Pediatric Annals

Special Issue Article 

Radiologic Evaluation of the Child with a Limp

Matthew Thompson, MD; Tatum Johnson, MD; George Koberlein, MD

Abstract

A child presenting with a limp can present a diagnostic challenge to pediatricians. Clinical presentation, age, and history all contribute to the initial differential diagnosis; however, imaging plays a key role in the ultimate diagnosis, and the correct imaging study is essential to save time and health care expenses. This article will present a few of the more common causes of a limp and the recently updated imaging recommendations from the American College of Radiology to aid in final diagnosis. [Pediatr Ann. 2020;49(9):e395–e402.]

Abstract

A child presenting with a limp can present a diagnostic challenge to pediatricians. Clinical presentation, age, and history all contribute to the initial differential diagnosis; however, imaging plays a key role in the ultimate diagnosis, and the correct imaging study is essential to save time and health care expenses. This article will present a few of the more common causes of a limp and the recently updated imaging recommendations from the American College of Radiology to aid in final diagnosis. [Pediatr Ann. 2020;49(9):e395–e402.]

The best current estimate of children presenting with a limp is 1.5 to 3.6 per 1,000 children.1,2 A limp is often a nonspecific symptom in pediatric patients, and a broad differential diagnosis ranging from developmental etiologies, minor trauma, neuromuscular disease, infections, and neoplastic processes should be considered (Table 1). Often, a detailed history along with a focused physical examination directs care and assessment, but disease overlap occurs such that a life-threatening process can be initially overlooked.

Differential Causes of a Limp in a Child

Table 1.

Differential Causes of a Limp in a Child

Often, the etiology of the limp is benign and requires little investigation; however, more aggressive pathologies may need to be considered in the appropriate clinical context. Thus, there must exist a balance between choosing the appropriate imaging examination to aid in identifying the diagnosis without risking over-investigation.3 The American College of Radiology (ACR) Appropriateness Criteria for assessing a limping child up to age 5 years were revised in 2018;4 however, this revision did not address older children and is limited to a few clinical scenarios. Thus, consideration of pathology outside this revision will need to be addressed in the future.

Clinical and Imaging Evaluation

Algorithms for assessment of gait are available that include alteration of gait to avoid pain while walking to protect the injured side.5 When this deviation from normal is identified, clinical assessment, often with aid of imaging, seeks to identify the underlying pathology. The “Image Gently” campaign and “As Low As Reasonably Achievable” campaign have highlighted dose-reduction techniques in pediatric imaging; thus, pediatric radiologists often recommend the least invasive and least dose-dependent imaging study to arrive at the ultimate diagnosis, hoping to reduce radiation exposure.

From a differential standpoint, the most common diseases producing a limp are often considered by age and/or trauma history (Table 2). In reference to age, toddlers often present with a limp as a result of a congenital process such as developmental dysplasia of the hip (DDH) or Toddler's fracture. Children older than toddlers are prone to transient synovitis and avascular necrosis of the hip. Adolescents often succumb to slipped capital femoral epiphysis (SCFE) and osteochondral lesions.

Differential Diagnosis of Limp Based on Patient Age

Table 2.

Differential Diagnosis of Limp Based on Patient Age

If presentation is secondary to trauma, radiographs of the site of trauma often are sufficient to assess for acute pathology.2 However, more advanced imaging may be required for final diagnosis in the absence of definitive radiographic findings.

Alternatively, if there is no recent history of trauma and physical examination findings are nonspecific, clinical suspicion of disease may need to drive imaging assessment. For example, pediatric pelvic and hip pain can both present with a limp, but if there is strong clinical suspicion for hip pathology, a few classic pediatric processes should be considered. However, it is important to keep in mind that septic arthritis, osteomyelitis, trauma, and neoplastic causes can be considered in any age group.6 Additionally, a limp may be a secondary finding in the setting of spinal or intra-abdominal pathology, both of which are beyond the scope of this article.

Age-Related Causes of LIMP

Developmental Dysplasia of the Hip

DDH is often diagnosed in infancy secondary to clinical suspicion or asymmetric skin folds. However, DDH should still be considered when a child starting to walk presents with a limp or an active adolescent presents with hip or groin pain.7 Initial imaging in infancy consists of an ultrasound to assess the angle between the acetabular roof and the vertical cortex of the ilium (alpha angle), and the degree of femoral head epiphysis coverage by the acetabular roof (normal is >50%). However, ultrasound is only helpful up to age 6 months, after which the femoral head ossification causes shadowing, decreasing test sensitivity. Radiographs of the pelvis and hips are typically obtained in children older than age 6 months to assess for hip dysplasia by measuring the acetabular index and degree of subluxation (Figure 1A).

