What Causes Leg Pain?

Patient Presentation
A 13-year-old male came to clinic for his health supervision visit. He was a runner but had had no athletic injuries. He did complain of intermittent bilateral lower leg pain. It occurred mainly in the evenings after running. He wasn’t sure how long it lasted for but less than 1 hour usually. The pain did not awaken him when sleeping and did not occur during school. It occurred approximately 1x/week and wasn’t changing in location, radiation or intensity. It did not cause limping, but was achy with rest and brief massage helping. The pain was a generalized soreness. He was running track, but had not started other events such as jumping or throwing. He was running about the same mileage on grass or a rubber track. His coach would make them run counterclockwise during warm-ups to help decrease stress on the inside track leg. The past medical history was negative. The family history was positive for a benign bone tumor in a maternal adult cousin who currently had no other problems. The review of systems was negative for fevers, chills, night sweats, easy bruising or bleeding, joint swelling, myalgia, or arthralgias.

The pertinent physical exam showed a well-appearing male with growth parameters around 50% for age. He had normal weight gain compared to a sick visit 3 months previously. His physical examination was normal. The diagnosis of of a healthy male was made. The pediatrician felt that the symptoms were most consistent with growing pains of the legs. He recommended making sure that the patient was stretching adequately before, during and after practices in addition to drinking adequate fluids. The patient was having routine screening laboratory evaluations for his age completed that day, so the physician also ordered an erythrocyte sedimentation rate and C-reactive protein which were normal. The patient was to followup with a diary of the leg pain in 2 months or sooner if new symptoms occurred.

Discussion
“Growing pains” of the legs are a common complaint in children. Heterogeneous studies from 1928-2004 have found prevalence rates of 2.6-49.4% in children ages 4-19. The studies are heterogeneous because of time, location, and especially definition of growing pains. A study of 1445, 4-6 year olds in 2004 using a validated tool showed a prevalence rate of 36.9%.

The definition of growing pains used by Peterson in the 2004 study is chronic “…intermittent (nonarticular) pains in both legs that generally occur late in the day or at night…” with a normal physical examination and laboratory testing (if any is done). The pain is in the thigh or calf muscles. The pain can occur over weeks or months. Patients should not have a history of trauma but because the time period over which the pains occur, patients and families will often relate histories of minor trauma. The cause of growing pains is not known but theories include muscle fatigue, anatomic differences such as flat feet or knock-knees or being part of a larger pain constellation such as headache or abdominal pain.

Leg pain that has different characteristics such as localized, persistent or intensifying pain, pain that occurs at different times of the day, obvious joint involvement, limb swelling or erythema or systemic symptoms demand a more extensive history and laboratory and/or radiological investigation. For many children and young adolescents, intermittent viral syndromes with myalgias or athletic overuse are common problems that may have similar presentations to growing pains.

Learning Point
The differential diagnosis of leg pain includes:

  • Infectious Disease
    • Arthritis, septic
    • Toxic synovitis
    • Lyme disease
    • Osteomyelitis
    • Rheumatic fever
    • Viral syndromes
  • Hematology/Oncology
    • Bone tumor
    • Leukemia
    • Muscle tumor
    • Neuroblastoma
  • Orthopaedic
    • Compartment syndrome
    • Entrapments
      • Arterial
      • Nerve
    • Fracture
      • Growth plate
      • Stress
        • Medial tibial stress syndrome (i.e. shin splints)
        • Osgood-Schlatter disease
      • Hypermobility
      • Legg-Calve-Perthes disease
      • Muscle cramps
      • Slipped capital femoral epiphysis
      • Soft tissue injuries
        • Bursitis
        • Condritis
        • Injections
        • Meniscus
        • Myositis
        • Tendonitis
  • Rheumatology
    • Arthritis, reactive
    • Dermatomyositis
    • Henoch Schonlein purpura
    • Juvenile idiopathic arthritis
    • Systemic lupus erythematosus
  • Other
    • Deep vein thrombosis
    • Fibromyalgia
    • Growing pains
    • Psychiatry/psychological problems
      • Conversion reaction
      • Munchausen syndrome or by proxy
      • Stress
    • Radiation from other body area, i.e. hip, back
      • Spinal stenosis
    • Reflex sympathetic dystrophy

Questions for Further Discussion
1. If a child has both upper extremity and lower extremity pain, how does that change your differential diagnosis?
2. What are indications for radiographs for patients with leg pain?
3. What laboratory evaluations could be considered for patients with leg pain?
4. What are indications for orthotics or similar shoe devices for the treatment of leg pain?

