medicine (IOM) and
the Affordable Care Act have explicitly recognized the criti-
cal role of nurse practitioners and nurses in providing
health care to the population in the United States (IOM
Report, 2010).
The book emphasizes prevention and management of
problems from the primary care provider’s point of view.
Each chapter is organized to introduce key concepts and
foundations for care in a narrative format followed by a
discussion of the identification and management of diagno-
ses using an outline format. Experienced clinicians can
simply jump to the topic or diagnosis in question while the
student can read the chapter for immersion into the topic.
Additional resources for each chapter include websites to
access organizations and printed materials that may be
useful for clinicians, their patients, and families. Our con-
tributing authors are experts in their fields.
Special Features of the Sixth Edition
Some features of the sixth edition about which we are par-
ticularly excited include the following:
• Updated content reflects the latest developments in our
understanding of disease processes, disease management
in children, and current trends in pediatric health care
• NEW Pediatric Pharmacology chapter
• NEW Specialist Referral highlights to alert busy
practitioners to cues that signal the need for urgent
referral
• NEW graduate-level Quality and Safety Education for
Nurses (QSEN) integration (Cronenwett et al, 2009):
The Safety, Informatics, Teamwork and Collaboration,
and Evidence–based competencies
• NEW full-color design and illustration format to
improve usability and teaching/learning value
• NEW focus on diversity among cultures in Chapter 3
provides greater emphasis on the need for providers to
approach differences between themselves and their clients
with humility and competence
• Reorganized application of Gordon’s Functional
Health Patterns to provide a more conceptually consis-
tent flow of content (Gordon, 1987, 2010)
• Expanded coverage of health literacy—obtaining,
reading, understanding, and using health care informa-
tion to make appropriate health decisions
• Expanded, updated coverage of growth and develop-
ment for greater consistency with contemporary theories
of development
• Unique chapter on integrative/complementary thera-
pies promotes the primary care provider’s knowledge
about many of the less conventional health care strategies
that families may be inquiring about or using
• Refocused Practice Management chapter (Chapter
44) is now available to readers on the Evolve website.
This chapter focuses on content more specific to pediat-
ric practice management, including the various settings
for pediatric primary care, such as school-based clinics
and the health care home. This refocused chapter also
addresses informatics and other essential topics influ-
enced by the Affordable Care Act, as well as National
Patient Safety Goals and the growing trend of interpro-
fessional collaboration.
• Discussion questions and NEW PowerPoint slides are
available on the Evolve site for educators. These are
written by nurse practitioner educators to assist students
to think about the implications of the material for their
clinical practice.
Organization of the Book
We recognize that children are a special population and that
providing health care to them must be approached using
several unique perspectives: their developmental changes
over time, their dependency on their parents, the differen-
tial epidemiology of child health, the different demographic
patterns of children and their families, and the individuality
vii
viii Preface
of their genetic makeup. These themes are carried through-
out the text.
The book is organized into four major sections—Pediatric
Primary Care Foundations, Management of Develop-
ment, Approaches to Health Management in Pediatric
Primary Care, and Approaches to Disease Management.
Each chapter follows the same format. Standards and guide-
lines for care are highlighted, the physiologic and assess-
ment parameters are discussed, management strategies are
identified, and management of common problems is pre-
sented in a problem-oriented format. The scope of practice
of the primary care provider is always kept in mind with
appropriate referral and consultation points identified.
We hope this text will continue to promote the very best
evidence-based care possible for children and families in
primary care settings by all the providers with whom they
come in contact.
Editors
Catherine E. Burns, PhD, RN, CPNP-PC, FAAN
Ardys M. Dunn, PhD, RN, PNP
Margaret A. Brady, PhD, RN, CPNP-PC
Nancy Barber Starr, MS, APRN-BC (PNP), CPNP-PC
Catherine G. Blosser, MPA:HA, RN, PNP
Dawn Lee Garzon, PhD, PNP-BC, CPNP-PC, PMHS,
FAANP
Associate Editor
Nan M. Gaylord, PhD, RN, CPNP-PC
References
Cronenwett L, Sherwood G, Pohl J, et al: Quality and safety educa-
tion for advanced nursing practice, Nurs Outlook 5(6):338–348,
2009.
Gordon M: Nursing diagnosis: process and application, New York,
1987, McGraw-Hill.
Gordon M: Manual of nursing diagnosis, ed 12, Sudbury, MA, 2010,
Jones and Bartlett.
Institute of Medicine (IOM) of the National Academies: The future
of nursing: leading change, advancing health, 2010. Available at:
http://www.iom.edu/Reports/2010/The-Future-of-Nursing-
Leading-Change-Advancing-Health (accessed October 28, 2014).
Acknowledgments
A book of this size and complexity cannot be completed
without considerable help—the work of the contributors
who researched, wrote, and revised content; the consulta-
tion and review of experts in various specialties who cri-
tiqued drafts and provided important perspectives and
guidance; and the essential technical support from those
who managed the production of the manuscript and the
final product. Lee Henderson and Charlene Ketchum have
provided consistent Elsevier support through the past two
editions.
Contributors to the Fifth Edition
These people were instrumental in helping us develop the
fifth edition of the book. Although they are not authors in
this edition, their ideas and work have contributed greatly
to our work, and we are deeply indebted to them: Barbara
Deloian, Mary Murphy, Maxine Fookson, Lynn Frost,
Denise Abdoo, Roberta Bentson Royal, Veronica Kane,
Martha K. Swartz, Anne Albers, Melissa Reider-Demer,
Shirley Becton McKenzie, Peggy Vernon, Jan Bazner-
Chandler, and Constance Brehm.
Our Thanks to Family and Friends
• To my husband, Jerry Burns: Thanks so very much for
giving me the time and support to work on this text one
more time; to my loving daughters Jennifer and Jill and
their families; other family and friends; and to the many
PNPs, FNPs, and NP faculty who have expressed their
appreciation for this text and encouraged us to continue
the project. Catherine E. Burns
• To Marvin Dunn; Malcolm and Megan Dunn; Philip
Dunn and Liz Flynn, grandchildren Miles, Claire,
Simon, and Eleanor Dunn (from “the craziest Nana in
the whole wide world!”)—thanks for being my joy and
inspiration; and to so many other family and friends, you
are the spice of a well-flavored life. Ardys M. Dunn
• With deep appreciation for the circle of love and support
from my dear family and friends who are always there
surrounding me with warmth, laughter, and joy. Marga-
ret A. Brady
• Aloha and mahalo to my Jon, Jonah, and AnnaMei. I
am ever grateful for the joy you bring to my life as well
as your support of my time with “the book.” Likewise, I
am ever thankful for Denise and my APA colleagues who
give me the flexibility and challenge to work hand in
hand to provide model pediatric care. Nancy Barber Starr
• To my husband, Terry, for his continued love and support
and my admiration for all the littlest Blosser offspring
for their years of sharing their humor, strides, and
challenges—they are amazing examples of the wonder of
growth and development. Catherine G. Blosser
• My thanks to the students, parents, and families who
make me a better person; to Rachel and Elizabeth Garzon
who give my life meaning; and to Amy DiMaggio,
friends, and family for loving me and giving me wings.
Dawn Lee Garzon
• To my parents who first loved, supported, and encour-
aged me. To my husband, Mark, who loved me second
and continues to love, support, and encourage me in all
my professional endeavors. To my children, Curtis and
Leah, who make life fun and will continue to do so with
their own children. Nan Gaylord
Contents

