eMedicine Specialties > Pediatrics: General Medicine > Rheumatology

Mixed Connective Tissue Disease: Treatment & Medication

Author: Marisa S Klein-Gitelman, MD, MPH, Associate Professor of Pediatrics, Northwestern University Feinberg School of Medicine; Head, Division of Rheumatology, Children's Memorial Hospital
Contributor Information and Disclosures

Updated: Sep 29, 2009

Treatment

Medical Care

  • The most important tools in treatment of mixed connective tissue disease (MCTD) include tailoring the medical regimen, promptly attending to disease flare, and performing careful and frequent clinical and laboratory evaluations to test for new disease manifestations.
  • Some patients have physical findings and laboratory studies that more closely resemble lupus (particularly double-stranded DNA and hypocomplementemia), and treatment should be tailored to treat a lupuslike disease.
  • Strongly consider annual echocardiography, pulmonary function testing, and barium swallow.

Surgical Care

  • No specific surgical care is required.

Consultations

  • A rheumatologist should be an integral part of the medical care team supporting the patient with mixed connective tissue disease.
  • Other consultants depend on the organ systems involved and the disease severity.

Diet

  • Diet restrictions are driven by medical therapy and disease manifestations. Prescribe a low-fat, calcium-sufficient diet with no added salt for patients receiving corticosteroids.
  • Recognize and evaluate nontraditional remedies along with traditional medications for safety and efficacy.

Activity

  • Encourage the patient with mixed connective tissue disease to maintain a healthy lifestyle.
  • Limitations should occur only secondary to serious organ involvement that prevents performance of activities.
  • Advise patients with mixed connective tissue disease to avoid fatigue.
  • Advise patients with mixed connective tissue disease to avoid significant cold exposures or to dress accordingly to decrease Raynaud symptoms.

Medication

Therapeutic interventions for children with mixed connective tissue disease (MCTD) should occur under the direction or with the advice of an experienced physician. Various medications are used to treat individuals with mixed connective tissue disease and are chosen depending on disease manifestations. Goals of therapy are to control disease manifestations, allowing the child to have a good quality of life without major disease exacerbations, and to prevent serious organ damage that adversely affects function or life span. At the same time, the physician is challenged to prevent intolerable adverse effects from the therapeutic regimen.

Prior to treatment, identify diagnostic criteria and exclude other possible diagnoses. For those patients who do not have sufficient findings to fulfill diagnostic criteria, determine a course of action based on medical judgment and set time aside to answer all questions with the patient, family, and caregivers. Because they may be helpful, offer literature and support groups.

Many of these drugs have serious adverse effects, contraindications, and drug interactions. A high risk of infection, infertility, and future cardiovascular disease exists. Most medications are contraindicated during pregnancy. Advise patients with mixed connective tissue disease who are pregnant to consult an obstetrician and a rheumatologist with experience in treating other patients in similar conditions. The most important tool in the treatment of individuals with mixed connective tissue disease is meticulous and frequent reevaluation of patients. Reevaluation includes clinical and laboratory evaluation, allowing prompt recognition and treatment of disease flare that is essential to positive outcome.

As in individuals with systemic lupus erythematosus (SLE), patients may require little or no medication or may require long-term immunosuppression. Some of the medications patients require can be found below. Other specific medications may be applicable if the patient has another disease manifesting with mixed connective tissue disease. Because of the rarity of this disease, advise the patient to consult a physician with experience in the treatment of mixed connective tissue disease. Patients with hypertension should be aggressively treated. If hypertension is a consequence of corticosteroid therapy, consider immunomodulating medications as steroid-sparing agents to help control hypertension. Calcium channel blockers used to treat hypertension may also be used to treat Raynaud phenomenon.

For more information, see Hypertension.

Nonsteroidal anti-inflammatory drugs

For children who present with mild disease, treat symptomatically and monitor closely for signs of disease progression. Treat individuals with arthritis and musculoskeletal pain with nonsteroidal anti-inflammatory drugs (NSAIDs).

Select a specific agent based on patient response to medication, history of previous drug allergy or reaction, and ease of use. These medications have analgesic and anti-inflammatory properties to treat arthralgia and arthritis and are available with slightly different safety and efficacy profiles.


