What Are Some Potential Indicators of Human Trafficking?

Patient Presentation
A pediatrician was travelling when she noted several public service advertisements encouraging the air traveling public to be aware of potential victims of human trafficking. One advertisement advocated just being aware of the problem, while others listed potential behavioral changes that might be noted in victims or traffickers. The pediatrician was disturbed by her own lack of knowledge and awareness, so when she returned home she decided to read more about the subject.

Discussion
Human trafficking is estimated to be the second largest criminal activity in the world after illegal arms trafficking. It affects all nations with an estimated 27 million people of all ages worldwide but only a small number are identified. It is defined by the United Nations as “the recruitment, transfer, harboring, or receipt of persons by means of threat or use of force or other forms of coercions, abduction, fraud, deception, the abuse of power, or a position of vulnerability to achieve the consent of a person, having control over another person, for the purpose of exploitation.” It includes commercial sex and labor or services. Victims include adults and children of all genders and sexual orientations, including people who are foreign nationals or native citizens. Anyone can be a victim.

In the U.S. any child less than 18 years of age who is involved in prostitution is considered a victim of sex trafficking, regardless of the use of coercion, force or fraud by another person. The average age that children enter the commercial sex trade in the U.S. is 12-14 years and it is estimated that children who move to live on the streets are approached for sex trafficking within 2 days of living on the streets. Trafficking may involve individuals being transported across domestic or international borders but does not require crossing a border. Restraint, abuse and physical force may also be involved but again are not required to define human trafficking.

When interviewing patients whom trafficking is suspected, separate the patient from accompanying persons. This usually can be done while performing the physical examination, testing, or filling out paperwork (in a separate area). Try to build rapport and trust, with open, yet directed questions while sitting at eye level and maintaining eye contact. Use a trained interpreter if needed and provide the patient with immediate needs such as food and water.

Questions that 2 papers suggest to ask include:

  • “Where do you live?
  • Who takes care of you?
  • Do you feel trapped in your situation?
  • Is anyone forcing you to do things you do not want to do?
  • Has anyone threatened your family?
  • Tell me about your tattoo.
  • Has anyone at home or work ever physically harmed you?
  • Have you ever been denied food, water, sleep, or medical care?”

    AND

  • “Can you come and go from your home (or job) whenever you please?
  • Has anyone at home or work every physically harmed you?
  • Have you ever been threatened for trying to leave your job?
  • Is anyone forcing you to do things you do not want to do?
  • Do you have to ask permission to eat, sleep or use the bathroom?
  • Are there locks on your doors and windows that keep you from leaving?
  • Have you ever been denied food, water, sleep, or medical care?
  • Has anyone threatened your family?
  • Has anyone taken away your identification papers or cards?”

Avoid using words such as coercion, sex worker, trafficking victim, call girl, escort, or pimp.

National Human Trafficking Resource Center Hotline 888-373-7888, TEXT 233733, https://humantraffickinghotline.org is available to anyone including victims and healthcare providers.

Each situation is unique and victims should be offered protection and assistance for their situation. Children should have child protection services and/or law enforcement contacted. Adults should be offered services, but they cannot be compelled to utilize them. For future reference, unlabeled telephone and other resources contacts can be written on a small piece of paper that can be hidden or on discharge paperwork from the hospital or clinic. For victims who are not U.S. citizens there is a federal program “…that enables trafficking victims to obtain medical care, witness protection, and other social service assistance, including the ability to obtain legal immigration status.”

Learning Point
Health care providers may be unaware of the complexities and scope of human trafficking. One study found < 5% of emergency room clinicians were confident in their ability to recognize a victim.

Indicators that may arouse suspicion of human trafficking (many of which overlap categories):

