# -*- coding: utf-8 -*-
DATA = {}

DATA[391] = [
 {"title": "Clinical paths", "content": "When reviewing prenatal history, a documented MVP under 2 cm is treated as oligohydramnios and the likely cause is specifically asked about: membrane rupture, placental insufficiency, postdate gestation, chronic hypertension, or a suspected fetal renal/urinary anomaly. On the newborn exam, the Potter sequence facies (recessed chin, low-set posteriorly rotated ears, flattened or beaked nose, suborbital creases) and limb findings (clubfoot/clubhand, joint contractures, hip dislocation) are actively looked for whenever oligohydramnios was noted antenatally."},
 {"title": "Diagnosis", "content": "In a male newborn with prenatal oligohydramnios and hydronephrosis, evaluation is made for [[399|posterior urethral valves]] (voiding difficulty, poor stream, urinary ascites) as well as bilateral renal agenesis or severe cystic renal disease, since these differ substantially in management and prognosis despite a similar antenatal fluid picture. For infants who survive the immediate perinatal period, the broader pattern of associated anomalies (cardiac defects, GI atresias, imperforate anus, Pierre Robin sequence) is screened for rather than assuming an isolated renal or pulmonary problem."},
 {"title": "Management", "content": "Respiratory distress from pulmonary hypoplasia is anticipated - a low threshold for respiratory support is kept, and preparation is made for [[396|pneumothorax]]. Because severe oligohydramnios from bilateral renal agenesis or severe renal dysplasia carries an extremely high mortality risk (respiratory insufficiency from pulmonary hypoplasia), antenatal counseling is coordinated with maternal-fetal medicine and neonatology as soon as significant oligohydramnios with a suspected renal cause is identified, so families understand the prognosis before delivery. Developmental dysplasia of the hip is screened for in any infant with a history of oligohydramnios, since intrauterine crowding increases this risk; most minor ultrasound findings between 6 weeks and 4 months resolve with observation, but referral to orthopedics is made if clinical instability (positive Barlow test) persists."},
]

DATA[392] = [
 {"title": "Clinical paths", "content": "Any child with a blow to the head, face, neck, or body is evaluated for the five symptom categories of [[200|concussion]]: somatic (headache, dizziness, nausea, light/noise sensitivity, fatigue), vestibular, cognitive (amnesia, confusion, difficulty concentrating), emotional (irritability, anxiety), and sleep-related. Loss of consciousness occurs in fewer than 5% of concussions and does not predict severity or recovery time, so its absence should not be reassuring nor its presence alarming on its own. Risk factors for prolonged recovery — female sex, [[308|migraine]] history, prior concussion, family/social stressors, a neurodevelopmental disorder, or psychiatric illness — are specifically asked about, since initial symptom burden combined with these factors helps anticipate which children are more likely to develop persistent postconcussion symptoms."},
 {"title": "Diagnosis", "content": "Laboratory workup (CBC, electrolytes, glucose, toxicology, coagulation studies) is reserved for significant [[139|head trauma]] or altered consciousness, rather than routine concussion presentations."},
 {"title": "Management", "content": "Management starts with cognitive and physical rest, favoring a reduction rather than complete elimination of activity, with the plan individualized to the child's specific symptom spectrum. A stepwise, progressive return-to-activity program is used for both school and sport, advancing physical and cognitive demands gradually while monitoring for symptom recurrence at each stage — advancement does not continue if symptoms return. Athletes and families are counseled that a second head injury before full recovery from the first risks second impact syndrome, a catastrophic and sometimes fatal complication, so strict avoidance of return to play until complete symptom resolution is essential. Referral for formal neuropsychological or neurobehavioral testing is made when recovery extends beyond the usual 7-10 day window or symptoms are substantially interfering with school or daily function. For athletes with a history of multiple concussions, especially those from progressively lesser force, taking longer to resolve, or showing a change from baseline, a more conservative eligibility decision is favored for continued contact or collision sport participation."},
]