(A) Developmental dysplasia of the hip. Neutral view of the pelvis in a 13-month-old toddler with limp. The right hip is located and appropriately covered by the acetabulum. The left hip is subluxed laterally with a shallow, dysplastic-appearing acetabulum. If one were to measure the acetabular index on the left, it would be too high. (B) Transient synovitis. Ultrasound images of the bilateral hips in a 4-year-old boy with a limp. The right hip demonstrates an effusion as evidenced by joint distention with simple-appearing fluid (between the solid arrows). The left hip joint is not distended and no effusion is seen on the left. (C) Legg-Calve-Perthes disease. Neutral view of the pelvis demonstrating a sclerotic, flattened appearance of the proximal femoral epiphysis consistent with vascular insult (avascular necrosis). (D) Slipped capital femoral epiphysis. Frog-leg view of the left hip. There is widening of the proximal left femoral physis and one can see the posterior, inferior displacement of the proximal femoral epiphysis relative to the metaphysis, which is diagnostic.

Figure 1.

(A) Developmental dysplasia of the hip. Neutral view of the pelvis in a 13-month-old toddler with limp. The right hip is located and appropriately covered by the acetabulum. The left hip is subluxed laterally with a shallow, dysplastic-appearing acetabulum. If one were to measure the acetabular index on the left, it would be too high. (B) Transient synovitis. Ultrasound images of the bilateral hips in a 4-year-old boy with a limp. The right hip demonstrates an effusion as evidenced by joint distention with simple-appearing fluid (between the solid arrows). The left hip joint is not distended and no effusion is seen on the left. (C) Legg-Calve-Perthes disease. Neutral view of the pelvis demonstrating a sclerotic, flattened appearance of the proximal femoral epiphysis consistent with vascular insult (avascular necrosis). (D) Slipped capital femoral epiphysis. Frog-leg view of the left hip. There is widening of the proximal left femoral physis and one can see the posterior, inferior displacement of the proximal femoral epiphysis relative to the metaphysis, which is diagnostic.

In older patients with examination and radiographic findings consistent with hip dysplasia, magnetic resonance imaging (MRI) or computed tomography (CT) may be ordered by an orthopedic surgeon for further assessment of hip deformity, acetabular morphology, or labral pathology.7 It should be noted that advanced imaging has a limited role in initial diagnosis and should only be considered in patients requiring additional information for operative repair.

Transient Synovitis

Transient synovitis is a benign, self-limiting disease that often presents between ages 3 and 8 years and is one of the most common causes of a limp in the pediatric patient.8,9 This condition overlaps in presentation with septic arthritis and can only be diagnosed after this more serious condition has been excluded. The criteria by Kocher et al.10 provide an algorithm to aid in distinguishing septic arthritis from transient synovitis on a clinical basis, but imaging is often obtained to aid in diagnosis.

Imaging initially begins with pelvic radiographs, which are helpful in excluding osseous pathology but can be normal or demonstrate slight joint space widening if a joint effusion is present.9 ultrasound is typically the next step in imaging evaluation and may show a sterility indeterminate hip effusion11 (Figure 1B). Hip aspiration may then be performed to exclude septic hip from consideration if warranted.

Legg-Calve-Perthes Disease

Legg-Calve-Perthes (LCP) disease results from idiopathic osteonecrosis of the femoral epiphysis in children age 2 to 14 years, with a peak at age 5 to 6 years.12 The patient will present with a limp or hip pain, often with no history of trauma. Initial radiographs will demonstrate a spectrum of findings involving the femoral epiphysis that ranges from sclerosis, flattening, lucency, and fragmentation, depending on the stage of disease (Figure 1C). However, because LCP is a diagnosis of exclusion, other etiologies must first be excluded, such as osteomyelitis, trauma, and sickle cell disease, among others. MRI may also be obtained after initial radiographs to assess for degree of cartilaginous involvement or to aid in treatment planning.13

Slipped Capital Femoral Epiphysis

SCFE occurs more often in obese or overweight adolescent children who present with a limp or pain in the hip or groin with no known prior trauma.14 SCFE results from a fracture occurring at the proximal femoral physis. The neutral anteroposterior view of the hips may show subtle widening at the physis compared to the contralateral hip, or it may be normal. Therefore, frog-leg view radiographs are essential for diagnosis and will show posterior displacement of the epiphysis relative to the metaphysis, which is diagnostic of this condition14 (Figure 1D).

