The little black book of pediatrics

The Little Black Book of

Pediatrics
Series Editor: Daniel K. Onion

Chiedza G. Jokonya, MD, MRCPCH
Maine Dartmouth Family Medicine
Residency Program
Augusta, Maine

Sydney R. Sewall, MD, MPH
Kennebec Pediatrics
Augusta, Maine


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book may not be applicable to all people; likewise, some people may require a dose or experience a side effect that
is not described herein. Drugs and medical devices are discussed that may have limited availability controlled
by the Food and Drug Administration (FDA) for use only in a research study or clinical trial. Research, clinical
practice, and government regulations often change the accepted standard in this field. When consideration is
being given to use of any drug in the clinical setting, the healthcare provider or reader is responsible for determining FDA status of the drug, reading the package insert, and reviewing prescribing information for the most
up-to-date recommendations on dose, precautions, and contraindications, and determining the appropriate usage
for the product. This is especially important in the case of drugs that are new or seldom used.
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Library of Congress Cataloging-in-Publication Data
Jokonya, Chiedza G.
The little black book of pediatrics / Chiedza G. Jokonya, Sydney R. Sewall.
p.; cm. — (Little black book series)
Includes bibliographical references and index.
ISBN-13: 978-0-7637-5446-4 (pbk.)
ISBN-10: 0-7637-5446-3 (pbk.)
1. Pediatrics—Handbooks, manuals, etc. I. Sewall, Sydney R. II.
Title. III. Series: Little black book series.
[DNLM: 1. Pediatrics—Handbooks. WS 39]
RJ48.J595 2012
618.92—dc22
2010050877
6048
Printed in the United States of America
15 14 13 12 11
10 9 8 7 6 5 4 3 2 1


Dedication

This book is dedicated to my father, Tichaona Joseph Jokonya
(1933–2006), and my mother, Winifrieda Jokonya. Their love,
guidance, and nurturing made me the person I am today.
—CGJ
To Joan Marson, RN, Case Manager at MaineGeneral Health,
whose dedication to her many animals is only exceeded by her
caring efforts toward helping our most needy patients.
—SRS


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Contents
Preface
Medical Abbreviations
Journal Abbreviations
Notice

Chapter 1 Emergency
Pediatrics
1.1
1.2
1.3
1.4
1.5

Acute Life-Threatening
Event
Altered Mental Status

Intravenous Fluids
Diabetic Ketoacidosis
Status Asthmaticus

Chapter 2 Neonatology
2.1
2.2
2.3
2.4
2.5
2.6
2.7
2.8
2.9
2.10
2.11
2.12

Neonatal Resuscitation
Sepsis
Newborn Discharge Exam
Meconium Aspiration
Syndrome
Transient Tachypnea of the
Newborn
Neonatal Hypoglycemia
Unconjugated
Hyperbilirubinemia
Conjugated
Hyperbilirubinemia

Cyanotic Newborn
Newborn Metabolic Screen
Hearing Screen
Brachial Plexus Injury

ix
xi
xvii
xxi

1
1
3
5
8
10

13
13
14
17
18
20
22
24
27
29
31
32
35

2.13
2.14
2.15
2.16
2.17
2.18
2.19
2.20

Developmental Dysplasia
of the Hip
Testicular Torsion
Undescended Testes
(Cryptorchidism)
Inguinal Hernia
Hydrocele
Hypospadias
Circumcision
Cleft Lip and Palate

Chapter 3 Pulmonology
3.1
3.2
3.3
3.4
3.5
3.6
3.7
3.8

Wheezing in Toddlers
Asthma
Cystic Fibrosis
Pneumonia
Bronchiolitis
Allergic Rhinitis
Croup
Tuberculosis

37
38
40
41
42
43
44
45

47
47
48
56
58
60
62
64
66

Chapter 4 Infectious Diseases 69

4.1
4.2
4.3
4.4
4.5
4.6
4.7
4.8

Fever Without a Source
Cat Scratch Disease
Acute Otitis Media
Otitis Media with Effusion
Streptococcus Pharyngitis
Epiglottitis
Peritonsillar Abscess
Methicillin-Resistant
Staphylococcus Aureus