DATA[393] = [
 {"title": "Clinical paths", "content": "Every infant is stratified by [[288|eczema]] severity and egg-allergy status before deciding on peanut introduction timing. Any presentation of rash, swelling, and wheezing after peanut exposure is treated as [[143|anaphylaxis]]."},
 {"title": "Diagnosis", "content": "For an infant with severe eczema, egg allergy, or both, referral for peanut-specific IgE and/or skin prick testing (with an oral food challenge if results are indeterminate) is strongly considered before peanut is introduced; a skin prick wheal of 0-2 mm is interpreted as low risk (introduce at home or in a supervised office feeding), 3-7 mm as moderate-to-severe risk (refer to a specialist or arrange supervised office feeding), and 8 mm or more as very likely allergic (continue management with a specialist) - the same risk tiers apply to peanut-specific IgE using the 0.35 kUA/L cutoff. After stabilization from a reaction, a complete allergy evaluation and allergist referral are arranged for any child suspected of having peanut allergy - history alone is not relied upon given the risk of both under- and overdiagnosis."},
 {"title": "Management", "content": "For an infant with severe eczema, egg allergy, or both, introduction is aimed for as early as 4-6 months once safety is established, per the risk tier identified on testing. For an infant with mild-to-moderate eczema, peanut-containing foods are introduced around 6 months without needing prior testing. For an infant with no eczema or known food allergy, peanut-containing foods are introduced whenever age-appropriate, per family preference and cultural practice. Families are not counseled to delay peanut introduction as a preventive strategy, even with a strong family history of allergy - the evidence instead supports early, regular introduction (at least 6 g of peanut protein over 3+ meals weekly in high-risk infants) as protective. Epinephrine is given promptly for any reaction, along with antihistamines and systemic corticosteroids, and observation for a late-onset (biphasic) reaction occurs before discharge. The family is equipped with a written avoidance plan, instruction on careful food-label reading, an epinephrine auto-injector to be carried at all times, and a medical alert bracelet."},
 {"title": "Prognosis and outcome", "content": "The evidence (LEAP trial) supporting early, regular peanut introduction in high-risk infants shows it is protective, cutting allergy risk from about 17% to about 3% by age 5 in that population. Families are counseled that most children with peanut allergy do not outgrow it, and that any resolution occurs almost exclusively within the first 5 years of life - so ongoing allergist follow-up and periodic reassessment (rather than a one-time diagnosis) is the appropriate long-term model of care."},
]

DATA[394] = [
 {"title": "Clinical paths", "content": "The proactive evaluation thresholds are applied rather than waiting until age 16: referral or workup is begun for a girl with no menses by age 15 despite normal growth and secondary sexual characteristics, no menses more than 3 years after thelarche onset, or no secondary sexual characteristics at all by age 13. Evaluation is prompt, regardless of age, if delayed secondary sexual development accompanies the amenorrhea or if cyclic pelvic pain is present alongside primary amenorrhea, since the latter suggests an outflow tract obstruction (imperforate hymen, transverse vaginal septum) with trapped menstrual blood. In a competitive female athlete, any positive menstrual-history screening question (absent menarche by 15, menarche not within 5 years of initial breast development) is treated as a trigger for further endocrine and gynecologic evaluation, with low energy availability considered alongside other causes."},
 {"title": "Diagnosis", "content": "Pregnancy is always ruled out first, even in a girl who denies sexual activity and even though primary amenorrhea from pregnancy is rare. Given that chromosomal/gonadal dysgenesis (especially Turner syndrome) and outflow tract anomalies (Müllerian agenesis, imperforate hymen, transverse vaginal septum) together account for the majority of primary amenorrhea, pubertal staging and external genitalia are examined carefully, and karyotype and pelvic imaging are considered early rather than late in the workup. If secondary sexual characteristics (especially breast development) are present but pubic/axillary hair is sparse or absent, androgen insensitivity syndrome is considered and LH/FSH and karyotype are checked. If the clinical picture suggests chronic illness, undernutrition, excessive exercise, or disordered eating, hypothalamic suppression is evaluated for as a diagnosis of exclusion — but only after structural and chromosomal causes have been reasonably excluded, since hypothalamic dysfunction should not be assumed by default."},
 {"title": "Management", "content": "Cyclic pelvic pain alongside primary amenorrhea points to an outflow tract obstruction with trapped menstrual blood that needs timely surgical attention."},
]