Trauma

Trauma to the lower extremities can occur at any age and is often witnessed with an obvious site of injury. However, minor trauma, unwitnessed trauma, and nonaccidental trauma may all present with a limp. The ACR Appropriateness Criteria2 recommend radiographs initially, which may include the entire lower extremity in younger patients. There are a large number of lower extremity fractures that can result in acute injuries that result in a limp. Some of the most common fractures seen in the limping child are discussed below.

Toddler's Fracture

The “Toddler's fracture” has historically referred to subtle nondisplaced fractures of the tibia in children age 1 to 3 years who refuse to walk or bear weight on the affected extremity. But, Toddler's fractures can also include fractures of the femur, fibula, talus, cuboid, calcaneus, or even the metatarsals. What classifies a fracture as a Toddler's fracture is that it occurs when the child begins to walk or run.

Radiographs are the initial test of choice if the fracture is not clinically evident. However, the classic Toddler's fracture of the tibia may be subtle and nondisplaced, and, therefore, easily overlooked.15 More obvious appearances of Toddler's fracture of the tibia will show buckling of the cortex or a transverse fracture line. Fractures of the femur, fibula, talus, cuboid, calcaneus, and metatarsals may show a lucent fracture line, buckling of the cortex, or sclerotic bands (especially in the cuboid or calcaneus). If no fracture is visualized but clinical suspicion for Toddler's fracture remains high, consider obtaining follow-up radiographs in 10 to 14 days, which may show periosteal reaction and callus formation, as can be seen with healing (Figure 2A, 2B).

Traumatic causes of a limp. (A) Toddler's fracture. Radiograph of the left lower extremity demonstrates a faintly visible oblique lucent line along the distal diaphysis (solid black arrow). This lucent line is often so subtle that nondisplaced Toddler's fracture can initially be occult. (B) Toddler's fracture on follow-up; 14 days after initial injury, the fracture (white arrow) is more apparent and evidence of healing with periosteal reaction is clearly visible (black arrow). (C) Stress fracture. A faint transverse lucent line is seen with cortical thickening along the lateral aspect of the fourth metacarpal (black arrow), consistent with a stress fracture. (D) Pelvic avulsion fracture. A faint curvilinear calcification at the level of the right anterior superior iliac spine (black arrow) consistent with a pelvic avulsion fracture is present.

Figure 2.

Traumatic causes of a limp. (A) Toddler's fracture. Radiograph of the left lower extremity demonstrates a faintly visible oblique lucent line along the distal diaphysis (solid black arrow). This lucent line is often so subtle that nondisplaced Toddler's fracture can initially be occult. (B) Toddler's fracture on follow-up; 14 days after initial injury, the fracture (white arrow) is more apparent and evidence of healing with periosteal reaction is clearly visible (black arrow). (C) Stress fracture. A faint transverse lucent line is seen with cortical thickening along the lateral aspect of the fourth metacarpal (black arrow), consistent with a stress fracture. (D) Pelvic avulsion fracture. A faint curvilinear calcification at the level of the right anterior superior iliac spine (black arrow) consistent with a pelvic avulsion fracture is present.

The differential diagnosis for Toddler's fracture includes child abuse, osteomyelitis, developmental disease, or potential malignancy. Plain film radiographs in these settings will show additional fractures in the setting of abuse, periosteal reaction in the setting of osteomyelitis or malignancy, and bone formation/mineralization in the setting of developmental disease.