Related Cases

    Symptom/Presentation: Pain

To Learn More
To view pediatric review articles on this topic from the past year check PubMed.

Evidence-based medicine information on this topic can be found at SearchingPediatrics.com, the National Guideline Clearinghouse and the Cochrane Database of Systematic Reviews.

Information prescriptions for patients can be found at MedlinePlus for this topic: Leg Injuries and Disorders

To view current news articles on this topic check Google News.

To view images related to this topic check Google Images.

To view videos related to this topic check YouTube Videos.

Evans AM, Scutter SD. Prevalence of “growing pains” in young children. J Pediatr. 2004 Aug;145(2):255-8.

Pell RF 4th, Khanuja HS, Cooley GR. Leg pain in the running athlete. J Am Acad Orthop Surg. 2004 Nov-Dec;12(6):396-404.

Tse SM, Laxer RM. Approach to acute limb pain in childhood. Pediatr Rev. 2006 May;27(5):170-9.

ACGME Competencies Highlighted by Case

  • Patient Care
    1. When interacting with patients and their families, the health care professional communicates effectively and demonstrates caring and respectful behaviors.
    2. Essential and accurate information about the patients’ is gathered.
    3. Informed decisions about diagnostic and therapeutic interventions based on patient information and preferences, up-to-date scientific evidence, and clinical judgment is made.
    4. Patient management plans are developed and carried out.
    5. Patients and their families are counseled and educated.

  • Medical Knowledge
    10. An investigatory and analytic thinking approach to the clinical situation is demonstrated.
    11. Basic and clinically supportive sciences appropriate to their discipline are known and applied.

  • Practice Based Learning and Improvement
    13. Information about other populations of patients, especially the larger population from which this patient is drawn, is obtained and used.

  • Systems Based Practice
    24. Cost-effective health care and resource allocation that does not compromise quality of care is practiced.

    Author

    Donna M. D’Alessandro, MD
    Professor of Pediatrics, University of Iowa Children’s Hospital

  • When Can A Child Start Strength Training?

    Patient Presentation
    A 12-year-old female came to clinic for health maintenance and a sports physical. She was entering 7th grade and wanted to run cross-country. When asked about other sports and activities she said that she had started strength training as she wanted to participate in body-building competitions. She was doing the strength training at the local recreation center without supervision while her mother was swimming. Additional history revealed that her parents and 2 older siblings were active people who ran, biked and swam. She had an uncle who did weight training but did not do competitions. She had seen some body-building on television and said she liked how the people looked and understood that it was a good way to be active and be healthy. Her goal was to enter a competition in a couple of years. She liked running and biking and had entered local races with her family, but thought that body-building was something different to do than the rest of her family. She and her mother denied excessive exercise, or disordered eating. She did not appear to have a distorted body image of herself and acknowledged that body-builders sometimes can not look healthy. The past medical history showed an ulnar fracture from falling off playground equipment, but no athletic injuries. The family history showed diabetes, stroke and heart attacks in older relatives. The review of systems was negative.

    The pertinent physical exam showed a healthy female with weight at the 15% (36.2 kg), height at the 50% (151 cm), and BMI of 15.9 (5%). She was Tanner stage 3 for breast and pubic hair development. The rest of her examination was normal. The diagnosis of a healthy female was made. The family was counseled about strength training in children and adolescents, and the pediatrician did not recommend body-building as she was not skeletally mature. The mother agreed with having a more structured approach to the strength training and to monitoring her daughter’s weight. The patient’s clinical course 4 months later showed that she had competed in cross-country and was now swimming both of which she greatly enjoyed. She was doing some strength training under the guidance of physical education teachers and coaches at school 1-2 times/week. She continued to gain an appropriate amount of weight and did not appear to be losing excessive fat or becoming more muscular appearing. She denied disordered eating or body image. She was now less interested in body-building but did like the weight training as she felt it made her stronger for her other sports.

    Discussion
    Exercise is an important part of health and daily life. A review of recommendations for general exercise for children and adults can be found here. Many people use pedometers as a marker of their activity and a list of activities and their equivalent steps can be found here.