Unit 1: Pediatric Primary Care Foundations 16 Values, Beliefs, and Spirituality, 299

1 Health Status of Children: Global and 17 Role Relationships, 311

National Perspectives, 2
18 Self-Perception Issues, 339
2 Child and Family Health Assessment, 10
19 Coping and Stress Tolerance: Mental Health
3 Cultural Considerations for Pediatric Primary and Illness, 355
Care, 33
20 Cognitive-Perceptual Disorders, 386
Unit 2: Management of Development
4 Developmental Management in Pediatric Unit 4: Approaches to
Primary Care, 46 Disease Management
5 Developmental Management of Infants, 61 21 Introduction to Disease Management, 428

6 Developmental Management of Early 22 Prescribing Medications in Pediatrics, 451

Childhood, 80
23 Pediatric Pain Management, 459
7 Developmental Management of School-Age
Children, 101 24 Infectious Diseases and Immunizations, 474

8 Developmental Management of 25 Atopic, Rheumatic, and Immunodeficiency

Adolescents, 121 Disorders, 549

Unit 3: Approaches to Health 26 Endocrine and Metabolic Disorders, 596

Management in Pediatric
27 Hematologic Disorders, 626
Primary Care
28 Neurologic Disorders, 660
9 Introduction to Functional Health Patterns
and Health Promotion, 141
29 Eye Disorders, 703
10 Nutrition, 158
30 Ear Disorders, 736
11 Breastfeeding, 198
31 Cardiovascular Disorders, 756
12 Elimination Patterns, 216
32 Respiratory Disorders, 794
13 Physical Activity and Sports for Children
and Adolescents, 233 33 Gastrointestinal Disorders, 833

14 Sleep and Rest, 273 34 Dental and Oral Disorders, 889

15 Sexuality, 285 35 Genitourinary Disorders, 911

ix
x Contents

36 Gynecologic Disorders, 948 42 Environmental Health Issues, 1170

37 Dermatologic Disorders, 983 43 Complementary Health Therapies in Pediatric

Primary Care: An Integrative Approach, 1199
38 Musculoskeletal Disorders, 1042
Resources on the Evolve Website
39 Perinatal Disorders, 1082
44 Strategies for Managing a Pediatric Health
40 Common Injuries, 1124 Care Practice

