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 Challenging Cases in

Challenging Cases in Pediatric Hospital Medicine

Challenging Cases in Pediatric

Pediatric
Hospital Medicine
Editors
Daniel A. Rauch, MD, SFHM, FAAP • Snezana Nena Osorio, MD, MS, FAAP

Hospital Medicine
Associate Editors
Jennie G. Ono, MD, MS, FAAP • Jennifer Oshimura, MD
Written by pediatric hospitalists and clinician-educators, this valuable
reference and learning tool features 50 real-life case studies to guide you
expertly through the types of cases (both common and rare) encountered by
practicing pediatric hospitalists.
Each chapter begins with the patient presentation. Next, the chapter steps Editors
through the patient hospital course and the case workup and management, Daniel A. Rauch, MD, SFHM, FAAPﾠ●ﾠSnezana Nena Osorio, MD, MS, FAAP
as well as the patient outcome and follow-up. Chapters conclude with the Associate Editors
clinical competencies that were addressed, followed by valuable pearls— Jennie G. Ono, MD, MS, FAAPﾠ●ﾠJennifer Oshimura, MD
discussions of aspects of care that do not just cover disease management
but truly reflect the scope of pediatric hospital medicine. Recommended
readings round out each chapter.
With its case-based format, this book is both a valuable clinical tool and a superb
learning and training aid for various levels of learners on a medical team.
Chapters include
• Asthma Care Challenges in Adolescents
• Prolonged Fever and Rash
• Intentional Ingestion
• Persistent Neonatal Jaundice
• Cough and Chest Pain
• Unintentional Lead Poisoning
• Recurrent Pancreatitis Rauch • Osorio
• Extreme Inflammatory Response
• And much more

For other pediatric resources, visit the American Academy

of Pediatrics at shop.aap.org.

AAP
 Challenging Cases in
Pediatric
Hospital Medicine
Editors
Daniel A. Rauch, MD, SFHM, FAAP • Snezana Nena Osorio, MD, MS, FAAP
Associate Editors
Jennie G. Ono, MD, MS, FAAP • Jennifer Oshimura, MD

Challenging Cases in Hospital Med_Book.indb 1 07/08/20 9:26 AM

 American Academy of Pediatrics Publishing Staff
Mary Lou White, Chief Product and Services Officer/SVP, Membership, Marketing, and Publishing
Mark Grimes, Vice President, Publishing
Carrie Peters, Editor, Professional/Clinical Publishing
Theresa Wiener, Production Manager, Clinical and Professional Publications
Amanda Helmholz, Medical Copy Editor
Linda Smessaert, MSIMC, Senior Marketing Manager, Professional Resources
Mary Louise Carr, MBA, Marketing Manager, Clinical Publications

Published by the American Academy of Pediatrics

345 Park Blvd
Itasca, IL 60143
Telephone: 630/626-6000
Facsimile: 847/434-8000
www.aap.org

The American Academy of Pediatrics is an organization of 67,000 primary care pediatricians,

pediatric medical subspecialists, and pediatric surgical specialists dedicated to the health, safety, and
well-being of infants, children, adolescents, and young adults.
The recommendations in this publication do not indicate an exclusive course of treatment
or serve as a standard of medical care. Variations, taking into account individual circumstances, may
be appropriate.
Statements and opinions expressed are those of the authors and not necessarily those of the
American Academy of Pediatrics.
Any websites, brand names, products, or manufacturers are mentioned for informational
and identification purposes only and do not imply an endorsement by the
American Academy of Pediatrics (AAP). The AAP is not responsible for the content of
external resources. Information was current at the time of publication.
This publication has been developed by the American Academy of Pediatrics. The contributors are
expert authorities in the field of pediatrics. No commercial involvement of any kind has been solicited
or accepted in the development of the content of this publication. Disclosures: Dr Rauch disclosed a
consultant relationship with the American Board of Pediatrics; Dr Kenny (Chapter 16) disclosed a board
of directors position with Cardinal Health.
Every effort has been made to ensure that the drug selection and dosage set forth in this text are
in accordance with the current recommendations and practice at the time of publication. It is the
responsibility of the health care professional to check the package insert of each drug for any change in
indications and dosage and for added warnings and precautions.
Every effort is made to keep Challenging Cases in Pediatric Hospital Medicine consistent with the most recent
advice and information available from the American Academy of Pediatrics.
Please visit www.aap.org/errata for an up-to-date list of any applicable errata for this publication.
Special discounts are available for bulk purchases of this publication.
Email Special Sales at [email protected] for more information.

