Case Based Pediatrics For Medical Students and Residents - Health 92291

Page - 118 Page - 118 Case Based Pediatrics For Medical Students and Residents Editors: Loren G. Yamamoto, MD, MPH, MBA Alson S. Inaba, MD Jeffrey K. Okamoto, MD Mary Elaine Patrinos, MD Vince K. Yamashiroya, MD Department of Pediatrics University of Hawaii John A. Burns School of Medicine Kapiolani Medical Center For Women And Children Honolulu, Hawaii Copyright 2004, Department of Pediatrics, University of Hawaii John A. Burns School of Medicine Case Based Pediatrics For Medical Students and Residents I. Office Primary Care: Section Editor - Jeffrey K. Okamoto, MD 1. Pediatric Primary Care - Melinda J. Ashton, MD . . . . . . . . 16 2. Growth Monitoring - Vince K. Yamashiroya, MD . . . . . . . . 19 3. Developmental Screening of Infants, Toddlers and Preschoolers - Jeffrey K. Okamoto, MD . 21 4. Immunizations - Dennis A. Conrad, MD . . . . . . . . . 24 5. Hearing Screening - Teresa Han Seo . . . . . . . . . . 30 6. Anticipatory Guidance - Corinne C. Chan-Nishina, MD . . . . . . . 32 7. Common Behavioral Problems in Toddlers and Young Children - Sharon M. Tisza, MD . 35 8. Disabilities and Physician Interactions with Schools - Jeffrey K. Okamoto, MD . . 38 9. Autism and Language Difficulties - Mai Anh K. Nguyen, MD . . . . . 40 10. Attention Deficit/Hyperactivity Disorder - Jeffrey K. Okamoto, MD . . . . 43 11. Medical Insurance Basics - Richard Y. Mitsunaga, MD . . . . . . 46 12. Pediatric Dental Basics - Cindy W. Yang . . . . . . . . . 50 II. Nutrition: Section Editor - Loren G. Yamamoto, MD, MPH, MBA 1. Overview - Caron M. Hong . . . . . . . . . . . . 54 2. Breast Feeding - Meta T. Lee, MD, MSEd . . . . . . . . . 57 3. Infant Formulas - Nadine Tenn Salle, MD . . . . . . . . . 60 4. Fluids and Electrolytes - Loren G. Yamamoto, MD, MPH, MBA . . . . . 62 5. Failure to Thrive - Anthony P. S. Guerrero, MD . . . . . . . . 69 6. Malnutrition and Vitamin Deficiencies - Adeline Winkes, MD . . . . . 71 III. Neonatology: Section Editor - Mary Elaine Patrinos, MD 1. Routine Newborn Care - Joan Ceccarelli Meister, MD . . . . . . . 75 2. Neonatal Hyperbilirubinemia - Carol Hirai, MD . . . . . . . . 77 3. Newborn Resuscitation - Sheree Kuo, MD . . . . . . . . . 81 4. High Risk Pregnancy - Mary Elaine Patrinos, MD . . . . . . . . 84 5. Common Problems of the Preterm Infant - Venkataraman Balaraman, MBBS . . . 87 6. Respiratory Distress in the Newborn - Daniel T. Murai, MD . . . . . . 90 7. Cyanosis in Newborns - Kenneth Ash, MD . . . . . . . . . 94 8. Neonatal Hypoglycemia - Joel Ruff, MD . . . . . . . . . 97 9. Neonatal Seizures - Lynn M. Iwamoto, MD . . . . . . . . . 101 10. Neonatal Sepsis - Sherry W.H. Loo, MD . . . . . . . . . 103 11. Congenital and Perinatal Infections - Sheree Kuo, MD . . . . . . . 107 12. Necrotizing Enterocolitis - Kelly S. Yamasato . . . . . . . . 111 IV. Genetics: Section Editor - Mary Elaine Patrinos, MD 1. Prenatal Genetic Screening and Testing - Greigh I. Hirata, MD . . . . . 114 2. Congenital Malformation and Teratogenesis - Greigh I. Hirata, MD . . . . 116 3. Common Chromosomal Disorders - Julie Won Ireland, MD . . . . . . 119 4. Inborn Errors of Metabolism - Catherine Y.H. Wagoner, MD . . . . . . 122 5. Inherited Connective Tissue Disorders - Steven C. Crook, MD . . . . . 126 6. Genetic Testing and Gene Therapy - Steven C. Crook, MD . . . . . . 128 7. Basic Genetics Principles - Bryan O. King, MS . . . . . . . . 130 V. Allergy and Immunology: Section Editor - Loren G. Yamamoto, MD, MPH, MBA 1. Common Allergies and Management - Akaluck Thatayatikom, MD . . . . 134 2. Anaphylaxis and Other Acute Allergic Reactions - Todd T. Kuwaye, MD, MS . . 141 3. Food Allergies - Akaluck Thatayatikom, MD . . . . . . . . . 143 4. Corticosteroids - M. Scott Hickman, MD . . . . . . . . . 148 5. Immune Deficiency - Akaluck Thatayatikom, MD . . . . . . . . 152 6. Hematopoietic Stem Cell Transplantation and Graft Versus Host Disease - Jocelyn M. Sonson . 159 VI. Infectious Disease: Section Editor - Loren G. Yamamoto, MD, MPH, MBA 1. Virology - Loren G. Yamamoto, MD, MPH, MBA . . . . . . . . 162 2. Bacteriology - Loren G. Yamamoto, MD, MPH, MBA . . . . . . . 165 3. Fever - Marian E. Melish, MD . . . . . . . . . . . 169 4. Inhibitory and Bactericidal Principles (MIC & MBC) - Loren G. Yamamoto, MD, MPH, MBA 174 5. Antibiotics - Loren G. Yamamoto, MD, MPH, MBA . . . . . . . 177 6. Otitis Media and Otitis Externa - Vince K. Yamashiroya, MD . . . . . 181 7. Sinusitis - Kathleen Morimoto, MD . . . . . . . . . . 184 8. Mastoiditis - Kathleen Morimoto, MD . . . . . . . . . . 185 9. Oral and Upper Respiratory Infections - Joel Ruff, MD . . . . . . . 187 10. Pertussis - Leo U. Pascua, MD . . . . . . . . . . . 191 11. Pulmonary Infections - Kimberly N. Otsuka, MD . . . . . . . . 194 12. Croup and Epiglottitis - Paul J. Eakin, MD . . . . . . . . . 198 13. Cellulitis - Leo U. Pascua, MD . . . . . . . . . . . 201 14. Meningitis - Raul Rudoy, MD . . . . . . . . . . . 204 15. Encephalitis - Jonathan K. Marr, MD . . . . . . . . . . 207 16. Sepsis - Guliz Erdem, MD . . . . . . . . . . . . 212 17. Kawasaki Disease - Kara S. Yamamoto, MD & Marian E. Melish, MD . . . . 215 18. Staphylococcal and Streptococcal Toxic Shock Syndromes - Judy Makowski Vincent, MD . 218 19. Tuberculosis - Wallace J. Matthews, Jr., MD . . . . . . . . 222 20. Human Immunodeficiency Virus Infections - Guliz Erdem, MD & Cecilia M. Shikuma, MD . 225 21. Sexually Transmitted Infections - Reina M. Ahern, MD . . . . . . 229 22. Common Viral Exanthems - Kalamaoka'aina Kil Soon Niheu, MD . . . . 234 23. Epstein-Barr Virus Infections - Jhoanna D. Mabutas MD . . . . . . 237 24. Polio - Rodney K. Yamaki . . . . . . . . . . . . 239 25. Rabies - Grant L.Y. Chen, MS . . . . . . . . . . . 242 26. Rocky Mountain Spotted Fever - Douglas K. Kwock, MD . . . . . . 245 27. Lyme Disease - Judy Makowski Vincent, MD . . . . . . . . 247 28. Leptospirosis - Selena S.P. Chen, MD, MPH . . . . . . . . 250 29. Cat Scratch Disease - Judy Makowski Vincent, MD . . . . . . . 252 30. Malaria - M. Scott Hickman, MD . . . . . . . . . . 254 31. Protozoans and Parasites - Loren G. Yamamoto, MD, MPH, MBA . . . . 258 32. Candidal and Fungal Infections - Wendy C. Matsuno, MD . . . . . . 261 33. Necrotizing Fasciitis - Chad S.D. Sparks . . . . . . . . . 264 34. Lymphadenitis and Lymphangitis - Teresa M. Bane-Terakubo, MD . . . . 267 VII. Cardiology: Section Editor - Loren G. Yamamoto, MD, MPH, MBA 1. Congestive Heart Failure - Lance K. Shirai, MD, MS . . . . . . . 269 2. Acyanotic Congenital Heart Disease - Edgar C.K. Ho, MD . . . . . . 272 3. Cyanotic Congenital Heart Disease - D. Venu Reddy, MD, MPH . . . . . 275 4. Rheumatic Fever - David K. Kurahara, MD . . . . . . . . . 278 5. Carditis - David K.M. Wong, MD . . . . . . . . . . . 282 6. Arrhythmias - Lance K. Shirai, MD, MS . . . . . . . . . 286 7. Vascular Rings and Slings - Cheryl M. Takao, MD . . . . . . . 289 VIII. Pulmonology: Section Editor - Mary Elaine Patrinos, MD 1. Interpretation of Blood Gases and Pulse Oximetry - Loren G. Yamamoto, MD, MPH, MBA . 292 2. Asthma - Franklin Y. Yamamoto, MD . . . . . . . . . . 296 3. Cystic Fibrosis - Wallace J. Matthews, Jr., MD . . . . . . . . 302 4. Chronic Lung Disease of Infancy (Bronchopulmonary Dysplasia) - Mary Elaine Patrinos, MD . 306 5. Bronchiectasis - Charles W. Calahan, DO . . . . . . . . . 309 6. Foreign Body Aspiration - Edward W. Fong, MD . . . . . . . . 311 7. Pulmonary Hemosiderosis - Scott J. Sheets, DO . . . . . . . . 314 8. Pulmonary Vascular Anomalies - Jason H. Brown & Edward W. Fong, MD . . . 317 9. Bronchogenic Cysts and Cystic Adenomatoid Malformation - Scott J. Sheets, DO . . 