41 Genetics Disorders, 1148

 UNIT 1

Pediatric Primary Care Foundations

1
1
T
he health status of all children must be viewed with
a global lens. Whether considering pandemic infec­
tious diseases or the global emigration of popula­
tions between continents, the health of all children is
interconnected worldwide. Inequalities in the health status
of children globally and nationally are largely determined
by common biosocial factors affecting health, which include
where they are born, live, are educated, their work, and their
age (World Health Organization [WHO], 2014a). The bio­
social factors also include the systems in place to address
health and illness in children and families.
The biosocial circumstances or social deter inants of
child health are shaped by economics, soci polic,;ies, and
politics in each region and country. In order to impact
health outcomes, scaling up the efforts nationally and glob­
ally to build better health systems is required. Significant
progress has been made in reducing childhood morbidity
and mortality using this approach. [he framework of the
United Nations Millennium Development Goals 2014
(United Nations, 2015) and the Healthy People 2020 (U.S.
Department of Health and Human Services [HHS] Office
of Disease Prevention and Health Promotion, 2015a) goals
set the mark for improving child health status. It is for
societies to embrace and prioritize these goals on behalf of
children.
This chapter presents an overview of the global health
status of children, including the issue of global food inse­
curity, child health status in the United States and current
health inequalities, the progress toward achieving the Mil­
lennium Development Goals and Healthy People 2020
targets, the effect of health care reform in the United States
on access to care for children and adolescents, and the
important role pediatric health care providers have in advo­
cating for polices that foster health equity and access to
quality health care services for all children and families. The
2
final section
available tc-> pcidiatric health care providers to assess and
monitor the health and well-being of children from infancy
to young aduldiood.
Global Health Status of Children
'lliirty-five million children younger than 20 years old are
r,art of the international migration of populations across
continents (UNICEF, 2014). Emigrant children have
increased health and educational needs that impact the
health and well-being of communities; many of these com­
munities have fragile health care systems. The United
Nations Convention on the Rights of Children (UNCRC)
charter was established 25 years ago and declares the
minimum entitlements and freedoms for children globally,
including the right to the best possible health (United
Nations International Children's Fund, 2009). Emigrant
children have the right to be protected under this charter
(Box 1-1). Governments are advised to provide good quality
health care, clean water, nutritious foods, and clean environ­
ments so that children can stay healthy. The charter is
founded on the principle of respect for the dignity and
worth of each individual, regardless of race, color, gender,
language, religion, opinions, origins, wealth, birth status, or
ability. The UNCRC continues to work on ensuring that
all children have these basic human rights and freedoms.
Special emphasis is placed on the responsibility and strength
of families and the vital role of the international community
to protect and secure the rights of children, including access
to health care and primary health care services.
Health equity is the absence of unfair or remediable dif­
ferences in health services and health outcomes among
populations (WHO, 20146). Although the rate of child
mortality globally remains high, there have been significant
 CHAPTER 1 Health Status of Children: Global and National Perspectives
• BOX 1-1 UNICEF* Summary of the United
Nations Convention on the Rights of
Children
The UNICEF conventions include 42 articles that are
summarized in the following list. They represent the worldwide
standards for the rights of children. The conventions apply to all
children younger than 18 years old. The best interests of
children must be a top priority in all actions concerning children.
• Every child has the right to:
• Life and best possible health
• Time for relaxation, play, and opportunities for a variety of
cultural and artistic activities
• A legally registered name and nationality
• Knowledge of and care by his or her parents, as far as
possible, and prompt efforts to restore the child-parent
relationship if they have been separated
• Protection from dangerous work
• Protection from use of dangerous drugs
• Protection from sale and social abuse, exploitation,
physical and sexual abuse, neglect and special care to
help them recover their health if they have experienced
such toxic life events
• No incarceration with adults and opportunities to maintain
contact with parents
• Care with respect for religion, culture, and language if not
provided by the parents
• A full and decent life in conditions that promote dignity,
independence, and an active role in the community, even
if disabled
• Access to reliable information from mass media,
television, radio, newspapers, as well as protection from
information that might harm them
• Governments must do all that they can to fulfill the rights of
children as listed above.
*UNICEF stands for the full name United Nations International Children’s
Emergency Fund. In 1953, its name was shortened to the United Nations
Children’s Fund. However, the original acronym was retained.
reductions in the rate over the past few decades. Since 1990,
child mortality in children younger than 5 years old has
decreased by 47% due to targeted policies to reduce child-
hood pneumonia, diarrhea, and malaria and also to reduce
the number of preterm births and perinatal complications.
Despite these efforts, 6.3 million children younger than 5
years old die each year worldwide (Wang et al, 2014). To
reach the World Health Organization (WHO) target of
two-thirds reduction in mortality for children younger than
5 years old, more rapid progress is needed, particularly in
sub-Saharan Africa, where the highest rate of infant mortal-
ity occurs. Currently, sub-Saharan Africa and Southern Asia
account for 81% of the infant mortality globally (United
Nations, 2015).
Diarrhea and pneumonia remain the leading infectious
causes of childhood morbidity and mortality globally. The
highest proportion of deaths due to these two conditions is
in children younger than 2 years old; undernutrition, sub-
optimum breastfeeding, and zinc deficiency contribute sig-
nificantly to the mortality rate from these diseases. (Zinc