  • Medical history
    • Not knowing basic information such as their location, or how to get home from current location
    • Vague or inconsistent history or injuries
    • Unexpected demeanor – hostile, aggressive, irritated, anxious, flat affect, poor eye contact, etc.
    • When law enforcement, social work, etc. are referenced, becomes apprehensive or hostile
    • Does not have personal documentation such as driver license, etc.
    • Does not have access or little access to money, food, clothing, housing, medical care or other
    • Person accompanying the patient is unwilling or very reluctant to leave the patient. “Traffickers may present themselves as a partner, family member, friend, or advocate. Traffickers may also actually be a partner or family member.”
    • History of running away from home or foster care placements
    • Truancy or attending school
    • Highly sexualized behavior or dress
    • Pregnancy at young age
    • Evidence of abortions at young age
    • Early sexual initiation
    • Abnormal number of sexual partners for young age
    • Unwilling pregnancy
  • Injuries
    • Genital trauma to vagina and/or rectum, retained foreign object
    • Sexually transmitted infection or urinary tract infection symptoms
    • Bruises, whip marks, ligature marks
    • Burns
    • Head trauma or loss of consciousness
    • Lacerations
    • Gunshot wounds
    • Hair pulled out
    • Injuries that do not match history or seem violent – hit by car, fell down stairs
  • Physical signs and symptoms
    • Acute or chronic disease
      • Untreated or undertreated problems – asthma, diabetes
      • Back pain
      • Dental disease
      • Dizziness
      • Fatigue
      • Gastrointestinal disorders including abdominal pain
      • Nausea and emesis
      • Malnutrition
      • Migraine
      • Poorly healed fractures and strains
      • Respiratory problems that are frequent
      • Skin disorders from close contact and poor environment
      • Substance abuse
      • Tuberculosis
    • Genitourinary
      • Sexually transmitted infection
      • Pelvic inflammatory disease
    • Tattoo – “especially of a male name or a nickname, in unusual locations such as the inner thigh, underarm, breast, or back of neck, may suggest branding.”
  • Mental health
    • Anxiety including panic attacks
    • Depression including suicidal ideation and attempts, flat affect
    • Agoraphobic
    • Dissociative reaction
    • Fear for family members’ safety
    • Memory loss
    • Poor self esteem
    • Shame and guilt
    • Substance abuse
  • Other
    • Poor hygiene
    • Repetitive yawning, being excessively tired

    School personnel can also see trafficked children. In its information for school professionals, the United States Department of Education notes the following:

    “However, once a student is victimized, identifying him or her can prove difficult for a variety of reasons: (1) the student’s reluctance to disclose the problem due to a sense of shame and fear; (2) the stigma associated with forced prostitution; (3) the power and control of the tracker’s seduction and manipulation; and (4) the student’s inability to recognize that he or she is a victim and, therefore, is unwilling to seek help.
    Possible behavioral indicators of a child sex trafficking victim include, but are not limited to, the following:

    • an inability to attend school on a regular basis and/or unexplained absences
    • frequently running away from home
    • references made to frequent travel to other cities
    • bruises or other signs of physical trauma, withdrawn behavior, depression, anxiety, or fear
    • lack of control over a personal schedule and/or identification or travel documents
    • hunger, malnourishment, or inappropriate dress (based on weather conditions or surroundings)
    • signs of drug addiction
    • coached or rehearsed responses to questions
    • a sudden change in attire, behavior, relationships, or material possessions (e.g., expensive items)
    • uncharacteristic promiscuity and/or references to sexual situations or terminology beyond age-specific norms
    • a “boyfriend” or “girlfriend” who is noticeably older and/or controlling
    • an attempt to conceal scars, tattoos, or bruises
    • a sudden change in attention to personal hygiene
    • tattoos (a form of branding) displaying the name or moniker of a tracker, such as “daddy”
    • hyperarousal or symptoms of anger, panic, phobia, irritability, hyperactivity, frequent crying, temper tantrums, regressive behavior, and/or clinging behavior
    • hypoarousal or symptoms of daydreaming, inability to bond with others, inattention, forgetfulness,
      and/or shyness

    Additional behavioral indicators for labor tracking include the following:

    • being unpaid, paid very little, or paid only through tips
    • being employed but not having a school-authorized work permit
    • being employed and having a work permit but clearly working outside the permitted hours for students
    • owing a large debt and being unable to pay it
    • not being allowed breaks at work or being subjected to excessively long work hours
    • being overly concerned with pleasing an employer and/or deferring personal or educational decisions to a boss
    • not being in control of his or her own money
    • living with an employer or having an employer listed as a student’s caregiver
    • a desire to quit a job but not being allowed to do so”

    Questions for Further Discussion
    1. What are your local policies if a child is identified as a victim of child abuse, neglect or trafficking?
    2. How might adolescents present differently than adults who are victims of human trafficking?