320 10. Congenital Airway Problems - Winona K. Lee, MD . . . . . . . 323 11. Sleep disorders - Sze Mei Chung . . . . . . . . . . . 325 12. Sudden Infant Death Syndrome - Mary Elaine Patrinos, MD . . . . . . 328 IX. Gastroenterology: Section Editor - Mary Elaine Patrinos, MD 1. Infant Colic - Rodney B. Boychuk, MD . . . . . . . . . . 331 2. Abdominal Pain - Walton K.T. Shim, MD . . . . . . . . . 335 3. Gastroenteritis and Dehydration - Sherloune Normil-Smith, MD . . . . . 337 4. Biliary Atresia - Jason T. Nomura, MD . . . . . . . . . . 342 5. Hepatitis - Vince K. Yamashiroya, MD . . . . . . . . . . 346 6. Gastroesophageal Reflux - Ken Nagamori, MD . . . . . . . . 350 7. Gastrointestinal Foreign Bodies - Lu'ukia Ruidas, MD . . . . . . . 353 8. Constipation - Ken Nagamori, MD . . . . . . . . . . 355 9. Hirschsprung's Disease - Walton K.T. Shim, MD . . . . . . . . 359 10. GI bleeding and Peptic Ulcer Disease - Ken Nagamori, MD . . . . . . 361 11. Inflammatory Bowel Disease - Alan K. Ikeda, MD . . . . . . . 367 12. Malabsorption Conditions - Max C. Miranda . . . . . . . . 370 13. Meckel's Diverticulum - Gareth K. Nakasone . . . . . . . . 373 X. Surgery: Section Editor - Loren G. Yamamoto, MD, MPH, MBA 1. Wound Management - Jeffrey J. Wong, MD . . . . . . . . . 376 2. Hernias and Hydroceles - Leticia P. Borja, MD . . . . . . . . 379 3. Appendicitis - Walton K.T. Shim, MD . . . . . . . . . . 382 4. Intussusception - Lynette L. Young, MD . . . . . . . . . 384 5. Malrotation and Volvulus - Loren G. Yamamoto, MD, MPH, MBA . . . . 387 6. Gastroschisis and Omphalocele - Rodney B. Boychuk, MD . . . . . . 388 7. Diaphragmatic Hernia - Rodney B. Boychuk, MD . . . . . . . . 391 8. Pyloric Stenosis - Kevin H. Higashigawa, MD . . . . . . . . 394 9. Intestinal Atresias, Duplications and Microcolon - Timur M. Roytman . . . . 396 10. Craniofacial Malformations - Robert L. Peterson, MD . . . . . . . 398 11. Abscesses - Myrna I. Kuo . . . . . . . . . . . . 400 12. Lymphangiomas - John J. Chung, MS, MPH . . . . . . . . 404 XI. Hematology: Section Editor - Loren G. Yamamoto, MD, MPH, MBA 1. Anemia - Darryl W. Glaser, MD . . . . . . . . . . . 407 2. Thalassemia - Kelley A. Woodruff, MD . . . . . . . . . . 412 3. Sickle Cell Disease - Kelley A. Woodruff, MD . . . . . . . . 414 4. Bone Marrow Failure - Desiree Medeiros, MD . . . . . . . . 417 5. Newborn Hematology - Robert W. Wilkinson, MD . . . . . . . 419 6. Bleeding Disorders - Desiree Medeiros, MD . . . . . . . . . 420 7. Transfusion Medicine - Kelley A. Woodruff, MD . . . . . . . . 426 8. Neutrophil Disorders - Wade T. Kyono, MD . . . . . . . . . 429 XII. Oncology: Section Editor - Loren G. Yamamoto, MD, MPH, MBA 1. Oncology Treatment Principles - Nu Lu . . . . . . . . . . 433 2. Leukemia and Lymphoma - Bruce T. Shiramizu, MD . . . . . . . 435 3. Solid Tumor Childhood Malignancies - Christina Keolanani Kleinschmidt . . . 437 4. Palliative Care - Dianne Fochtman, RN, MN, CPNP, CPON . . . . . . 442 XIII. Nephrology/Urology: Section Editor - Jeffrey K. Okamoto, MD 1. Nephritic Syndrome/Glomerulonephritis - Teresa M. Bane-Terakubo, MD . . . 444 2. Nephrotic Syndrome - Paul J. Eakin, MD . . . . . . . . . 446 3. Cystic Kidneys - Miki E. Shirakawa . . . . . . . . . . 449 4. Dialysis - James H.E. Ireland, MD & Julie Won Ireland, MD . . . . . . 451 5. Hemolytic Uremic Syndrome - Jonathan K. Marr, MD . . . . . . . 453 6. Urinary Tract Infection - Janet M. Berreman, MD . . . . . . . . 456 7. Hydronephrosis and Reflux - Robert G. Carlile, MD . . . . . . . 460 8. Circumcision - Robert G. Carlile, MD . . . . . . . . . . 464 9. Enuresis - Potenciano Reynoso Paredes, MD . . . . . . . . . 466 10. Acute Scrotum - Robert G. Carlile, MD . . . . . . . . . 468 11. Ambiguous Genitalia - Robert G. Carlile, MD . . . . . . . . 470 12. Hypospadias - Robert G. Carlile, MD . . . . . . . . . . 474 XIV. Critical Care and Emergency Medicine: Section Editor - Alson S. Inaba, MD 1. Pulmocardiac Resuscitation - Rodney B. Boychuk, MD & Alson S. Inaba, MD . . 476 2. Shock - Rodney B. Boychuk, MD . . . . . . . . . . . 479 3. Respiratory Failure - Paula A. Vanderford, MD . . . . . . . . 483 4. Intubation - Paula A. Vanderford, MD . . . . . . . . . . 486 5. Mechanical Ventilation - Paula A. Vanderford, MD . . . . . . . 488 6. Submersion Injuries - Francisco J. Garcia, MD . . . . . . . . 491 7. Pneumothorax and Other Air Leaks - Edward W. Fong, MD . . . . . . 493 8. Trauma - Alson S. Inaba, MD & Rodney B. Boychuk, MD . . . . . . 496 9. Toxicology - Alson S. Inaba, MD . . . . . . . . . . . 499 10. Acetaminophen Overdose - Lynette L. Young, MD . . . . . . . 505 11. Iron Overdose - Lynette L. Young, MD . . . . . . . . . 507 12. Child Abuse - Cynthia H. Tinsley, MD . . . . . . . . . 509 XV. Endocrinology: Section Editor - Loren G. Yamamoto, MD, MPH, MBA 1. Diabetes Mellitus - Greg Y. Uramoto, MD . . . . . . . . . 514 2. Thyroid Disorders - Melanie L. Shim, MD . . . . . . . . . 516 3. Short Stature - Maureen M. Petersen, MD & Anita M. Pedersen, MD . . . . 519 4. Adrenal Disorders - Jose L. Gonzalez, MD, MSEd, JD . . . . . . . 521 5. Anti-Diuretic Hormone - Daniel C. H. Kidani, MD . . . . . . . 526 6. Calcium Disorders - David F. Crudo, MD . . . . . . . . . 530 XVI. Rheumatology: Section Editor - Loren G. Yamamoto, MD, MPH, MBA 1. Systemic Lupus Erythematosus - Kara S. Yamamoto, MD . . . . . . 535 2. Juvenile Rheumatoid Arthritis - Kara S. Yamamoto, MD . . . . . . 538 3. Vasculitis - Donald A. Person, MD . . . . . . . . . . 542 XVII. Ophthalmology: Section Editor - Loren G. Yamamoto, MD, MPH, MBA 1. Neonatal Conjunctivitis and Eye Prophylaxis - Sheree Kuo, MD . . . . . 544 2. Primary Care Examination - Vince K. Yamashiroya, MD . . . . . . 546 3. Strabismus and Amblyopia - Julie K. Nishimura, MD . . . . . . . 548 4. Conjunctivitis and Eyelid Infections - Peggy M. Liao, MD . . . . . . 549 5. Corneal Abrasions - Peggy M. Liao, MD . . . . . . . . . 551 XVIII. Neurology: Section Editor - Jeffrey K. Okamoto, MD 1. Neurologic Examination - Vince K. Yamashiroya, MD . . . . . . . 553 2. Cerebral Palsy - Mari Uehara, MD . . . . . . . . . . 557 3. Febrile Seizures - Vince K. Yamashiroya, MD . . . . . . . . 559 4. Epilepsy - Keith K. Abe, MD . . . . . . . . . . . 561 5. Status Epilepticus - Loren G. Yamamoto, MD, MPH, MBA . . . . . . 568 6. Infant Botulism - Daniel W. Ulrich, MD . . . . . . . . . 571 7. Guillain-Barre Syndrome - Judy T. Okimura, MD . . . . . . . . 573 8. Multiple Sclerosis - Lori S. Murayama . . . . . . . . . . 575 9. Hydrocephalus - Andrée M. Bouterie, MD . . . . . . . . . 577 10. Neural Tube Defects - Mari Uehara, MD . . . . . . . . . 581 11. Neurofibromatosis - Vince K. Yamashiroya, MD . . . . . . . . 583 12. Tuberous Sclerosis Complex - Vince K. Yamashiroya, MD . . . . . . 586 13. Head Trauma and Hemorrhage - Floyd S. Ota, MD . . . . . . . 589 14. Muscular Dystrophy - Vince K. Yamashiroya, MD . . . . . . . 593 15. Myopathy and Myositis - Dominic C. Chow, MD, MPH . . . . . . 596 16. Developmental Brain Anomalies - Kaipo T. Pau . . . . . . . . 599 17. Reye Syndrome - David W. Boldt . . . . . . . . . . 601 18. Brain Tumors - Wade T. Kyono, MD . . . . . . . . . . 603 19. Arteriovenous Malformations - Chia Sonia Granda . . . . . . . 605 XIX. Orthopedics: Section Editor - Loren G. Yamamoto, MD, MPH, MBA 1. Fractures - Annemarie Uliasz . . . . . . . . . . . 609 2. Splinting - Erick M. Itoman . . . . . . . . . . . . 613 3. Scoliosis - Robert C. Durkin, MD . . . . . . . . . . . 616 4. Osteomyelitis - Floyd S. Ota, MD . . . . . . . . . . . 619 5. Septic Arthritis - Floyd S. Ota, MD . . . . . . . . . . 621 6. Hip conditions - Robert C. Durkin, MD . . . . . . . . . . 624 7. Common Sprains and Dislocations - Brian T. Garcia . . . . . . . 