© 2021 American Academy of Pediatrics

All rights reserved. No part of this publication may be reproduced, stored in a retrieval system,
or transmitted in any form or by any means—electronic, mechanical, photocopying, recording, or
otherwise—without prior permission from the publisher (locate title at http://ebooks.aappublications.org
and click on © Get permissions; you may also fax the permissions editor at 847/434-8780 or
email [email protected]).

Printed in the United States of America

9-456/0920               1 2 3 4 5 6 7 8 9 10
MA0996
ISBN: 978-1-61002-456-3
eBook: 978-1-61002-457-0
Cover and publication design by Peg Mulcahy

Library of Congress Control Number: 2020932855

Challenging Cases in Hospital Med_Book.indb 2 07/08/20 9:26 AM

 Contributors

Editors
Daniel A. Rauch, MD, SFHM, FAAP Snezana Nena Osorio, MD, MS, FAAP
Professor of Pediatrics Professor of Clinical Pediatrics
Tufts University School of Department of Pediatrics
Medicine Weill Cornell Medicine
Chief of Pediatric Hospital New York-Presbyterian Komansky
Medicine Children’s Hospital
Floating Hospital for Children at New York, NY
Tufts Medical Center
Boston, MA

Associate Editors
Jennie G. Ono, MD, MS, FAAP Jennifer Oshimura, MD
Medical Director, Inpatient Formerly of Children’s Healthcare
Pediatrics of Atlanta at Scottish Rite
Assistant Professor of Clinical Atlanta, GA
Pediatrics
Weill Cornell Medicine
New York-Presbyterian Komansky
Children’s Hospital
New York, NY

Challenging Cases in Hospital Med_Book.indb 3 07/08/20 9:26 AM

 iv Contributors

Authors
Sarah T. Adams, MD, IBCLC, FAAP Kathleen Bradford, MD
Assistant Professor of Pediatrics Professor of Pediatrics
Division of Hospital Pediatrics University of North Carolina
University of North Carolina Chapel Hill, NC
Chapel Hill, NC 20: Unintentional Lead Poisoning
12: Altered Mental Status April O. Buchanan, MD, FAAP
Namrata Ahuja, MD Associate Dean for Curriculum
Assistant Professor of Clinical and Pediatric Hospitalists
Pediatrics University of South Carolina
Division of Hospital Medicine School of Medicine Greenville
Children’s Hospital Los Angeles Prisma Health Children’s Hospital
University of Southern California Greenville, SC
Los Angeles, CA 7: Chronic Leg Pain
15: Failure to Thrive Beyond Lisa Capra, MD
Infancy Medical Director, Newborn
Sarah Bauer, MD Nursery
Assistant Professor, Hospital Division of Pediatric Hospitalist
Medicine Medicine
Medical College of Wisconsin Floating Hospital for Children at
Milwaukee, WI Tufts Medical Center
37: Incomplete Maternal History Boston, MA
Confounding the Diagnosis 32: A Newborn With Black Stools
Julia Beauchamp-Walters, MD, Megan Cardoso, MD, FAAP
FAAP Attending Pediatrician,
Clinical Professor of Pediatrics Chelmsford Pediatrics
Division of Pediatric Hospital Pediatric Medical Director,
Medicine Wellforce Medicaid ACO
University of California San Diego Dunstable, MA
San Diego, California 14: Fever and Refusal to Walk
23: Developmental Regression and Sonia Chaudhry, MD, FAAP
Transaminitis Assistant Professor of Pediatrics
Bo Borch-Christensen, MD , FAAP Division of Neonatology
Pediatric Hospital Medicine University of Connecticut School
Phoenix Children’s Hospital of Medicine
Phoenix, AZ Connecticut Children’s Medical
24: Food Allergy in Infancy Center
Hartford, CT
33: Diabetic Ketoacidosis

