I’ve been busy, as you might imagine, with work, study, and applying for medical residency. However, I thought it was about time to get people up to date with some of the clerkships I’ve finished in the meantime before letting you guys in on some of the decision-making processes involved in choosing a residency.

So, time to talk about pediatrics. Pediatrics, despite a reputation for warmth and fuzziness, is a challenging field. Kids aren’t just little adults, and the treatment and diseases of infants are different than those of toddlers, which are different from pre-adolescents, which are different from the problems of teenagers and young adults. It’s an intense mixture of preventative medicine, diagnostics, and a lot of the intangible skills involved in getting the necessary information out of uncooperative patients and distressed parents. One also has to remember that a pediatrician has to spot the rare very sick kid in a field of sniffles, coughs, and possibly malingering youngsters who just want out of school. It’s a helluva a field of medicine, and if anything it has made me more passionate about educating against anti-vaxxers and quacks. For one pediatrics is critically dependent on prevention – which the anti-vax movement seeks to undermine with potentially dangerous consequences. For another, many of the diseases of childhood when they do occur are serious – but imminently treatable if recognized. The idea of a quack tinkering in this field without proper respect for the enormous amount of medicine involved, and potential for harm, is terrifying.

So let’s talk about a set of pediatric cases and just to piss off the gun nuts, why it’s a good thing that pediatricians screen for guns in homes.

Let’s emphasize the differences between medicine in different age groups. Because it’s pediatrics the past medical history is easy – they have none. Here are two cases, details altered, but both real patients I saw almost at the exact same time.

Patient #1: A 2.5-year-old male presents to the ED because her mom is concerned he is “puffy”. She sought care in a PCP’s office 6 days ago who initially treated him for a potential allergic reaction with Benadryl and advised her to return if he did not get better. The child has had no illnesses except for a cold 2 weeks ago, has met developmental milestones and is fully immunized. Mom has lost confidence in her PCP and now presents to UVA, very worried. On physical exam the child appears to be alert, awake, in no acute distress, with completely normal physical exam except for puffiness – non-pitting edema in the extremities and face.

Should we be concerned? What tests would you order in this patient?

Patient #2: A 14.5 year old male presents to the ED with a camp counselor with complaint of fainting during band practice (it’s summer and it’s hot). For the last week he has felt unwell, but has been continuing to go to practice and participating in activities. He has had no other illnesses, is fully vaccinated and has a normal physical exam. He has no other complaints except his eyes are “puffy”.

Should we be concerned? What tests would you order in this patient?

First let’s talk about what the majority of pediatrics is about – prevention. And the main thing you have to remember is that, thanks to vaccines, the majority of serious threats to health in children involve trauma and accidents. Starting from the first day of life, pediatrics begins with parent education about child safety. No parent should leave the hospital these days without being advised about the SIDS back to sleep campaign (kids sleep on their backs, in a crib, without soft bedding pillows or toys, always), and car seats which should be in the back seat, and rear-facing for the first year of life and until the child is at least 20 lbs. There are about 40 or 50 other items of importance that we usually go over and send the parents home with in a small book. Every kid also gets set up with a pediatrician who will continue the process of screening, marking developmental and growth milestones, and making sure every kid is up to date with immunizations.

With each well-child visit, new risks are screened for, and trauma and accidents are always at the top of the list – although the potential risks are different at different ages. Starting from avoiding dangerous items within reach of cruising youngsters, to proper safety equipment for bikes and sports, prevention of avoidable accidents is one of the primary responsibilities of the pediatrician. And yes, this includes, and should include, screening for guns in the home. In a landmark study in 2001, Jackman et. al found that of 8-12 year old kids who found a gun most will handle it and about half will pick it up and pull the trigger. Most parents underestimate the stupidity of children in their response to guns.

This is exactly why prevention is important, and gun nut paranoia about the grand pediatrician conspiracy against guns is misplaced. Your job as a parent raising a kid is to protect them from danger, and that includes locking up poisons, medicines, and guns. Kids are dumb, and accidents represent the greatest threat to their health. Car accidents, bike accidents, accidents in the home, accidental poisonings, gun accidents etc. Pediatricians screen for safety practices for all of these things and guns should be no exception. If you are the parent of a child with guns in the home, they should be made inaccessible to your child/locked up or preferably removed from the home as statistically they are a greater danger to your children than some imaginary criminal. Child use of guns – hunting trips, sharpshooting, whatever – should be age appropriate and always with close adult supervision – if only to avoid being shot in the ass by your own son. Granted, many pediatricians would love to see guns banned forever, they tend to be a liberal bunch, but don’t fear the gun safety screening. It is sensible and necessary because parents just don’t get how stupid kids are about guns. This really should be non-controversial.

