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

NEW[311] = [
    {"title": "Clinical paths", "content": "OSAS is screened for using the history and exam findings above whenever a child presents with habitual snoring, witnessed apnea, morning headache, daytime sleepiness, new-onset secondary enuresis, or ADHD-like symptoms/learning problems, with specific examination for tonsillar hypertrophy, adenoidal facies, micrognathia, and growth parameters (failure to thrive or obesity), plus blood pressure. In a child or adolescent with poorly controlled, unstable asthma — especially if overweight or obese — coexisting OSA is screened for specifically, since the two conditions frequently overlap and untreated OSA can be contributing to asthma instability."},
    {"title": "Diagnosis", "content": "Referral for polysomnography is made to confirm the diagnosis and grade severity, rather than relying on history and exam alone, since these clinical features cannot reliably distinguish benign primary snoring from true OSAS, and polysomnography is also needed to detect coexisting central sleep apnea, which would change the management plan. In the child with unstable asthma and suspected OSA, confirmation with polysomnography precedes starting CPAP, since CPAP helps genuine coexisting apnea but can disrupt sleep if apnea is not actually present."},
    {"title": "Management", "content": "For a child with confirmed OSAS from adenotonsillar hypertrophy, referral for adenotonsillectomy is made as first-line treatment; CPAP is added for children who are poor surgical candidates or who have persistent OSA after surgery. [[98|Allergic rhinitis]] and nasal congestion are managed as a shared contributing factor when both conditions coexist, since nasopharyngeal congestion and resultant mouth breathing can worsen both asthma and OSA together."},
    {"title": "Prognosis and outcome", "content": "Families are counseled that untreated OSAS carries real long-term risk — neurocognitive impairment, behavioral problems, failure to thrive, and, if severe and prolonged, cor pulmonale and systemic/pulmonary hypertension — and that appropriate treatment can meaningfully improve behavior and cognitive function, which supports timely referral rather than a wait-and-see approach."},
]

NEW[312] = [
    {"title": "Clinical paths", "content": "In a child with unilateral eyelid erythema and swelling, the first and most important task is screening for orbital involvement: proptosis, pain with eye movement, and limitation of extraocular movement are checked for. If any of these are present, it is treated as orbital [[353|cellulitis]] - outpatient management is not attempted. If these are absent and the exam is consistent with well-demarcated preseptal swelling without proptosis or movement restriction, periorbital cellulitis is more likely. There is a low threshold to reconsider necrotizing fasciitis if swelling and systemic illness progress unusually rapidly with skin necrosis or blistering - this requires emergent surgical debridement in addition to antibiotics."},
    {"title": "Diagnosis", "content": "For suspected orbital cellulitis, a CT of the orbits and sinuses is obtained. Antecedent trauma, insect bites, primary skin lesions, and recent upper respiratory or sinus symptoms are asked about specifically to help identify the likely source and organism. Reassessment occurs at 24 hours: if there has been no clinical response, or if orbital involvement is newly suspected, CT imaging of the sinuses and orbits is obtained."},
    {"title": "Management", "content": "For confirmed orbital involvement, immediate hospitalization for IV antibiotics follows, and ophthalmology is involved (and otolaryngology if sinus disease is found). For confirmed periorbital cellulitis, most children can be treated as outpatients with oral amoxicillin-clavulanate or clindamycin and close follow-up. Hospitalization/IV antibiotics are reserved for infants under 1 year old, toxic-appearing children, those who cannot tolerate oral medication, or those who fail an outpatient trial. If there has been no clinical response on reassessment, treatment is escalated to IV antibiotics."},
]