reduces the duration and severity of diarrhea and likelihood
3
of reinfections for 2 to 3 months. As a micronutrient, it is
essential for protein supplementation, cell growth, immune
function, and intestinal transport of water and electrolytes
[Khan and Sellen, 2015].) Rotavirus is the most common
cause of diarrhea globally and Streptococcus pneumoniae is
the leading cause of pneumonia (Walker et al, 2013). Both
of these are vaccine-preventable infectious diseases.
Successful vaccination programs have markedly reduced
the mortality caused by some infectious diseases, particu-
larly measles and tetanus. Cambodia serves as a noteworthy
example. To reduce childhood mortality in children younger
than 5 years old, Cambodia targeted measles vaccination
due to the high mortality associated with the disease. Within
a decade, health workers were able to increase the rate of
measles immunization by 71% in children younger than
1 year old (United Nations, 2015). To achieve complete
eradication of measles, WHO helped the Cambodian
national immunization program to identify and reach
communities at high risk for low rates of immunizations.
A national immunization program also began providing
a booster dose of a measles-containing vaccine after
18 months old. The result was measles eradication in
Cambodia since 2012. Such sustained immunization pro-
grams by partnerships between communities, governments,
and international aid organizations can markedly improve
global child health status. However, emerging viral and
bacterial infectious diseases present complex challenges to
public health infrastructure and threaten the global progress
made on reducing childhood mortality (see Chapter 24).
The majority of the extremely poor live in five
countries—India, China, Nigeria, Bangladesh, and the
Democratic Republic of Congo. The risk of maternal death
from pregnancy-related complications and childbirth in
developing regions is 230 deaths per 100,000 births; this
rate is 14 times higher than in developed countries (United
Nations, 2015).
Global Food Insecurity and Effect on
Children’s Health
Hunger and undernutrition are often referred to as food
insecurity, which is the condition that exists when popula-
tions do not have physical and economic access to sufficient,
safe, nutritious, and culturally acceptable food to meet
nutritional needs. Food insecurity occurs in impoverished
populations in developing countries and in industrialized
nations, particularly among migrant populations. Children
affected by migration and family separation are at risk for
food insecurity and are vulnerable to further health conse-
quences, including exposure to exploitation and child traf-
ficking. Growing evidence on climate change indicates the
dramatic effect on food crops that lead to food distribution
issues, which is one of the primary contributors to food
insecurity (Fig. 1-1).
Globally, undernutrition is an important determinant of
maternal and child health and accounts for 45% of all child
4 UNIT 1 Pediatric Primary Care Foundations
Regional weather
changes
Climate
• Heatwaves
change • Extreme weather
• Temperature
• Precipitation
Research
• Figure 1-1 Health effects of climate change.
deaths in children younger than 5 years old (United Nations,
2015). Suboptimal breastfeeding remains a problem in
developed and developing nations. Children who are exclu-
sively breastfed for the first 6 months of life are 14 times
more likely to survive than non-breastfed infants (United
Nations, 2015). Vitamin A and zinc deficiencies also con-
tribute to the disease burden in mortality for children
younger than 5 years old. In developing countries, 55
million women are stunted from undernutrition and lack
of micronutrients, including iron, folic acid, vitamin A, and
zinc (Save the Children, 2015). Preventable nutritional defi-
ciencies are a compelling case for further implementation
of the Millennium Development Goals and increased
support for micronutrient supplementation for children in
developing regions.
United Nations Millennium Development
Goals: Project Goals
The Millennium Project, a global health project of research
and study to improve prospects for a better future for
humanity, publishes a framework (Millennium Develop-
ment Goals) annually to address the challenges, both local
and global, facing the world populations. Health and access
to health care in the context of social determinants are
covered in the document. Figures 1-2 and 1-3 and Box 1-2
illustrate the collaborative action required among govern-
ments, international organizations, corporations, universi-
ties, and individuals and societies to address the issue of
health equity from a global perspective (The Millennium
Project, 2014).
Health effects
Temperature-related
illness and death
Moderating Extreme weather-
influences related health effects
• Contamination
pathway
Air pollution-related
health effects
• Transmission
dynamics Water- and food-borne
• Food diseases
availability
• Migration Vector- and rodent-borne
diseases
Psychological effects
Adaptation
measures Malnutrition
One of the main goals of the Millennium Development
Goals framework is to reduce infant mortality by at least
two-thirds by 2016 in 27 countries. Eight goals consist of
21 quantifiable targets measured by 60 health indicators
(see Fig. 1-3). They provide a framework for the interna-
tional community to ensure socioeconomic development
reaches all children.
Progress on the Millennium
Development Goals
Significant progress has been made in many areas, including
reductions in child mortality and preterm birth. In 30
developing countries, progress toward achieving reductions
in child mortality has been faster than predicted due to
income, education, and secular shifts in living and work
environments (Wang et al, 2014). However, increased assis-
tance in improving economic status and levels of maternal
education is required to sustain the effort.
Since 1990, progress has been made by reducing world
poverty by half, access to clean drinking water has improved
for 2.3 billion people, chronic undernutrition in children
causing stunting has decreased by 40%, and 90% of chil-
dren in developing regions are attending primary school
(United Nations, 2015). The achievements are the result of
the collaborations between governments, international
communities, civil societies, and private corporations. To
make further sustained progress, expansion and acceleration
of the interventions by the WHO are required to target the
leading causes of death in the target countries.
The economic growth potential remains strong in
many of the developing regions, and partnerships between
 CHAPTER 1 Health Status of Children: Global and National Perspectives 5