Now, back to our cases. What causes fluid to leave the intravascular space and go into peripheral tissues? Or more appropriately, what keeps all that water in the bloodstream and not in the cells? In the first case puffiness all over is very concerning because it indicates that the child doesn’t have adequate amounts of protein in his blood to keep the fluid where it belongs. This case is serious because there tends to be three causes for inadequate protein in a kid this age. Inadequate production (liver failure, nutrition), loss through the kidneys, or loss through the gut. All three indicate a potentially dangerous pathology and needs to be worked up. Be concerned for the young child with generalized puffiness, it may be a simple allergic reaction but it also could be glomerulonephritis of several origins, Henoch-Schonlein Purpura, protein-losing enteropathy, severe malnutrition (Kwashiokor, liver disease etc. It gets a huge work up, and pretty much any test you named would have been a good choice. In this case it was loss through the gut – a post-infectious wasting of protein through the digestive tract that will likely resolve with supportive treatment. This is one of those cases that I would be terrified would land in the hands of an quack (and hopefully most quacks wouldn’t touch with a ten foot pole since they only really want to treat healthy people or stable illness).

Now for case number two, this one is actually pretty simple. Two or three tests would work in this case and you only really need to order one. Give me your suggestions in the comments.


  1. The Blind Watchmaker

    The patient in #2 is apparently a previously healthy teenage boy with syncope and periorbital edema. The physical exam is normal This presumably means that the cardiac exam reveals normal rate, normal valve sounds, no murmurs, and no “fixed split S2” sound (i.e. likely no atrial septal defect).

    In this instance, the first tests would be an EKG and a UA. The EKG is to look for delta waves to rule out Wolf-Parkinson-White syndrome. The UA would tell allot about level of dehydration, diabetes, or protein losing nephropathies.

    If these were normal, I still likely would get a TSH as hypothyroidism can cause syncope and periorbital edema. A CBC would be nice too, but likely would be normal.

    Now about the guns. I used to ask about guns in the house along with the list of other safety measures. I now use blanket advice about gun safety instead of asking the parents directly about it. One father became so incensed about my questions and was sure that the government was using me to get gun information. Others refused to answer.

    Many of the safety issues can be tactfully enforced without seeming confrontational. Remind families to put their babies to sleep on their backs, to use smoke and carbon monoxide detectors, to keep the water heater at 120 degrees or less, to use toddler gates and outlet covers, to practice stove safety, to use the car-seat and booster seats properly, and yes – to practice gun safety.

    These recommendations should be spread out over the visits as they become relevant to the child’s age.

  2. EKG normal
    CBC not normal. For some reason you added a diff and it came back with many atypical lymphs.

  3. For some reason you added a diff

    Maybe because a cbc without a diff is practically useless unless all you care about is the hgb or maybe the platelets (and even then you can miss a lot if you don’t know what the WBC are up to.)

  4. So how about the first kid? What do his basic labs show? in particular, how do his BUN/Cr, albumin, and CBC/diff look?

  5. Our local City Park hosted a fire and gun safety presentation where the presenters dressed in authentic Wild West gear. It was fun! But more importantly, they gave out FREE gunlocks to all the kids (more than one if the kids knew their parents had multiple weapons).

    My boy was so overwhelmed by the noise the guns made when fired (blanks only) that I doubt he will want to go near one any time soon!

  6. Dr. Hoofnagle,

    All infants should be put to sleep on the backs to prevent SIDS?

    Do you know anything at all about the SIDS statistics being useles? Of course not.

    Do you know anything about the unintended negative consequeneces of back sleep for infants? Social Skills Delays, Motor Skills Delays, Plagiocephaly, Torticollis, Strabismus? Of course not.


  7. Oh…I forgot to add:

    Keep on Drinking the SIDS “Back to Sleep” Kool-Aid. It’s much easier than doing critical thinking and challenging yourself to see if the SIDS “Back to Sleep” campaign is really safe.

    You don’t believe me? Ask Dr. Kattwinkel, the head of the CDC SIDS Task Force, if he thinks the SIDS Statistics are correct or if it is all just “Code Shifting”? Check out what he said to Bowman and Hargrove of Scripps News Service because his answer there was “We don’t know”.