NEW[313] = [
    {"title": "Clinical paths", "content": "For any preterm infant, gestational age at birth (and, closely related, birthweight) is the single most useful piece of information for anticipating risk - the earlier the birth, the higher the risk of respiratory disease, IVH, NEC, retinopathy of prematurity, and long-term neurodevelopmental impairment, with the highest risk concentrated in infants born at or before 25 weeks."},
    {"title": "Diagnosis", "content": "In primary care follow-up, chronologic age is always corrected for degree of prematurity when assessing growth and [[10|developmental milestones]]. Proactive - not just reactive - screening is done for the recognized long-term risks of prematurity: [[378|language delay]], visual-perceptual problems, minor neuromotor dysfunction, attention and executive function difficulties, learning disabilities, and social/emotional problems, since these can be subtle and are common even in children who look well at early exams, including those born late preterm (33-36 weeks) who are often mistakenly treated as low-risk. Growth parameters, especially head circumference, are tracked as an early marker of nutritional adequacy and neurodevelopmental risk."},
    {"title": "Management", "content": "Enteral feeding is started as early as feasible even in very preterm infants, since nutrition is closely tied to long-term head growth and neurodevelopmental outcome, and [[214|malnutrition]] (particularly in VLBW infants) is specifically linked to smaller head size, poorer psychomotor/mental outcomes, and higher rates of [[164|cerebral palsy]] and autism. Longer well-child visits are planned to properly evaluate nutritional status, developmental trajectory, and family coping. Given the described association between preterm/low birth weight and later hypertension, blood pressure monitoring is considered for incorporation into longer-term follow-up for children with a preterm birth history, while recognizing the evidence here is still preliminary."},
]

NEW[314] = [
    {"title": "Clinical paths", "content": "When a child fails vision screening, or a parent/teacher reports squinting, eye rubbing, sitting too close to the television, headaches, or fatigue with visual tasks, referral is made for a comprehensive ophthalmic evaluation. Referral is prioritized in children with recognized risk factors for refractive error - prematurity, Down syndrome, a parent with refractive error, or connective tissue disorders such as Stickler, Marfan, or Ehlers-Danlos syndrome - even in the absence of specific complaints, since young children may not reliably report visual symptoms themselves."},
    {"title": "Diagnosis", "content": "A comprehensive ophthalmic evaluation including cycloplegic retinoscopy is used rather than relying on instrument-based (autorefractor) screening alone, since autorefraction can overestimate myopia in children."},
    {"title": "Management", "content": "Once a significant refractive error or anisometropia is identified, prompt correction with glasses is arranged as first-line treatment to prevent amblyopia and strabismus - the risk that drives the urgency of treating refractive error in children rather than in adults. Contact lenses are reserved for very high or markedly asymmetric refractive errors or for adolescents who decline glasses. Referral for off-label laser refractive surgery is considered only in the specific circumstance of a child who cannot tolerate glasses or contact lenses (due to neurobehavioral impairment or severe compliance issues) and has an amblyopiogenic refractive error, recognizing this is not a routine or approved pediatric treatment. Consistent follow-up is arranged for any child treated for amblyopia or anisometropia to confirm the corrective strategy (glasses, contacts) is being used as intended, since compliance failures in this population directly translate into missed windows for preventing permanent [[343|visual impairment]]."},
]

NEW[315] = [
    {"title": "Clinical paths", "content": "For any child presenting after a seizure, first classify the event: was it generalized or focal, provoked (identifiable trigger) or unprovoked, and did it show the abrupt-onset/no-postictal-period pattern of [[342|absence seizure]] or the prodrome-aura-ictal-postictal sequence of a tonic-clonic seizure. If a seizure is ongoing, any seizure lasting more than about 5 minutes is treated as early status epilepticus, acting quickly rather than waiting for the classic 30-minute threshold."},
    {"title": "Diagnosis", "content": "For a well-appearing, fully immunized 6-12 month old with a simple [[292|febrile seizure]], a lumbar puncture is not routinely performed; it is reserved as an option specifically when the child received antibiotics before the seizure or has an unknown/deficient immunization history (especially for Hib and pneumococcus). For most children with a first-time seizure who are back to baseline, routine labs and neuroimaging are avoided unless the history or exam suggests a specific secondary cause (trauma, toxin exposure, focal deficits, signs of infection). Throughout, reversible contributors are actively screened for and corrected - a bedside glucose is checked, electrolyte derangements (sodium, calcium, magnesium) are considered, and medication nonadherence (subtherapeutic anticonvulsant level) or toxin/drug exposure is asked about - since these can both explain the seizure and change immediate management independent of the antiepileptic drugs given."},
    {"title": "Management", "content": "A benzodiazepine is given first (diazepam 0.4 mg/kg IV or rectal, or lorazepam 0.1 mg/kg IV/IO), and repeated once if the seizure persists 5 minutes after the first dose - but different benzodiazepines are not combined given the additive respiratory depression risk. If seizures continue despite two benzodiazepine doses, treatment moves to phenobarbital (15-20 mg/kg slow IV push) or phenytoin (18 mg/kg in 100 mL normal saline over 20 minutes) as second-line therapy."},
]