69
71
73
75
76
77
78
80

v

4.9
4.10
4.11
4.12
4.13
4.14
4.15
4.16
4.17

4.18

Cytomegalovirus Infection
Human Immunodeficiency
Virus
Lyme Disease
Urinary Tract Infection
Cervical Adenitis
Gastroenteritis
Ehrlichiosis
Rocky Mountain
Spotted Fever
Pediatric Autoimmune
Neuropsychiatric Disorders
Associated with
Streptococcus Infections
Infantile Botulism

Chapter 5 Gastroenterology

5.1
5.2
5.3
5.4
5.5
5.6
5.7
5.8
5.9
5.10
5.11
5.12
5.13

Encopresis
Pyloric Stenosis
Gluten Enteropathy: Celiac
Disease
Milk Protein Sensitivity
Food Allergies
Diarrhea
Inflammatory Bowel
Disease
Chronic Hepatitis
Viral Hepatitis
Pancreatitis
Gastroesophageal
Reflux
Recurrent Abdominal
Pain

Acute Abdomen

Chapter 6 Nephrology
6.1
6.2

vi

Nephrotic Syndrome
Renal Tubular Acidosis

Contents

82
84
86
88
90
91
93

6.3

6.4
6.5
6.6
6.7
6.8

Lowe Syndrome

(Oculocerebrorenal
Syndrome)
Congenital Hypokalemic
Alkalosis
Glomerular Disease
Enuresis
Proteinuria
Hematuria

140
141
143
152
155
156

94

Chapter 7 Hematology
and Oncology
95
97

99
99
101
102
104
105
108

110
115
116
122
124
126
127

7.1
7.2
7.3
7.4
7.5
7.6
7.7
7.8
7.9
7.10
7.11

Anemia
Neutropenia
Sickle Cell Disease
Neuroblastoma
Wilm’s Tumor
(Nephroblastoma)
Leukemia
Hemophilia
Von Willebrand
Disease

Lymphoma
Bone Tumors
Brain Tumors

Chapter 8 Neurology
8.1
8.2
8.3
8.4
8.5

133

8.6

133
137

8.7

Duchenne Muscular
Dystrophy
Cerebral Palsy
Headaches
Childhood Periodic
Syndromes
Benign Paroxysmal
Vertigo
Benign Paroxysmal
Torticollis

Guillain-Barré Syndrome

159
159
164
166
169
171
173
176
178
180
183
186

189
189
191
193
195
198
199
200


8.8
8.9
8.10
8.11

Seizures
Port Wine Stains
Acute Disseminated
Encephalomyelitis
Restless Legs Syndrome

Chapter 9 Endocrinology
9.1
9.2
9.3
9.4
9.5
9.6
9.7
9.8
9.9
9.10
9.11
9.12
9.13

Precocious Puberty
Pubertal Delay
Short Stature
Tall Stature
Abnormal Head Growth
Hypothyroidism
Hyperthyroidism
Hypoglycemia
Obesity

Adrenal Insufficiency
Diabetes Mellitus
Type 1
Diabetes Mellitus
Type 2 in Childhood
Calcium Metabolism
Disorders

Chapter 10 Adolescence
10.1
10.2
10.3
10.4
10.5

Polycystic Ovary
Syndrome
Menstrual Disorders
Infectious
Mononucleosis
Pelvic Inflammatory
Disease
Eating Disorders

Chapter 11 Cardiology
11.1
11.2
11.3

Heart Murmurs

Cardiac Arrhythmias
Syncope

202
204
206
207

211
211
214
217
219
220
221
225
226
227
230

11.4

Hypertension

258

Chapter 12 Rheumatology
12.1
12.2
12.3

Juvenile Idiopathic
Arthritis
Systemic Lupus
Erythematosus
Acute Rheumatic Fever

Chapter 13 Psychiatric
Conditions
13.1

261
261
264
267

269

Attention Deficit
Hyperactivity Disorder
Anxiety
Depression
Tourette Syndrome
Autism Spectrum
Disorder
Sleep Disorders