DATA[395] = [
 {"title": "Clinical paths", "content": "Watch is kept for [[354|chronic diarrhea]], [[214|malnutrition]], and failure to thrive as the presenting pattern. If abdominal wall edema, [[353|cellulitis]], distention, or crepitus develop, this is treated as a sign of delayed recognition of a severe complication requiring urgent attention, since delay risks severe SBS or death."},
 {"title": "Diagnosis", "content": "In a neonate who has undergone significant small bowel resection — most often for necrotizing enterocolitis, but also intestinal atresia, gastroschisis, or volvulus — short bowel syndrome is anticipated and the specific prognostic factors are assessed early: residual bowel length, whether the ileocecal valve and ileum were preserved, whether the colon is intact, and the health of other digestive organs (stomach, pancreas, liver). Colitis-like symptoms are monitored closely when enteral feeding is initiated. The specific prognostic factors are tracked over time — residual bowel adaptive potential, infection frequency, and the function of other organs — to guide the pace of weaning from parenteral nutrition and to identify children who may eventually need consideration for intestinal transplantation."},
 {"title": "Management", "content": "Total parenteral nutrition is started in the immediate postoperative period to meet caloric, fluid, and electrolyte needs while the bowel is insufficient, but enteral feeding is introduced as early as feasible, since this maximizes enteric hormonal stimulation and promotes bowel adaptation (elongation, hypertrophy, and slowed peristalsis) rather than leaving the bowel unstimulated. A multidisciplinary short bowel program is involved early, given the substantial survival benefit these programs and improved catheter/PNALD management have demonstrated."},
 {"title": "Prognosis and outcome", "content": "An NEC or gastroschisis etiology tends to predict a more prolonged clinical course than other causes. Recovery can take years, sometimes requiring TPN for the first several years of life, and over 90% survival has been demonstrated in recent series."},
]

DATA[396] = [
 {"title": "Clinical paths", "content": "In a neonate with respiratory distress - especially a premature infant with surfactant deficiency, a meconium aspiration history, or one receiving positive pressure ventilation or high PEEP - a high suspicion for pneumothorax is maintained, since it can progress rapidly to a tension pneumothorax. In a child with asthma who acutely deteriorates, particularly on mechanical ventilation, pneumothorax or pneumomediastinum is suspected even without classic findings, since up to 30% of associated pneumomediastinum cases are initially missed on radiography - a low threshold is kept to repeat imaging or escalate care. In a tall, thin adolescent male presenting with sudden chest pain and dyspnea without trauma, primary spontaneous pneumothorax is considered, with smoking, vaping, or drug use (marijuana, cocaine, MDMA) asked about. In a child with known asthma, cystic fibrosis, or another chronic lung disease presenting with pneumothorax, it is classified as secondary spontaneous pneumothorax. Iatrogenic causes (recent central line placement, intubation, biopsy, or mechanical ventilation) are considered in any hospitalized child who develops sudden respiratory decline. In an adolescent female with recurrent spontaneous pneumothorax temporally linked to menstruation, the rare diagnosis of catamenial pneumothorax is considered."},
 {"title": "Diagnosis", "content": "CT imaging for apical blebs is considered if recurrence or diagnostic uncertainty exists; an underlying connective tissue disorder (Marfan syndrome, Ehlers-Danlos syndrome) is also considered if there are supporting physical features or family history."},
 {"title": "Management", "content": "For significant respiratory distress with suspected pneumothorax, decompression is done immediately with a large syringe, 20-gauge needle, or catheter-over-needle and three-way stopcock at the fourth intercostal space anterior axillary line or the second intercostal space midclavicular line, then an 8F chest tube is placed using standard technique. For a child with known chronic lung disease presenting with secondary spontaneous pneumothorax, the underlying disease is addressed alongside the acute air leak. Appropriate referral is made for catamenial pneumothorax, since standard management alone will not address the underlying diaphragmatic defect. Even a small, seemingly stable pneumothorax in a child should prompt admission for observation given its potential to progress."},
]

