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

NEW[298] = [
    {"title": "Clinical paths", "content": "In a child presenting during influenza season with sudden fever, myalgia, headache, and respiratory symptoms, influenza is considered regardless of vaccination status, and presentation is recognized to look quite different by age - a nonspecific sepsis-like picture in infants, or otitis media, croup, [[3|bronchiolitis]], or pneumonia rather than a classic influenza syndrome in young children. Influenza pneumonia, [[100|myocarditis]], and influenza-associated encephalopathy are kept on the differential for any child with unexpectedly severe respiratory, cardiac, or neurologic findings during an influenza illness."},
    {"title": "Diagnosis", "content": "If diagnostic confirmation will change management (e.g., antiviral decision-making in a high-risk or hospitalized patient), a rapid antigen test or molecular assay from a nasal swab/wash is obtained within the first 3 days of symptoms, since test sensitivity falls as viral load declines after that window - viral culture or serology are not relied upon for real-time decisions."},
    {"title": "Management", "content": "Most children are managed with supportive care (fluids, rest), with improvement anticipated by 48-72 hours; if fever recurs, is prolonged, or the child clinically deteriorates instead of improving on this timeline, evaluation for bacterial superinfection is undertaken and treatment with antibiotics is given if confirmed or strongly suspected. Antiviral treatment is prioritized for children at higher risk for complications, notably those younger than 2 years of age. Because children shed virus longer and at higher titers than adults (up to 10+ days in young or immunocompromised children), families are counseled on continued infection-control precautions (hand hygiene, staying home) beyond the point symptoms improve, not just during the acute febrile period."},
]

NEW[299] = [
    {"title": "Clinical paths", "content": "Clinical signs of a larger hemorrhage in a preterm infant are watched for - sudden deterioration, unexplained anemia, new seizures, tense or bulging fontanels, split/widened sutures, new apnea/bradycardia with desaturation, poor perfusion, hypotension, worsening [[387|metabolic acidosis]], or rising oxygen/ventilator requirements - prompting urgent cranial ultrasound if these develop. Because up to 90% of hemorrhages occur within the first 72 hours of life and most are clinically silent, clinical signs alone are not relied upon in the highest-risk population - any infant born before 31 weeks' gestation or weighing less than 1,500 g - given the 15-25% incidence of GMH/IVH in this group, with the highest risk in infants born before 26 weeks."},
    {"title": "Diagnosis", "content": "A screening cranial ultrasound is obtained according to unit protocol rather than waiting for symptoms, with imaging repeated over the first week given that about 20% of early hemorrhages progress to greater severity during this window. When a hemorrhage is identified, it is graded using the standard I-IV system to guide prognostic counseling and follow-up intensity, with grade IV findings (parenchymal extension) understood to reflect periventricular hemorrhagic infarction from venous obstruction rather than simple IVH extension, carrying a correspondingly worse prognosis."},
    {"title": "Management", "content": "Serial ultrasound surveillance for posthemorrhagic ventricular dilation is continued after any grade II or higher hemorrhage, and long-term neurodevelopmental follow-up is coordinated proportional to hemorrhage severity, since both mortality and neurologic sequelae increase substantially with higher grades and lower birthweight. Modifiable perinatal contributors are addressed where possible - avoiding blood pressure fluctuations, hypocapnia/hypercapnia, and hypoxemia during ventilatory management - since these are recognized associations with GMH/IVH risk."},
]