    But, please keep on giving parents the THALIDOMIDE advice..ummm…sorry I meant the SIDS “Feel Good” Back to Sleep advice.

    All the Best with the Propaganda!


  8. Wow. SIDS denialism. That is wonderful.

    I don’t know what this guy’s beef is but for those of you who want to know the truth, the back to sleep campaign is responsible for a 50% reduction in SIDS deaths since it was implemented. Do not listen to this guy.

    It is also good to give kids face time – while awake and observed by and adult. They do, after all, need to develop the muscles to lift their heads up eventually. But for sleeping the data could not be more clear. Kids sleep on their backs, away from soft bedding and toys, and not in bed with mom and dad. This has had a remarkable change in the rate of SIDS and is one of the better public health interventions I can think of.

  9. The Blind Watchmaker

    Yes. Back sleeping is associated with less SIDS. I’m sorry that you do not agree.

    BTW, check a monospot in the teenager.

  10. The blind watchmaker wins. This is indeed mono.

    Tv first kid has normal renal function tests and liver function tests. Endoscopy demonstrated recent cmv infection as a cause of post viral protein loss through the to tract.

  11. The Blind Watchmaker

    Plagiocephaly and torticolis are problems associated with back sleeping. Tom is correct. However, the risk in SIDS appears very real. However, here is a statement that is interesting.

    Oct. 10, 2005 — The American Academy of Pediatrics (AAP) has updated its position statement on sudden infant death syndrome (SIDS), providing new recommendations for further reducing the incidence. The updated guidelines appear in the Oct. 10 Early Release issue of Pediatrics.

    “Since the AAP published its last statement on SIDS in 2000, several issues have become relevant, including the significant risk of side sleeping position; the AAP no longer recognizes side sleeping as a reasonable alternative to fully supine sleeping,” write John Kattwinkel, MD, and colleagues from the AAP Task Force on SIDS. “The AAP also stresses the need to avoid redundant soft bedding and soft objects in the infant’s sleeping environment, the hazards of adults sleeping with an infant in the same bed, the SIDS risk reduction associated with having infants sleep in the same room as adults and with using pacifiers at the time of sleep, the importance of educating secondary caregivers and neonatology practitioners on the importance of ‘back to sleep,’ and strategies to reduce the incidence of positional plagiocephaly associated with supine positioning.”

  12. Can someone please tell me again about the 50% reduction after reading this:

    SIDS deaths in the U.S. decreased from 4,895 in 1992 to 2,247 in 2004. But, during a similar time period, 1989 to 2004, SIDS being listed as the cause of death for sudden infant death (SID) decreased from 80% to 55%. According to Dr. John Kattwinkel, chairman of the Center for Disease Control (CDC) Special Task Force on SIDS “A lot of us are concerned that the rate (of SIDS) isn’t decreasing significantly, but that a lot of it is just code shifting”.

    Are you so sure now?

    I give up though. The propagandists win! Good luck in 20 years when we find out that the SIDS Back to Sleep Campaign was this eras thalidomide. Good Luck Spreading Propaganda. Of course, cratchety old grand-mothers and such still think putting babies to sleep on their stomach is good so based on the Kool-Aid way of thinking that means the Back to Sleep Campaign is correct.

  13. FYI:

    Here is the response of Dr. Rafael Pelayo of Stanford to the AAP letter above and below that is a short detailed summary of why SWS (Stage 3 and Stage 4 NREM Sleep) is important.

    In a 2006 letter to the editor in the Journal of Pediatrics Dr. Rafael Pelayo, Dr. Judith Owens, Dr. Jodi Mindell, and Dr. Stephen Sheldon asked the following question of the American Academy of Pediatrics Task Force on Sudden Infant Death Syndrome after their Pacifier and Co-sleeping report was published:
    “…from the perspective of the field of pediatric sleep medicine, the policy statement’s laudable but narrow focus on SIDS prevention raises a number of important issues that need to be addressed. In particular, the revised recommendations regarding cosleeping and pacifier use have the potential to lead to unintended consequences on both the sleep and the health of the infant. The potential implications of a SIDS risk-reduction strategy that is based on a combination of maintaining a low arousal threshold and reducing quiet (equivalent to Delta or slow-wave sleep) in infants must be considered. Because slow-wave sleep is considered the most restorative form of sleep and is believed to have a significant role in neurocognitive processes and learning, as well as in growth, what might be the neurodevelopmental consequences of chronically reducing deep sleep in the first critical 12 months of life?”