Naproxen (Aleve, Naprelan, Naprosyn, Anaprox)

For relief of mild to moderate pain; inhibits inflammatory reactions and pain by decreasing activity of cyclooxygenase, which is responsible for prostaglandin synthesis. Available in SR formulation for once daily dosing as Naprelan.

Adult

500-1000 mg/d PO divided bid

Pediatric

7-20 mg/kg/d PO divided bid/tid; not to exceed adult dose

Coadministration with aspirin increases risk of inducing serious NSAID-related adverse effects; probenecid may increase concentrations and, possibly, toxicity of NSAIDs; may decrease effect of hydralazine, captopril, and beta-blockers; may decrease diuretic effects of furosemide and thiazides; may increase PT when taking anticoagulants (instruct patients to watch for signs of bleeding); may increase risk of methotrexate toxicity; phenytoin levels may be increased when administered concurrently

Documented hypersensitivity; gastritis; hepatic or renal insufficiency; coagulopathy; other conditions in which changes in platelet function could be harmful

Pregnancy

C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus

Precautions

Category D in third trimester of pregnancy; acute renal insufficiency, interstitial nephritis, hyperkalemia, hyponatremia, and renal papillary necrosis may occur; patients with preexisting renal disease or compromised renal perfusion risk acute renal failure; leukopenia occurs rarely, is transient, and usually returns to normal during therapy; persistent leukopenia, granulocytopenia, or thrombocytopenia warrants further evaluation and may require discontinuation; occasionally, patient with SLE has a hypersensitivity reaction, most often characterized as a hepatotoxicity, but reaction can include other symptoms and must be kept in mind


Tolmetin (Tolectin)

For relief of mild to moderate pain; inhibits inflammatory reactions and pain by decreasing activity of cyclooxygenase, which is responsible for prostaglandin synthesis.

Adult

1200-1800 mg/d PO divided tid

Pediatric

<2 years: Not established
>2 years: 15-30 mg/kg/d PO divided tid/qid; not to exceed adult dose

May increase serum concentrations of methotrexate or lithium; aspirin and probenecid may increase serum concentrations; tolmetin and warfarin lead to increased PT and bleeding; drug interactions similar to other NSAIDs may occur (eg, blunting antihypertensive effects of beta-blocking agents); other GI irritants may increase GI adverse reactions

Documented hypersensitivity; gastritis; hepatic or renal insufficiency; coagulopathy; other conditions in which changes in platelet function could be harmful

Pregnancy

C - Fetal risk revealed in studies in animals but not established or not studies in humans; may use if benefits outweigh risk to fetus

Precautions

Caution with renal or liver disease; avoid during pregnancy; occasionally, patient with SLE has hypersensitivity reaction, most often characterized as hepatotoxicity, but reaction can include other symptoms and must be kept in mind; routinely monitor for gastritis, renal toxicity, hepatic toxicity, and bone marrow suppression, hepatitis, interstitial nephritis, CNS changes


Diclofenac (Voltaren-XR)

Inhibits prostaglandin synthesis by decreasing activity of enzyme cyclooxygenase, which decreases formation of prostaglandin precursors.
Available in SR formulation as Voltaren-XR (100 mg).

Adult

100-200 mg/d PO divided bid

Pediatric

<12 years: Not established
>12 years: 2-3 mg/kg/d PO divided bid; not to exceed adult dose

Coadministration with aspirin increases risk of inducing serious NSAID-related adverse effects; probenecid may increase concentrations and, possibly, toxicity of NSAIDs; may decrease effect of hydralazine, captopril, and beta-blockers; may decrease diuretic effects of furosemide and thiazides; may increase PT when taking anticoagulants (instruct patients to watch for signs of bleeding); may increase risk of methotrexate toxicity; phenytoin levels may be increased when administered concurrently

Documented hypersensitivity; gastritis; hepatic or renal insufficiency; coagulopathy; other conditions in which changes in platelet function could be harmful

Pregnancy

C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus

Precautions

Category D in third trimester of pregnancy; acute renal insufficiency, hyperkalemia, hyponatremia, interstitial nephritis, and renal papillary necrosis may occur; increases risk of acute renal failure in patients with preexisting renal disease or compromised renal perfusion; low WBC counts occur rarely and usually return to normal in ongoing therapy; discontinuation of therapy may be necessary with persistent leukopenia, granulocytopenia, or thrombocytopenia; occasionally, patient with SLE has hypersensitivity reaction, most often characterized as hepatotoxicity, but reaction can include other symptoms and must be kept in mind

Antimalarials

Patients in whom major disease manifestation is lupus, rash, and other minor symptoms can be treated with hydroxychloroquine.