278
281

Chapter 14 Dermatology

285

13.2
13.3
13.4
13.5

231
13.6

269
272
274
277

233
235

239
239
240

14.1
14.2
14.3
14.4

253

14.5
14.6
14.7
14.8
14.9
14.10
14.11

253
254
257

14.12
14.13

246
247
250

Eczema
Viral Exanthems
Acne
Kawasaki Disease
(Mucocutaneous Lymph
Node Syndrome)
Diaper Dermatitis
Pityriasis Rosea
Urticaria
Scabies

Tinea
Alopecia Areata
Other Causes of Hair
Loss
Malignant Melanoma
Head Lice

Contents

285
287
289

290
292
293
295
296
298
299
300
300
302

vii


Chapter 15 General Topics
15.1
15.2

15.3
15.4
15.5
15.6
15.7
15.8

Abuse
The Limping Child
Lipid Screening
Ingestion
Lead Poisoning
Colic
Labial Adhesions
(Synechia Vilvae)
Amblyopia and
Strabismus (Squint)

Chapter 16 Genetics
16.1
16.2
16.3

Tuberous Sclerosis
Complex
Neurofibromatosis Type 1
Neurofibromatosis Type 2

viii

Contents

305
305
308
310
312
315
317
319
320

325
325
327
329

16.4
16.5
16.6
16.7
16.8
16.9
16.10

Down Syndrome
Turner Syndrome
Williams Syndrome
Klinefelter Syndrome
Marfan Syndrome

Fetal Alcohol Syndrome
Velocardiofacial
Syndrome
16.11 Friedreich Ataxia
16.12 Spina Bifida

Chapter 17 Childhood
Immunizations

330
332
333
335
336
337
338
339
340

343

Chapter 18 Growth Charts 355
Index

369


Preface
Syd Sewell and I were asked by Dan Onion to contribute to a
pediatric edition of the Little Black Book (LBB) series. Our book

generally follows the format of the LBB series, with the goal
of providing an overview of common topics in pediatrics with
embedded references that support the text and discussing controversies or current research into new management modalities. Our
target audiences are physicians in general, as well as pediatricians
and primary care clinicians in training.
I’d like to express my thanks to Dan Onion, who acted as a
mentor through the process of writing this book and for his valuable advice in reviewing the book for me. I’d also like to thank
Karen Gershman and Misha Lazerow, who also helped review
chapters of the book.
Chiedza G. Jokonya

ix


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Medical Abbreviations

×
␮g

times
microgram

AAP

American Academy of
Pediatrics
airway, breathing,

circulation in
resuscitation
allergic bronchopulmonary aspergillosis
angiotensin-converting
enzyme inhibitor
antidiuretic hormone
attention deficit hyperactivity disorder
acid-fast bacilli
acquired immune
deficiency syndrome
acute lymphoblastic
leukemia
alanine transferase
acute myeloblastic
leukemia
altered mental status
antinuclear antibody
acute otitis media
anteroposterior Xray
ascending reticular
activating system

ABCs

ABPA
ACEI
ADH
ADHD
AFB
AIDS

ALL
ALT
AML
AMS
ANA
AOM
AP
ARAS

ARM
ART
ASA
AST
ATN
AVN

anorectal manometry
antiretroviral therapy
aminosalicylic acid
aspartate transferase
acute tubular necrosis
atrioventricular node

BCG

Bacille CalmetteGuérin
blood glucose level
body mass index
bone marrow
transplant

blood pressure
bleeding time
blood urea nitrogen

BGL
BMI
BMT
BP
BT
BUN
CAH
cAMP
CBC
CBC/D
CD
CDC

CF

congenital adrenal
hyperplasia
cyclic adenosine
monophosphate
complete blood count
complete blood count/
differential
Crohn’s disease
Centers for
Disease Control and
Prevention

cystic fibrosis

xi


CFTR

cystic fibrosis transmembrane conductance regulator
(gene)
congestive heart failure
chloride
cytomegalovirus
central nervous system
creatinine
phosphokinase
C-reactive protein
cerebrospinal fluid
computerized
tomography
chest Xray