    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 and the Cochrane Database of Systematic Reviews.
    Information prescriptions for patients can be found at MedlinePlus for these topics: Sexual Assault and Homeless Health Concerns.

    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.

    U.S. Department of Education, Offce of Safe and Healthy Students, Human Tracking in America’s Schools, Washington, D.C., 2015.
    Available from the Internet at: http://safesupportivelearning.ed.gov/human-tra cking-americas-schools (cited 1/28/19)

    Becker HJ, Bechtel K. Recognizing victims of human trafficking in the pediatric emergency department. Pediatr Emerg Care. 2015 Feb;31(2):144-7; quiz 148-50.

    Viergever RF, West H, Borland R, Zimmerman C. Health care providers and human trafficking: what do they know, what do they need to know? Findings from the Middle East, the Caribbean, and Central America. Front Public Health. 2015 Jan 29;3:6.

    Shandro J, Chisolm-Straker M, Duber HC, Findlay SL, Munoz J, Schmitz G, Stanzer M, Stoklosa H, Wiener DE, Wingkun N. Human Trafficking: A Guide to Identification and Approach for the Emergency Physician. Ann Emerg Med. 2016 Oct;68(4):501-508.e1.

    Greenbaum J, Bodrick N; Committee on Child Abuse and Neglect; Section on International Child Health. Global Human Trafficking and Child Victimization. Pediatrics. 2017 Dec;140(6). pii: e20173138.

    United Nations Office on Drugs and Crime. Human Trafficking. Available from the Internet at https://www.unodc.org/unodc/en/human-trafficking/what-is-human-trafficking.html (rev. 2019 cited 1/28/19).

    National Human Trafficking Resource Center. Recognizing and Responding to Human Trafficking in a Healthcare Context.
    Available from the Internet at: https://humantraffickinghotline.org/resources (cited 1/28/19).

    Author
    Donna M. D’Alessandro, MD
    Professor of Pediatrics, University of Iowa

  • How Commonly Are Brain Tumors Seen in Spasmus Nutans?

    Patient Presentation
    A 4-month-old male came to clinic for his well child check. His parents reported that he was doing well. He was breastfeeding vigorously and was smiling and trying to roll over. The past medical history was non-contributory. The family history was negative for any neurological, ophthalmological or genetic problems.

    The pertinent physical exam showed a smiley baby with growth parameters in the 10-50% and trending appropriately. Eye examination revealed pupils that were equal, round and reactive to light, normal red reflexes bilaterally. However, there was bilateral, intermittent, lateral, nystagmus that varied in amplitude. During the examination the nystagmus wouldn’t always occur. His head showed some very mild positional plagiocephaly on the right occiput without changes to the ear or face. There was a mild right sternocleidomastoid muscle torticollis as well. The neurological examination was normal. The diagnosis of nystagmus was made. With further questioning the parents said that a family member had noted it the previous week, but that they really didn’t think much of it as he overall seemed well. They denied any other unusual movements or posturing and no seizures. “His head is always turned toward the left and he always lays on that side,” his mother offered. The pediatrician discussed the findings and instructed the family how to improve the positioning for his plagiocephaly as well as starting to do some stretching exercises of his neck. An ophthalmologist examined the infant within the week and found bilateral, horizontal and vertical nystagmus that was intermittent and of low amplitude. Electroretinography was negative. He also noted head bobbing in the infant and the torticollis, and

    the diagnosis of spasmus nutans was made. He ordered a head magnetic resonance imaging study that was negative. Over the next few weeks, the torticollis improved but needed more intensive physical therapy without cranial banding. At his 9 month examination, the patient still had intermittent nystagmus and head bobbing.

    Discussion
    Nystagmus is periodic eye movement that is involuntary where there is a slow drift of fixation. The slow drift can be followed by a fast saccade back to fixation. The pathological movement is the slow phase, but nystagmus is described by the fast phase (i.e. horizontal nystagmus, vertical nystagmus).

    Spasmus nutans (SN) is a movement disorder that is rare. The classic triad includes nystagmus, head bobbing or titubation, and torticollis, with these problems being in the absence of any ophthalmological or neurological condition. Onset is in the first year of life but ranges from 6-36 months. Time to resolution is sometimes stated as 1-2 years, but others disagree citing longer time frames. There is no harm to visual acuity.