    The benefits of strength training includes improved performance, injury prevention and rehabilitation, improved cardiovascular fitness, improved bone mineral density, improved blood lipid profiles and mental health. Improvements in strength can be found in properly structured programs of at least 8 weeks duration occurring at least 1-2 times/week. Strength training more than 4x/week does not add to strength and may lead to overuse injuries.

    The most common risk is injury and most of these “…occur on home equipment with unsafe behavior and unsupervised settings.” Children with hypertension, seizures and obesity should be evaluated first and monitored closely. Children with Marfan syndrome, congenital heart disease, or history of cardiotoxic medication such as chemotherapy are often counseled against participation but should be appropriately evaluated and counseled.

    Body-building involves strength, endurance, and flexibility and balance as integral parts of the sport. Additionally there can be additional benefits such as improved nutrition (including possibly lower cholesterol and bone strength) and improved stress management. The International Federation of Bodybuilding and Fitness has a number of competitions and programs. Fitness competitions for children in a fitness category for as young as 8 years of age are sponsored and rules can be seen here.

    Other counseling issues regarding strength training include discussing with the child, teen and family the possibility of eating disorders, distorted body image, and the use of anabolic steroids and other substances.

    Learning Point
    The American Academy of Pediatrics (AAP) recommends not to begin strength training until at least 7-8 years or when balance and postural controls skills have matured to adult levels which is around this age. There are other general pragmatic considerations too. The child should be able to listen, wait, understand and follow instructions of an adult. They should have some body sense and control over their body so they can perform the exercise properly, and make the necessary adjustments when they are not doing it properly. Children should be enjoying the activity and not feel coerced to initiating or continuing the activity. These are sensible considerations for any sport. Children and adolescents should perform more repetitions of the exercise using a low amount of weight (i.e. increased weight with fewer repetitions is not recommended). Explosive, rapid lifting of weight is not recommended. Similarly there are no specific ages when an adolescent can begin power training, body-building, or maximal lifts, but many experts including the AAP recommend after the adolescent is skeletally mature to mitigate the risks to the bones, tendons, ligaments and muscles themselves.

    Prepubescent children and early adolescents will generally not have muscle hypertrophy but will have recruitment of muscle groups so that they will be better able to perform the exercises. The strength training therefore helps to improve muscle skill for performing the exercise which can translate to improved skill with the sport.

    It is important that children and teens have supervision so they can learn to perform the exercises properly initially, receive feedback and have ongoing monitoring so that they continue to perform the exercises properly. Supervision also about numbers of repetitions and weights for workouts can also be devised and monitored. Children and adolescent also do not always use the best judgement and adult supervision can help to ensure safety in the weight room.

    Questions for Further Discussion
    1. When should children begin competitive sports?
    2. When should children begin elite sports?
    3. What are medical conditions that preclude particular sports?

    Related Cases

    To Learn More
    To view pediatric review articles on this topic from the past year check PubMed.

    Evidence-based medicine information on this topic can be found at SearchingPediatrics.com, the National Guideline Clearinghouse and the Cochrane Database of Systematic Reviews.

    Information prescriptions for patients can be found at MedlinePlus for these topics: Exercise for Children and Sport Fitness.

    To view current news articles on this topic check Google News.

    To view images related to this topic check Google Images.

    To view videos related to this topic check YouTube Videos.

    American Academy of Pediatrics Policy Statement. Overuse Injuries, Overtraining, and Burnout in Child and Adolescent Athletes. Pediatrics. 2007:119;1242.

    American Academy of Pediatrics Policy Statement. Strength Training by Children and Adolescents. Pediatrics. 2008:V121;835.

    American College of Sports Medicine. Youth Strength Training. Available from the Internet at: http://www.acsm.org/docs/current-comments/youthstrengthtraining.pdf (cited 4/1/14).

    American College of Sports Medicine. Preseason Conditioning for Young Athletes. Available from the Internet at: http://www.acsm.org/docs/current-comments/youthstrengthtraining.pdf (cited 4/1/14).

    ACGME Competencies Highlighted by Case

  • Patient Care
    1. When interacting with patients and their families, the health care professional communicates effectively and demonstrates caring and respectful behaviors.
    2. Essential and accurate information about the patients’ is gathered.
    3. Informed decisions about diagnostic and therapeutic interventions based on patient information and preferences, up-to-date scientific evidence, and clinical judgment is made.
    4. Patient management plans are developed and carried out.
    5. Patients and their families are counseled and educated.
    8. Health care services aimed at preventing health problems or maintaining health are provided.