Sustainable development
and climate change

Global ethics 1 Clean water

15 2
Science and Population
technology 14 3 and resources

Energy 13 Democratization
4

Transnational Global foresight

5
organized crime 12 and decision-making

Status of women 11 6 Global

convergence of IT

10 7 Rich–poor gap
Peace and conflict
9 8
Education Health issues
• Figure 1-2 Fifteen global challenges facing humanity. IT, Information technology.

• BOX 1-2 Preterm Birth Rate by Race

Goal 1: Eradicate extreme poverty and hunger and Ethnicity
Births before 37 weeks’ gestation can result in lifelong
disabilities, and children born preterm are at higher risk of death
Goal 2: Achieve universal primary education during their first few days of life.

Race and Ethnicity Preterm Birth Rate

African American, non-Hispanic 16.5%
Goal 3: Promote gender equality and empower women
mothers
American Indian or Alaska Native 13.3%
mothers
Goal 4: Reduce child mortality Hispanic mothers 11.6%
White, non-Hispanic mothers 10.3%
Asian or Pacific Islander mothers 10.2%
Goal 5: Improve maternal health
The African American preterm birth rate is more than
1.5 times higher than that experienced by Asians or Pacific
Islanders.
Goal 6: Combat HIV/AIDS, malaria, and other diseases HHS Office of Disease Prevention and Health Promotion: LHI infographic
gallery: maternal, infant, and child health (April 2014): preterm births and infant
deaths, HealthyPeople.gov (website): www.healthypeople.gov/2020/leading
-health-indicators/LHI-Infographic-Gallery#Apr-2014. Accessed August 13,
Goal 7: Ensure environmental sustainability 2015.

Goal 8: Develop a global partnership for development

• Figure 1-3 List of eight Millennium Development Goals. AIDS,

Acquired immune deficiency syndrome; HIV, human immunodeficiency
virus.
6 UNIT 1 Pediatric Primary Care Foundations
developing countries and nongovernmental organizations
(NGOs) continue to provide significant sources of develop-
mental assistance. Official development assistance is at the
highest level ever recorded by the United Nations agency
partners (United Nations, 2015). Developing countries
require further debt relief, reduced trade barriers, improved
access to technologies for renewable energy production, and
enhanced protection from and response to environmental
disasters to sustain current advances. Further, global politi-
cal efforts are required to support achievement of the Mil-
lennium Development Goals beyond 2015 and a renewed
commitment to the future health and well-being of children
everywhere.
Health Status of Children
in the United States
Globalism will increasingly affect child health in the United
States. The demographic mix of children and families cared
for by pediatric health care providers in the United States
has become increasingly complex, with a greater number
of children living in poverty who are at increased risk for
chronic physical and mental health conditions and exposure
to intimate partner violence (IPV), gun violence, and abuse
(American Academy of Pediatrics [AAP], 2014). Child
poverty rates in the United States remain higher than in
other economically developed nations. One in five children
(out of 16.3 million) in the United States live in families
with incomes below the federal poverty level (FPL) (Annie
E. Casey Foundation, 2015). The rate of household poverty
is higher (one in three) for Latino and African American
children.
Most concerning among the child health indicators is the
percentage of overweight and obese children. Seventeen
percent of youth are “obese” as defined as a body mass index
(BMI) greater than the 95th percentile for age on the BMI
age and gender–specific growth charts. For infants and chil-
dren younger than 2 years old, the rate of obesity is 8.1%
as determined by weight for recumbent length charts.
Although rates of obesity among children and youth remain
high, surveillance studies show that the rate of increase in
overweight and obesity has stabilized. The obesity rate
among 2- to 5-year-olds showed a significant decrease of
5.5% between 2004 and 2013 (Ogden et al, 2014).
Obese and overweight children and youth are more at
risk for developing adult health problems, including heart
disease, type 2 diabetes, stroke, and osteoarthritis. Poor
eating patterns are a major factor in the high rate of obesity
among children and adolescents. Children’s diets have been
out of balance over the past two decades with too much
added sugar and saturated fats, and limited fruits, vegeta-
bles, and whole grains. Of all the child health indicators,
overweight and obesity will significantly affect the cost of
providing health care services in the United States in the
coming years. Chapter 10 discusses childhood obesity, the
comorbidities, and the related cost of health care.
Food Insecurity in Children
in the United States
Despite many government food assistance programs, nearly
one in five children in the United States lives in a food-
insecure household. Children who are food insecure are
more likely to have poorer general health, higher rates of
hospitalization, increased incidence of overweight, asthma,
anemia, and experience behavioral problems. Factors other
than income do impact whether a household is food
insecure. Maternal education, single-parent households,
intimate-partner violence, and parental substance abuse also
contribute to food insecurity in households. Children living
in households where the mother is moderately-to-severely
depressed have a 50% to 80% increased risk of food inse-
curity (Gundersen and Ziliak, 2015).
Three-quarters of children spend some portion of the
preschool years being cared for outside of the home.
Depending on child care arrangements, the care can con-
tribute to or ameliorate the effects of food insecurity for
children. Young children who attend a preschool or child
care center have lower food insecurity, whereas children
cared for at home by an unrelated adult are at higher risk
for food insecurity (Gundersen and Ziliak, 2015). The
Supplemental Nutritional Assistance Program (SNAP), the
Special Supplemental Nutrition Program for Women,
Infants, and Children (WIC) and the School Breakfast
Program (SBP) are federally funded programs with the
purpose to combat childhood hunger. In 2013, 11.2 million
children participated in the SBP for a free or reduced price,
and WIC served 8.7 million women and children at a cost
of $6.45 billion (Gundersen and Ziliak, 2015). The average
monthly WIC benefit for families is $43.
Addressing Children’s Health
in the United States
Healthy People 2020
The Healthy People 2020 goals for children include foci
specific to early and middle childhood and adolescents,
social determinants of health in childhood, health-related
quality of life for children, and on specific disparities in
child health to improve health care services and health
outcomes (HHS Office of Disease Prevention and Health
Promotion, 2015a). With increased proportions of children
with developmental delays, Healthy People 2020 focuses
on objectives to increase the percentage of children younger
than 2 years old who receive early intervention services for
developmental disabilities and to increase the proportion of
children entering kindergarten with school readiness in all
five domains of healthy development—physical well-being
and motor development, social emotional development,
approaches to learning, language development, and cogni-
tion, and general development. The objectives also address
the increase in maladaptive behaviors in the pediatric popu-
lation and set benchmarks to increase the percentage of
Another random document with
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The Project Gutenberg eBook of Nick Carter Stories
No. 120, December 26, 1914: An uncanny revenge; or,
Nick Carter and the mind murderer
This ebook is for the use of anyone anywhere in the United States
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Title: Nick Carter Stories No. 120, December 26, 1914: An uncanny
revenge; or, Nick Carter and the mind murderer