CHF
Cl
CMV
CNS
CPK
CRP
CSF
CT
CXR

ERCP

ESR
ESRD
ETEC

FDA
FHT
FSGS
FSH

d
DIC

day(s)
disseminated intravascular coagulation
distal interphalangeal
diabetes ketoacidosis
diabetes mellitus
Duchenne muscular
dystrophy
dysfunctional uterine
bleeding
diagnosis

DIP
DKA
DM
DMD

DUB
dx
EBV
EEG
EKG
ELISA
EMG
ENT

xii

Epstein-Barr virus
electroencephalogram
electrocardiogram
enzyme-linked immunosorbent assay
electromyelogram
ear nose and throat

Medical Abbreviations

FTT
GBM
GBS
GC
GERD
GFR
GH
gi
GN
GU

HϩP
HAART

endoscopic retrograde
cholangiopancreatography
erythrocyte sedimentation rate
end-stage renal disease
enterotoxigenic
Escherichia coli
Food and Drug
Administration
fetal heart tones/
tracing
focal segmental
glomerulosclerosis
follicle-stimulating
hormone
failure to thrive
glomerular basement
membrane
Guillain-Barré
syndrome
Neisseria gonorrhoeae
gastroesophageal reflux
disease
glomerular filtration
rate
growth hormone
gastrointestinal
glomerulonephritis

genitourinary
history and physical
highly active antiretroviral therapy


hb/hgb
HbA1c
HCO3
HIV
HPV
HR
hr
hx
I&D
I&O
IBD
ICU
IDA
IDDM
Ig
IL
im
IRT
IU
IUGR
IV
IVDU
IVIG
IVP

hemoglobin
glycosylated hemoglobin (major fraction)
bicarbonate
human immunodeficiency virus
human papillomavirus
heart rate
hour(s)
history
incision and drainage
intake and output
inflammatory bowel
disease
intensive care unit
iron deficiency anemia
infant of diabetic
mother
immunoglobulin
interleukin
intramuscular
immunoreactive
trypsinogen
international unit
intrauterine growth
restriction
intravenous
IV drug user
IV immunoglobulin
intravenous pyelogram

kg

KOH

kilogram
potassium hydroxide

L
LBW
LDH
LDL
LFT
LH
LLQ
LP
LV

liter
low birthweight
lactate dehydrogenase
low-density lipoprotein
liver function test
luteinizing hormone
left lower quadrant
lumbar puncture
left ventricle

M:F
MCGN

male-to-female ratio
minimal change

glomerulonephritis
micturating
cystourethrogram
mean cell volume
milligram
magnesium sulphate
milliliter
measles, mumps,
rubella
mental retardation
magnetic resonance
imaging
methicillin-resistant
Staphylococcus aureus
mother-to-child
transmission

MCUG
MCV
mg
MgSO4
mL
MMR
MR
MRI
MRSA
MTCT

JIA

juvenile idiopathic
arthritis

Na
NBICU

Kϩ

potassium

NG

sodium
newborn intensive care
unit
nasogastric

Medical Abbreviations

xiii


NGT
NPO
NS
NSAID

nasogastric tube
nothing by mouth
normal saline

nonsteroidal antiinflammatory drug

OME

otitis media with
effusion
oral rehydration
solution
oral rehydration
therapy
over the counter

ORS
ORT
OTC
PBS
PCOS
PCP
PCR
PICU
PID
po
PPD
PPI
PSGN
pt
PT
PTH
PTSD
PTT

xiv

peripheral blood smear
polycystic ovary
syndrome
Pneumocystis carinii
polymerase chain
reaction
pediatric intensive care
unit
pelvic inflammatory
disease
per os; orally
purified protein
derivative
protein pump inhibitor
poststreptococcal
glomerulonephritis
patient
ProTime
parathyroid hormone
posttraumatic stress
disorder
partial thromboplastin
time