628 8. Sports Injuries - Brent K. Ogawa, MD . . . . . . . . . . 631 XX. Adolescent Medicine: Section Editor - Loren G. Yamamoto, MD, MPH, MBA 1. Puberty - Sherrel L. Hammar, MD . . . . . . . . . . . 637 2. Anabolic Steroids - Robert J. Bidwell, MD . . . . . . . . . 640 3. Substance Abuse - Anthony P. S. Guerrero, MD . . . . . . . . 642 4. Suicide and Violence - Anthony P. S. Guerrero, MD . . . . . . . 644 5. Eating Disorders - Robert J. Bidwell, MD . . . . . . . . . 646 6. Sexuality - Robert J. Bidwell, MD . . . . . . . . . . . 648 7. Adolescent Gynecology - Renee L. Sato, MD . . . . . . . . 650 XXI. Skin: Section Editor - Loren G. Yamamoto, MD, MPH, MBA 1. Eczematous Dermatitis (Atopic Dermatitis and Seborrhea) - M. Stanton Michels, MD . 656 2. Acne - M. Stanton Michels, MD . . . . . . . . . . . 658 3. Hemangiomas, Vascular Malformations and Nevi - M. Stanton Michels, MD . . . 659 4. Burns - Annemarie Uliasz . . . . . . . . . . . . 661 5. Bites and Stings - Todd T. Kuwaye, MD, MS . . . . . . . . 663 6. Common Skin Conditions - Annemarie Uliasz . . . . . . . . 666 XXII. Reviewing the Medical Literature: Section Editor - Loren G. Yamamoto, MD, MPH, MBA 1. Statistics - Loren G. Yamamoto, MD, MPH, MBA . . . . . . . . 670 2. Evidence-Based Medicine - Claudine Kimura, MD . . . . . . . 674 3. Epidemiology and Research Methodology - Loren G. Yamamoto, MD, MPH, MBA . 679 Case Based Pediatrics For Medical Students and Residents - Contributors Keith K. Abe, MD, MS Clinical Instructor in Pediatrics, University of Hawaii John A. Burns School of Medicine. Resident in Pediatrics (Graduating 2004), Kapiolani Medical Center For Women And Children, Honolulu, Hawaii. Reina M. Ahern, MD Clinical Instructor in Obstetrics/Gynecology, University of Hawaii John A Burns School of Medicine. Resident in Obstetrics/Gynecology (Graduating 2007), Kapiolani Medical Center For Women And Children, Honolulu, Hawaii. Kenneth Ash, MD, FAAP Associate Professor of Pediatrics, University of Hawaii John A. Burns School of Medicine. Medical Director of Neonatal/Pediatric Transport, Kapiolani Medical Center For Women And Children, Honolulu, Hawaii. Melinda J. Ashton, MD, FAAP Pediatrician in Private Practice. Clinical Professor of Pediatrics, University of Hawaii John A. Burns School of Medicine. Medical Director, Physicians Health Hawaii, Inc., Honolulu, Hawaii. Venkataraman Balaraman, MBBS, FAAP Associate Professor of Pediatrics, University of Hawaii John A. Burns School of Medicine. Medical Director, Neonatal Special Care Unit, Kapiolani Medical Center For Women And Children, Honolulu, Hawaii. Teresa M. Bane-Terakubo, MD, FAAP Assistant Professor of Pediatrics, University of Hawaii John A. Burns School of Medicine. Attending Pediatrician, Queen Emma Clinic, Queen's Medical Center, Honolulu, Hawaii. Janet M. Berreman, MD, FAAP Clinical Assistant Professor of Pediatrics, University of Hawaii John. A. Burns School of Medicine. Attending Pediatrician, Waianae Coast Comprehensive Health Center, Waianae, Hawaii. Robert J. Bidwell, MD, FAAP Associate Professor of Pediatrics, University of Hawaii John A. Burns School of Medicine. Adolescent Medicine Specialist, Kapiolani Medical Center For Women And Children, Honolulu, Hawaii. David W. Boldt Medical Student, University of Hawaii John A Burns School of Medicine (Class of 2005), Honolulu, Hawaii. Leticia P. Borja, MD Clinical Instructor in Pediatrics, University of Hawaii John A. Burns School of Medicine. Chief Resident in Pediatrics, Kapiolani Medical Center For Women And Children, Honolulu, Hawaii. Andrée M. Bouterie, MD Clinical Instructor, Department of Pediatrics, University of Hawaii John A. Burns School of Medicine. Fellow in Child Psychiatry, Department of Psychiatry, University of Hawaii John A. Burns School of Medicine. Rodney B. Boychuk, MD, FAAP Professor of Pediatrics and Surgery, University of Hawaii John. A. Burns School of Medicine. Past Chief of Staff, Kapiolani Medical Center For Women And Children, Honolulu, Hawaii. Jason H. Brown Medical Student, University of Hawaii John A Burns School of Medicine (Class of 2005), Honolulu, Hawaii. Charles W. Callahan, DO, FAAP, COL, MC, USA Chief of Pediatrics and Pediatric Pulmonology, Tripler Army Medical Center. Clinical Professor of Pediatrics, University of Hawaii John A Burns School of Medicine, Honolulu, Hawaii. Professor of Pediatrics, Uniformed University of the Health Sciences, Bethesda, Maryland. Robert G. Carlile, MD Clinical Assistant Professor of Surgery, University of Hawaii John. A. Burns School of Medicine. Urologic Surgeon in Private Practice, Honolulu, Hawaii. Corinne C. Chan-Nishina, MD, FAAP Clinical Assistant Professor of Pediatrics, University of Hawaii John A. Burns School of Medicine. Developmental-Behavioral Pediatrician in Private Practice, Honolulu, Hawaii. Grant L.Y. Chen, MS Medical Student, University of Hawaii John A Burns School of Medicine (Class of 2004), Honolulu, Hawaii. Selina S.P. Chen, MD, MPH Clinical Instructor in Pediatrics and Internal Medicine, University of Hawaii John A. Burns School of Medicine. Former Resident in Pediatrics and Internal Medicine (Graduated 2003), Queen's Medical Center & Kapiolani Medical Center For Women And Children, Honolulu, Hawaii. Dominic C. Chow, MD, MPH, FAAP Assistant Professor of Pediatrics and Medicine, University of Hawaii John A. Burns School of Medicine. Associate Director, Internal Medicine/Pediatrics Residency Program, University of Hawaii John A. Burns School of Medicine. Attending Physician, Queen Emma Clinics, Honolulu, Hawaii. John J. Chung, MS, MPH Medical Student, University of Hawaii John A Burns School of Medicine (Class of 2005), Honolulu, Hawaii. Sze Mei Chung Medical Student, University of Hawaii John A Burns School of Medicine (Class of 2004), Honolulu, Hawaii. Dennis A. Conrad, MD Professor of Pediatrics and Deputy Chairman for Children's Hospital Affairs, University of Texas Health Science Center at San Antonio, San Antonio, Texas. Consultant in Pediatric Infectious Diseases, Christus Santa Rosa Children's Hospital, San Antonio, Texas. Steven C. Crook, MD Clinical Instructor in Pediatrics, University of Hawaii John A. Burns School of Medicine. Resident in Pediatrics (Graduating 2004), Kapiolani Medical Center For Women And Children, Honolulu, Hawaii. David F. Crudo, MD, FAAP Colonel, Medical Corps, Pediatric Endocrinology, US Army Health Clinic, Schofield Barracks, Hawaii. Clinical Associate Professor of Pediatrics, University of Hawaii John A. Burns School of Medicine, Honolulu, Hawaii. Clinical Assistant Professor of Pediatrics, Uniformed Services University of the Health Sciences, Bethesda, Maryland.. Robert C. Durkin, MD Clinical Assistant Professor of Surgery and Pediatrics, University of Hawaii John A. Burns School of Medicine. Pediatric Orthopedic Surgeon in Private Practice, Honolulu, Hawaii. Paul J. Eakin, MD Clinical Instructor in Pediatrics, University of Hawaii John A. Burns School of Medicine. Former Resident in Pediatrics (Graduated 2003), Kapiolani Medical Center For Women And Children, Honolulu, Hawaii. Fellow in Pediatric Emergency Medicine, University of Texas Southwestern Medical School, Children's Medical Center of Dallas, Dallas, Texas. Guliz Erdem, MD Assistant Professor of Pediatrics, University of Hawaii John A. Burns School of Medicine. Pediatric Infectious Disease Consultant, Kapiolani Medical Center For Women And Children, Honolulu, Hawaii. Dianne Fochtman, RN, MN, CPNP, CPON Pediatric Oncology Nurse Practitioner, Kapiolani Medical Center For Women And Children. Clinical Associate Professor of Nursing, University of Hawaii School of Nursing, Honolulu, Hawaii. Edward W. Fong, MD Pediatric Pulmonology Fellow, University Medical Center, University