NEW[300] = [
    {"title": "Clinical paths", "content": "Because most children with lead toxicity are asymptomatic, screening is relied upon rather than waiting for symptoms - a blood lead level is checked in any child with recognized risk factors (older housing with lead paint, relevant parental/household occupational exposure, imported ceramics/jewelry/remedies, pica behavior, or iron deficiency), and local/CDC screening recommendations are followed given that a majority of at-risk children nationally are not currently being screened. Encephalopathy - seizures, altered mental status, or signs of raised intracranial pressure - is watched for in any child with an elevated BLL, since this represents a medical emergency regardless of the specific level, and asymptomatic children with a very high BLL (especially over 100 mcg/dL) are treated as being at significant CNS risk needing urgent treatment even without overt symptoms."},
    {"title": "Diagnosis", "content": "Any measurable BLL is technically abnormal; levels above 10 mcg/dL are treated as clinically significant and levels above 5 mcg/dL as warranting attention and follow-up."},
    {"title": "Management", "content": "For a child with an elevated BLL, the essential first step is removing the child from the lead source - the home environment is identified and remediated before or alongside any pharmacologic treatment. Chelation is not given for BLL under 45 mcg/dL. For BLL at or above that threshold, or for any symptomatic child, hospital admission is arranged for full evaluation, decontamination planning, and chelation therapy; care is escalated to PICU level with IM dimercaprol (BAL) followed by IV calcium disodium EDTA plus aggressive supportive care for any child needing this emergency level of care for lead encephalopathy. After treatment is started, expectations are set with families that BLL falls fastest in the first 2 months but that full normalization, especially from a markedly elevated starting point, may take years even with complete source elimination - so continued monitoring and reinforcement of environmental remediation matters well beyond the initial hospitalization."},
]

NEW[301] = [
    {"title": "Clinical paths", "content": "When a caregiver describes clusters of brief, stereotyped flexion or extension movements of the neck, trunk, and limbs — especially occurring around sleep transitions, with crying between events and any accompanying developmental regression — this is not dismissed as colic, reflux, or a benign startle. Infantile spasms are distinguished from benign look-alikes using the presence or absence of behavioral arrest and developmental regression: Sandifer syndrome is tied consistently to feeding, benign paroxysmal vertigo and infantile shuddering do not impair responsiveness, and the infantile gratification phenomenon stops with distraction — none of these produce the loss of responsiveness characteristic of a true spasm."},
    {"title": "Diagnosis", "content": "An urgent EEG is obtained to look for hypsarrhythmia. MRI of the brain and metabolic/genetic testing are pursued in parallel to identify a treatable underlying cause (e.g., tuberous sclerosis, a structural malformation, a metabolic disorder), since roughly 70–80% of affected children have an abnormal MRI and identifying the cause both guides treatment and informs the family about developmental prognosis (children with an identified underlying cause carry a higher risk of developmental impairment than cryptogenic cases)."},
    {"title": "Management", "content": "Prompt referral is made to [[119|pediatric neurology]], since treatment initiated early has the potential to improve long-term developmental outcome."},
    {"title": "Prognosis and outcome", "content": "Families are counseled that West syndrome (the triad of spasms, hypsarrhythmia, and developmental delay/regression) carries a guarded prognosis and that over half of affected children develop other [[206|epilepsy]] types later, including in some cases progression to Lennox-Gastaut syndrome, so ongoing neurologic follow-up after the acute spasms are controlled remains important even if the spasms themselves respond to treatment."},
]

NEW[302] = [
    {"title": "Clinical paths", "content": "The vomiting pattern and abdominal exam are used to localize the obstruction before imaging confirms it: nonbilious vomiting with a scaphoid abdomen points to a proximal, preduodenal process, while bilious vomiting with a distended abdomen points to a more distal obstruction; maternal polyhydramnios is asked about in the neonatal history, since this also favors a proximal lesion. In any neonate who has not passed meconium within 24–48 hours of birth, or who has [[144|feeding intolerance]], distention, persistent vomiting, or is aspirating more than 20 mL of gastric contents, prompt evaluation for intestinal obstruction with directed imaging is pursued rather than watchful waiting. Intussusception is considered urgently in any infant with intermittent severe abdominal pain, vomiting, and lethargy, since delayed reduction risks strangulation, ischemia, and necrosis, and the condition is fatal if left untreated."},
    {"title": "Diagnosis", "content": "If a child presents with a longstanding history of alternating constipation/diarrhea, abdominal distention, and no demonstrable mechanical blockage on imaging, chronic intestinal pseudo-obstruction is considered, with evaluation for coexisting bladder dysfunction and bacterial overgrowth as part of the workup."},
    {"title": "Management", "content": "In an older child with a prior abdominal surgery presenting with obstructive symptoms, nasogastric decompression is started first for suspected adhesive obstruction, since this can resolve symptoms and prevent progression; if the obstruction does not begin to resolve promptly, emergency surgical exploration follows rather than prolonging conservative management. In a patient with cystic fibrosis and new obstructive symptoms, management is escalated stepwise: pancreatic enzymes are continued or increased and polyethylene glycol is added for intermittent symptoms, large-volume PEG bowel lavage (oral or NG) follows if this fails, and a therapeutic contrast enema with concurrent large-volume IV fluids is reserved for complete obstruction. For any child with severe fecal impaction, milk-and-molasses, soap suds, or tap water enemas are avoided given documented serious adverse events, and surgical disimpaction is considered if impaction is severe and unresponsive to safer measures."},
]