Hydroxychloroquine (Plaquenil)

Antimalarial drugs inhibit synthesis of DNA, RNA, and proteins by interacting with nucleic acids. Antimalarial drugs have various immunosuppressive effects, can act as antioxidants, and interfere with prostaglandins. Hydroxychloroquine sulfate 200 mg is equivalent to 155 mg hydroxychloroquine base and 250 mg chloroquine phosphate.

Adult

200-400 mg/d PO (3-7 mg/kg/d)

Pediatric

3-7 mg/kg/d PO; not to exceed 400 mg/d

Few reported; chloroquine may potentiate possible ocular toxicity; serum levels increase with cimetidine; magnesium trisilicate may decrease absorption

Documented hypersensitivity; G-6-PD deficiency; retinal or visual field changes; porphyria; psoriasis

Pregnancy

C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus

Precautions

Caution in hepatic disease, G-6-PD deficiency, psoriasis, and porphyria; not recommended for long-term use in children; perform periodic (ie, 6 mo) ophthalmologic examinations for retinal pigment changes; test periodically for muscle weakness; adverse effects are infrequent and include eye changes, GI symptoms (diarrhea is most prominent), and CNS changes

Corticosteroids

Use corticosteroids to treat children with hypocomplementemia and elevated levels of anti-DNA antibodies, children with active myositis, and children with significant manifestations of scleroderma. Dose varies with intensity of disease activity. Consider daily prednisone (1 mg/kg/d) or higher-dose alternate-day prednisone (5 mg/kg/d, not to exceed 150-250 mg depending on size of patient). Alternatively, lower-dose daily prednisone (0.5 mg/kg) may be used in conjunction with intermittent high-dose IV methylprednisolone (30 mg/kg/dose, not to exceed 1 g) on a weekly basis. Of note, recent case reports suggest that 3 days of pulse IV methylprednisolone followed by moderate-to-high dose oral steroids improved pulmonary artery pressures in a patient with mixed connective tissue disease and pulmonary artery hypertension.


Prednisone (Deltasone, Orasone)/Methylprednisolone (Adlone, Solu-Medrol)

Decreases inflammation by suppression of immune system: decreased lymphocyte volume and activity; decreased PMN migration; decreased or reversal of capillary permeability. High doses, especially over periods longer than 2-3 wk, suppress adrenal function.

Adult

1-2 mg/kg/d PO

Pediatric

1-2 mg/kg/d PO initially in divided doses not to exceed qid, then consolidated to daily dose before tapering total mg/d
30 mg/kg IV not to exceed 1 g/d as methylprednisolone for severe disease; may be administered as 3-d pulse regimen or as part of steroid regimen under guidance of rheumatologist

Coadministration with digoxin may increase digitalis toxicity secondary to hypokalemia; estrogens may increase levels of methylprednisolone; phenobarbital, phenytoin, and rifampin may decrease levels of methylprednisolone (adjust dose); monitor patients for hypokalemia with concurrent diuretic use

Documented hypersensitivity; serious infection except septic shock or tuberculous meningitis but including systemic fungal infection and varicella

Pregnancy

B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals

Precautions

Carefully monitor patients on corticosteroids for infection and carefully evaluate in setting of fever with no obvious source; monitor patients for diabetes, osteoporosis, osteonecrosis, hypertension, glaucoma, cataract, altered mood, gastritis; evaluate patients for occult infection, including TB and HIV, prior to starting corticosteroids
Sudden discontinuation in patients on chronic steroids even in face of active infection; infection can cause disease flare and sudden discontinuation of steroids may cause Addisonian crisis; carefully consider use of steroids in setting of active infection and discuss with experienced physicians; consider alternate types of immunosuppression in patients who develop diabetes while on corticosteroids and taper steroids carefully; in interim, may require insulin

Immunosuppressive agents

Evaluate children with signs of active nephritis to determine World Health Organization (WHO) classification category of their nephritis. For patients with class IV nephritis and some patients with class III nephritis, treat with corticosteroids and cyclophosphamide. Use azathioprine for individuals with milder nephritis. Use methotrexate for persons with arthritis not controlled by NSAIDs and for persons with fibrosis, especially sclerodermatous skin. Consider cyclophosphamide for individuals with severe systemic involvement of other vital organs, especially brain and lung. Consider other agents (eg, mycophenolate mofetil, cyclosporine) when standard therapies have failed. Other treatments under study include hormonal therapy, biologic agents that target cytokine production, and anti-DNA antibodies. For patients with severe persistent disease, autologous and stem cell transplantation is under study.