    • The SN nystagmus is usually intermittent, high frequency of small or low amplitude. It is “…variably disconjugate or disjunctive, greater in the abducting eye, and may have a vertical component.” Amblyopia and strabismus may coexist with SN.
    • The head bobbing is irregular may have both vertical and horizontal components.
    • Torticollis occurs as the child moves the head to try to obtain better visual acuity. The differential diagnosis of torticollis can be reviewed here.

    The differential diagnosis of SN includes ophthalmic problems such as congenital (infantile) nystagmus (a review can be found here), refractive disorders and retinal diseases, and problems of the central nervous system such as optic chiasm gliomas, diencephalic tumors, brain malformations, opsoclonus-myoclous, and bobble-head doll syndrome.

    Learning Point
    As SN is rare, reports of complications are even rarer but most concerning are potential underlying brain tumors particularly optic chiasm gliomas or neurological abnormalities. Rates of optic gliomas have been reported in small studies from 0% to 9%.

    In a 2017 study of 40 patients with SN who had magnetic resonance imaging, 25 patients had normal findings, none had optic nerve gliomas or other masses, and 2 had optic nerve hypoplasia. Other patients, including many who were otherwise healthy, had a variety of imaging findings which could or could not be clinically significant. The authors concluded that “…the risk of optic gliomas in children without other neurological deficits or signs concerning for intracranial mass lesions is very low.”

    In a 2018 long-term followup study of 22 patients, 17 had neuroimaging and all 17 were negative for any space occupying lesions, and 1 “…had findings suggesting hydrocephalus….”

    In this same 2018 long-term followup study, their patients had an average age of SN onset of 9.7 months (range 3-33 months ) and followup of 62.6 months (range 7-156). Nystagmus “…resolved in 4 [patients], from 2 to 49 months after presentation (mean 20 months), at ages ranging from 11-54 months (mean 30 months).” Head bobbing “…resolved during follow-up ranging from 1 to 49 months (mean 20 months), at ages ranging form 10 to 54 months (mean 27 months).” Torticollis improved in only 1 of 7 children, 39 months after presentation at the age of 51 months. During the study, no patients developed additional problems such as myopia, photophobia, night blindness or specific retinal pathology. With this data, the authors state that they advise families “…that many children do well, assuming normal imaging, but that nystagmus, torticollis and even titubations may persist.”

    Questions for Further Discussion
    1. What causes strabismus?
    2. What are common movement disorders in children? A review can be found here

    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 and the Cochrane Database of Systematic Reviews.
    Information prescriptions for patients can be found at MedlinePlus for this topic: Eye Movement Problems

    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.

    Delorme C, Gras D, Roze E. Spasmus Nutans: More Than Meets the Eye. Pediatr Neurol. 2015 Oct;53(4):367-8.

    Bowen M, Peragallo JH, Kralik SF, Poretti A, Huisman TAGM, Soares BP. Magnetic resonance imaging findings in children with spasmus nutans. J AAPOS. 2017 Apr;21(2):127-130.

    Parikh RN, Simon JW, Zobal-Ratner JL, Barry GP. Long-Term Follow-up of Spasmus Nutans. J Binocul Vis Ocul Motil. 2018 Oct-Dec;68(4):137-139.

    Author
    Donna M. D’Alessandro, MD
    Professor of Pediatrics, University of Iowa

    What Are Treatment Options for Pediatric Onycomycosis?

    Patient Presentation
    A 15-year-old male came to clinic because of his left great toenail had become yellowish and thicker over the last 1-2 months. He played multiple sports and had tinea pedis during basketball season 3-4 months earlier, but had noticed this during the spring baseball season. He denied any erythema, burning, itching or pain in his feet or nails. He had no changes to his hands. “I’ve been changing my socks more often, using shower shoes in the locker room and airing out my feet at home, but now I have this,” he commented. The past medical history was non-contributory. The family history was negative for dermatological problems with the exception of atopic dermatitis in one sister.

    The pertinent physical exam showed a healthy male with normal vital signs and weight in the 50% and height in the 90%. His dermatological examination was negative including his hands with the exception of his left great toe with showed hyperkeratotic, easily friable nail with yellowish coloration. There was no erythema, drainage, pain or other problems with the nail, along with no signs of other affected nail or tinea pedis. The diagnosis of onychomycosis was made. A culture was sent which eventually grew Trichophyton rubrum. He was treated with intraconazole daily for 12 weeks. He appeared to have clinical resolution at this time. His nailbed returned to normal by 9 months.

