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Pocket ‘Pearls’

Now in its 22nd edition, The Harriet Lane Handbook — known as the bible of pediatrics for trainees — remains valued (and dog-eared) the world over as a quick reference for vital information. | Photos by Chris Myers

Pocket ‘Pearls’

Nicole Shilkofski was first introduced to The Harriet Lane Handbook as a medical student, during her pediatrics clerkship rotation at Tulane University. There, she observed all of the pediatrics residents carrying the handbook in the pockets of their white coats.

“People call it the bible of pediatrics for trainees,” says Shilkofski, who is now vice chair of education and residency director of the Department of Pediatrics at Johns Hopkins. The handbook, compiled every three years by Johns Hopkins pediatrics residents, is “meant to be a quick reference to help guide management strategies,” she says, “and there’s a lot of great charts and diagrams within the book designed to help interns quickly digest facts about a patient’s presentation.”

Her own copy of the handbook — with its updated practice guidelines for pediatrics and information on drug dosages and lab values for children of all ages — quickly became dog-eared, with notations in the margins. “You could tell the sections that were utilized most often,” she says, “because those were the pages that either were soiled or crinkled.”

When it came time to apply for residencies, Shilkofski says the handbook piqued her interest in Johns Hopkins. “I thought, what a cool thing that it’s really a handbook written by house staff for house staff,” she says. “When I was making my own rank list for the residency match, that definitely played a factor, and I was strongly considering that as something I wanted to be involved in as a resident.”

She did land at Johns Hopkins for her pediatrics residency and was thrilled to be asked to become chief resident — and an editor of the 17th edition.

‘Everything You Needed to Know’

For nearly seven decades, The Harriet Lane Handbook has been beloved and used widely by trainees in pediatrics around the world. While the manual has adapted with the times to provide the newest information in pediatrics management — and a range of online content — what hasn’t changed is its popularity and prestige.

The handbook was first developed in 1950, after Harrison Spencer, a chief resident in that era, suggested residents write a pocket-sized “pearl book” to share. Henry Seidel ’46, editor of the first edition, was noted to say that he and his co-residents began it “without funds and without [the] supervision of our elders, meeting sporadically around a table in the library of the Harriet Lane Home” (see “Who Was Harriet Lane?” p. 36). Their efforts resulted in a “concise yet comprehensive handbook that became an indispensable tool for the residents of the [former] Harriet Lane Home,” according to Keith Kleinman, Lauren McDaniel andMatthew Molloy ’15, editors of the 22nd edition, released in May.

Those original authors got together on Friday nights when they were on call and put together information that they didn’t want to memorize, such as drug dosing information and how to perform procedures like urinalysis, says Jerry Winkelstein, former director of the Division of Allergy and Immunology at the Children’s Center.

“It was meant to be a handbook, not a textbook,” he says. That edition, and the next three, were compiled on loose-leaf paper that fit inside a standard small binder purchased at stationery stores. As word spread, interns from around the country would write to the Department of Pediatrics and ask for copies, which may have been about $4 at the time, Winkelstein says. The unbound copies were mailed in small brown envelopes by the department director’s secretary, with proceeds going to a house staff fund to support picnics and other events.

By the late 1960s, Robert Cooke, then the director of pediatrics, decided the book should be commercially published in a softcover format. The fifth edition from 1969 (and subsequent ones) included drawings by Baltimore illustrator Aaron Sopher, who was often seen sketching throughout the former Harriet Lane Home and children’s hospital.

Winkelstein, who edited the fifth and sixth editions, says as a house officer, it often felt like he used the handbook every 15 to 20 minutes, to check the dose of a medication or help convert kilograms to pounds.

“At that time, there were no personal computers, so everything you needed to know had to be looked at on paper,” he says. “This handbook at that time was a major, major significant source of information. It really was incredibly valuable.”

As an editor, he met with his fellow residents once a week and went over the previous editions page by page to decide what should be included.

“We were very strict about the size,” he says. At the time, antibiotics were “exploding in the number available for children,” he says. “We had to be careful not to include every possible drug. We wanted to keep it a small book.”