    In a currently utilized model that explains the process in which slow wave sleep is involved in memory consolidation the hippocampus acts as a temporary storage facility for new memories which are then transferred to the neocortex during slow wave sleep (SWS) [8]. In this model, acetylcholine acts a feedback loop inhibitor inside the hippocampus during REM sleep and wakefulness. The activity during the high cholinergic wakefulness period is believed to provide an environment which allows for the encoding within the hippocampus of new declarative memories. The low cholinergic environment during SWS is thought to then allow these memories to be transferred from the temporary storage of the hippocampus to their permanent storage environment in the neocortex and for memory consolidation [9, 10].
    A significant way of decreasing slow wave sleep in infants is by changing their sleeping position from prone to supine. It has been shown in studies of preterm infants [11, 12], full-term infants [13, 14], and older infants [15], that they have greater time periods of quiet sleep and also decreased time awake when they are positioned to sleep in the prone position.

    8. Hasselmo, M.E. 1999. Neuromodulation: Acetylcholine and memory consolidation. Trends Cogn. Sci. 3: 351�359.
    9. Buzs�ki, G. 1989. Two-stage model of memory trace formation: A role for �noisy� brain states. Neuroscience 31: 551�570.
    10. Hasselmo, M.E. 1999. Neuromodulation: Acetylcholine and memory consolidation. Trends Cogn. Sci. 3: 351�359.
    11. Myers MM, Fifer WP, Schaeffer L, et al. Effects of sleeping position and time after feeding on the organization of sleep/wake states in prematurely born infants. Sleep 1998;21:343�9.
    12. Sahni R, Saluja D, Schulze KF, et al. Quality of diet, body position, and time after feeding influence behavioral states in low birth weight infants. Pediatr Res 2002;52:399�404.
    13. Brackbill Y, Douthitt TC, West H. Psychophysiologic effects in the neonate of prone versus supine placement. J Pediatr 1973;82:82�4.
    14. Amemiya F, Vos JE, Prechtl HF. Effects of prone and supine position on heart rate, respiratory rate and motor activity in full term infants. Brain Dev 1991;3:148�54.
    15. Kahn A, Rebuffat E, Sottiaux M, et al. Arousal induced by proximal esophageal reflux in infants. Sleep 1991;14:39�42.

    I think I need some Kool-Aid to wash down all this SIDS Back to Sleep Propaganda!

  14. Man, there are denialists for everything.

  15. Man, there are propagandists and Kool-Aid drinkers for everything.

  16. Tom said “But, please keep on giving parents the THALIDOMIDE advice.”

    What does that mean? How many American babies were affected by thalidomide?

  17. People, don’t argue with cranks. He’s already called you propagandists and Kool-Aid drinkers (next he’ll claim oppression). He’s using flimsy quote-mining to back up this nonsense. Please just ignore him and I’ll disemvowel from here on out.

  18. How Ironic, a blog called denialism used to promote propaganda. That’s rich.

    Hmmmm….a bunch of academic grunts posing as intellectuals. That’s even richer.

  19. “People, don’t argue with cranks. He’s already called you propagandists and Kool-Aid drinkers (next he’ll claim oppression). He’s using flimsy quote-mining to back up this nonsense. Please just ignore him and I’ll disemvowel from here on out.

    Posted by: MarkH | November 9, 2008 12:07 AM”

    Sooooooo……You’re going to “disemvowel” me? Oh No! Oh No! I won’t be able to say “a,e,i,o,u, and sometimes y” anymore. Ha Ha Ha. Please learn how to spell before you embarrass yourself any further. Academic grunts posing as intellectuals. Too funny!

  20. Mark, I am sorry. I just get irritated at the “thalidomide” bit. It is like the cranks are denying Dr. Frances Kelsey’s existence. I hate that.

  21. “Mark, I am sorry. I just get irritated at the “thalidomide” bit. It is like the cranks are denying Dr. Frances Kelsey’s existence. I hate that.

    Posted by: HCN | November 9, 2008 2:09 AM”

    On this blog Dr. Frances Kelsey would be called a Denialist! Ha Ha Ha! Anyone who doesn’t go along with Propaganda and drink the Kool-Aid is called a Denialist on this blog. Ha Ha Ha. BTW, I am using the term thalidomide as a METAPHOR. You may have heard of that word before? It takes a little bit of using your noggin to understand it though so maybe not. The metaphor is that thalidomide was once prescribed to many pregnant women in the world and it wasn’t until later that the unintended consequences (birth defects) appeared. The same is true for the SIDS Back to Sleep Campaign. The long-term negative unintended consequences are caused by not allowing the infant to get proper amounts of Slow Wave Sleep. I know doctors that are too cool for school don’t know what Slow Wave Slee is so I’ll edumacated you: It’s the combination of Stage 3 and Stage 4 NREM sleep (AKA Deep Sleep or Quiet Sleep).