of Arizona School of Medicine, Tucson, Arizona. Brian T. Garcia Medical Student, University of Hawaii John A Burns School of Medicine (Class of 2004), Honolulu, Hawaii. Francisco J. Garcia, MD, FAAP Assistant Professor of Pediatrics, University of Hawaii John A. Burns School of Medicine. Attending Pediatric Emergency Physician, Kapiolani Medical Center For Women And Children, Honolulu, Hawaii. Darryl W. Glaser, MD, FAAP Assistant Professor of Pediatrics, University of Hawaii John A. Burns School of Medicine. Attending Pediatric Hematologist/Oncologist, Kapiolani Medical Center For Women And Children, Honolulu, Hawaii. Jose L. Gonzalez, MD, MSEd, JD, FAAP Associate Professor of Pediatrics and Director of Pediatric Medical Education, Texas A&M College of Medicine. Pediatric Endocrinologist, Scott & White Hospital, Temple, Texas. Chia Sonia Granda Medical Student, University of Hawaii John A Burns School of Medicine (Class of 2005), Honolulu, Hawaii. Anthony P. S. Guerrero, MD, FAAP Associate Professor of Pediatrics and Psychiatry, Associate Director, Division of Child and Adolescent Psychiatry, Director of Psychiatric Medical Student Education, University of Hawaii John A. Burns School of Medicine. Medical Director, Kapiolani Behavioral Health Service, Kapiolani Medical Center for Women and Children. Attending Pediatrician, Queen Emma Clinics, Honolulu, Hawaii. Sherrel L. Hammar, MD, FAAP Professor and Former Chairman of Pediatrics, Former Dean, University of Hawaii John A. Burns School of Medicine. Chairman of Kapiolani Medical Specialists, Kapiolani Medical Center For Women And Children, Honolulu, Hawaii. M. Scott Hickman, MD Resident in Internal Medicine, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, New York. Resident in Ophthalmology (2005), University of Missouri – Kansas City School of Medicine, Kansas City, Missouri. University of Hawaii John A. Burns School of Medicine, Class of 2003. Kevin H. Higashigawa, MD Clinical Instructor in Orthopedic Surgery, University of Hawaii John A Burns School of Medicine. Resident in Orthopedic Surgery, Queen's Medical Center, Honolulu, Hawaii. Carol Hirai, MD Assistant Professor of Pediatrics, University of Hawaii John A. Burns School of Medicine. Staff Neonatologist, Kapiolani Medical Center For Women And Children, Honolulu, Hawaii. Greigh I. Hirata, MD Medical Director, Fetal Diagnostic Center, Ob/Gyn Ultrasound and Medical Genetics, Kapiolani Medical Center For Women and Children. Assistant Professor of Obstetrics & Gynecology, University of Hawaii John A. Burns School of Medicine, Honolulu, Hawaii. Edgar C.K. Ho, MD, FAAP Clinical Professor of Pediatrics, University of Hawaii John A. Burns School of Medicine. Pediatric Cardiologist, Straub Clinic & Hospital, Honolulu, Hawaii. Caron M. Hong Medical Student, University of Hawaii John A Burns School of Medicine (Class of 2004), Honolulu, Hawaii. Alson S. Inaba, MD, FAAP Associate Professor of Pediatrics, University of Hawaii John A. Burns School of Medicine. Pediatric Emergency Medicine Attending Physician, Kapiolani Medical Center For Women And Children. PALS National Faculty, American Heart Association Hawaii Affiliate. Medical Director, Hawaii Poison Center, Honolulu, Hawaii. Alan K. Ikeda, MD Clinical Instructor in Pediatrics, University of Hawaii John A. Burns School of Medicine. Resident in Pediatrics, Kapiolani Medical Center For Women And Children, Honolulu, Hawaii. James H.E. Ireland, MD Fellow in Nephrology, Mayo Clinic, Rochester, Minnesota. Julie Won Ireland, MD Former Resident in Pediatrics (2002), Kapiolani Medical Center For Women And Children, Honolulu, Hawaii. Fellow in Medical Genetics, Mayo School of Medicine, Rochester, Minnesota. Erick M. Itoman Medical Student, University of Hawaii John A Burns School of Medicine (Class of 2004), Honolulu, Hawaii. Lynn M. Iwamoto, MD, FAAP Assistant Professor of Pediatrics, University of Hawaii John A. Burns School of Medicine. Attending Neonatologist, Kapiolani Medical Center For Women And Children, Honolulu, Hawaii. Daniel C. H. Kidani, MD Clinical Instructor in Internal Medicine, University of Hawaii John A Burns School of Medicine. Resident in Internal Medicine, University of Hawaii Affiliated Hospitals, Honolulu, Hawaii. Resident in Anesthesiology (2004), University of California Irvine Medical Center, Irvine, California. Claudine Kimura, MD Assistant Clinical Professor of Internal Medicine and Clinical Instructor of Pediatrics, University of Hawaii John A. Burns School of Medicine, Honolulu, Hawaii. Bryan O. King, MS Medical Student, University of Hawaii John A Burns School of Medicine (Class of 2005), Honolulu, Hawaii. Christina Keolanani Kleinschmidt Medical Student, University of Hawaii John A Burns School of Medicine (Class of 2005), Honolulu, Hawaii. David K. Kurahara, MD, FAAP Assistant Professor of Pediatrics, University of Hawaii John A. Burns School of Medicine. Pediatric Rheumatologist, Kapiolani Medical Center For Women And Children, Honolulu, Hawaii. Myrna I. Kuo Medical Student, University of Hawaii John A Burns School of Medicine (Class of 2005), Honolulu, Hawaii. Sheree Kuo, MD, FAAP Assistant Professor of Pediatrics, University of Hawaii John A. Burns School of Medicine. Attending Neonatologist, Kapiolani Medical Center For Women And Children, Honolulu, Hawaii. Todd T. Kuwaye, MD, MS Attending Pediatrician/Internist, Kaiser Permanente Hawaii Nanaikeola Clinic, Nanakuli, Hawaii. Douglas K. Kwock, MD, FAAP Assistant Professor of Pediatrics, University of Hawaii John A. Burns School of Medicine. Pediatric Infectious Disease Consultant, Kapiolani Medical Center For Women And Children, Honolulu, Hawaii. Wade T. Kyono, MD Assistant Professor of Pediatrics, University of Hawaii John A. Burns School of Medicine. Pediatric Hematologist/Oncologist, Kapiolani Medical Center For Women And Children, Honolulu, Hawaii. Meta T. Lee, MD, MSEd Assistant Professor of Pediatrics, University of Hawaii John A. Burns School of Medicine. Attending Pediatrician, Queen Emma Clinic, Queen's Medical Center, Honolulu, Hawaii. Winona K. Lee, MD Assistant Professor of Pediatrics, University of Hawaii John A. Burns School of Medicine. Fellow, Native Hawaiian Center of Excellence, University of Hawaii John A. Burns School of Medicine, Honolulu, Hawaii. Peggy M. Liao, MD Clinical Assistant Professor of Surgery, University of Hawaii John A. Burns School of Medicine. Pediatric Ophthalmologist in Private Practice, Honolulu, Hawaii. Sherry W.H. Loo, MD Associate Professor of Pediatrics, University of Hawaii John A. Burns School of Medicine. Attending Neonatologist, Kapiolani Medical Center For Women And Children, Honolulu, Hawaii. Nu Lu Medical Student, University of Hawaii John A Burns School of Medicine (Class of 2004), Honolulu, Hawaii. Jhoanna D. Mabutas, MD Clinical Instructor in Pediatrics and Internal Medicine, University of Hawaii John A. Burns School of Medicine. Former Resident in Pediatrics and Internal Medicine (Graduated 2003), Queen's Medical Center & Kapiolani Medical Center For Women And Children, Honolulu, Hawaii. Jonathan K. Marr, MD Clinical Instructor in Pediatrics, University of Hawaii John A. Burns School of Medicine. Former Resident in Pediatrics (Graduated 2003), Kapiolani Medical Center For Women And Children, Honolulu, Hawaii. Wendy C. Matsuno, MD Clinical Instructor in Pediatrics, University of Hawaii John A. Burns School of Medicine. Resident in Pediatrics (Graduating 2005), Kapiolani Medical Center For Women And Children, Honolulu, Hawaii. Wallace J. Matthews, Jr., MD, FAAP Clinical Associate Professor of Pediatrics, University of Hawaii John A. Burns School of Medicine. Medical Director of Respiratory Care, Kapiolani Medical Center