Challenging Cases in Hospital Med_Book.indb 4 07/08/20 9:26 AM

 Contributors v

Margaret A. Connolly, MD, FAAP Sandra Gage, MD, PhD, SFHM,

Assistant Professor of Clinical FAAP
Pediatrics Associate Division Chief of Hospital
Renaissance School of Medicine at Medicine
Stony Brook University Phoenix Children’s Hospital
Division of Pediatric Hospital Associate Professor of Pediatrics
Medicine University of Arizona College of
Stony Brook Children’s Hospital Medicine – Phoenix
Stony Brook, NY Phoenix, AZ
45: Infant With Fever 24: Food Allergy in Infancy
Ami Doshi, MD, FAAP 26: Severe Headaches
Associate Professor of Pediatrics 30: Extreme Inflammatory Response
Division of Hospital Medicine 35: Recurrent Stridor
University of California San Diego 39: “Direct” Hyperbilirubinemia in
Director of Inpatient Palliative a Newborn
Care 50: Cardiac Arrest
Rady Children’s Hospital Laurie Gordon, MD, MA, FAAP
San Diego, CA Pediatric Hospitalist
9: Palliative Care in Hospital Associate Professor of Clinical
Medicine Pediatrics
Julie A. Dunbar, MD, FAAP Weill Cornell Medicine
Division of Pediatric Hospital New York, NY
Medicine 36: Sickle Cell Disease and
The Children’s Hospital at Cognitive Biases
Montefiore Cori Green, MD, MS, FAAP
Assistant Professor of Pediatrics Director of Behavioral Health
Albert Einstein College of Education and Integration in
Medicine Pediatrics
Bronx, NY Associate Professor of Clinical
34: Ventriculoperitoneal Shunt Pediatrics
Complications Weill Cornell Medical Center
New York, NY
19: Hypotonia and Poor Feeding

Challenging Cases in Hospital Med_Book.indb 5 07/08/20 9:26 AM

 vi Contributors

Matt Grisham, MD, FAAP Maheshwor Kafle, MD

Clinical Assistant Professor of Pediatric Hospitalist
Pediatrics Phoenix Children’s Hospital
Division of General Pediatrics Assistant Professor of Child Health
Prisma Health/University of South University of Arizona
Carolina School of Medicine Phoenix, AZ
Greenville 39: “Direct” Hyperbilirubinemia in
Greenville, SC a Newborn
17: Intentional Ingestion Michelle Katzow, MD, MS, FAAP
Jennifer S. Hall, MD, FAAP Diplomate of the American Board
Pediatric Hospital Medicine Fellow of Obesity Medicine
Phoenix Children’s Hospital Cohen Children’s Medical Center
Phoenix, AZ Northwell Health
50: Cardiac Arrest New Hyde Park, NY
Patricia Hametz, MD, MPH, FAAP 8: Right Upper Quadrant Pain in an
Chief, Division of Pediatric Adolescent
Hospital Medicine Gregory Kenny, MD
Associate Professor of Pediatrics Department of Pediatrics
Albert Einstein College of Elmhurst Hospital Center, NYC
Medicine/The Children’s Health + Hospitals
Hospital at Montefiore Assistant Professor of Pediatrics
Bronx, NY Icahn School of Medicine at Mount
34: Ventriculoperitoneal Shunt Sinai
Complications New York, NY
Katherine Harer, MD 16: Breastfeeding Difficulties
Floating Hospital for Children at Manaswitha Khare, MD
Tufts Medical Center Clinical Assistant Professor of
Boston, MA Pediatrics
44: Unusual Bruising in an Active Division of Pediatric Hospital
Child Medicine
Vanessa L. Hill, MD, FAAP Rady Children’s Hospital
Associate Professor of Pediatrics University of California San Diego
Section of Pediatric Hospital San Diego, CA
Medicine 38: Recurrent Pancreatitis
Baylor College of Medicine
The Children’s Hospital of San
Antonio
San Antonio, TX
3: Thinking Beyond Bronchiolitis