  • Medical Knowledge
    10. An investigatory and analytic thinking approach to the clinical situation is demonstrated.
    11. Basic and clinically supportive sciences appropriate to their discipline are known and applied.

    Author

    Donna M. D’Alessandro, MD
    Professor of Pediatrics, University of Iowa Children’s Hospital

  • What is in the Differential Diagnosis of Purpura?

    Patient Presentation
    A 2.5-year-old male came to clinic because of a new onset rash. The child had cold symptoms 2 weeks previously that had improved. He again began to have some rhinorrhea 2 days ago but was afebrile and otherwise well. That morning he awoke with a bright red rash on his extremities, trunk, buttocks and face that was slightly pruritic. His mother denied new soap/lotions, skin products, medications or complementary and alternative products or treatments. He was drinking well but eating less. There were several children at the daycare he attended who had recent colds. The past medical history showed a generalized rash to amoxicillin. The family history was negative for any autoimmune or kidney disease. The review of systems was otherwise normal.

    The pertinent physical exam revealed normal vital signs including a temperature of 99.3°, blood pressure of 78/58, and growth parameters in the 5-15%. HEENT showed clear rhinorrhea. Lungs were clear. Extremities had no edema. His skin had bright red, uniform lesions that were generally well-demarcated without central clearing. The lesions were 1 cm with a great deal of coalescence. Some on the lower extremities felt slightly raised. The lesions were located on the face, extremities, buttocks and trunk and spared the scalp, genitals, hands, feet and intertrigenous areas. He had no mucous membrane involvement including his urethra. The diagnosis of a viral exanthem was made and the mother was instructed to monitor the child. She was told that it was possible that the pruritus could get worse and diphenhydramine could be used, as well as acetaminophen for discomfort.

    The patient’s clinical course showed that on the early evening of the next day, the mother called because the boy’s rash on his legs was now purple and his feet had become swollen earlier in the day. She denied any other changes as to where the rash was located or how it looked other than that it was darker and more purplish. It was not “bumpier.” She denied any new “dots,” bleeding, oral lesions, eye changes, or edema of the face or hands. He continued to be afebrile, eating and drinking well. She had given him one dose of diphenhydramine earlier in the day. He had been acting normally during the day. The pediatrician who had seen the child was on call that evening and thought that this possibly could be Henoch-Schönlein purpura, but as the child was well, was drinking and urinating well, and had had a normal blood pressure the day before, he recommended to monitor closely the child for any changes and see the child the next day. The following day, the rash had begun to fade and was less pruritic. His blood pressure was normal. The purple changes that the mother had described were reproduced in the clinic when the child sat down. The lesions near the buttocks had a slightly darker hue to them that resolved when the child stood up. He had no edema on physical examination. The rash continued to fade over the next 2-3 days.

    Discussion
    Children presenting with rashes are common but certain characteristics may be concerning such as descriptions of petechiae or purpura. Purpura are characterized by non-blanching skin lesions between 3-10 mm in size that are caused by bleeding into the skin. Usually they are reddish-purplish hence the name purpura coming from the Latin word. Non-blanching lesions that are 10 mm are ecchymosis.

    Henoch-Schönlein purpura (HSP) is a generalized vasculitis that commonly involves the gastrointestinal tract, kidneys, skin and joints, and is especially seen in children 2-11 years old. Classically HSP presents with purpura of the lower-extremities (or other dependent areas), migratory polyarthritis, colicky abdominal pain, and renal disease. A macular-papular or urticarial rash can precede the purpura, but generally resolves within 24 hours such as the one above. Peripheral edema can occur because of the renal involvement. Its etiology is uncertain but is probably multifactorial with antigens, environmental and genetic factors. It is thought to be caused by an unknown antigen stimulating a rise in IgA producing and antigen-antibody complexes being deposited locally in the body and activating pathways leading to necrotizing vasculitis. Associations with bacteria, viruses, vaccinations and drugs have been reported. Most children have complete recovery but serious renal and gastrointestinal complications may occur.