NEW[303] = [
    {"title": "Clinical paths", "content": "When a child presents with joint pain/swelling and a morning-predominant pattern of pain or stiffness lasting more than 6 weeks, JIA is evaluated for systematically: the joint count and pattern are characterized (oligoarticular ≤4 joints vs. polyarticular ≥5 joints), the tempo of onset is noted (insidious vs. rapid), and systemic features (fever, rash, hepatosplenomegaly, lymphadenopathy, serositis) are looked for specifically, since these would point toward systemic JIA rather than one of the other subtypes. Acute phase reactants are watched over time in any child with established JIA, particularly systemic JIA — a relative fall in previously elevated inflammatory markers is a red flag for macrophage activation syndrome rather than reassuring improvement."},
    {"title": "Diagnosis", "content": "ANA and RF are neither required nor sufficient for diagnosis — they are ordered to help refine subtype and guide uveitis screening, not to rule JIA in or out. If fever is prominent, systemic JIA is not assumed prematurely: it is treated as a diagnosis of exclusion, with a thorough infectious and oncologic workup pursued before confirming, and most other JIA subtypes should not be associated with fever, so its presence should specifically raise or lower suspicion for the systemic subtype."},
    {"title": "Management", "content": "Asymptomatic anterior uveitis is screened for on the schedule appropriate to the child's ANA status and age at diagnosis, since this complication frequently causes no symptoms until vision is already threatened. Leg-length discrepancy and muscle atrophy are assessed for and documented at follow-up visits, since these indicate an established, chronic disease process needing more aggressive management, and functional impact is addressed directly — handwriting difficulty, morning limp, and any regression of gross motor skills are asked about, since these are practical markers of disease impact on daily life and school. Referral to [[221|pediatric rheumatology]] is made early, since earlier treatment improves both time to remission and overall rate of achieving remission, and delayed referral increases morbidity related to growth, development, and pain."},
]

NEW[304] = [
    {"title": "Clinical paths", "content": "In an infant with blood-streaked stools, [[354|chronic diarrhea]], or repetitive vomiting, first determine whether the pattern suggests IgE-mediated allergy (immediate symptoms within minutes - urticaria, facial swelling, vomiting, shock-like state) versus a non-IgE, GI-predominant presentation (painless hematochezia in an otherwise well infant, or chronic diarrhea with occult blood, protein loss, and peripheral eosinophilia)."},
    {"title": "Diagnosis", "content": "For suspected IgE-mediated allergy, skin-prick testing or specific IgE levels can support the diagnosis, with a negative test making IgE-mediated allergy unlikely. For suspected non-IgE disease, skin testing is skipped (it is not reliable here) and a trial of complete milk protein elimination is proceeded to directly."},
    {"title": "Management", "content": "The elimination algorithm is followed stepwise: milk/milk products are eliminated first and reassessed; if unresolved, compliance is checked and hidden bovine milk sources are ruled out, then soy is eliminated as well given the high concurrence rate; if still unresolved, egg, peanut, and fish are removed (considering multiple food protein allergy); if there is still no response, an extensively hydrolyzed or elemental formula/diet is moved to. If a child responds, the milk-free diet is maintained for about a year before a carefully supervised reintroduction, with elimination resumed if symptoms recur. If a child fails to respond despite this full elimination ladder, restriction is not escalated indefinitely - referral to a specialist is made and alternative diagnoses such as [[122|immunodeficiency]], [[254|inflammatory bowel disease]], or [[152|tuberculosis]] are reconsidered, with repeat endoscopy and small bowel imaging as part of that re-evaluation. For any child with anaphylactic-type reactions, the family is equipped with an epinephrine autoinjector and a medical alert bracelet before they leave the visit."},
]