Challenging Cases in Hospital Med_Book.indb 6 07/08/20 9:26 AM

 Contributors vii

Anika Kumar, MD, FHM, FAAP Daniel M. Lercher, DM

Clinical Assistant Professor of Assistant Professor, Pediatric
Pediatrics Critical Care Medicine
Department of Pediatric Hospital Department of Pediatrics
Medicine University of North Carolina
Cleveland Clinic Children’s Chapel Hill, NC
Cleveland Clinic Lerner College 20: Unintentional Lead Poisoning
of Medicine of Case Western Michael Levy, MD
Reserve University Assistant Professor of Pediatrics
Cleveland, OH Division of Hospital Medicine
11: Managing Eating Disorders in Rady Children’s Hospital
the Hospital San Diego, CA
Janelle Laudone, MD, FAAP 6: Pelvic Pain
Assistant Professor of Pediatrics Huay-ying Lo, MD, FAAP
Division of Pediatric Hospital Assistant Professor of Pediatrics
Medicine Pediatric Hospital Medicine
Tufts University School of Medicine Texas Children’s Hospital and
Boston, MA Baylor College of Medicine
33: Diabetic Ketoacidosis Houston, TX
Dassi Leader, MD 27: Hand Swelling After an Animal
Associate Chair for Clinical Bite
Services, Pediatrics Department Christopher Lops, MD, MA, FAAP
Director, Inpatient Pediatrics Clinical Instructor of Pediatrics
Staten Island University Hospital, Tufts University School of Medicine
Northwell Health Division of Pediatric Hospital
Assistant Professor, Donald and Medicine
Barbara Zucker School of Cape Cod Hospital
Medicine at Hofstra/Northwell Hyannis, MA
41: Abdominal Pain After a 48: Urinary Tract Infection
Resolved Splenic Pseudocyst
David Lyczkowski, MD, FAAP
Vivian Lee, MD, FAAP Medical Director, Inpatient
Assistant Professor of Clinical Pediatrics
Pediatrics Newton-Wellesley Hospital
USC Keck School of Medicine Newton, MA
Division of Hospital Medicine 46: Staphylococcal Skin Abscess
Children’s Hospital Los Angeles
Molly Maenchen, MD, FAAP
Los Angeles, CA
Resident Physician
29: Fever of Unknown Origin in a
Phoenix Children’s Hospital
Child Who Has Immigrated
Phoenix, AZ
50: Cardiac Arrest

Challenging Cases in Hospital Med_Book.indb 7 07/08/20 9:26 AM

 viii Contributors

Candice Maietti Foy, MD, FAAP Jorge Masuello, MD, FAAP

Assistant Professor of Clinical Academic Pediatric Hospitalist
Pediatrics Phoenix Children’s Hospital
Division of Hospital Medicine Clerkship Director
Stony Brook Children’s Hospital University of Arizona College of
Stony Brook, NY Medicine – Phoenix
43: Newborn Screening and Failure Clinical Assistant Professor
to Thrive Department of Child Health
Leah Mallory, MD, FAAP University of Arizona
Associate Professor of Pediatrics Phoenix, AZ
Tufts University School of Medicine 26: Severe Headaches
Pediatric Hospitalist Jessica S. Meyer, MD, FAAP
The Barbara Bush Children’s Assistant Professor of Pediatrics
Hospital Pediatric Hospitalist
Maine Medical Center University of Virginia Children’s
Portland, ME Hospital
5: Cough and Chest Pain Charlottesville, VA
Jennifer Maniscalco, MD, MPH, 2: Prolonged Fever and Rash
MAcM, FAAP Jennifer Murzycki, MD, PhD,
Assistant Professor of Pediatrics FAAP
Johns Hopkins University School of Assistant Professor of Pediatrics
Medicine Tufts University School of Medicine
Baltimore, MD Division of Pediatric Hospital
Designated Institutional Official Medicine
Johns Hopkins All Children’s Floating Hospital for Children at
Hospital Tufts Medical Center
St Petersburg, FL Boston, MA
15: Failure to Thrive Beyond 22: Newborn With In Utero
Infancy Polysubstance Exposure
Michelle Marks, DO, SFHM, FAAP Jennifer Orr Vincent, MD
Clinical Associate Professor of Assistant Professor of Pediatrics
Pediatrics Division of Hospital Pediatrics
Cleveland Clinic Lerner College of University of North Carolina
Medicine Chapel Hill, NC
Chair, Pediatric Hospital Medicine 18: Convulsive-like Movements
Cleveland Clinic Children’s Hospital Jennifer Oshimura, MD
Cleveland, OH Formerly of Children’s Healthcare
11: Managing Eating Disorders in of Atlanta at Scottish Rite
the Hospital Atlanta, GA
1: Asthma Care Challenges in
Adolescents