DATA[397] = [
 {"title": "Clinical paths", "content": "Passive or environmental exposure (transplacental, breast milk, inhalation, or presence where drugs are used or manufactured) is considered in an infant or young child with unexplained intoxication signs, and substance use or withdrawal is considered in any adolescent with chronic, persistent irritability."},
 {"title": "Diagnosis", "content": "Airway, breathing, circulation, and mental status assessment are prioritized immediately in any child with suspected substance intoxication, before a detailed history or diagnostic workup is pursued. Once stabilized, a comprehensive history is gathered from witnesses, family, and friends about the nature of the substance, timing, and circumstances, recognizing that a clear history is often unavailable and that toxicology screening does not always clarify the picture — a high index of suspicion is maintained regardless. Examination for pallor (hemolysis) or cyanosis (methemoglobinemia) is performed as clues to specific toxic mechanisms, and evaluation for ataxia and metabolic derangement (hypoglycemia, [[170|hyponatremia]], hyperammonemia) is done alongside the standard exam."},
 {"title": "Management", "content": "The standard sequence is followed: stabilize ABCs, remove the source of poison, provide supportive care, decontaminate (GI tract, skin, eyes, or other exposed body cavity as relevant), consider measures to hasten elimination of absorbed toxin, and give a specific antidote when one exists. For adolescents specifically, screening for alcohol use is done proactively at every visit rather than waiting for a presentation of intoxication, given that alcohol is the most commonly abused substance in this age group and binge drinking prevalence rises sharply with age (about 50% of drinkers at 12-14 years to about 72% at 18-20 years); alcohol exposure in children can come from unexpected sources like hand sanitizer, mouthwash, and food extracts, not just beverages. Prevention is emphasized — safe storage of medications and household chemicals, anticipatory guidance for families with toddlers, and routine adolescent substance-use screening — since prevention is more effective than intervention after intoxication has already occurred."},
]

DATA[398] = [
 {"title": "Clinical paths", "content": "Every child with polytrauma is approached using the ABCDE sequence, with airway prioritized above all else, since airway compromise kills faster than any other injury - assessment is made for obstruction from positioning, blood, teeth, vomitus, or foreign material, and level of consciousness, maxillofacial injury, and stridor or cyanosis are evaluated. Internal injury is actively suspected whenever the mechanism of injury is severe enough to cause it, even in the complete absence of external signs of trauma, given children's thinner protective musculature and padding. A normal blood pressure does not rule out significant blood loss - children can lose 25-30% of their circulating volume while maintaining a normal systolic pressure."},
 {"title": "Diagnosis", "content": "A length-based tool is used to estimate weight quickly for accurate drug dosing and equipment sizing rather than waiting for an actual weight. Other perfusion markers (heart rate, capillary refill, mental status) are relied upon rather than blood pressure alone to assess for hemorrhagic shock. The Pediatric Trauma Score is used to help gauge severity."},
 {"title": "Management", "content": "The cervical spine is protected throughout the assessment and stabilization process in every child with polytrauma, regardless of the apparent primary injury site. If a child remains in shock despite adequate initial fluid/blood resuscitation, the differential is broadened beyond ongoing hemorrhage to include neurogenic shock, cardiac contusion, and cardiac tamponade, and investigated accordingly rather than simply escalating volume resuscitation. Care is organized under a single multidisciplinary team leader when multiple specialties (neurosurgery, orthopedics, general/trauma surgery, plastic surgery) are involved, and continuous monitoring is maintained after initial resuscitation, since deterioration can occur even after apparent stabilization. For very low Pediatric Trauma Scores, rapid transport to the nearest facility is prioritized over transfer to a more specialized but more distant center. Psychological and social support is built into the care plan from the time of resuscitation onward."},
 {"title": "Prognosis and outcome", "content": "Polytrauma can affect the developing brain and contribute to long-term morbidity beyond the physical injuries themselves."},
]