For Women And Children, Honolulu, Hawaii. Desiree Medeiros, MD Assistant Professor of Pediatrics, University of Hawaii John A. Burns School of Medicine. Attending Pediatric Hematologist/Oncologist, Kapiolani Medical Center For Women And Children, Honolulu, Hawaii. Joan Ceccarelli Meister, MD, FAAP Clinical Assistant Professor of Pediatrics, University of Hawaii John A. Burns School of Medicine. Attending Neonatologist, Kapiolani Medical Center For Women And Children, Honolulu, Hawaii. Marian E. Melish, MD, FAAP Professor of Pediatrics, Tropical Medicine and Medical Microbiology. Chief of Pediatric Infectious Disease, University of Hawaii John A. Burns School of Medicine. Medical Director of Infection Control, Kapiolani Medical Center For Women And Children, Honolulu, Hawaii. M. Stanton Michels, MD, FAAP Assistant Professor of Pediatrics, University of Hawaii John A. Burns School of Medicine. Attending Pediatrician, Queen Emma Clinics, Queen's Medical Center, Honolulu, Hawaii. Max C. Miranda Medical Student, University of Hawaii John A Burns School of Medicine (Class of 2004), Honolulu, Hawaii. Richard Y. Mitsunaga, MD, FAAP Pediatrician in Private Practice. Medical Director, HMSA QUEST (Medicaid Managed Care Plan). Clinical Professor of Pediatrics, University of Hawaii John A Burns School of Medicine, Honolulu, Hawaii. Kathleen A. Morimoto, MD Clinical Instructor in Pediatrics, University of Hawaii John A. Burns School of Medicine. Pediatrician in Private Practice, Kaneohe, Hawaii. Daniel T. Murai, MD, FAAP Associate Professor of Pediatrics, University of Hawaii John A. Burns School of Medicine. Attending Neonatologist, Kapiolani Medical Center for Women and Children, Honolulu, Hawaii. Lori S. Murayama Medical Student, University of Hawaii John A Burns School of Medicine (Class of 2004), Honolulu, Hawaii. Ken Nagamori, MD, FAAP Clinical Associate Professor of Pediatrics, University of Hawaii John A. Burns School of Medicine. Attending Pediatric Gastroenterologist in Private Practice, Honolulu, Hawaii. Gareth K. Nakasone Medical Student, University of Hawaii John A Burns School of Medicine (Class of 2005), Honolulu, Hawaii. Mai Anh K. Nguyen, MD Assistant Professor of Pediatrics and Psychiatry, University of Hawaii John A. Burns School of Medicine, Honolulu, Hawaii. Kalamaoka'aina Kil Soon Niheu, MD Clinical Instructor in Family Practice, University of Hawaii John A Burns School of Medicine. Resident in Family Practice (Graduating 2006), Wahiawa General Hospital, Wahiawa, Hawaii. Julie K. Nishimura, MD, FAAO Pediatric Ophthalmologist, Kaiser Permanente Medical Group, Honolulu, Hawaii. Jason T. Nomura, MD Resident in Emergency Medicine/Internal Medicine, Christiana Care Health Services, Delaware Sherloune Normil-Smith, MD Clinical Instructor in Pediatrics, University of Hawaii John A. Burns School of Medicine. Former Resident in Pediatrics (Graduated 2003), Kapiolani Medical Center For Women And Children, Honolulu, Hawaii. Brent K. Ogawa, MD Resident in Orthopedic Surgery, University of Southern California School of Medicine, Los Angeles, California. Jeffrey K. Okamoto, MD, FAAP Assistant Professor of Pediatrics, University of Hawaii John A. Burns School of Medicine. Medical Director of Rehabilitative Services, Kapiolani Medical Center for Women and Children, Honolulu, Hawaii. Judy T. Okimura, MD Clinical Instructor in Pediatrics and Internal Medicine, University of Hawaii John A. Burns School of Medicine. Former Resident in Pediatrics and Internal Medicine (Graduated 2003), Queen's Medical Center & Kapiolani Medical Center For Women And Children, Honolulu, Hawaii. Floyd S. Ota, MD Clinical Instructor in Pediatrics, University of Hawaii John A. Burns School of Medicine. Fellow in Pediatric Emergency Medicine, University of Texas Southwestern Medical School, Children's Medical Center of Dallas, Dallas, Texas. Kimberly N. Otsuka, MD Pediatric Pulmonology Fellow, University of Arizona, Tucson, Arizona. Potenciano Reynoso Paredes, MD Clinical Instructor in Pediatrics, University of Hawaii John A. Burns School of Medicine. Former Resident in Pediatrics (Graduated 2002), Kapiolani Medical Center For Women And Children, Honolulu, Hawaii. Leo U. Pascua, MD Clinical Assistant Professor of Family Practice, University of Hawaii John A. Burns School of Medicine. Pediatrician in Private Practice. Vice-Chief of Staff, Wahiawa General Hospital, Wahiawa, Hawaii. Mary Elaine Patrinos, MD, FAAP Assistant Professor of Pediatrics, University of Hawaii John A. Burns School of Medicine. Attending Neonatologist, Kapiolani Medical Center For Women And Children, Honolulu, Hawaii. Kaipo T. Pau Medical Student, University of Hawaii John A Burns School of Medicine (Class of 2005), Honolulu, Hawaii. Anita M. Pedersen, MD, FAAP, LTC, MC, USA Chief, Pediatric Endocrinology, Tripler Army Medical Center. Clinical Assistant Professor of Pediatrics, University of Hawaii John A Burns School of Medicine, Honolulu, Hawaii. Donald A. Person, MD, COL, MC, USA, FAAP Medical Director and Senior Scientist, Department of Clinical Investigation, Tripler Army Medical Center. Clinical Professor of Pediatrics, University of Hawaii John A. Burns School of Medicine, Honolulu, Hawaii. Maureen M. Petersen, MD, CPT, MC, USA Attending Pediatrician, Tripler Army Medical Center, Honolulu, Hawaii. Clinical Assistant Professor of Pediatrics, University of Hawaii John A Burns School of Medicine, Honolulu, Hawaii. Robert L. Peterson, MD Assistant Professor of Surgery, University of Hawaii John A. Burns School of Medicine. Chairman of Surgery, Kapiolani Medical Center For Women And Children.. Medical Director, Athena Clinics International, Honolulu, Hawaii. D. Venu Reddy, MD, MPH, FAAP Professor of Pediatrics, University of Hawaii John A. Burns School of Medicine. Director, Pediatric Cardiology, Kapiolani Medical Center For Women And Children, Honolulu, Hawaii. Timur M. Roytman Medical Student, University of Hawaii John A Burns School of Medicine (Class of 2005), Honolulu, Hawaii. Raul Rudoy, MD, MPH, FAAP Professor and Chairman, Department of Pediatrics, University of Hawaii John A. Burns School of Medicine. Pediatric Infectious Disease Specialist, Kapiolani Medical Center For Women And Children, Honolulu, Hawaii. Joel Ruff, MD Clinical Instructor in Pediatrics, University of Hawaii John A. Burns School of Medicine. Former Resident in Pediatrics (Graduated 2003), Kapiolani Medical Center For Women And Children, Honolulu, Hawaii. Lu'ukia Ruidas, MD Clinical Instructor in Family Practice, University of Hawaii John A. Burns School of Medicine. Resident in Family Practice, Wahiawa General Hospital, Wahiawa, Hawaii. Nadine Tenn Salle, MD Clinical Instructor in Pediatrics and Internal Medicine, University of Hawaii John A. Burns School of Medicine. Practicing Pediatrician and Internist, Honolulu, Hawaii. Renee L. Sato, MD Clinical Instructor in Obstetrics/Gynecology, University of Hawaii John A. Burns School of Medicine. Resident in Obstetrics/Gynecology (Graduating 2006), Kapiolani Medical Center For Women And Children, Honolulu, Hawaii. Teresa Han Seo Medical Student, University of Hawaii John A Burns School of Medicine (Class of 2004), Honolulu, Hawaii. Scott J. Sheets, DO, MAJ, MC, USA Chief, Pediatric Pulmonology, Tripler Army Medical Center. Clinical Assistant Professor of Pediatrics, University of Hawaii John A Burns School of Medicine, Honolulu, Hawaii. Cecilia M. Shikuma, MD Associate Professor of Medicine, University of Hawaii John A. Burns School of Medicine. Director, Hawaii AIDS Clinical Research Program, Honolulu, Hawaii Melanie L. Shim, MD, FAAP Clinical Instructor, Division of Pediatric Endocrinology, Department of Pediatrics, UCLA School of Medicine. Attending