Cyclophosphamide (Cytoxan, Neosar)

Interferes with normal function of DNA by alkylation and cross-linking strands of DNA and by possible protein modification.

Adult

500-1000 mg/m2 IV every mo; not to exceed 1000 mg/m2

Pediatric

Administer as in adults

Allopurinol may increase risk of bleeding or infection and enhance myelosuppressive effects; may potentiate doxorubicin-induced cardiotoxicity; may reduce digoxin serum levels and antimicrobial effects of quinolones
Chloramphenicol may increase half-life while decreasing metabolite concentrations; may increase effect of anticoagulants; coadministration with high doses of phenobarbital may increase rate of metabolism and leukopenic activity; thiazide diuretics may prolong cyclophosphamide-induced leukopenia and neuromuscular blockade by inhibiting cholinesterase activity

Documented hypersensitivity; severely depressed bone marrow function

Pregnancy

D - Fetal risk shown in humans; use only if benefits outweigh risk to fetus

Precautions

Regularly examine hematologic profile (particularly neutrophils and platelets) to monitor for hematopoietic suppression; regularly examine urine for RBCs, which may precede hemorrhagic cystitis


Azathioprine (Imuran)

Antagonizes purine metabolism and may inhibit synthesis of proteins, RNA, and DNA. May interfere with mitosis and cellular metabolism.

Adult

1-2.5 mg/kg/d PO

Pediatric

1-3 mg/kg/d PO

Toxicity increases with allopurinol; concurrent use with ACE inhibitors may induce severe leukopenia; may increase levels of methotrexate metabolites and decrease effects of anticoagulants, neuromuscular blockers, and cyclosporine

Documented hypersensitivity; low levels of serum TPMT

Pregnancy

D - Fetal risk shown in humans; use only if benefits outweigh risk to fetus

Precautions

Monitor carefully for renal toxicity and hepatotoxicity; caution in patients with liver or renal disease; decrease dose by 25-33% in patients receiving allopurinol and azathioprine


Methotrexate (Rheumatrex)

An antimetabolite that interferes with enzyme dihydrofolate reductase, leading to depletion of DNA precursors and inhibition of DNA and purine synthesis, particularly adenosine.

Adult

5-30 mg PO/IV/SC qwk

Pediatric

5-20 mg/m2 PO/IV/SC qwk; many pediatric rheumatologists increase dose (not to exceed 30 mg/m2; approximately equivalent to 1 mg/kg)

Oral aminoglycosides may decrease absorption and blood levels of concurrent PO methotrexate (MTX); charcoal lowers MTX levels; coadministration with etretinate may increase hepatotoxicity of MTX; folic acid or derivatives contained in some vitamins may decrease response to MTX
Coadministration with NSAIDs may be fatal; indomethacin and phenylbutazone can increase MTX plasma levels; may decrease phenytoin serum levels
Probenecid, salicylates, procarbazine, and sulfonamides, including TMP/SMZ, may increase effects and toxicity of MTX; may increase plasma levels of thiopurines

Documented hypersensitivity; alcoholism; hepatic insufficiency; documented immunodeficiency syndromes; preexisting blood dyscrasias (eg, bone marrow hypoplasia, leukopenia, thrombocytopenia, significant anemia); renal insufficiency

Pregnancy

X - Contraindicated; benefit does not outweigh risk

Precautions

Monitor CBC counts monthly and liver and renal function every 1-3 mo during therapy (monitor more frequently during initial dosing, dose adjustments, or when risk of elevated MTX levels [eg, dehydration]); MTX has toxic effects on hematologic, renal, GI, pulmonary, and neurologic systems; discontinue if significant drop in blood counts; aspirin, NSAIDs, or low-dose steroids may be administered concomitantly with MTX (possibility of increased toxicity with NSAIDs, including salicylates, has not been tested)

Calcium and vitamin D therapies

All patients who are on corticosteroids or who have arthritis are at greater risk for osteopenia and its complications. Diet and appropriate supplementation with vitamin D and calcium are important tools for bone health in these patients.