Author: Nicholas Carter

Contributor: Burke Jenkins

Release date: June 22, 2022 [eBook #68376]

Language: English

Original publication: United States: Street & Smaith, 1914

Credits: David Edwards, Chuck Greif and the Online Distributed

Proofreading Team at https://www.pgdp.net (Northern Illinois
University Digital Library)

*** START OF THE PROJECT GUTENBERG EBOOK NICK

CARTER STORIES NO. 120, DECEMBER 26, 1914: AN UNCANNY
REVENGE; OR, NICK CARTER AND THE MIND MURDERER ***
Issued Weekly. Entered as Second-class Matter at the New York Post Office,
by Street & Smith, 79-89 Seventh Ave., New York.
Copyright, 1915, by Street & Smith. O. G. Smith and G. C. Smith,
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No. 120. NEW YORK, December 26, 1914. Price Five
Cents.
 AN UNCANNY REVENGE;

Or, NICK CARTER AND THE MIND MURDERER.

Edited by CHICKERING CARTER.

 CHAPTER I.

A TRAGEDY OF THE STAGE.

The members of Nick Carter’s household all happened to meet at the

breakfast table that morning—a rather unusual circumstance.
The famous New York detective sat at the head of the table. Ranged
about it were Chick Carter, his leading assistant; Patsy Garvan, and the
latter’s young wife, Adelina, and Ida Jones, Nick’s beautiful woman
assistant.
It was the latter who held the attention of her companions at that moment.
She was a little late, and had just seated herself. Her flushed cheeks and
sparkling eyes gave no hint that she had reached the house—they all shared
the detective’s hospitable roof—a little after three o’clock that morning.
“You good people certainly missed a sensation last night,” she declared.
“It was the strangest thing—and one of the most pitiable I ever beheld!”
Nick, who had been glancing at his favorite newspaper, looked up.
“What do you mean?” he asked.
It was Ida’s turn to show surprise.
“Is it possible you don’t know, any of you?” she demanded, looking
around the table. “Haven’t you read of Helga Lund’s breakdown, or
whatever it was?”
Helga Lund, the great Swedish actress, who was electrifying New York
that season in a powerful play, “The Daughters of Men,” had consented, in
response to many requests, to give a special midnight performance, in order
that the many actors and actresses in the city might have an opportunity to
see her in her most successful rôle at an hour which would not conflict with
their own performances.
The date had been set for the night before, and, since it was not to be
exclusively a performance for professionals, the manager of the theater, who
was a friend of Nick Carter’s, had presented the detective with a box.
Much to Nick’s regret, however, and that of his male assistants, an
emergency had prevented them from attending. To cap the climax, Adelina
Garvan had not been feeling well, so decided not to go. Consequently, Ida
Jones had occupied the box with several of her friends.
Nick shook his head in response to his pretty assistant’s question.
“I haven’t, anyway,” he said, glancing from her face back to his paper.
“Ah, here’s something about it—a long article!” he added. “I hadn’t seen it
before. It looks very serious. Tell us all about it.”
Ida needed no urging, for she was full of her subject.
“Oh, it was terrible!” she exclaimed, shuddering. “Helga Lund had been
perfectly wonderful all through the first and second acts. I don’t know when
I have been so thrilled. But soon after the third act began she stopped right in
the middle of an impassioned speech and stared fixedly into the audience,
apparently at some one in one of the front rows of the orchestra.
“I’m afraid I can’t describe her look. It seemed to express merely
recollection and loathing at first, as if she had recognized a face which had
very disagreeable associations. Then her expression—as I read it, at any rate
—swiftly changed to one of frightened appeal, and then it jumped to one of
pure harrowing terror.
“My heart stopped, and the whole theater was as still as a death chamber
—at least, the audience was. Afterward I realized that the actor who was on
the stage with her at the time had been improvising something in an effort to
cover up her lapse; but I don’t believe anybody paid any attention to him,
any more than she did. Her chin dropped, her eyes were wild and seemed
ready to burst from their sockets. She put both hands to her breast, and then
raised one and passed it over her forehead in a dazed sort of way. She
staggered, and I believe she would have fallen if her lover in the play hadn’t
supported her.
“The curtain had started to descend, when she seemed to pull herself
together. She pushed the poor actor aside with a strength that sent him
spinning, and began to speak. Her voice had lost all of its wonderful music,
however, and was rough and rasping. Her grace was gone, too—Heaven
only knows how! She was positively awkward. And her words—they
couldn’t have had anything to do with her part. They were incoherent
ravings. The curtain had started to go up again. Evidently, the stage manager
had thought the crisis was past when she began to speak. But when she only
made matters worse, it came down with a rush. After a maddening delay, her
manager came out, looking wild enough himself, and announced, with many
apologies, that Miss Lund had suffered a temporary nervous breakdown.
Nick Carter had listened intently, now and then scanning the article which
described the affair.
“Too bad!” he commented soberly, when Ida had finished. “But haven’t
you any explanation, either? The paper doesn’t seem to have any—at least, it
doesn’t give any.”
A curious expression crossed Ida’s face.
“I had forgotten for the moment,” she replied. “I haven’t told you one of
the strangest things about it. In common with everybody else, I was so
engrossed in watching Helga Lund’s face that I didn’t have much time for
anything else. That is why there wasn’t a more general attempt to see whom
she was looking at. We wouldn’t ordinarily have been very curious, but she
held our gaze so compellingly. I did manage to tear my eyes away once,
though; but I wasn’t in a position to see—I was too far to one side. She
appeared to be looking at some one almost on a line with our box, but over
toward the other side of the theater. I turned my glasses in that direction for a
few moments and thought I located the person, a man, but, of course, I
couldn’t be sure. I could only see his profile, but his expression seemed to be
very set, and he was leaning forward a little, in a tense sort of way.”
Nick nodded, as if Ida’s words had confirmed some theory which he had
already formed.
“But what was so strange about him?” he prompted.
“Oh, it doesn’t mean anything, of course,” was the reply; “but he bore the
most startling resemblance to Doctor Hiram Grantley. If I hadn’t known that
Grantley was safe in Sing Sing for a long term of years, I’m afraid I would
have sworn that it was he.”
The detective gave Ida a keen, slightly startled look.
“Well, stranger things than that have happened in our experience,” he
commented thoughtfully. “I haven’t any reason to believe, though, that
Grantley is at large again. He would be quite capable of what you have
described, but surely Kennedy would have notified me before this if——”
The telephone had just rung, and, before Nick could finish his sentence,
Joseph, his butler, entered. His announcement caused a sensation. It was:
“Long distance, Mr. Carter. Warden Kennedy, of Sing Sing, wishes to
speak with you.”
 The detective got up quickly, without comment, and stepped out into the
hall, where the nearest instrument of the several in the house was located.
Patsy Garvan gave a low, expressive whisper.
“Suffering catfish!” he ejaculated. “It looks as if you were right, Ida!”
After that he relapsed into silence and listened, with the others. Nick had
evidently interrupted the warden.
“Just a moment, Kennedy,” they heard him saying. “I think I can guess
what you have to tell me. It’s Doctor Grantley who has escaped, isn’t it?”
Naturally, the warden’s reply was inaudible, but the detective’s next
words were sufficient confirmation.
“I thought so,” Nick said, in a significant tone. “One of my assistants was
just telling me of having seen, last night, a man who looked surprisingly like
him. When did you find out that he was missing?... As early as that?... I
see.... Yes, I’ll come up, if necessary, as soon as I can; but first I must set the
ball rolling here. I think we already have a clew. I’ll call you up later.... Yes,
certainly.... Yes, good-by!”
A moment later he returned to the dining room.
“Maybe your eyes didn’t deceive you, after all, Ida,” he announced
gravely. “Grantley escaped last night—in time to have reached the theater
for the third act of that special performance, if not earlier. And it looks as if
he subjected one of the keepers of the prison to an ordeal somewhat similar
to that which Helga Lund seems to have endured.”
 CHAPTER II.

ESCAPE BY SCHEDULE.

“What do you mean by that, chief?” demanded Chick.