    Discussion
    Onycomycosis is a fungal infection of the nails. It has a world-wide prevalence of 0.3% with some geographical variations such as in the U.S. it is 0.44%. It is an uncommon problem especially in children. It is very uncommon in those under 6 years and only very sporadic case reports in those under 2 years. The lower incidence is felt to be due to children’s faster nail growth, smaller surface to infect, reduced exposure to fungi, lower prevalence of tinea pedis and especially less cumulative trauma. Onycomycosis is more common in families (unsure if this is due to genetic factors or family members having more onycomycosis and therefore increased environmental exposure), people with immunodeficiencies (especially adult diabetic patients or HIV), and people with Down’s syndrome. Trauma is a major predisposing factor as is hyperhidrosis.

    Clinical presentation includes color changes of the nail plate (often yellowish), debris under the nail bed, hyperkeratosis and thickening of the nail, and onycholysis.

    Family members should also be checked for onycomycosis and tinea pedis.

    Distal and lateral subungual onycomycosis is the most common. Dermatophytes especially are the usual cause especially Trichophyton rubrum but other causes include Candida sp. and nondermatophyte species such as Aspergillus.

    Learning Point
    Onycomycosis is difficult to treat and can recur. Systemic medications (often prolonged) are often the mainstay, but topical medications are also being used more. Because onycomycosis is uncommon in the pediatric age groups, clinical treatment studies very limited.

    A 2017 review article found 7 studies with the sample size from 1-40 patients (5 studies had only 8 or fewer patients enrolled). In the largest study of 40 patients, a control or ciclopirox nail lacquer was applied daily for 32 weeks. At 32 weeks, 34.2% were cured. At one year, 12 patients were available to be evaluated and 11 of the 12 were cured. During the study, 2 patients using the vehicle also had cure, which the authors believe may be due to “…weekly removal of lacquer and mechanical trimming….”

    A 2018 review of treatment agents in children found “…antifungal therapies used to treat onychomycosis in children are associated with a low incidence of adverse events. Current dosing regimens for antifungal drugs are effective and appear safe to use in children….” The weighted average cure rates were highest for intraconazole (oral), terbinafine (oral) and ciclopirox (topical). Cure rates depend on definition (i.e. clinical cure and/or myocological cure.

    Other topical treatments include amorolfine, bifonazole, terbinafine, ketoconazole, efinazonazole and tavaborole. Systemic medications frequently include intraconazole, terbinafine, griseofulvin and fluconazole.

    Questions for Further Discussion
    1. What are some potential side effects of systemic oral treatment for onychomycosis?
    2. What causes white nails (leukonychia)? For a review, click here.
    3. What does tinea pedis look like?

    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 and the Cochrane Database of Systematic Reviews.
    Information prescriptions for patients can be found at MedlinePlus for these topics: Nail Disease and Fungal Infections.

    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.

    Chadeganipour M, Mohammadi R. Causative Agents of Onychomycosis: A 7-Year Study. J Clin Lab Anal. 2016 Nov;30(6):1013-1020.

    Solis-Arias MP, García-Romero MT. Onychomycosis in children. A review. Int J Dermatol. 2017 Feb;56(2):123-130.

    Eichenfield LF, Friedlander SF. Pediatric Onychomycosis: The Emerging Role of Topical Therapy. J Drugs Dermatol. 2017 Feb 1;16(2):105-109.

    Gupta AK, Mays RR, Versteeg SG, Shear NH, Friedlander SF. Onychomycosis in children: Safety and efficacy of antifungal agents. Pediatr Dermatol. 2018 Sep;35(5):552-559.

    Author
    Donna M. D’Alessandro, MD
    Professor of Pediatrics, University of Iowa

    What Does the Liver Do?