Among the 1972 class of interns who received the softcover version was George Dover, who went on to direct pediatric hematology and then directed pediatrics at Johns Hopkins for 20 years.

“Mine is worn thin,” says Dover of that manual. “The back came off. The pages are thinned out. There’s scribbling all over it. We had to wear white coats in those days, and you just didn’t put your white coat on unless it had the Harriet Lane manual in it.”

Winkelstein’s introduction in that edition clearly stated that the handbook was no substitute for experience and practicing pediatrics, which Dover says he still considers prophetic today. “The original manuals were really an information book on how to do things, not how to diagnose,” he says. Over time, the handbooks grew in page count along with the increasing volume of information relevant to pediatrics and the demands for that knowledge.

Peter Rowe, director of the Chronic Fatigue Clinic at the Children’s Center, says the ninth edition he trained with from 1981 is “pretty beaten up, with taped, reinforced edges of the pages and a lot of scribbles in the margins for numbers we had to call back in those days to get to the blood bank or chemistry lab, how to order a nuclear medicine scan, and little notes about things to try for asthma or diabetes. It was really incredibly useful.”

He later edited the 11th edition, in 1987. That was the first to bring in information about pulse oximetry and MRI. The 16th edition in 2002 added a chapter on dermatology and pictures of various rashes; the 17th edition in 2005 (by Shilkofski) featured the first chapter on rheumatological diseases in children and was one of the first to offer companion software through which readers could download diagnostic and management guidelines to a PalmPilot or Blackberry device. The 18th edition in 2008 added a chapter on palliative care, recalls Julia McMillan, pediatrics residency director from 1990 to 2012. And the 20th edition, in 2014, was the first to be offered digitally.

“The combination of up-to-date scientific information provided by the faculty and the residents’ day-to-day knowledge of how it would be most helpful to present that information is, I think, what makes The Harriet Lane Handbook so valuable,” McMillan says.

This year’s slightly slimmed-down edition (661 pages, not including the formulary — about 100 fewer pages than the previous edition) features a new chapter on psychiatry, separating out and adding to content that previously had been included in a section on development, behavior and mental health. Additional updates include putting critical care and emergency management together, with management of trauma and burns in a separate chapter; adding a section on vaccine hesitancy to the immunoprophylaxis chapter; and including expanded content on the management of overweight and obese children to the nutrition and growth chapter. Just before printing, the editors added a line about COVID-19.

“What’s cool and interesting to me in how the handbook has evolved is it mirrors and reflects what’s happening in the field of pediatrics as a whole,” McDaniel says. “Many primary care and subspecialist pediatricians will tell you they feel there’s an increasing need for the pediatrician to manage mental and behavioral health conditions.”

Cause for Celebrity

The chief residents who will become the editors are selected early in their residency training, based on personality, leadership skills and work ethic, Dover says. “It’s an absolutely huge deal to be chosen,” McMillan adds. “Their names will be known around the world.”

The process of editing the handbook takes almost the full three years between editions, says Molloy. During the first year, editors work with their resident colleagues to select the authors and faculty advisers for each chapter. The second year is the meat of the process: writing, rewriting and making edits. The third year is largely spent working with the publisher (now Elsevier) to edit and review page proofs. There is no protected time for these assignments, with authors and editors expected to fit this in around clinical duties.

“We get sympathy, primarily from former editors,” Kleinman laughs.

Previous editors say the handbook brought them some notoriety. Rowe says some attendees of Society for Pediatric Research meetings asked him to sign their handbooks. Winkelstein was frequently introduced as the editor of the handbook when giving guest lectures at other universities. Although it’s been 15 years since Shilkofski edited her edition, she says, “it was back then and probably still is the line item on my CV that I get asked about the most.”

But it’s not solely hard work. Editors of the early editions liked to insert their own jokes or announcements into the handbooks, Rowe says. One running gag started by Winkelstein was to list lab values for the fictitious “serum porcelain.”

“Occasionally, we would receive inquiries by mail about what was the SI [International System of Units] equivalent of the serum porcelain level,” Rowe says. “You just thought, ‘People can’t really be taking it that seriously,’ but they were.”