NEW[305] = [
    {"title": "Clinical paths", "content": "A high index of suspicion for neonatal HSV is maintained in any febrile neonate under 28 days old, even in the absence of a maternal history of genital herpes - most mothers of affected infants have no relevant history, since primary maternal infection is frequently asymptomatic. Cerebrospinal fluid pleocytosis, elevated liver transaminases, or coagulopathy are looked for specifically in a septic-appearing neonate, since these findings should raise HSV alongside standard bacterial sepsis/meningitis considerations, and vesicular skin lesions - while highly suggestive when present - are absent in half to two-thirds of cases, so their absence should not lower suspicion."},
    {"title": "Diagnosis", "content": "When HSV is suspected, CSF is sent for HSV PCR (the most sensitive test for CNS disease), surface/vesicle cultures or direct fluorescent antibody staining are obtained if lesions are present, and the Tzanck smear or serologic antibody testing are not relied upon, as these are unhelpful in this setting."},
    {"title": "Management", "content": "Given the time-sensitivity of outcomes, empiric intravenous acyclovir is started promptly whenever clinical suspicion is significant, rather than waiting for confirmatory testing, since early treatment initiation is the strongest lever available for reducing mortality and morbidity."},
    {"title": "Prognosis and outcome", "content": "Families of survivors are counseled that recurrent skin lesions are common (about 50%) in the weeks after completing the initial IV acyclovir course, and close follow-up is arranged, particularly after CNS disease, given the risk of long-term neurodevelopmental sequelae."},
]

NEW[306] = [
    {"title": "Clinical paths", "content": "In an adolescent with persistent bone pain - especially pain that wakes them at night, is worsened by activity, or is accompanied by a palpable mass near the knee or proximal humerus - a sports injury or sprain is not assumed, particularly if symptoms fail to improve with a reasonable trial of conservative therapy (rest, activity modification) over a few weeks."},
    {"title": "Diagnosis", "content": "A plain radiograph is ordered as the first-line imaging study; if it shows a mixed lytic/sclerotic lesion with cortical destruction, an irregular tumor-bone margin, or a periosteal reaction (Codman triangle, sunburst pattern), MRI is obtained and prompt referral is made to [[192|pediatric oncology]] rather than pursuing extended conservative management, since routine labs are typically normal and cannot be used to reassure against malignancy. Once osteosarcoma is suspected, percutaneous core-needle biopsy is arranged with careful planning of the needle tract in coordination with the surgical team, since the tract itself must later be resected during definitive surgery - poor planning here can worsen recurrence risk. While biopsy and staging are awaited, Ewing sarcoma and osteoid osteoma are kept on the differential: fever/weight loss and a diaphyseal or flat-bone lesion point toward Ewing sarcoma rather than osteosarcoma, while dramatic NSAID responsiveness and a small radiolucent nidus point toward benign osteoid osteoma."},
    {"title": "Management", "content": "Families are counseled that treatment will combine chemotherapy (typically including doxorubicin, with dexrazoxane considered to reduce cardiotoxicity) and surgical resection."},
    {"title": "Prognosis and outcome", "content": "Presence of metastatic disease at diagnosis is the single most important prognostic factor, and survivors need long-term monitoring for musculoskeletal, cardiac, renal, and reproductive late effects of treatment."},
]

