Harriet Lane Handbook: Pediatric Insights from The Johns Hopkins Hospital

Tolulope Fatola, MD and Julia F. Shalen, MD from Johns Hopkins Hospital discuss Rheumatology: A systematic approach to differentiating the various childhood arthritic conditions. Key takeaways:Core diagnostic cues and red flags for common pediatricrheumatic diseases discussed, with quick signs you can check on exam.Key physical exam findings and how to differentiateinflammatory vs. noninflammatory presentations in children (joints, skin, mucosal) to guide when to escalate.Initial workup steps and criteria for urgent rheumatology referral, including when to order imaging or labs.First-line treatment principles in pediatrics: NSAIDs,steroid-sparing approaches, and DMARDs/biologics, with pediatric dosing caveats and vaccine considerations.Monitoring and safety considerations for children onimmunomodulatory therapy (growth, infections, lab monitoring, long-term risks).Controversies or debated points raised in the episode (e.g., sequencing of DMARDs/biologics, use of steroids, steroid-sparing strategies) with succinct takeaways or guidelines mentioned.Practical clinical pearls and common pitfalls for residents(how to simplify complex cases, how to communicate with families, and what to document consistently).

Juliet A. Joseph, MD and Emily Johnson, CRNP from Johns Hopkins Hospital discuss end of life decision makingin the adolescent palliative care patient.Key takeaways:Proactively include PPC in routine care for serious pediatric illnesses.Use structured, family-centered conversations to clarify goals, preferences, and trade-offs.Leverage a multidisciplinary team to support complex decisions.Emphasize clear communication, cultural sensitivity, and ongoing family support.Address adolescent autonomy and ethically challenging situations.

Katelyn Williams, MD and Nathaniel J. Silvestri, MD fromJohns Hopkins Hospital discuss the initial presentation and workup of acute lymphoblastic leukemia.  Acute lymphoblastic leukemia (ALL) is the most commonpediatric cancer. Early recognition and prompt workup are critical for improvedoutcomes.A case-based conversation featuring a 5-year-old withfatigue, bone pain, pallor, and reduced activity, guided by pediatric hematology/oncology expert input. The discussion outlines red flags, initial laboratory tests, imaging, differential diagnoses, and referral pathways. Key points:Red flags for ALL in children include persistent bone/backpain, refusal to bear weight, unexplained bruising, pallor, and diminishedactivity.Comprehensive physical exam should assess forhepatosplenomegaly, lymphadenopathy, and, in boys, testicular involvement.Initial laboratory workup (if malignancy is suspected) centers on CBC with differential and reticulocyte count, with attention to red cell indices (MCV, iron studies), hemoglobin, platelets, and neutrophils; LDH and uric acid; CMP and coag studies; and peripheral smear.WBC counts can be normal, low, or high at presentation;imaging (e.g., chest X-ray) is considered to evaluate potential mediastinal mass, particularly with risk for T‑cell leukemia.Differential includes infectious diseases and rheumatologicconditions; neuroblastoma should be considered in the differential of bone pain.Referral to pediatric oncology or the emergency departmentis advised when alarm features or concerning labs are present.Management considerations in the ED/outpatient settinginclude non-emergent procedures planning, NPO status when needed, and cautious use of steroids due to risks such as tumor lysis and diagnostic masking.Resources and collaboration with oncology, vaccinationconsiderations during therapy, and family education are emphasized.Implications: The talk reinforces recognizing early ALLsigns, initiating appropriate labs and imaging, timely referrals, and coordinated care to optimize outcomes.

Edward Corty, MD and Melissa Lutz, MD from Johns Hopkins Hospital discuss pediatric food insecurity.This podcast features a discussion on childhood foodinsecurity, emphasizing its significance as a health and social issue in the United States. Hosted by Edward Corty, MD and Melissa Lutz, MD from Johns Hopkins Hospital, the conversation begins with a case study of a four-year-oldboy, illustrating how food insecurity can affect families even when children appear well.Key points include:Definition and importance: Food insecurity is the lack of consistent access to enough food for an active,healthy life, affecting about 15% of U.S. households with children. It can lead to nutritional deficiencies, physical illnesses, behavioral health issues, developmental delays, and long-term health risks like diabetes and heart disease.Screening practices: Pediatricians are recommended to routinely screen for food insecurity using tools like theHunger Vital Signs, which involve simple questions about food access over the past year. Sensitive, private conversations and permission are essential.Interventions and resources: Multiple levels of intervention are available, including federal assistance programs (e.g., SNAP, WIC, school meal programs), healthcare-based resources (food vouchers, clinics), and community resources (food banks, churches,community organizations). Follow-up is crucial to ensure families connect with and benefit from these resources.Ongoing management: Continuous follow-up within the healthcare setting helps track progress and adapt support.

Maria Molinaro, MD, Molly Himmelrich, MD, Alex Testino, MD, and Eric H. Kossoff, MD from Johns Hopkins Hospital discuss seizure mimics and an age-based approach.   

Megan Gates, MD and Kartikeya Makker, MBBS from Johns Hopkins Hospital discuss ventilation strategies in theneonatal ICU.

Ashley Wallace Wu, MD, Amali Gunawardana, MD, and John McAteer, DO, MPH from Johns Hopkins Hospital discussresistance mechanisms in gram negative rods    

Anna Bitners, MD and Courtney Lawrence, MD from Johns Hopkins Hospital discuss Hemophilia/Emicizumab.

Nadav Weinstock, MD, PhD and Shira G. Ziegler, MD, PhD from Johns Hopkins Hospital discuss the newborn screening.

Kaysha Henry, MD, MPH and Steven Miller, MD from Johns Hopkins Hospital discuss the framework for gastrointestinal bleeding by age.

Fred Lam, MD and W. Reid Thompson III, MD from Johns Hopkins Hospital discuss tetralogy of fallot: review of the congenital heart disease and accompanying cardiac surgeries.

Kyla Cordrey, MD, Rebecca Dryer, MD, and W. ReidThompson III, MD discuss auscultation and heart sounds.

Matthew Kosasih, MD and Sapna Kudchadkar, MD, PhD from Johns Hopkins Hospital discuss medications for analgesia and sedation.

Andrea Silvas, MD and Errol Fields, MD, PhD, MPHfrom Johns Hopkins Hospital discuss an interactive walk through the HEADSS assessment, and next steps.

Zainab Khan, MD and Roselyn Appenteng, MD from Johns Hopkins Hospital discuss pediatric toxicology ingestions, workup, and management.

Rachel Darko, MD and Katherine E. Hoops, MD, MPH from Johns Hopkins Hospital discuss advocacy, gun violence, and healthcare utilization.

Camille C. Anderson, MD, Sunaina Kapoor, MD, and Tiffany E. Mark, MD were the Chief Residents of Pediatrics for The Johns Hopkins Hospital. As Editors of the 23rd edition of The Harriet Lane Handbook, they introduce the new discussions with residents and faculty on case studies and healthcare disparities.