“Kennedy says that one of the keepers was found, in a peculiar sort of
stupor, as he calls it, in Grantley’s cell, after the surgeon had gone. He had
evidently been overpowered in some way, and his keys had been taken from
him. Kennedy assumes, rightly enough, I suppose, that Grantley lured him
into the cell on some pretext, and then tried his tricks. The man is still
unconscious, and the prison physician can do nothing to help him. Kennedy
wants me to come up.”
“But I don’t see what that has to do with Helga Lund,” objected Chick.
“Even if it was Grantley that Ida saw—which remains to be proved—I don’t
see any similarity. He didn’t render her unconscious, and, anyway, he wasn’t
near enough to——”
“Think it over, Chick,” the detective interrupted. “The significance will
reach you, by slow freight, sooner or later, I’m sure. I, for one, haven’t any
doubt that Ida saw the fugitive last night. If so, Grantley did a very daring
thing to go there without any attempt at disguise—not as daring as might be
supposed, however. He doubtless counted on just what happened. If any one
who knew him by sight had noticed him in the theater, the supposition would
naturally be that it was a misleading resemblance, for the chances were that
any one who would be likely to know him would be aware of his conviction,
and be firmly convinced that he was up the river.
“There doesn’t seem to be any doubt that he disguised himself carefully
enough for his flight from Sing Sing, and covered his tracks with unusual
care, for Kennedy has been unable to obtain any reliable information about
his movements. If he was at the play, we may be sure that he restored his
normal appearance deliberately, in defiance of the risks involved, in order
that one person, at least, should recognize him without fail—that person
being Helga Lund. And that implies that he was again actuated primarily by
motives of private revenge, as in the case of Baldwin.
“The scoundrel seems to have a supply of enemies in reserve, and is
willing to go to any lengths in order to revenge himself upon them for real or
fancied grievances. If he’s the man who broke up Lund’s performance last
night, it is obvious that he knew of the special occasion and the unusual hour
before he made his escape. In fact, it seems probable that he escaped when
he did for the purpose of committing this latest outrage. Even if his chief
object has been attained, however, I don’t imagine he will return to Sing
Sing and give himself up. We shall have to get busy, and, perhaps, keep so
for some time. Plainly, the first thing for me to do is to seek an interview
with Helga Lund, if she is in a condition to receive me. She can tell, if she
will, who or what it was that caused her breakdown. If there turns out to be
no way of connecting it with Grantley, we shall have to begin our work at
Sing Sing. If it was Grantley, we shall begin here. Did you see anything
more of the man you noticed, Ida?”
“Nothing more worth mentioning. He slipped out quickly as soon as the
curtain went down; but lots of others were doing the same, although many
remained and exchanged excited conjectures. I left the box when I saw him
going, but by the time I reached the lobby he was nowhere in sight, and I
couldn’t find any one who had noticed him.”
“Too bad! Then there’s nothing to do but try to see Helga. The rest of you
had better hang around the house until you hear from me. Whatever the
outcome, I shall probably want you all on the jump before long.”
Nick hastily finished his breakfast, while his assistants read him snatches
from the accounts in the various morning newspapers. In that way he got the
gist of all that had been printed in explanation of the actress’ “attack” and in
regard to her later condition.
All of the accounts agreed in saying that Helga Lund was in seclusion at
her hotel, in a greatly overwrought state, and that two specialists and a nurse
were in attendance.
The prospect of a personal interview with her seemed exceedingly
remote; but Nick Carter meant to do his best, unless her condition absolutely
forbade.
* * * * * * *
Doctor Hiram A. Grantley was very well, if not favorably, known to the
detectives, in addition to thousands of others.
For a quarter of a century he had been famous as an exceptionally daring
and skillful surgeon. In recent years, however, his great reputation had
suffered from a blight, due to his general eccentricities, and, in particular, to
his many heartless experiments upon live animals.
At length, he had gone so far as to perform uncalledfor operations on
human beings in his ruthless search for knowledge.
Nick Carter had heard rumors of this, and had set a trap for Grantley. He
had caught the surgeon and several younger satellites red-handed.
Their victim at that time was a young Jewish girl, whose heart had been
cruelly lifted out of the chest cavity, without severing any of the arteries or
veins, despite the fact that the girl had sought treatment only for
consumption.
Grantley and his accomplices had been placed on trial, charged with
manslaughter. The case was a complicated one, and the jury disagreed. The
authorities subsequently released the prisoners in the belief that the chances
for a conviction were not bright enough to warrant the great expense of a
new trial.
Nevertheless, as a result of the agitation, a law was passed, which
attached a severe penalty to all such unjustifiable experiments or operations
on human beings.
After a few weeks of freedom, Grantley had committed a still more
atrocious crime. His victim in this instance had been one of the most
prominent financiers in New York, J. Hackley Baldwin, who had been
totally blind for years.
For years Grantley had been nursing two grievances against the afflicted
millionaire. Under pretense of operating on Baldwin’s eyes—after securing
the financier’s complete confidence—he had removed parts of his patient’s
brain.
Owing to Grantley’s great skill, the operation had not proved fatal; but
Baldwin became a hopeless imbecile.
Nick Carter and his assistants again captured the fugitive, who had fled
with his assistant, Doctor Siebold. This pair was locked up, together with a
nurse and Grantley’s German manservant, who were also involved.
To these four defendants, Nick presently added a fifth, in the person of
Felix Simmons, another famous financier, who had been a bitter rival of
Baldwin’s for years, and who was found to have aided and abetted the
rascally surgeon.
 It was a startling disclosure, and all of the prisoners were convicted under
the new law and sentenced to long terms of confinement.
That had been several months before; and now Doctor Grantley was at
large again, and under suspicion of having been guilty of some strange and
mysterious offense against the celebrated Swedish actress, who had never
before visited this country.
* * * * * * *
Nick had learned from the papers that Helga Lund was staying at the
Wentworth-Belding Hotel. Accordingly, he drove there in one of his motor
cars and sent a card up to her suite. On it he scribbled a request for a word
with one of the physicians or the nurse.
Doctor Lightfoot, a well-known New York physician, with a large
practice among theatrical people, received him in one of the rooms of the
actress’ suite.
He seemed surprised at the detective’s presence, but Nick quickly
explained matters to his satisfaction. Miss Lund, it seemed, was in a serious
condition. She had gone to pieces mentally, passed a sleepless night, most of
the time walking the floor, and appeared to be haunted by the conviction that
her career was at an end.
She declared that she would not mind so much if it had happened before
any ordinary audience, but as it was, she had made a spectacle of herself
before hundreds of the members of her own profession. That thought almost
crazed her, and she insisted wildly that she would never regain enough
confidence to appear in public again.
If that was the case, it was nothing short of a tragedy, in view of her great
gifts.
Doctor Lightfoot hoped, however, that she would ultimately recover from
the shock of her experience, although he stated that it would be months, at
least, before she was herself again. Meanwhile, all of her engagements
would have to be canceled, of course.
In response to Nick’s questions, the physician assured him that Helga
Lund had given no adequate explanation of her startling behavior of the
night before. She had simply said that she had recognized some one in the
audience, that the recognition had brought up painful memories, and that she
had completely forgotten her lines and talked at random. She did not know
what she had said or done.
 Her physicians realized that she was keeping something back, and had
pleaded with her to confide fully in them as a means of relieving her mind
from the weight that was so evidently pressing upon it. But she had refused
to do so, having declared that it would serve no good purpose, and that the
most they could do was to restore her shattered nerves.
The detective was not surprised at this attitude, which, as a matter of fact,
paved the way to an interview with the actress.
“In that case I think you will have reason to be glad I came,” he told
Doctor Lightfoot. “I believe I know, in general, what happened last night,
and if you will give me your permission to see Miss Lund alone for half an
hour, I have hope of being able to induce her to confide in me. My errand
does not reflect upon her in any way, nor does it imply the slightest danger
or embarrassment to her, so far as I am aware. My real interest lies
elsewhere, but you will readily understand how it might help her and
reënforce your efforts if I could induce her to unbosom herself.”
“There isn’t any doubt about that, Carter,” was the doctor’s reply; “but
it’s a risky business. She is in a highly excitable state, and uninvited calls
from men of your profession are not apt to be soothing, no matter what their
object may be. How do you know that some ghost of remorse is not haunting
her. If so, you would do much more harm than good.”
“If she saw the person I think she saw in the audience last night,” Nick
replied, “it’s ten to one that the remorse is on the other side—or ought to be.
If I am mistaken, a very few sentences will prove it, and I give you my word
that I shall do my best to quiet any fears my presence may have aroused, and
withdraw at once. On the other hand, if I am right, I can convince her that I
am her friend, and that I know enough to make it worth her while to shift as
much of her burden as possible to me. If she consents, the tension will be
removed at once, and she will be on the road to recovery. And, incidentally, I
shall have gained some very important information.”
The detective was prepared, if necessary, to be more explicit with Doctor
Lightfoot; but the latter, after looking Nick over thoughtfully for a few
moments, gave his consent.
“I’ve always understood that you always know what you are about,
Carter,” he said. “There is nothing of the blunderer or the brute about you, as
there is about almost all detectives. On the contrary, I am sure you are
capable of using a great deal of tact, aside from your warm sympathies. My
colleague isn’t here now, and I am taking a great responsibility on my
shoulders in giving you permission to see Miss Lund alone at such a time.
She is a great actress, remember, and, if it is possible, we must give her back
to the world with all of her splendid powers unimpaired. She is like a
musical instrument of incredible delicacy, so, for Heaven’s sake, don’t
handle her as if she were a hurdy-gurdy!”
“Trust me,” the famous detective said quietly.
“Then wait,” was the reply, and the physician hurried from the room.
Two or three minutes later he returned.
“Come,” he said. “I have prepared her—told her you are a specialist in
psychology, which is true, of course, in one sense. You can tell her the truth
later, if all goes well.”
 CHAPTER III.