DATA[399] = [
 {"title": "Clinical paths", "content": "Bilateral hydronephrosis in a male infant, whether identified prenatally or postnatally, is treated as an urgent indication to exclude posterior urethral valves. In a neonate with a palpable [[235|abdominal mass]], hypertension, urinary ascites, or unexplained renal failure, PUV is included in the differential. Parental report of a weak urinary stream is not relied upon to trigger evaluation, since most children with PUV are not brought in for this symptom specifically - suspicion is maintained based on the broader clinical picture (vomiting, poor weight gain, abdominal distention, recurrent UTI) since more than half of cases are not diagnosed until several months of age. In an older boy with incontinence, recurrent UTI, or unexplained renal impairment, previously unrecognized PUV is considered as part of the work-up."},
 {"title": "Diagnosis", "content": "A voiding cystourethrogram, the key diagnostic study, is obtained, looking for a dilated/elongated posterior urethra, thickened trabeculated bladder, bladder neck hypertrophy, and [[271|vesicoureteral reflux]]. Renal function (creatinine, BUN) and electrolytes are checked at diagnosis, and evaluation for vesicoureteral reflux is performed, since about half of neonates with PUV have VUR."},
 {"title": "Management", "content": "Endoscopic fulguration of the valves is arranged as early as feasible once the diagnosis is confirmed; cutaneous vesicostomy or another temporary diversion is reserved for very small infants in whom endoscopic treatment is not practical. Prophylactic antibiotics are considered for higher-grade (3-5) reflux in infants and young children, weighing this against the risks of prolonged antibiotic exposure. Nephrectomy is considered for a kidney with severely impaired function that does not improve with temporary nephrostomy, or that is a source of severe hypertension or recurrent infection."},
 {"title": "Prognosis and outcome", "content": "Expectations are set with families that unilateral disease with contralateral renal sparing carries a better prognosis than bilateral involvement, and that even after technically successful valve ablation, about 30% of patients progress to chronic or end-stage renal disease because of underlying renal dysplasia established before birth - so long-term nephrology follow-up is needed regardless of surgical success."},
]

DATA[400] = [
 {"title": "Clinical paths", "content": "In an otherwise healthy 1- to 10-year-old presenting with sudden bruising, petechiae, or mucosal bleeding 1-4 weeks after a viral illness or vaccination, a CBC and peripheral smear are obtained. In a newborn with thrombocytopenia, maternal history (preeclampsia, autoimmune disease, medications) is evaluated alongside neonatal causes (alloimmunization, [[155|congenital infection]], sepsis, NEC)."},
 {"title": "Diagnosis", "content": "Isolated thrombocytopenia with large platelets, normal white count and hemoglobin, normal PT/PTT, and no hepatosplenomegaly or lymphadenopathy is classic for ITP and needs no further testing initially. Pseudothrombocytopenia is ruled out first if the count seems inconsistent with the clinical picture, by redrawing in a citrate or heparin tube rather than EDTA. New medications (sulfonamides, vancomycin, valproic acid, phenytoin, carbamazepine, heparin) are specifically asked about as a cause of drug-induced thrombocytopenia, which should improve within 1-2 days of stopping the offending drug. If pancytopenia, anemia, organomegaly, lymphadenopathy, or an abnormal PT/PTT accompanies the thrombocytopenia, the workup is broadened (bone marrow exam, direct Coombs, ANA) to evaluate for leukemia, autoimmune disease, hemolytic uremic syndrome, or a marrow failure syndrome rather than assuming simple ITP. If thrombocytopenia persists beyond 3-6 months, additional testing (HIV, hepatitis C, H. pylori, ANA, anticardiolipin antibodies) is pursued rather than continuing to assume self-limited acute ITP. Hematology is consulted if newborn thrombocytopenia persists beyond 10 days of life."},
 {"title": "Management", "content": "For classic ITP without significant bleeding, observation with serial platelet counts is a reasonable initial approach. Active treatment (IVIG, corticosteroids, or other agents) is reserved for significant bleeding or very low platelet counts, and platelet transfusion is used to manage an acute bleeding crisis. In a menstruating adolescent with ITP, close monitoring for heavy menstrual bleeding occurs if the platelet count falls below 10,000/µL."},
 {"title": "Prognosis and outcome", "content": "For classic ITP, 60-75% resolve within 2-4 months regardless of treatment. Families are counseled that [[379|intracranial hemorrhage]], while the most serious complication, occurs in under 1% of ITP cases; warning signs (severe headache, neurologic change) are nonetheless emphasized given the roughly one-third mortality when ICH does occur."},
]