Pediatric Endocrinologist, Mattel Children's Hospital at UCLA, Los Angeles, California. Walton K.T. Shim, MD, FACS, FAAP Professor of Surgery and Pediatrics, University of Hawaii John A. Burns School of Medicine. Attending Pediatric Surgeon and Chief of Staff, Kapiolani Medical Center For Women And Children, Honolulu, Hawaii. Lance K. Shirai, MD, MS, FAAP, FACC Clinical Assistant Professor of Pediatrics, University of Hawaii John A. Burns School of Medicine. Pediatric Cardiologist, Kaiser Permanente Medical Center, Honolulu, Hawaii. Miki E. Shirakawa Medical Student, University of Hawaii John A Burns School of Medicine (Class of 2004), Honolulu, Hawaii. Bruce T. Shiramizu, MD Associate Professor of Pediatrics, University of Hawaii John A. Burns School of Medicine. Director, Hawaii HIV and Immunology Laboratory, Honolulu, Hawaii. Jocelyn M. Sonson Medical Student, University of Hawaii John A Burns School of Medicine (Class of 2005), Honolulu, Hawaii. Chad S.D. Sparks Medical Student, University of Hawaii John A Burns School of Medicine (Class of 2004), Honolulu, Hawaii. Cheryl M. Takao, MD Clinical Instructor in Pediatrics, University of Hawaii John A. Burns School of Medicine. Resident in Pediatrics (Graduated 2002), Kapiolani Medical Center For Women And Children, Honolulu, Hawaii. Fellow in Pediatric Cardiology, Children's Hospital of Los Angeles, Los Angeles, California. Akaluck Thatayatikom, MD Assistant Professor of Pediatrics, Faculty of Medicine, Thammasat University, Thailand. Former Fellow in Allergy and Immunology, National Jewish Medical and Research Center, Denver, Colorado. Former Resident in Pediatrics (graduated 2002), Kapiolani Medical Center for Women and Children, Honolulu, Hawaii. Fellow in Pediatric Rheumatology, Washington University, St. Louis Children's Hospital, St. Louis, Missouri. Cynthia H. Tinsley, MD Pediatric Intensivist, Pomona Valley Hospital, Pomona Valley, California. Sharon M. Tisza, MD Clinical Instructor, Department of Pediatrics, University of Hawaii John A. Burns School of Medicine. Fellow in Forensic Psychiatry, Department of Psychiatry, University of Hawaii John A. Burns School of Medicine, Honolulu, Hawaii. Attending Child and Adolescent Psychiatrist, Aloha House, Kahului, Hawaii. Mari Uehara, MD Pediatrician and Child Development Specialist, Kapiolani Medical Center For Women And Children. Clinical Instructor of Pediatrics, University of Hawaii John A. Burns School of Medicine, Honolulu, Hawaii. Annemarie Uliasz Medical Student, University of Hawaii John A Burns School of Medicine (Class of 2004), Honolulu, Hawaii. Daniel W. Ulrich, MD Clinical Instructor in Pediatrics, University of Hawaii John A. Burns School of Medicine. Resident in Pediatrics & Psychiatry, Fellow in Child Psychiatry, Kapiolani Medical Center For Women And Children, Honolulu, Hawaii. Greg Y. Uramoto, MD Pediatric Endocrinologist, Central Medical Clinic. Clinical Assistant Professor of Pediatrics, University of Hawaii John A. Burns School of Medicine, Honolulu, Hawaii. Paula A. Vanderford, MD, FAAP Assistant Professor of Pediatrics, University of Hawaii John A. Burns School of Medicine. Medical Director, Pediatric Intensive Care Unit, Kapiolani Medical Center For Women And Children, Honolulu, Hawaii. Judy Makowski Vincent, MD, FAAP Colonel (Ret.), Medical Corps, United States Army, Senior Consultant in Pediatric Infectious Diseases, Tripler Army Medical Center. Clinical Associate Professor of Pediatrics, University of Hawaii John A. Burns School of Medicine, Honolulu Hawaii. Catherine Y.H. Wagoner, MD Pediatrician in Private Practice, Reno, Nevada. Robert Wilkinson, MD, FAAP Professor of Pediatrics, University of Hawaii John A. Burns School of Medicine. Attending Hematologist/Oncologist in Private Practice. Director, Hawaii Children's Blood and Cancer Group, Honolulu, Hawaii. Adeline Winkes, MD, FAAP Assistant Professor of Pediatrics, University of Hawaii John A. Burns School of Medicine. Attending Hospitalist Pediatrician, Kapiolani Medical Center For Women And Children, Honolulu, Hawaii. David K.M. Wong, MD Clinical Instructor in Surgery, University of Hawaii John A. Burns School of Medicine. Resident in Surgery, University of Hawaii Affiliated Hospitals, Honolulu, Hawaii. Jeffrey J. Wong, MD Clinical Instructor in Internal Medicine, University of Hawaii John A. Burns School of Medicine. Resident in Internal Medicine, University of Hawaii Affiliated Hospitals, Honolulu, Hawaii. Resident in Ophthalmology (2004), New York University, New York, New York. Kelley A. Woodruff, MD, FAAP Assistant Professor of Pediatrics, University of Hawaii John A. Burns School of Medicine. Attending Pediatric Hematologist/Oncologist, Hawaii Children's Blood and Cancer Group, Honolulu, Hawaii. Rodney K. Yamaki Medical Student, University of Hawaii John A Burns School of Medicine (Class of 2004), Honolulu, Hawaii. Franklin Y. Yamamoto, MD, FAAP, FAAAAI Director, Pediatric Allergy Clinic, Kapiolani Medical Center For Women And Children. Associate Professor of Pediatrics, University of Hawaii John A. Burns School of Medicine, Honolulu, Hawaii. Kara S. Yamamoto, MD, FAAP, FACR Assistant Professor of Pediatrics, University of Hawaii John A. Burns School of Medicine. Attending Pediatric Rheumatologist, Kapiolani Medical Center For Women And Children, Honolulu, Hawaii. Loren G. Yamamoto, MD, MPH, MBA, FAAP, FACEP Professor of Pediatrics, University of Hawaii John A. Burns School of Medicine. Pediatric Emergency Medicine Medical Director, Kapiolani Medical Center For Women And Children, Honolulu, Hawaii. Kelly S. Yamasato Medical Student, University of Hawaii John A Burns School of Medicine (Class of 2005), Honolulu, Hawaii. Vince K. Yamashiroya, MD, FAAP Clinical Assistant Professor of Pediatrics, University of Hawaii John A. Burns School of Medicine. Pediatrician in Private Practice, Honolulu, Hawaii. Cindy W. Yang Medical Student, University of Hawaii John A Burns School of Medicine (Class of 2005), Honolulu, Hawaii. Lynette L. Young, MD, FAAP Assistant Professor of Pediatrics, University of Hawaii John A. Burns School of Medicine. Pediatric Emergency Medicine Attending Physician, Kapiolani Medical Center For Women And Children, Honolulu, Hawaii. Chapter I.1. Pediatric Primary Care Melinda J. Ashton, MD A six year old male presents to your office for his annual well child visit. He is accompanied by his mother. You have cared for this child since his birth, and he has had regular well child care. You last saw him for his visit prior to entering kindergarten at age five years. Today his mother notes that she has been anxiously awaiting this visit as she has several concerns to discuss: 1. He is having some difficulty in school (now just finishing the first quarter of first grade). He is struggling to learn to read, and has some difficulty with arithmetic. His teacher called his mother yesterday to report that he hasn't been turning in his homework or completing his classroom assignments. His mother indicates that she was very surprised to hear this, as the previous teacher reports have indicated that he was doing adequate work. 2. He has frequent complaints of stomachache. He has a good appetite, but has always been a "picky eater". He enjoys drinking milk. 3. He has been having increasing nasal congestion over the last few months. He has had some sneezing attacks, and seems to clear his throat often. He does cough at night. The cough often sounds "wet" to his mother. He also joins in to tell you that he has a hard time breathing during PE. He has no other regular physical activity, but his mother reports that he is always "busy doing something". His mother reminds you that he was born prematurely at 34 weeks, and had