THE ACTRESS CONFIDES.

Nick was led through a couple of sumptuously furnished rooms into the
great Swedish actress’ presence.
Helga Lund was a magnificently proportioned woman, well above
medium height, and about thirty years of age.
She wore a loose, filmy negligee of silk and lace, and its pale blue was
singularly becoming to her fair skin and golden hair. Two thick, heavy ropes
of the latter hung down far below her waist.
She was not merely pretty, but something infinitely better—she had the
rugged statuesque beauty of a goddess in face and form.
She was pacing the floor like a caged lioness when Nick entered. Her
head was thrown back and her hands were clasped across her forehead,
allowing the full sleeves to fall away from her perfectly formed, milk-white
arms.
“Miss Lund, this is Mr. Carter, of whom I spoke,” Doctor Lightfoot said
gently. “He believes he can help you. “I shall leave you with him, but I will
be within call.”
He withdrew softly and closed the door. They were alone.
The actress turned for the first time, and a pang shot through the tender-
hearted detective as he saw the tortured expression of her face.
She nodded absent-mindedly, but did not speak.
“Miss Lund,” the detective began, “I trust you will believe that I would
not have intruded at this time if I hadn’t believed that I might possibly
possess the key to last night’s unfortunate occurrence, and that——”
“You—the key? Impossible, sir?” the actress interrupted, in the precise
but rather labored English which she had acquired in a surprisingly short
time in anticipation of her American tour.
“We shall soon be able to tell,” Nick replied. “If I am wrong, I assure you
that I shall not trouble you any further. If I am right, however, I hope to be
able to help you. In any case, you may take it for granted that I am not trying
to pry into your affairs. I have seen you on the stage more than once, both
here and abroad. It is needless to say that I have the greatest admiration for
your genius. Beyond that I know nothing about you, except what I have
read.”
“Then, will you explain—briefly? You see that I am in no condition to
talk.”
“I see that talking, of the right kind, would be the best thing for you, if the
floodgates could be opened, Miss Lund,” Nick answered sympathetically. “I
shall do better than explain; with your permission, I shall ask you a
question.”
“What is it?”
“Simply this: Are you acquainted with a New York surgeon who goes by
the name of Doctor Grantley—Hiram A. Grantley?”
The actress, who had remained standing, started slightly at the detective’s
words. Her bosom rose and fell tumultuously, and her clenched hands were
raised to it, as Ida Jones had described them.
A look of mingled amazement and fright overspread her face.
Nick did not wait for her to reply, nor did he tell her that it was
unnecessary. Nevertheless, he had already received his answer and it gave
him the greatest satisfaction.
He was on the right track.
“Before you reply, let me say this,” he went on quickly, in order to
convince her that she had nothing to fear from him: “Grantley is one of the
worst criminals living, and it is solely because our laws are still inadequate
in certain ways that he is alive to-day. As it is, he is a fugitive, an escaped
prisoner, with a long term still to serve. He escaped last night, but he will
undoubtedly be caught soon, despite his undeniable cleverness, and returned
to the cell which awaits him. Now you may answer, if you please.”
He was, of course, unaware of the extent of Helga Lund’s knowledge of
Grantley. It might not be news to her, but he wished—in view of the actress’
evident fear of Grantley—to prove to her that he himself could not possibly
be there in the surgeon’s interest.
His purpose seemed to have been gained. Unless he was greatly mistaken,
a distinct relief mingled with the surprise which was stamped on Helga’s
face.
 “He is a—criminal, you say?” she breathed eagerly, leaning forward,
forgetful that she had not admitted any knowledge of Grantley at all.
“You do not know what has happened to Doctor Grantley here in the last
year?”
“No,” was the reply. “I have never been in America before, and I have
never even acted in England. I do not read the papers in English.”
“You met Grantley abroad, then, some years ago, perhaps?”
The actress realized that she had committed herself. She delayed for some
time before she replied, and when she did, it was with a graceful gesture of
surrender.
“I will tell you all there is to tell, Mr. Carter,” she said, “if you will give
me your word as a gentleman that the facts will not be communicated to the
newspapers until I give you permission. Will you? I think I have guessed
your profession, but I am sure I have correctly gauged your honor.”
“I promise you that no word will find its way, prematurely, into print
through me,” Nick declared readily. “I am a detective, as you seem to have
surmised, Miss Lund. I called on you, primarily, to get a clew to the
whereabouts of Doctor Grantley, but, as I told you, I am confident that it will
have a beneficial effect on you to relieve your mind and to be assured, in
return, that Grantley is a marked and hunted man, and that every effort will
be made to prevent him from molesting you any further.”
“Thank you, Mr. Carter,” the actress responded, throwing herself down
on a couch and tucking her feet under her.
The act suggested that her mental tension was already lessened to a
considerable degree.
“There is very little to tell,” she went on, after a slight pause, “and I
should certainly have confided in my physicians if I had seen any use in
doing so. It is nothing I need be ashamed of, I assure you. I did meet Doctor
Grantley—to my sorrow—five years ago, in Paris. He was touring Europe at
the time, and I was playing in the French capital. He was introduced to me as
a distinguished American surgeon, and at first I found him decidedly
interesting, despite—or, perhaps, because of—his eccentricities. Almost at
once, however, he began to pay violent court to me. He was much older than
I, and I could not think of him as a husband without a shudder. With all his
brilliancy, there was something sinister and cruel about him, even then. I
tried to dismiss him as gently as I knew how, but he would not admit defeat.