    Learning Point
    The differential diagnosis of purpura includes:

    • Acute hemorrhagic edema of infancy – For more information about AHEI click here.
    • Acute streptococcal glomerulonephritis
    • Blood clotting disorders
    • Drugs – particularly which may cause fragile blood vessels or platelet problems
    • Hemolytic-uremic syndrome
    • Henoch-Schönlein or anaphalactoid purpura – for more information about HSP click here.
    • Hypersensitivity vasculitis
    • Hypertension – malignant, pre-eclampsia and similar gestational problems
    • Immune thrombocytopenic purpura
    • Infection
      • Disseminated intravascular coagulation / Sepsis
      • Purpura fulminans from Neisseria meningiditis
      • Congenital infections such as cytomegalovirus and rubella
      • Rickettsial diseases
    • Polyarteritis nodosa
    • Thrombotic thrombocytopenic purpura
    • Scurvy
    • Urticarial vasculitis
    • Trauma

    Questions for Further Discussion
    1. What causes urticaria?
    2. What are the potential complications of HSP?
    3. What are criteria for referral to a dermatologist?

    Related Cases

    To Learn More
    To view pediatric review articles on this topic from the past year check PubMed.

    Evidence-based medicine information on this topic can be found at SearchingPediatrics.com, the National Guideline Clearinghouse and the Cochrane Database of Systematic Reviews.

    Information prescriptions for patients can be found at MedlinePlus for these topics: Platelet Disorders and Vasculitis.

    To view current news articles on this topic check Google News.

    To view images related to this topic check Google Images.

    To view videos related to this topic check YouTube Videos.

    Weiss PF. Pediatric vasculitis. Pediatr Clin North Am. 2012 Apr;59(2):407-23.

    Rigante D, Castellazzi L, Bosco A, Esposito S. Is there a crossroad between infections, genetics, and Henoch-Schonlein purpura? Autoimmun Rev. 2013 Aug;12(10):1016-21.

    Mathur AN, Mathes EF. Urticaria mimickers in children. Dermatol Ther. 2013 Nov;26(6):467-75.

    Roberts PF. Henoch-Schonlein Purpura. EPocrates Online. Available from the Internet at https://online.epocrates.com/u/2935110/Henoch-Schonlein+purpura/Diagnosis/Differential (rev. 7/8/13, cited 3/11/14).

    MedlinePlus Encyclopedia. Purpura. Available from the Internet at http://www.nlm.nih.gov/medlineplus/ency/article/003232.htm (rev. 4/24/13, cited 3/11/14).

    ACGME Competencies Highlighted by Case

  • Patient Care
    1. When interacting with patients and their families, the health care professional communicates effectively and demonstrates caring and respectful behaviors.
    2. Essential and accurate information about the patients’ is gathered.
    4. Patient management plans are developed and carried out.
    5. Patients and their families are counseled and educated.

  • Medical Knowledge
    10. An investigatory and analytic thinking approach to the clinical situation is demonstrated.
    11. Basic and clinically supportive sciences appropriate to their discipline are known and applied.

  • Interpersonal and Communication Skills
    18. Using effective nonverbal, explanatory, questioning, and writing skills, the healthcare professional uses effective listening skills and elicits and provides information.

  • Systems Based Practice
    24. Cost-effective health care and resource allocation that does not compromise quality of care is practiced.

    Author

    Donna M. D’Alessandro, MD
    Professor of Pediatrics, University of Iowa Children’s Hospital

  • How is Pectus Carinatum Treated?

    Patient Presentation
    A family medicine physician contacted the on-call pediatrician about a 14-year-old male who was worried about his diagnosis of pectus carninatum. He had always had a prominent anterior chest but it had become more pronounced during puberty and he was now very self-conscious. The family medicine physician wanted to know when it was appropriate to refer to a surgeon and if the surgery staff at the regional children’s hospital did surgeries for this problem. The pediatrician said that she knew that there were open- and closed- surgical procedures for the problem and also thought that bracing was an option but she herself hadn’t treated anyone with this problem recently. The pediatrician recommended referring to the surgical services at the hospital. She also suggested considering some psychological support services for possible anxiety and body image problems the patient may be having. The family medicine physician said that he had already suggested the psychological services to the family and they were considering doing it. He was going to send the patient to the surgeons.