Medical Abbreviations

PUD

PWS

peptic ulcer disease
port wine stain

q

every

r/o
rbc
RLQ
RLS
RMSF

rule out
red blood cell
right lower quadrant
restless leg syndrome
Rocky Mountain spotted fever
radionucleotide
cystogram
rectal suction biopsy
respiratory syncytial
virus
renal tubular acidosis
right upper quadrant
right ventricle
treatment

RNC
RSB
RSV
RTA
RUQ
RV
rx
SϩS
sc
SCD
SHBG
si
SLE
SLIT
SMA
SOB
SSRI

signs and symptoms
subcutaneous
sickle cell disease
sex hormone-binding
globulin
signs
systemic lupus
erythematosus
sublingual
immunotherapy
spinal muscular
atrophy

short of breath
selective serotonin
reuptake inhibitor


SSSS
STI
sx

staphylococcus scalded
skin syndrome
sexually transmitted
infection
symptoms

UA
UC
UGI
URI
UTI

TB
TDD
TGV
TLC
TMJ
TPN
TSH
TSI
TSS

tuberculosis
total daily dose
transposition of the
great vessels
therapeutic lifestyle
change
temporomandibular
joint
total parenteral
nutrition
thyroid-stimulating
hormone
thyroid-stimulating
immunoglobulin
toxic shock syndrome

VCUG
VDRL

WCC
WHO

urinalysis
ulcerative colitis
upper gastrointestinal
upper respiratory
(tract) infection
urinary tract infection
voiding

cystourethrogram
Venereal Disease
Research Laboratory

wt

white blood cell count
World Health
Organization
week
Wolff-ParkinsonWhite syndrome
weight

yr

year(s)

wk
WPW

Medical Abbreviations

xv


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Journal Abbreviations

Acad Emerg Med
Am Fam Phys
Am J Clin Nutr
Am J Hum Genet
Am J Med Genet
Am J Obstet Gynecol
Am J Respir Crit Care Med
Am J Surg
Ann Emerg Med
Ann Intern Med
Ann NY Acad Sci
Arch Dermatol
Arch Dis Child
Arch Pediatr Adolesc Med

Academic Emergency Medicine
American Family Physician
American Journal of Clinical Nutrition
American Journal of Human Genetics
American Journal of Medical Genetics
American Journal of Obstetrics and
Gynecology
American Journal of Respiratory
and Critical Care Medicine
American Journal of Surgery
Annals of Emergency Medicine
Annals of Internal Medicine
Annals of the New York Academy
of Sciences
Archives of Dermatology

Archives of Diseases of Childhood
Archives of Pediatric Adolescent
Medicine

Brain Dev

Brain Development

Cancer
Circulation
Clin Infect Dis
Clin J Sport Med
Clin Pediatr
Cochrane Database Syst Rev
Crit Care Med

Cancer
Circulation
Clinical Infectious Diseases
Clinical Journal of Sports Medicine
Clinical Pediatrics
Cochrane Database of Systemic Reviews
Critical Care Medicine

xvii


Dermatol Clin
Diabet Med
Diabetes Care

Dermatology Clinic
Diabetes Medicine
Diabetes Care

Emerg Med J
Eur J Pediatr

Emergency Medicine Journal
European Journal of Pediatrics

J Am Acad Dermatol

Journal of the American Academy
of Dermatology
Journal of the American Society
of Nephrology
Journal of Clinical Endocrinology and
Metabolism
Journal of Clinical Oncology
Journal of Infectious Diseases
Journal of Pediatrics
Journal of Pediatric Endocrinology
and Metabolism
Journal of Pediatric Gastroenterology
and Nutrition
Journal of Pediatric Hematology
and Oncology
Journal of Rheumatology
Journal of Urology

Journal of Vascular Surgery
Journal of the American Medical
Association

J Am Soc Nephrol
J Clin Endocrinol Metab
J Clin Oncol
J Infect Dis
J Pediatr
J Pediatr Endocrinol Metab
J Pediatr Gastroenterol Nutr
J Pediatr Hematol Oncol
J Rheumatol
J Urol
J Vasc Surg
JAMA