NEW[307] = [
    {"title": "Clinical paths", "content": "In any child with cystic fibrosis, or with unexplained failure to thrive, [[354|chronic diarrhea]], steatorrhea, or fat-soluble vitamin deficiency, pancreatic insufficiency is considered. In a pancreas-sufficient CF patient who develops new abdominal pain, altered stool pattern, or growth faltering, re-testing for progression to pancreatic insufficiency is done rather than assuming their prior sufficiency status still holds."},
    {"title": "Diagnosis", "content": "A fecal elastase-1 level is checked as the standard first-line screening test - a level above 100 mcg/g essentially rules out pancreatic insufficiency (99% predictive value), but severe diarrhea can dilute stool and produce a falsely low result requiring cautious interpretation."},
    {"title": "Management", "content": "Once pancreatic insufficiency is confirmed, pancreatic enzyme replacement therapy is started with an enteric-coated product, dosed with every meal and snack and titrated to clinical response (using a 1:1 lipase ratio as a starting point if switching products). The diet is aimed at roughly 150% of normal caloric intake, with overnight gastrostomy feeding considered if oral intake cannot meet this target, and fat-soluble vitamin (A, D, E, K) supplementation is started given the near-universal need in this population. If the suspected etiology is chronic pancreatitis rather than CF, imaging (ultrasound/CT, then ERCP/MRCP as needed) is pursued to characterize ductal anatomy and structural complications, and coexisting endocrine insufficiency is screened for with fasting/postprandial glucose given the risk of diabetes developing over time. In a child with celiac disease or [[214|malnutrition]]-related pancreatic insufficiency, enzyme dependence may be expected to resolve with adequate nutritional rehabilitation rather than being lifelong, and periodic reassessment is done rather than assuming permanent PERT dependence in that specific context."},
]

NEW[308] = [
    {"title": "Clinical paths", "content": "Neuroimaging and further workup are reserved for red flags rather than ordered routinely for a classic migraine history: neurologic abnormalities, altered mental status, or meningeal signs should prompt evaluation for meningitis; a thunderclap headache pattern should prompt evaluation for a ball-valve intracranial cyst, [[379|intracranial hemorrhage]], or RCVS (especially with a history of migraine, pregnancy, or relevant drug exposure); and a child with a right-to-left cardiac shunt, [[122|immunodeficiency]], chronic ENT infection, or penetrating head injury presenting with new or worsening headache should be evaluated for brain abscess. When aura is present, the tempo (slow march over minutes, resolving within 5–60 minutes) distinguishes it from stroke, and the acephalic migraine subtypes (familial hemiplegic migraine, basilar migraine, migraine aura without headache) are considered when a stroke-like presentation lacks headache."},
    {"title": "Diagnosis", "content": "A careful history is taken as the primary diagnostic tool, since migraine diagnosis rests almost entirely on history plus a normal exam rather than any test or scan. Family history of migraine, associated motion sickness or vertigo, headache duration and location, throbbing quality, and associated nausea/vomiting/photophobia/phonophobia are asked about specifically, and whether the pattern fits an episodic syndrome (cyclical vomiting, abdominal migraine, benign paroxysmal vertigo or torticollis) rather than a typical headache is noted, particularly in a younger child."},
    {"title": "Management", "content": "Coexisting anxiety, depression, and sleep disturbance are screened for and addressed as part of migraine management, since anxiety predicts migraine persistence and poor sleep can trigger migraine attacks — addressing sleep hygiene and [[94|mental health]] may reduce migraine frequency independent of headache-specific therapy."},
    {"title": "Prognosis and outcome", "content": "Families are reassured that episodic childhood syndromes such as cyclical vomiting, abdominal migraine, and benign paroxysmal vertigo commonly evolve into typical [[217|migraine headache]] later, so a consistent family/personal history across these patterns supports the migraine diagnosis even when the current presentation doesn't look like a classic headache."},
]