Stress Fracture

Stress fractures are due to abnormal stress on normally mineralized bone and tend to occur in older children who may present with focal pain that increases with activity and improves with rest. The most common locations in the ankle and foot are the metatarsals, navicular, and calcaneus.16 Radiographs are not as sensitive for acute stress fractures and thus may be initially radiographically occult. Follow-up radiographs, however, may show focal periosteal reaction or a sclerotic line perpendicular to the long axis of the bone (Figure 2C). Both radiographs and MRI have been found to be useful for evaluating stress fractures in children; however, MRI should only be considered in the case of equivocal or negative radiographs and strong clinical suspicion.17

Lower Extremity Fractures

The Tillaux fracture occurs at approximately age 12 to 15 years in both boys and girls when the distal tibial physis is beginning to close. The physis begins to fuse medial to lateral, and an abnormal stress on the ankle at this time can result in a vertical fracture through the epiphysis and a lateral fracture through the physis along the path of weakness in the bone, which classifies this as a Salter-Harris III fracture. Radiographs are usually diagnostic and clearly show the fracture lines; however, CT may be requested by the orthopedic surgeon to determine the degree of articular surface distraction for treatment planning purposes.18

The classic triplane fracture occurs at the same age range as the Tillaux fracture (age 12–15 years). Like the Tillaux fracture, there is a vertical fracture line through the epiphysis and a horizontal fracture through the lateral physis. But unlike the Tillaux, there is also an oblique fracture through the posterior metaphysis of the distal tibia. Given the fracture extension through the metaphysis, physis, and epiphysis, the triplane fracture is classified as a Salter-Harris IV fracture. As there are multiple fracture planes, at least anteroposterior and lateral ankle radiographs are needed to make the diagnosis. A CT scan of the ankle may be requested by the orthopedic surgeons for treatment planning, depending on the severity of the fracture.19

The tibial tubercle avulsion fracture occurs with significant traction force by the patellar tendon on the tibial tubercle ossification center, resulting in avulsion from the underlying physis. It is most commonly seen with jumping and landing sports such as basketball.20 A lateral radiograph is usually sufficient for diagnosis and shows widening and displacement of the proximal apophysis. Osgood-Schlatter disease, which consists of irritation at the tibial tubercle due to chronic stress, can predispose to tibial tubercle avulsion fractures.

The patellar sleeve avulsion fracture occurs in skeletally immature patients age 8 to 16 years, mostly boys, and is due to an explosive force (such as jumping) or a fall resulting in sudden pain and inability to bear weight. Radiographs are usually sufficient for the diagnosis (especially the lateral view) and show a small ossific fragment displaced distally from the inferior pole of the patella due to forced contraction from the patellar tendon. Patellar sleeve avulsion fractures can also occur at the superior pole of the patella involving the quadriceps tendon, but these are less common.21

Pelvic Avulsion Fractures

There are several pelvic avulsion fractures that can occur in the child or adolescent that can present with a limp. The most common pelvic avulsion fractures occur at the anterior superior iliac spine (sartorius), the anterior inferior iliac spine (rectus femoris), the iliac crest (abdominal muscles and tensor fascia lata), the ischial tuberosity (hamstrings), and the inferior pubic symphysis (adductor tendon group)22 (Figure 2D). Anteroposterior radiographs of the pelvis are usually sufficient for diagnosis and reveal a thin ossific fragment adjacent to the anatomical location. However, if the suspected avulsed apophysis is nonossified or a nonosseous avulsion (eg, tendinous or ligamentous) is suspected, MRI may be required.23

Infection

A more indolent cause of limp, which may occur at any age, is the presence of an infection, which would include pathology such as cellulitis, abscess, septic joint, and osteomyelitis. Clinical findings of fever, tissue warmth, and redness or swelling, along with elevated inflammatory markers (such as erythrocyte sedimentation rate and C-reactive protein) often suggest this diagnosis.

Osteomyelitis

The incidence of osteomyelitis has been reported at 1 in 5,000, more often in males, with more than 50% of patients presenting before the age 5 years.24 When clinical suspicion for osteomyelitis is high, contrast-enhanced MRI may be the most appropriate imaging study.2 Advantages to this approach include more precise localization of sites of involvement, lack of ionizing radiation, and directing treatment approach (antibiotics vs surgical debridement). MRI findings of osteomyelitis include bone marrow edema, enhancing subperiosteal or intramedullary abscess, and non-enhancing regions of bone indicating ischemia and necrosis secondary to vascular thrombosis (Figure 3B, 3C).