    Discussion
    Pectus carinatum (PC) is the second most common congenital chest wall deformity after pectus excavatum. It presents usually in early adolescence around puberty, most commonly in males (4:1) and occurs 1 time in every 2500 persons. There are two common variants of the sternum and adjacent costal cartilages protrusion: chondrogladiolar (the body of the sternum protrudes, ie the gladiolus), and chondromanubrial (the superior part of the sternum protrudes). There can also be a mixed variant where the manubrium protrudes and the gladiolus is depressed. Most patients have symmetric deformities but they can be unilateral.

    The etiology is unknown but felt to be due to abnormal costal cartilage growth. A positive family history is found in ~25% of patients and PC is associated with Marfan and Noonan syndromes. Patients usually present during the adolescent growth spurt and usually have no other symptoms than the protruding chest. Sometimes patients can complain of chest wall discomfort particularly when lying prone. Heart palpitations or respiratory symptoms are unusual. The more common problems are disturbed body image and inability to wear clothing (particularly bras in females) with resulting decreased quality of life. The evaluation mainly is the history and clinical physical examination. Plain chest radiographs are usually enough to plan surgeries if needed. Patients with other symptoms or with mixed variations may need a cardiac evaluation and/or pulmonary function testing.

    Click here to learn more about pectus excavatum.

    Learning Point
    Once puberty has stopped, the PC progression is minimal. Age, pubertal status and chest wall flexibility helps determine the treatment options which are usually:

    • Watchful waiting and support – Many patients and families choose this option once they understand the natural history. Pectoral muscle strengthening can also be used help change the chest contour and make the PC appear less noticeable.
    • External bracing – This is the treatment option usually recommended for pre-pubertal and pubertal adolescents as it is non-invasive. The side effects are skin irritation and it is effective. There are multiple regimens but generally the bracing needs to be used multiple hours a day and for many months. Bracing is often continued until puberty has ceased.
    • Surgery – The Ravitch procedure (osteotomy and costal cartilage resection) and its variations have been used for more than 50 years. The Nuss procedure (stainless steel bar is used to compress the chest wall) is also used. The Nuss procedure has the advantage of being a minimally invasive technique and thus has aesthetic advantages.

    Questions for Further Discussion
    1. How is pectus excavatum treated?
    2. Besides pectus excavatum and pectus carinatum, what other chest wall deformities are there?
    3. List different cartilage disorders.

    Related Cases

    To Learn More
    To view pediatric review articles on this topic from the past year check PubMed.

    Evidence-based medicine information on this topic can be found at SearchingPediatrics.com, the National Guideline Clearinghouse and the Cochrane Database of Systematic Reviews.

    Information prescriptions for patients can be found at MedlinePlus for these topics: Cartilage Disorders and Chest Injuries and Disorders.

    To view current news articles on this topic check Google News.

    To view images related to this topic check Google Images.

    To view videos related to this topic check YouTube Videos.

    Blanco FC, Elliott ST, Sandler AD. Management of congenital chest wall deformities. Semin Plast Surg. 2011 Feb;25(1):107-16.

    Obermeyer RJ, Goretsky MJ. Chest wall deformities in pediatric surgery. Surg Clin North Am. 2012 Jun;92(3):669-84, ix.

    Desmarais TJ, Keller MS. Pectus carinatum. Curr Opin Pediatr. 2013 Jun;25(3):375-81.

    ACGME Competencies Highlighted by Case

  • Patient Care
    1. When interacting with patients and their families, the health care professional communicates effectively and demonstrates caring and respectful behaviors.
    2. Essential and accurate information about the patients’ is gathered.
    3. Informed decisions about diagnostic and therapeutic interventions based on patient information and preferences, up-to-date scientific evidence, and clinical judgment is made.
    9. Patient-focused care is provided by working with health care professionals, including those from other disciplines.

  • Medical Knowledge
    10. An investigatory and analytic thinking approach to the clinical situation is demonstrated.
    11. Basic and clinically supportive sciences appropriate to their discipline are known and applied.

  • Professionalism
    20. Respect, compassion, and integrity; a responsiveness to the needs of patients and society that supercedes self-interest; accountability to patients, society, and the profession; and a commitment to excellence and on-going professional development are demonstrated.

  • Systems Based Practice
    26. Partnering with health care managers and health care providers to assess, coordinate, and improve health care and how these activities can affect system performance are known.

    Author

    Donna M. D’Alessandro, MD
    Professor of Pediatrics, University of Iowa Children’s Hospital