Lancet

Lancet

Med Pediatr Oncol

Medical and Pediatric Oncology

N Engl J Med

New England Journal of Medicine

Pediatr Dermatol

Pediatr Infect Dis J

Pediatric Dermatology
The Pediatric Infectious Disease Journal

xviii

Journal Abbreviations


Pediatr J Neurol
Pediatr Rev
Pediatrics
Postgrad Med J

Pediatric Journal of Neurology
Pediatrics in Review
Pediatrics
Postgraduate Medicine Journal

Sleep Med
Soc Sci Med

Sleep Medicine
Social Science & Medicine

Journal Abbreviations

xix

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Notice
We have made every attempt to summarize accurately and
concisely a multitude of references. However, we must remind our readers that times and medical knowledge change,
transcription errors are always possible, and crucial details are
necessarily omitted whenever such a comprehensive distillation
is attempted in a limited space. And the primary purpose of this
compilation is to cite literature on various sides of controversial
issues, knowing that where “truth” lies is usually difficult to
discern. Thus, we cannot guarantee that every bit of information is absolutely accurate or complete. Readers should affirm
that cited recommendations are still reasonable by reading the
original articles and checking other sources, including local
consultants as well as recent literature, before applying them.
Drugs and medical devices are discussed that may have
limited availability, controlled by the Food and Drug Administration (FDA) for use only in research study or clinical trials.
The drug information presented has been derived from reference sources, recently published data, and pharmaceutical tests.
Research, clinical practice, and government regulations often
change the accepted standard in this field. When consideration
is given to the use of any drug in the clinical setting, the clinician or reader is responsible for determining the FDA status of
the drug; reading the package insert and prescribing information for the most up-to-date recommendations on dose, precautions, and contraindications; and determining the appropriate
use for the product. This is especially important in the case of
drugs that are new or seldom used.

xxi


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EMERGENCY PEDIATRICS

Chapter 1

Emergency Pediatrics
Acute Life-Threatening Event

EMERGENCY PEDIATRICS

1.1

General Ref
• Pediatr Rev 2007;28

Cause
• Multifactorial
• Previously “apnea” or “near-miss sudden infant death syndrome (SIDS)”

EMERGENCY PEDIATRICS

Epidem
• Separate entity from true SIDS (Pediatrics 2003;111:914).
• Estimated 2.46 per 1000 white births (AAP Grand Rounds
2005;13:55).
• Many cases represent benign events with overreaction by
caretaker.
• Over half remain idiopathic after complete workup
(Pediatr Rev 2002;23).

EMERGENCY PEDIATRICS

S؉S
• Infant “not breathing” or “choking” with breathing, color
change, decreased muscle tone.
• Sx can be first sign of respiratory syncytial virus (RSV) or
systemic bacterial infection, but more commonly infant appears well on presentation; can be symptom of Munchausen
by proxy or abuse.
1.1

Acute Life-Threatening Event

1


Lab
• Directed by HϩP, such as RSV or pertussis testing
• In “occult” cases, no single test adds much information.
• If admitted for observation and monitoring, get CBC/D,
electrolytes, UA, culture.
• Septic appearance warrants blood culture and lumbar
puncture (LP).
• Unrecognized inborn errors of metabolism are extremely
rare, but consider if infant acidotic without explanation or
unusual family hx.
• EKG for QT.
• Covert video screening applied in extreme circumstances.

Xray

• Chest Xray; consider barium swallow (and/or pH probe if
available).
• Consider child abuse; some recommend CNS imaging for all
(AAP Grand Rounds 2004;11:3) unless alternative dx obvious.

Rx
• Home monitoring not recommended (AAP, 2003)
• Rx triggering condition.
• Association with gastroesophageal reflux (GER) is controversial, but use H2 blockers if suspected.
• Discontinue smoking; reinforce “back to sleep.”
• Having parents know basic life support may give them
confidence.

Commentary
• First determine if infant is “sick” or “well,” and treat sick
infants emergently.
• If infant appears fine, usual course is admission for observation.
• Set parameters on any monitor to avoid frequent false alarms.
• Period of observation is the most helpful “test.”
2

Chapter 1: Emergency Pediatrics