NEW[309] = [
    {"title": "Clinical paths", "content": "When evaluating a suspected muscle contusion, the history is used first to exclude more serious injury: immediate swelling, deformity, numbness, give-way weakness, an audible pop, joint locking, or instability should redirect evaluation toward fracture or internal joint derangement rather than simple contusion management. The signs of myositis ossificans are watched for — disproportionate, escalating pain, warmth, and swelling with extreme tenderness on any movement of the adjacent joint — after a significant thigh or arm contusion, since this changes the management approach and prognosis timeline substantially. If the mechanism involved any blow to the head, neck, face, or body with subsequent headache, confusion, amnesia, dizziness, balance problems, or behavioral change, evaluation for [[200|concussion]] is warranted regardless of whether loss of consciousness occurred, and same-day return to play is not allowed, since symptoms can evolve over the following hours."},
    {"title": "Diagnosis", "content": "CT imaging is obtained only if there is deteriorating or altered mental status, prolonged loss of consciousness, repeated vomiting, severe headache, signs of skull fracture, a focal neurologic deficit, or a severe injury mechanism — CT is rarely needed beyond the first 24 hours for straightforward concussion."},
    {"title": "Management", "content": "For an uncomplicated contusion, rehabilitation is started immediately rather than simply prescribing rest: ice is applied for 20 minutes 3–4 times daily, compression is applied without compromising perfusion, the limb is elevated, NSAIDs or acetaminophen are used for pain control, and pain-free isometric and range-of-motion exercises are begun as soon as tolerated to prevent the deconditioning that comes from prolonged disuse. Exercise is avoided for the first 5–7 days, and local heat is reserved for after the acute swelling and tenderness phase has passed. For a quadriceps contusion specifically, management consists of ice and compression, with short-term crutches added for moderate-to-severe injuries, and a return to walking and activity as tolerated is allowed. For a hamstring injury, stretching and eccentric strengthening are prioritized in rehabilitation given the muscle's inherent two-joint vulnerability to reinjury."},
    {"title": "Prognosis and outcome", "content": "Families are counseled that most concussions resolve within 7–10 days, while the minority who develop persistent postconcussion symptoms beyond 28 days are watched for, requiring more structured support for return to school and sport."},
]

NEW[310] = [
    {"title": "Clinical paths", "content": "In a preschool-age child (2–6 years) presenting with edema, heavy proteinuria, hypoalbuminemia, and hyperlipidemia, with normal complement and no [[187|hematuria]]/hypertension, minimal change disease is the most likely diagnosis. Renal biopsy and closer secondary-cause workup are reserved for children outside this typical demographic — age over 12 years, sustained hypertension, significant hematuria, renal dysfunction, extrarenal symptoms (rash, arthralgias, fever), or depressed complement — since these features shift the differential toward FSGS, membranous nephropathy, MPGN, or a secondary cause such as SLE, IgA vasculitis nephritis, or a triggering infection or drug."},
    {"title": "Diagnosis", "content": "A corticosteroid trial is reasonable without upfront biopsy in the typical presentation, since more than 80% will respond. For a child whose presentation does not fit the classic MCD pattern, or who fails to respond to an appropriate steroid course, biopsy and a secondary-cause workup (infectious serologies, ANA/complement, medication history) are pursued rather than continuing empiric steroid therapy indefinitely, since a substantial minority of nephrotic syndrome — particularly outside the classic 2–6-year age range — reflects FSGS, membranous nephropathy, MPGN, or a secondary systemic process requiring different management."},
    {"title": "Management", "content": "The practical complications are managed proactively rather than only treating the proteinuria: signs of serious bacterial infection (peritonitis, pneumonia, sepsis) are monitored for, particularly from encapsulated organisms, given urinary immunoglobulin losses, and a high index of suspicion for thrombosis (renal vein, cerebral venous sinus, pulmonary veins) is maintained given the hypercoagulable state — even though absolute risk in children (2–5%) is lower than in adults, the consequences can be severe. The paradox of nephrotic syndrome fluid status is recognized: a child can be edematous and appear fluid-overloaded while simultaneously being intravascularly volume-depleted, which should inform cautious use of diuretics and fluid management to avoid precipitating or worsening intravascular depletion."},
]