    “By 1957, thalidomide was sold over-the-counter in Germany. By 1960, it was sold throughout Europe and South America, in Canada, and in many other parts of the world. To introduce it into the United States, the Richardson-Merrell pharmaceutical company of Cincinnati submitted an application to FDA in September 1960 to sell thalidomide under the brand name Kevadon.”

    In 1992, the American Academy of Pediatrics (AAP) recommended that healthy infants be positioned to sleep on their back (supine position) or side (lateral position) when being placed down for sleep to reduce the risk of Sudden Infant Death Syndrome (SIDS).(1) The reason for this recommendation was that epidemiological studies had reported an association between infants who were positioned to sleep on their front (prone position) and SIDS. The AAP�s 1992 recommendations were announced five years after the Netherlands had started it�s infant supine sleep position campaign in 1987.(2,3) The Netherlands recommendations were followed by infant supine sleep position campaigns in the United Kingdom, New Zealand, and Australia in 1991, the U.S. and Sweden in 1992, and Canada in 1993.(4,5) In 1994 a number of organizations in the United States combined to further communicate these supine sleep position recommendations and this became formally known as the �Back To Sleep� campaign.(6) In 1996, the AAP further refined its sleep position recommendation by stating that infants should only be placed to sleep in the supine position. But, these public health campaigns to educate mothers on how to position infants in bed, while successful, may have unintended negative consequences.(7)

    1. American Academy of Pediatrics Task Force on Infant Positioning and SIDS. Positioning and SIDS. Pediatrics. 1992;89:1120-1126
    2. Hogberg U, Bergstrom E. Suffocated Prone: The Iatrogenic Tragedy of SIDS. American Journal of Public Health. 2000;90:527-531
    3. H�gberg U, Bergstr�m E. Suffocated Prone: The Iatrogenic Tragedy of SIDS. Am J Public Health. 2000;90:527�531 (103)
    4. H�gberg U, Bergstr�m E. Suffocated Prone: The Iatrogenic Tragedy of SIDS. Am J Public Health. 2000;90:527�531 (104)
    5. Rusen I, Shiliang L, Sauve R, Joseph K, Kramer M. Sudden infant death syndrome in Canada: Trends in rates and risk factors, 1985-1998. Chronic Diseases in Canada. 2005;24:1 (105)
    6 U.S. Department of Human Services. “BACK TO SLEEP” CAMPAIGN SEEKS To Reduce Inicidence of SIDS In African American Populations PressRelease. Tuesday, Oct. 26, 1999
    7. American Academy of Pediatrics Task Force on Infant Positioning and SIDS. Positioning and sudden infant death syndrome (SIDS): update. Pediatrics. 1996;98:1216-1218

  22. Germany is not in the United States. Actually, most Americans (and many Canadians, including ex-Canadians… and my hubby is from the same island as Dr. Kelsey) don’t care what Europe does. I asked how many American babies were affected by thalidomide. You have not answered that question, even in the posts with vowels.

    On SIDS, you are selectively choosing specifically old papers. So I now reply with:

    You are being silly and cranky, and I am sure that any further posting by you will be disemvowelled (please!!!). Look at it, you are going nuts over sleeping positions of babies! It is nothing like circumcision, which actually involves sharp objects! (something I would not touch with a ten foot pole, go here for that kind of insanity, ).

    Good grief, get a grip!

  23. LanceR, JSG

    Disemvowel, to remove the vowels, see here before you make any more of a fool of yourself.

    And *we’re* the ones who don’t think? Classic nutter.

  24. Disemvoweling was too good for him, he got junked.

  25. Anonymous

    “Disemvowel, to remove the vowels, see here before you make any more of a fool of yourself.

    And *we’re* the ones who don’t think? Classic nutter.

    Posted by: LanceR, JSG | November 10, 2008 6:57 AM”

    It wss a joke. Dumb people never have sense of humor. Ha Ha Ha!

  26. LanceR, JSG

    it’s kind of like the Bush Administration and their so-called “Clear Skies Initiative”

    Actually, moron, that would be a SIMILE. You just keep getting dumber.

    Stop beating your wife yet?

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