Calcium carbonate (Oystercal, Caltrate)

Used as antacid and for prevention of calcium depletion.

Adult

1200 mg/d PO

Pediatric

<6 months: 360 mg/d PO
6-12 months: 540 mg/d PO
1-10 years: 800 mg/d PO
11-18 years: Administer as in adults

May decrease effects of tetracyclines, atenolol, salicylates, iron salts, and fluoroquinolones; large intakes of dietary fiber may decrease calcium absorption and levels

Renal calculi; hypercalcemia; hypophosphatemia; renal or cardiac disease; digitalis toxicity

Pregnancy

C - Fetal risk revealed in studies in animals but not established or not studies in humans; may use if benefits outweigh risk to fetus

Precautions

Caution in renal disease; cardiac disease; and sarcoidosis


Calcifediol (Calderol)

Vitamin D regulates calcium homeostasis, promoting absorption of calcium by gut, resorption of calcium by kidney, and increasing bone mineral metabolism.

Adult

20-100 mcg/d PO; titrate to obtain normal serum calcium and phosphorus levels

Pediatric

Suggested doses:
<30 kg: 20 mcg PO 3 times per wk
>30 kg: 50 mcg PO 3 times per wk

Effects enhanced by thiazide diuretics and reduced by cholestyramine and colestipol; may precipitate arrhythmia in conjunction with digitalis

Documented hypersensitivity; hypercalcemia

Pregnancy

C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus

Precautions

Pregnancy category C per manufacturer; expert analysis category A; category D if dosage exceeds RDA; adequate dietary calcium needed for clinical response; maintain adequate fluid intake; calcium-phosphate product (serum calcium times phosphorus) not to exceed 70; avoid use with renal function impairment and secondary hyperparathyroidism; avoid hypercalcemia

Rheostatic agents

These agents are used to improve peripheral blood flow and to improve delivery of oxygen to tissue suffering from peripheral vascular disease. In individuals with mixed connective tissue disease, used to decrease symptoms and damage from Raynaud phenomenon.


Pentoxifylline (Trental)

Methylxanthine used as hemorheologic agent by improving flow properties of blood by decreasing viscosity, which improves oxygenation to peripheral tissues. Precise mode of action is not defined; however, produces dose-related hemorheologic effects, lowering blood viscosity and improving erythrocyte flexibility. Another benefit is ability to increase leukocyte deformability and to inhibit neutrophil adhesion and activation.

Adult

400 mg PO tid with meals

Pediatric

Not established

Coadministration with cimetidine or theophylline increases effect, toxic potential, or both; increases effect of antihypertensives; patients taking warfarin should undergo more frequent monitoring of PTs

Documented hypersensitivity; recent cerebrovascular or retinal hemorrhage; serious adverse reaction to caffeine, theophylline, theobromine, or other methylxanthines

Pregnancy

C - Fetal risk revealed in studies in animals but not established or not studies in humans; may use if benefits outweigh risk to fetus

Precautions

Patients taking warfarin should undergo more frequent monitoring of PTs; frequently examine and monitor patients at increased risk for bleeding or with history of bleeding for change in hemoglobin or hematocrit levels

Phosphodiesterase (type 5) Enzyme Inhibitor

These agents increase peripheral vasodilation and may be helpful in treating symptoms associated with Raynaud disease.


Sildenafil (Revatio)

Inhibits phosphodiesterase type 5 in smooth muscle of pulmonary vasculature in which phosphodiesterase type 5 is responsible for the degradation of cGMP. Increased cGMP concentration results in pulmonary vasculature relaxation; vasodilation in the pulmonary bed and the systemic circulation (to a lesser degree) may occur. The systemic vasodilation may be helpful to reduce Raynaud disease symptoms.