Challenging Cases in Hospital Med_Book.indb 8 07/08/20 9:26 AM

 Contributors ix

Andrew Papez, MD Lindsay Rogozinski, MS, RN,

Director, Pediatric Cardiology PPCNP-BC
Fellowship Program Pediatric Hospital Medicine
Phoenix Children’s Hospital Complex Care Service, Lead
Phoenix, AZ Nurse Practitioner
50: Cardiac Arrest Pediatric General Care Units, Lead
Steven Pattishall, MD, FAAP Advanced Practice Provider
Pediatric Hospitalist Pediatric Hospital Medicine
Nemours Children’s Specialty Care University of Rochester
Jacksonville, FL Rochester, NY
4: Apnea in Infancy 28: Care of Medically Complex
Patients
Timothy Porter, MD, FAAP
Clinical Assistant Professor of Melanie Rudnick, MD, FAAP
Pediatrics Assistant Professor of Pediatrics,
Tufts University School of Medicine University of Connecticut
Pediatric Hospitalist School of Medicine
Floating Hospital for Children at Assistant Professor of Pediatrics,
Tufts Medical Center Frank H. Netter MD School of
Boston, MA Medicine
13: Persistent Neonatal Jaundice Division of Pediatric Hospital
Medicine, Connecticut
MacKenzi Preston, MD, MS
Children’s
Assistant Professor of Pediatrics
Hartford, CT
Division of General Academic
29: Fever of Unknown Origin in a
Pediatrics
Child Who Has Immigrated
Weill Cornell Medicine
New York, NY Amanda Sandford, MD, FAAP
25: Attention-Seeking Behavior of Director, Neonatal Hospitalist
Parents Program
Division of Neonatology
Jeffrey Riese, MD, FAAP
Beth Israel Deaconess Hospital
Pediatric Hospitalist
Boston, MA
Hasbro Children’s Hospital
47: Neonatal Hypoglycemia
Providence, RI
42: Agitation in an Adolescent Lori Singleton, MD, FAAP
Associate Professor of Pediatrics
Morehouse School of Medicine
Atlanta, GA
10: Nutrition and Autism Spectrum
Disorder

Challenging Cases in Hospital Med_Book.indb 9 07/08/20 9:26 AM

 x Contributors

Brooke Spector, MD Raegan Vanderput, MD

Assistant Professor of Pediatrics Division of Pediatric Hospital
Weill Cornell Medicine Medicine
New York, NY Phoenix Children’s Hospital
49: Kawasaki Shock Syndrome Phoenix, AZ
Matthew Suer, MD, FAAP 30: Extreme Inflammatory
Assistant Professor Response
Department of Pediatrics Cady Williams, MD, FAAP
Ohio State University Prisma Health−Upstate
Columbus, OH Clinical Assistant Professor of
35: Recurrent Stridor Pediatrics
Margaret Trost, MD, MS University of South Carolina
Assistant Professor of Clinical School of Medicine Greenville
Pediatrics Greenville, SC
Division of Hospital Medicine 31: Chronic Congestion and
University of Southern California Wheezing
Children’s Hospital Los Angeles Bethany Woomer, MD, FAAP
Los Angeles, CA Assistant Professor of Pediatrics
21: Prolonged Fever and Joint Pain Division of Pediatric Hospital
Daron Vandeleur, MD, FAAP Medicine
Clinical Instructor of Pediatrics University of Louisville
Division of Neonatology Norton Children’s Hospital
University of Washington Louisville, KY
Seattle, WA 40: Clavicular Mass and Fever
40: Clavicular Mass and Fever