Infectious cause of a limp. Osteomyelitis in a 9 year old presenting with clinical suspicion for infection. (A) Frontal radiograph of the knee. There is edema surrounding the knee as well as lucent lesions within the distal lateral femoral metaphysis and medal femoral condyle (black arrows). (B) Coronal T1-weighted magnetic resonance imaging of the same knee as in Panel A. Abnormal signal is seen with in the distal femoral metaphysis and epiphysis, and there is a focal rounded signal abnormality that corresponds to the lucent lesion seen within the distal lateral femoral metaphysis (black arrow). (C) Coronal contrast enhanced magnetic resonance imaging of the same knee as in panel A. The distal femoral metaphysis and epiphysis demonstrate avid enhancement. There is a peripherally enhancing lesion that corresponds to the metaphyseal lesion in Panel A, which is consistent with an abscess (black arrow). Imaging features in this patient are consistent with osteomyelitis given the clinical and laboratory findings.

Figure 3.

Infectious cause of a limp. Osteomyelitis in a 9 year old presenting with clinical suspicion for infection. (A) Frontal radiograph of the knee. There is edema surrounding the knee as well as lucent lesions within the distal lateral femoral metaphysis and medal femoral condyle (black arrows). (B) Coronal T1-weighted magnetic resonance imaging of the same knee as in Panel A. Abnormal signal is seen with in the distal femoral metaphysis and epiphysis, and there is a focal rounded signal abnormality that corresponds to the lucent lesion seen within the distal lateral femoral metaphysis (black arrow). (C) Coronal contrast enhanced magnetic resonance imaging of the same knee as in panel A. The distal femoral metaphysis and epiphysis demonstrate avid enhancement. There is a peripherally enhancing lesion that corresponds to the metaphyseal lesion in Panel A, which is consistent with an abscess (black arrow). Imaging features in this patient are consistent with osteomyelitis given the clinical and laboratory findings.

Although acute osteomyelitis is often radiographically occult, subacute or chronic osteomyelitis may show findings of ill-defined lucency, bone destruction, or periosteal reaction (Figure 3A). However, given the sensitivity of MRI in the setting of acute osteomyelitis, and the need to promptly begin treatment after diagnosis, MRI is recommended when there is high clinical suspicion.

As a variant presentation of osteomyelitis, chronic recurrent multifocal osteomyelitis (CRMO) may be considered when a child presents with a limp and leg pain. Radiographs for CRMO are often initially negative, similar to infectious osteomyelitis, but lytic lesions may be seen later in disease, followed by healing changes of sclerosis. Sites of involvement may mimic that of bacterial osteomyelitis but are more likely to be multifocal. MRI will show multiple sites of bone marrow edema and enhancement, which is a nonspecific finding that can also be seen with bacterial osteomyelitis and neoplasm. However, CRMO should be suspected when symptoms do not resolve with treatment and infection and neoplasm have been excluded.

Septic Joint

A septic joint presents with pain, fever, and decreased movement of the involved extremity that may present as a limp. A septic joint often occurs secondary to an adjacent focus of osteomyelitis, penetrating trauma, or bacterial seeding/embolization. Because the proximal femoral metaphysis is intra-articular, the hip is particularly susceptible to septic arthritis; however, the knee, ankle, and various joints about the foot can also be affected.

If there is high clinical suspicion for a septic joint, MRI may be the most appropriate imaging study given the association with osteomyelitis.2 Radiography is insensitive for a septic joint, and it may only be suspected when there are nonspecific radiographic findings of hip, knee, or ankle effusion, which require ultrasound for confirmation.

Ultrasound findings include hypoechoic joint fluid widening the joint capsule compared to the contralateral side. However, the joint effusion visualized on US cannot be distinguished from transient synovitis and is, therefore, indeterminate of sterility. The MRI findings of septic joint include joint effusion and enhancing synovium; but again, these findings are nonspecific and can also be seen in inflammatory etiologies. Therefore, hip aspiration is required to confirm diagnosis of septic joint.

Alternative Pathologies

The above pathological conditions represent some of the most common diseases encountered when patients present with a limp. However, it is important to keep in mind that neoplasia, noninfectious arthritis, osteoid osteoma, osteonecrosis, and other less common etiologies (Table 1) can also present with a limp.