Adult

20 mg PO qd initially; may increase, not to exceed 20 mg tid

Pediatric

Data limited; safety and efficacy has not been established
20 mg PO qd initially; may increase, not to exceed 20 mg bid
Not appropriate for small children

Potentiates vasodilatory effect of NO, resulting in potentially fatal drop in blood pressure; coadministration with ketoconazole, erythromycin, or cimetidine increases plasma sildenafil concentrations; coadministration with rifampin decreases plasma levels of sildenafil; coadministration with bosentan increases bosentan levels by 50% and reduces sildenafil levels by 63%

Documented hypersensitivity; concurrent or intermittent using of organic nitrates in any form

Pregnancy

B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals

Precautions

Adverse effects include headaches (16%), flushing (10%), upset stomach (7%), nasal congestion (4%), and a blue haze at the periphery of vision (3%); adverse effects occur more often in men taking the 100-mg dose; serious adverse effects occur in patients with severe heart disease and those who are taking nitrates; rates of MI were 1.7 and 1.4 per 100 man-years for sildenafil and placebo groups; sudden vision loss caused by nonarteritic anterior ischemic optic neuropathy (NAION) has been associated with phosphodiesterase type 5 inhibitors following use for ED, analysis is ongoing to determine causality

More on Mixed Connective Tissue Disease

Overview: Mixed Connective Tissue Disease
Differential Diagnoses & Workup: Mixed Connective Tissue Disease
Treatment & Medication: Mixed Connective Tissue Disease
Follow-up: Mixed Connective Tissue Disease
Multimedia: Mixed Connective Tissue Disease
References
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References

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  15. Singsen BH, Bernstein BH, Kornreich HK, et al. Mixed connective tissue disease in childhood. A clinical and serologic survey. J Pediatr. Jun 1977;90(6):893-900. [Medline].

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Further Reading

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Keywords

mixed connective tissue disease, MCTD, autoimmune disorder, Raynaud phenomenon, puffy fingers, mild myositis, arthritis, anti-U1-68kD antibody, undifferentiated connective tissue disease, UCTD, lupus, rheumatoid arthritis, systemic sclerosis, systemic lupus erythematosus, myositis, alopecia, leukopenia, anemia, pleuritis, pericarditis, trigeminal neuralgia, malar rash, thrombocytopenia, gastroesophageal reflux, GERD, treatment, diagnosis

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Contributor Information and Disclosures

Author

Marisa S Klein-Gitelman, MD, MPH, Associate Professor of Pediatrics, Northwestern University Feinberg School of Medicine; Head, Division of Rheumatology, Children's Memorial Hospital
Marisa S Klein-Gitelman, MD, MPH is a member of the following medical societies: American College of Rheumatology
Disclosure: Nothing to disclose.

Medical Editor

Barry L Myones, MD, Associate Professor, Departments of Pediatrics and Immunology, Pediatric Rheumatology Section, Baylor College of Medicine; Director of Research, Pediatric Rheumatology Center, Texas Children's Hospital
Barry L Myones, MD is a member of the following medical societies: American Academy of Pediatrics, American Association of Immunologists, American College of Rheumatology, American Heart Association, American Society for Microbiology, Clinical Immunology Society, and Texas Medical Association
Disclosure: Nothing to disclose.

Pharmacy Editor

Mary L Windle, PharmD, Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy, Pharmacy Editor, eMedicine
Disclosure: Pfizer Inc Stock Investment from financial planner; Avanir Pharma Stock Investment from financial planner ; WebMD Salary and stock Employment and investment from financial planner

Managing Editor

Thomas JA Lehman, MD, FAAP, FACR, Clinical Professor of Pediatrics, Department of Pediatrics, Division of Pediatric Rheumatology, Weill-Cornell University; Chief, Hospital for Special Surgery
Thomas JA Lehman, MD, FAAP, FACR is a member of the following medical societies: PM American Allergy Society
Disclosure: Nothing to disclose.

CME Editor

Daniel Rauch, MD, FAAP, Director, Pediatric Hospitalist Program, Associate Professor, Department of Pediatrics, New York University School of Medicine
Daniel Rauch, MD, FAAP is a member of the following medical societies: Ambulatory Pediatric Association, American Academy of Pediatrics, and Society of Hospital Medicine
Disclosure: Baxter Honoraria Consulting

Chief Editor

Lawrence K Jung, MD, Chief, Division of Pediatric Rheumatology, Children's National Medical Center
Lawrence K Jung, MD is a member of the following medical societies: American Association for the Advancement of Science, American Association of Immunologists, American College of Rheumatology, Clinical Immunology Society, and New York Academy of Sciences
Disclosure: Nothing to disclose.

 
 
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