Challenging Cases in Hospital Med_Book.indb 10 07/08/20 9:26 AM

 Dedication

To my wife, Mindy Stimell-Rauch, MD, FAAP, a stellar clinician who puts

up with my attempts at being academic (DAR)

To my daughter, Sophie; my husband, James; and my courageous fellow

New Yorkers—all of whom are my constant inspiration (SNO)

Challenging Cases in Hospital Med_Book.indb 11 07/08/20 9:26 AM

Challenging Cases in Hospital Med_Book.indb 12 07/08/20 9:26 AM
 Contents

Prefacexv
Chapter 1: Asthma Care Challenges in Adolescents 1
Chapter 2: Prolonged Fever and Rash 5
Chapter 3: Thinking Beyond Bronchiolitis 11
Chapter 4: Apnea in Infancy 17
Chapter 5: Cough and Chest Pain 21
Chapter 6: Pelvic Pain 25
Chapter 7: Chronic Leg Pain 29
Chapter 8: Right Upper Quadrant Pain in an Adolescent 35
Chapter 9: Palliative Care in Hospital Medicine 39
Chapter 10: Nutrition and Autism Spectrum Disorder 43
Chapter 11: Managing Eating Disorders in the Hospital 47
Chapter 12: Altered Mental Status 53
Chapter 13: Persistent Neonatal Jaundice 59
Chapter 14: Fever and Refusal to Walk 63
Chapter 15: Failure to Thrive Beyond Infancy 67
Chapter 16: Breastfeeding Difficulties 73
Chapter 17: Intentional Ingestion 79
Chapter 18: Convulsive-like Movements 85
Chapter 19: Hypotonia and Poor Feeding 91
Chapter 20: Unintentional Lead Poisoning 95
Chapter 21: Prolonged Fever and Joint Pain 99
Chapter 22: Newborn With In Utero
Polysubstance Exposure 105
Chapter 23: Developmental Regression
and Transaminitis 111
Chapter 24: Food Allergy in Infancy 117
Chapter 25: Attention-Seeking Behavior of Parents 123
Chapter 26: Severe Headaches 127
Chapter 27: Hand Swelling After an Animal Bite 133
Chapter 28: Care of Medically Complex Patients 139

Challenging Cases in Hospital Med_Book.indb 13 07/08/20 9:26 AM

 xiv Contents

Chapter 29: Fever of Unknown Origin in a Child

Who Has Immigrated 145
Chapter 30: Extreme Inflammatory Response 149
Chapter 31: Chronic Congestion and Wheezing 157
Chapter 32: A Newborn With Black Stools 163
Chapter 33: Diabetic Ketoacidosis 167
Chapter 34: Ventriculoperitoneal Shunt Complications 171
Chapter 35: Recurrent Stridor 177
Chapter 36: Sickle Cell Disease and Cognitive Biases 181
Chapter 37: Incomplete Maternal History
Confounding the Diagnosis 187
Chapter 38: Recurrent Pancreatitis 193
Chapter 39: “Direct” Hyperbilirubinemia in a Newborn 199
Chapter 40: Clavicular Mass and Fever 205
Chapter 41: Abdominal Pain After a Resolved
Splenic Pseudocyst 211
Chapter 42: Agitation in an Adolescent 215
Chapter 43: Newborn Screening and Failure to Thrive 221
Chapter 44: Unusual Bruising in an Active Child 227
Chapter 45: Infant With Fever 233
Chapter 46: Staphylococcal Skin Abscess 237
Chapter 47: Neonatal Hypoglycemia 241
Chapter 48: Urinary Tract Infection 247
Chapter 49: Kawasaki Shock Syndrome 251
Chapter 50: Cardiac Arrest 257
Index265

Challenging Cases in Hospital Med_Book.indb 14 07/08/20 9:26 AM

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