    Patient Presentation
    A teenage boy was talking at dinner one night explaining that a student in his high school had had a motor vehicle accident and was in the hospital. “He’s doing okay but they said he cut his liver. I don’t know what that really means or what your liver really does?” he asked. His pediatrician mother explained that the student might have a liver laceration. “You can still live without part of your liver, but it’s pretty important,” she explained. “It does all kinds of things…,” and she started to list them. His eyes got wider and he finally stopped her. “Okay so I get it. It’s pretty important so I should take care of it right? This is part of the don’t drink alcohol and don’t do drugs talk isn’t it?” he asked. She smiled and said, “You asked the question. I answered it. And yes drugs and alcohol aren’t good for your liver because it is the major detoxifier for your body. They’re not good for any other part of your body too,” she reiterated. “Plus, make sure you always wear your seatbelt. He may have hurt his liver, but he probably saved his life with the seatbelt,” she also added.

    Discussion
    The liver is one of the largest organs in the body, weighing just over 3 pounds in an adult. It is found in the upper right abdomen, under the right dome of the diaphragm. Grossly, it has asymmetric lobes with the right being larger than the left. The lobes are separated by a fibrous connective tissue band that also anchors the liver in the abdominal cavity. The gallbladder is located on the inferior surface of the liver and stores bile, which is then released into the duodenum. Microscopically, the liver cells are arranged in lobules with canals carrying blood vessels and bile ducts. At any moment about 10-13% of the body’s blood volume is in the liver. Blood with its nutrients, medications and toxic substances comes to the liver from the portal vein. The liver processes the substances and the resulting end products are released back into the blood and eliminated by the renal system, or released into the bile and eliminated by the gastrointestinal system.

    Patients with liver problems can present in many different ways including hepatomegaly, jaundice (see below) and abnormal laboratory testing. In children inborn errors of metabolism must be considered.

    Some common liver diseases are below.

    Learning Point
    Liver functions include:

    • Metabolism
      • Bile acid production – eliminates toxins, helps to break down and absorb fat in the small intestine, about 800 – 1000 ml/day of bile is made
      • Protein production
        • Amino acids
        • Coagulants and clotting factor regulation
        • Fat binding proteins
        • Immune factors
        • Plasma proteins – e.g. albumin, lipoproteins, transferrin, carrier proteins
      • Cholesterol production
      • Energy metabolism – e.g. glycolysis, gluconeongensis, lipogenesis, ketogenesis, amino acid production
    • Storage
      • Glycogen storage and glucose homeostasis
      • Mineral storage – iron and copper
    • Toxin breakdown and excretion
      • Alcohol
      • Ammonia
      • Bilirubin
      • Drug clearance
        • Drugs are either activated (often with the P450 catalyzing enzymes) or detoxified (e.g. glucuronidation, sulfonification, oxidation)
      • Heavy metal elimination – e.g. copper, zinc

    Questions for Further Discussion
    1. What are indications of liver failure?
    2. What are indications for a liver transplant?
    3. What nutritional changes need to be made for people with liver disease?
    4. What are the fat-soluble vitamins?

    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 and the Cochrane Database of Systematic Reviews.
    Information prescriptions for patients can be found at MedlinePlus for this topic: Liver Diseases

    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.

    Teitelbaum JE. The Liver and Bile Ducts. Rudolph’s Pediatrics. Rudolph C, et.al. eds. McGraw-Hill. New York, NY. 2003;1473-1477.

    Informed Health Online. How Does the Liver Work? Institute for Quality and Efficiency in Health Care. Available from the Internet at https://www.ncbi.nlm.nih.gov/books/NBK279393/ (rev. 8/22/16, cited 1/11/19).

    Johns Hopkins Health Library. Liver: Anatomy and Functions. Available from the Internet at https://www.hopkinsmedicine.org/healthlibrary/conditions/liver_biliary_and_pancreatic_disorders/liver_anatomy_and_functions_85,P00676 (cited 1/11/19)

    American Liver Foundation. Ways to love your liver. Available from the Internet at https://liverfoundation.org/25-ways-to-love-your-liver/ (rev. 8/4/17, cited 1/11/19).

    American Liver Foundation. Your Liver. Available from the Internet at https://liverfoundation.org/for-patients/about-the-liver/ (cited 1/11/19).

    MedlinePlus. Liver Diseases. National Library of MedicineAvailable from the Internet at https://medlineplus.gov/liverdiseases.html (rev. 10/28/18, cited 1/11/19).

    Author
    Donna M. D’Alessandro, MD
    Professor of Pediatrics, University of Iowa