Rowe’s resident colleague John McCloskey, now head of pediatric anesthesiology and critical care medicine at the Children’s Center, had just had a baby when the 11th edition was released. Under “J” in that year’s index is Jack, The Boy, on page 370. Winkelstein also used the handbook as a birth announcement for his daughter, Beth, listing her name in the index of the sixth edition.

A Formulary to Rely On

One of the handbook’s most well-used sections is the formulary, a listing of proper drug dosages for some 400 medications used in pediatric patients.

The late M. Deborah Gordin-Markel was the first pharmacist to help edit the section, making contributions to the 9th and 10th editions of the handbook before her untimely death from cholangiocarcinoma in 1988. She was just 30 years old at the time. Gordin-Markel, who worked in the Children’s Center’s pediatric pharmacy unit, had expertise in the development of pediatric dosages and total parenteral nutrition (a method of feeding that bypasses the gastrointestinal tract).

During the 1986–87 academic year, Gordin-Markel had many meetings with handbook section editors to help write, edit and factcheck the formulary, at a time when pharmacist involvement in clinical teams was becoming essential. She lent frequent evenings and weekends to the tasks of correcting and updating the material, as well as adding information about new drugs and antibiotics, yet remained behind the scenes as an uncredited contributor.

For the past 30 years, it’s been compiled by pediatric pharmacist Carlton K.K. Lee.

Prior to the 1980s, Lee says, there were a lot of incomplete data on the use of drugs in children and, as a result, a wide variety in dosage interpretation. Hearing buzz that the drug dosing section could be improved, Lee offered to lend a hand to the house staff for the 12th edition in 1990.

The process is tedious, Lee says. First, he meets with the editors to go over medications to be removed or added to the list. Then, he goes alphabetically through that list, scouring the medical literature and FDA databases to list the drugs’ trade names, dosage forms, dosing information, any major side effects or drug interactions, and any special considerations prescribers should note. Each drug entry has an icon designating if it is approved for use during pregnancy or breastfeeding, or bears a risk of renal or liver dysfunction. This year, he added a DNA icon for medications that could benefit from pharmacogenomic screening.

Working on the handbook “is a built-in continuing education for me every three years and keeps me up to date,” Lee says. It also has inspired him to complete a postdoctoral fellowship in pharmacokinetics/pharmacodynamics, participate in international pediatric drug development trials with antibiotics, and assist pediatric investigators on the design and data analysis of pharmacology-related research.

Lee is meticulous in providing expert opinion and the most up-to-date information on how drugs are metabolized by a 2-week-old versus a 2-year-old or 12-year-old, McMillan says.

“He’s a wonderful teacher, and he keeps track of everything so that people feel they can really rely on the information that’s provided in the handbook,” she says.

Global Reach

Over the years, the handbook has grown in popularity worldwide. Dover says by the time he became director of pediatrics in 1996, it had become ubiquitous. He traveled to children’s hospitals and pediatrics programs nationally and internationally, he says, “and it was always there. It had essentially become the defined pediatric manual for house officers around the world.”

That’s still true today, says Shilkofski, who travels internationally for her research and academic interests related to global health.

“Whenever I travel overseas, inevitably, I see a lot of both current and older editions in print in a lot of different countries,” she says. “I see it on pediatricians’ shelves in Africa, Asia and South America, so that’s always a neat thing. Whenever you say Johns Hopkins, pediatricians will immediately grab their Harriet Laneoff their shelf.”

The book has been translated into nine languages over the years (Spanish, Italian, Chinese, Portuguese, Turkish, Japanese, Polish, Russian and Greek), according to Elsevier. And, while it’s now available through an app-based platform offering additional content, Kleinman says, “Many of us still carry around our personal copies that are full of notes and highlights.”

“I’ve gotten emails from people all over about how grateful they are for this handbook, and also how important they think it is,” adds Janet Serwint, professor emerita of pediatrics and public health, and pediatrics residency director from 2012 to 2017. “The people who participate are really proud of the product they create.”

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