Neoplasms may present similarly to infection with constitutional symptoms and elevated inflammatory markers, or with focal pain, palpable mass, or altered gait. Ewing's sarcoma, osteosarcoma, and leukemia represent the most commonly occurring bone neoplasms in children. Ewing's sarcoma typically presents between ages 10 and 25 years, with osteosarcoma often presenting between ages 15 and 25 years. Radiography may be the initial examination ordered, and results may show nonspecific findings in early stages of disease such as periosteal reaction, lytic lesions, cortical irregularity, and soft tissue swelling (Figure 4). More advanced findings, such as osseous destructive changes, are more likely to be seen in later stages of disease. A high index of suspicion should exist for neoplasia when symptoms are nonspecific and radiography is negative, particularly if the patient presents again without resolution of symptoms after the initial testing is negative. MRI with contrast is appropriate if neoplasia is suspected, as it will better assess both osseous and soft tissues.

Ewing's sarcoma. (A). Frontal radiograph of the knee. There is a mixed sclerotic and lucent appearance of the proximal tibial metaphysis. The exact extent of this lesion and its margins are unclear. Additionally, a triangular region of periosteal reaction is seen laterally (Codman triangle). (B). Lateral radiograph of the knee. Remonstrated lesion in the proximal tibial metaphysis. (C). Coronal contrast-enhanced magnetic resonance image of the knee. Avid enhancement of this lesion with associated soft tissue component that could not be easily seen on the radiographs. At biopsy, this was proven to be Ewing's sarcoma.

Figure 4.

Ewing's sarcoma. (A). Frontal radiograph of the knee. There is a mixed sclerotic and lucent appearance of the proximal tibial metaphysis. The exact extent of this lesion and its margins are unclear. Additionally, a triangular region of periosteal reaction is seen laterally (Codman triangle). (B). Lateral radiograph of the knee. Remonstrated lesion in the proximal tibial metaphysis. (C). Coronal contrast-enhanced magnetic resonance image of the knee. Avid enhancement of this lesion with associated soft tissue component that could not be easily seen on the radiographs. At biopsy, this was proven to be Ewing's sarcoma.

The differential diagnosis for nonseptic arthritis is extensive, but a commonly suspected etiology is juvenile idiopathic arthritis (JIA). JIA is a polyarticular disease, typically initially presenting between ages 1 and 3 years, lasting at least 6 weeks, and can be rheumatoid factor-positive.25 JIA usually involves large joints, and the knee is most commonly affected. Radiographs are nonspecific but may show joint effusions or cartilage loss as evidenced by joint space narrowing. MRI with contrast is preferred for diagnosis and will show synovitis and synovial proliferation early in disease, and cartilage destruction, joint destruction, and ankylosis late in disease.

Conclusion

When a child presents with a limp, the clinician is faced with multiple diagnostic possibilities that often require an appropriate imaging examination. Some of the more common etiologies of limp in a child are referenced above with appropriate initial investigative imaging recommendations. However, it is important to keep in mind that additional imaging and/or clinical investigation may need to be considered when both the clinical and imaging findings suggest an alternative diagnosis.

References

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Differential Causes of a Limp in a Child

Primary bone cause   Trauma   Overuse injury   Neoplasia   Infection   Developmental disease   Osteonecrosis   Congenital disease Intra-articular cause   Infection   Congenital disease   Hemarthrosis   Rheumatologic   Trauma Intra-abdominal causes   Psoas abscess   Appendicitis   Neoplasia Soft tissue disease   Infection   Foreign body   Abscess Neurologic disease   Cerebral palsy   Meningitis   Diskitis   Central neoplasia   Muscular dystrophy

Differential Diagnosis of Limp Based on Patient Age

Toddler (age 1–3 years)   Developmental dysplasia of the hip   Nonaccidental   Toddler's fracture Child (age 3–10 years)   Transient synovitis   Arthritis   Legg-Calve Perthe's Adolescent (age 10 years to adult)   Arthritis   Slipped capital femoral epiphysis   Avulsion injury Any age   Trauma   Infection/septic joint   Malformative disease   Neoplasia
Authors

Matthew Thompson, MD, is an Assistant Professor of Radiology. Tatum Johnson, MD, is an Assistant Professor of Radiology. George Koberlein, MD, is an Assistant Professor of Pediatrics. All authors are affiliated with Wake Forest School of Medicine.

Address correspondence to George Koberlein, MD, Department of Pediatrics, Wake Forest School of Medicine, Medical Center Boulevard, Winston-Salem, NC 27157; email: gkoberle@wakehealth.edu.

Disclosure: The authors have no relevant financial relationships to disclose.

10.3928/19382359-20200821-01

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