difficulty with wheezing as a younger child, but he has done well in the last year or two and hasn't needed any medications for wheezing. Exam: VS are normal. Weight 30 kg (66#) (> 95%ile), height 117 cm (46") (50%). In general, he appears to be an overweight, friendly child who is cooperative and who appears to be his stated age. He is active in the exam room, exploring the contents of the drawers and cabinets. He interrupts his mother repeatedly during the interview. He appears to be mouth breathing with significant nasal congestion. His tonsils are large but not inflamed. His heart is regular without murmurs. His pulses are normal. His lungs have clear breath sounds, with transmitted upper airway rhonchi. There are no wheezes, but the I:E ratio is prolonged. His abdominal and neurologic screening exams are normal. The approach taken by a pediatrician when confronted with this patient with multiple complex complaints will vary considerably depending on factors such as training, availability of appropriate pediatric subspecialists, and past successes (or failures) when managing similar issues. As an example, the patient presented above could be referred to a psychologist for an educational assessment, a psychiatrist to manage possible ADHD, a gastroenterologist to manage his abdominal pain, an allergist, a pulmonologist, and possibly an otolaryngologist to evaluate his respiratory complaints, and a nutritionist or dietitian or weight management program to manage his obesity. It would be a daunting task to coordinate and manage all of these specialists, and it is likely that the parents would be thoroughly confused about how to improve his situation if they did receive input from all of these experts. On the other hand, a thoughtful pediatrician could successfully manage all of these issues without any consultations at all. Most pediatricians would probably develop a plan of care somewhere between these two extremes, using selected specialists to assist in the area of concern that they feel least comfortable managing. The medical home is a concept in which a primary care provider is the ultimate source of all health care for a child. This would include acute care visits for illnesses and injuries, anticipatory guidance, immunizations, growth and development monitoring, preventive health maintenance, and especially for children with special health care needs; the coordination of care among other medical and nonmedical specialists (audiology, speech therapy, child development programs, school programs, etc.). Although acute care office visits for illnesses and injuries are an important part of what pediatricians do, a significant component of pediatric primary care consists of anticipatory guidance, immunizations, growth and development monitoring, and preventive health maintenance (1). Coordination of care and providing after hours care are areas where there is a large amount of variation in approach. This variation is partly a result of personal style and choices, but it is also significantly influenced by location and type of practice. For example, a solo rural pediatrician would not be able to limit his/her availability after hours for emergencies in the same way that a pediatrician employed by a large group that provides full after hours coverage for emergencies, newborns and telephone triage would be able to. Even in urban areas with lots of coverage for emergency care and newborns, pediatricians vary in their accessibility to their patients. Some parents are told not to call their pediatrician after hours "unless it is an emergency", while others work with pediatricians who provide their home phone number and are easily accessible through an answering service for after hours concerns. Those pediatricians find that while many families feel comforted by the knowledge that they could reach their doctor easily if they needed to, not many families abuse the privilege. Another area of after hours care with great variability is the use of the emergency room to manage illness when the office is closed. Some pediatricians are not available to their patients for after hours advice at all, with their answering machine directing parents with concerns to take the patient to the nearest emergency room. Most pediatricians will discuss concerns that a parent may have after hours; the difficulty then is that you must offer advice about whether to seek care in the emergency room or wait until the office is again open. Concern about liability may cause some physicians to send most patients to the emergency room, particularly if there is another physician there who will see the child (so that they do not have to go in themselves). That will then transfer the problem to someone else, and an exam will be performed so that you are no longer accepting the parental observations as your only source of information. Unfortunately this is a very expensive way to provide care, so many pediatricians try to refer only those patients who sound like they might benefit from emergency care. Determining which patients should go becomes even more difficult when covering for a colleague after hours. Part of the decision making often includes knowledge of prior interactions with the parents. When the parents are strangers, it is more likely that they will be sent to the ER if they call with concerns. As primary care physicians, pediatricians are the first to be consulted by many parents for a wide range of concerns. It is useful to have a basic management plan (or algorithm) for the most common complaints that come in, including an assessment of when referral to a specialist might make sense. In developing such an algorithm, a primary consideration will be the local availability of pediatric subspecialists. For example, it is not useful to decide that any child presenting with a heart murmur will be evaluated by a pediatric cardiologist, if the nearest available pediatric cardiologist is hundreds of miles away. The varying availability of subspecialty care is one of the factors involved in the observed variability in the medical care provided in one locale compared to another. If a pediatric subspecialist is not available locally, the choices for a general pediatrician then become: a) evaluate and manage yourself, b) use a specialist who does not have pediatric subspecialty training, or c) send the patient to the specialist regardless of the distance/expense/inconvenience involved. In some locations, you may also have the option of managing the patient using a specialist available to you by telemedicine, but this is not a widespread practice yet. Certification is available from the American Board of Pediatrics in the following pediatric subspecialties: adolescent medicine, clinical and laboratory immunology, medical toxicology, pediatric cardiology, pediatric critical care medicine, pediatric emergency medicine, pediatric endocrinology, pediatric gastroenterology, pediatric hematology/oncology, pediatric infectious diseases, pediatric nephrology, neonatal-perinatal medicine, pediatric pulmonology, pediatric rheumatology, developmental-behavioral pediatrics, neurodevelopmental disabilities and sports medicine (2). Subspecialty certification (from other specialty Boards) is also available in: pediatric otolaryngology, child and adolescent psychiatry, pediatric radiology, pediatric surgery, and pediatric pathology (3). Other specialties may offer additional pediatric training to their fellows to allow them to be designated as subspecialists. For example, pediatric orthopedists and pediatric ophthalmologists have additional training and skills necessary for the appropriate care of children. Under traditional fee for service payment arrangements (doctors are paid for services that they deliver), access to pediatric subspecialty care was primarily limited by geographic availability. "Capitation" refers to a system in which physicians are paid a fixed amount per patient per month regardless of whether the patient is seen 20 times during the month or not at all. Capitation is risky in that physicians will not be adequately reimbursed for severe or chronically ill patients, but on average, this is offset by healthy patients who do not use the service. With other insurance payment arrangements covered under the umbrella of "managed care" (which may be pure capitation or a combination of capitation and fee for service), the access to pediatric subspecialty care may also be limited by the network of physicians who participate with (or are employed by) the health maintenance organization. A pediatrician who is deciding whether to contract with, or become employed by, a health maintenance organization may want to consider what degree of access to pediatric subspecialty care his/her patients will be able to count on. As access to subspecialists becomes more difficult, the primary care pediatrician will need to be able to provide more complex care for at least some of the patients in his/her panel. The American Academy of Pediatrics has addressed these issues in several policy statements. For example, in "Guiding Principles for Managed Care Arrangements for the Health Care of Newborns, Infants, Children and Young Adults" (4), some major principles were outlined including: 1. Access to Appropriate Primary Care Pediatricians: a. Choice of primary care clinicians for children must include pediatricians. b. Primary care pediatricians (PCPs) should serve as the child's medical home and ensure the delivery of comprehensive preventive, acute, and chronic care services. They should be accessible 24 hours a day, 7 days a week, or have appropriate coverage arrangements. c. The PCP should assume the role of the care coordinator (i.e., the physician who ensures that all referrals are medically necessary). The function of the PCP might be transferred to a pediatric medical subspecialist for certain children with complex physical and/or mental health problems (e.g., those with special health care needs, such as children with cystic fibrosis, juvenile rheumatoid arthritis) if the specialist assumes responsibility and financial risk for primary and specialty care. For certain physical, developmental, mental health, and social problems, the PCP may seek the assistance of a multidisciplinary team with participation by appropriate public programs (e.g., Title V Program for Children with Special Health Care Needs). d. Families should receive education at the time of enrollment to help them understand fully how managed care arrangements work for their individual policies. 2. Access to Pediatric Specialty Services: a. When children need the services of a physician specialist or other health care professionals, plans should use clinicians with appropriate pediatric training and expertise. Pediatric-trained physician specialists, including pediatric medical subspecialists and pediatric surgical specialists, should have completed an appropriate fellowship in their area of expertise and be certified by specialty boards in a timely fashion if certification is available. These physicians and other health care practitioners should be engaged actively in the ongoing practice of their pediatric specialty and should participate in continuing medical education in this area. b. There should be no financial barriers to access for pediatric specialty care above and beyond customary plan requirements for specialty care. c. Plans should contract with the appropriate number and mix of geographically accessible pediatric-trained physician specialists and tertiary care centers for children. d. Referral criteria for pediatric specialty clinicians should be developed. These criteria may include age of the patient, specific diagnoses, severity of conditions, and logistic considerations (e.g., geographical access and cultural competence). e. Processes for approving referrals to pediatric medical subspecialists and pediatric surgical specialists should be developed by health plans working collaboratively with PCPs and pediatric medical subspecialists and pediatric surgical specialists. There is particular concern about pediatric specialty care for children with special health care needs. As stated in the AAP policy statement "Managed Care and Children with Special Health Care Needs: A Review" (5): Children with disabilities differ from adults with disabilities in a managed care environment in a variety of ways. Three major differences include the following: 1) The changing dynamics of child development affect the needs of these children at different developmental stages and alter their expected outcomes. Illness and disability can delay, sometimes irreversibly, a child's normal development. 2) The epidemiology and prevalence of childhood disabilities, with many rare or low incidence conditions and few common ones, differ markedly from that of adults, in which there are few rare conditions and several common ones. 3) Because of children's need for adult protection and guidance, their health and development depend greatly on their families' health and socioeconomic status. This policy also states, "Children with disabilities and other chronic conditions that may lead to disability require the services of pediatric subspecialists in addition to primary care pediatricians. Access and availability of pediatric subspecialty services must not be significantly impeded by managed care arrangements. Although it is ideal for the primary care physician to manage and coordinate the care for a child's health needs, the complex or rare nature of a particular child's condition may make it difficult for the primary care physician to meet all of the needs of the child and family adequately without additional expertise" (5). A good pediatric primary care physician should also work with non-physician partners. Interactions with school personnel, public health nurses, social workers, various therapists (such as speech/language therapists, occupational therapists, physical therapists), early childhood educators or daycare providers are a common part of pediatric practice today. Learning to interact appropriately with these individuals, and to gain from their expertise, is an important part of pediatric training. Primary care pediatrics can be very challenging. Although there is a perception that office based pediatrics is largely limited to runny noses and ear infections, in fact there is a wide realm of issues and problems that a pediatrician may become involved in. The nature of the practice will depend to some extent on the ease of availability of subspeciality care, but will also depend on personal characteristics of the pediatrician that determine the practice style he or she is most comfortable with. Questions 1. True/False: When caring for pediatric patients, it is always more appropriate to use pediatric subspecialists than specialists who may be primarily trained to work with adults. 2. True/False: There is a standard for after hours accessibility that all pediatricians adhere to. 3. True/False: There is variability in the use of pediatric subspecialty care that results from factors other than availability of specialists. 4. If a pediatric subspecialist is not available, the pediatrician has the following choices: a. Evaluate and manage the patient without referral. b. Use a specialist who does not have pediatric subspecialty training. c. Send the patient to a pediatric subspecialist regardless of cost and inconv