NEW[316] = [
    {"title": "Clinical paths", "content": "If canal swelling is too severe for drops to penetrate proximally, a wick is placed — and referral to ENT is made if the swelling is severe enough that the tympanic membrane cannot be visualized, since these patients need specialist canal management and a temporary wick. Evaluation for malignant otitis externa with imaging is performed in any diabetic or immunosuppressed patient who has disproportionate pain, otorrhea, or new cranial nerve findings — this population should not be managed with topical therapy alone."},
    {"title": "Diagnosis", "content": "The diagnosis is confirmed using the 48-hour onset criterion plus tragal/auricular traction tenderness, and the canal is gently debrided both to confirm the diagnosis directly and to allow topical medication to reach the inflamed skin. If drainage persists beyond 2 weeks despite appropriate treatment, referral to otolaryngology is made; if it persists beyond 6 weeks, evaluation for cholesteatoma is undertaken; and if it persists beyond 3 months despite multiple antibiotic courses, MRSA is considered the likely organism and antimicrobial coverage is adjusted accordingly."},
    {"title": "Management", "content": "First-line topical combination antibiotic-corticosteroid drops (polymyxin/neomycin or a fluoroquinolone) are started for uncomplicated cases, and oral analgesia is added given how painful this condition typically is. Escalation to oral ciprofloxacin is made for cases not responding to topical therapy or when [[353|cellulitis]] has spread beyond the external canal. For prevention, families are counseled to dry the ear canal after swimming and to avoid cotton swabs and other objects that disrupt the protective cerumen layer or cause canal trauma, and drying drops (e.g., dilute acetic acid or alcohol-based solutions) are considered for children with recurrent episodes, particularly frequent swimmers, since disruption of the natural cerumen barrier is the central mechanism driving this condition."},
]

NEW[317] = [
    {"title": "Clinical paths", "content": "Suspected PUD is approached differently depending on age. In an infant with [[138|feeding difficulty]], vomiting, or unexplained GI bleeding, stress ulcer is considered a leading cause and is managed as a potential emergency, since infant PUD can present with perforation or significant bleeding; pediatric GI/surgery is involved early if there is any sign of hemodynamic instability or [[193|acute abdomen]]. In a school-age child or adolescent presenting with epigastric or periumbilical pain, nausea, and dyspepsia — especially with a family history, nocturnal pain, or occult blood in the stool — referral is made for pediatric GI evaluation and endoscopy rather than treating empirically for an extended period. In the emergency setting, it is first determined whether the child has a significant complication (GI hemorrhage, perforation, or gastric outlet obstruction) requiring stabilization, since this is rare but is the primary reason to escalate beyond outpatient management."},
    {"title": "Diagnosis", "content": "Endoscopy both confirms PUD and enables H. pylori biopsy testing. When H. pylori is confirmed on biopsy, treatment follows - serology is not relied upon to make the initial diagnosis, reserving it only for children who already have an endoscopically or radiographically confirmed ulcer."},
    {"title": "Management", "content": "For most children in whom PUD is suspected as a cause of abdominal pain, it is appropriate to arrange outpatient diagnostic workup, start a gastric antisecretory regimen empirically, and ensure close follow-up rather than admitting for immediate inpatient workup. Confirmed H. pylori is treated with triple therapy (PPI plus two antibiotics) for 7–14 days, followed by continued acid suppression for a period afterward (e.g., 2 months) to support healing. Medication history is actively reviewed for NSAID use, since drug-induced ulceration is the most common ulcer type in children, and this modifiable cause is addressed directly (stopping the NSAID) as part of management alongside acid suppression."},
]

NEW[318] = [
    {"title": "Clinical paths", "content": "If an infant presents with vomiting, irritability, an eczematous rash, and a musty/mousy odor — particularly if fairer in complexion than unaffected relatives — PKU is considered even if newborn screening was reportedly normal or is pending. For any young woman with PKU approaching or during childbearing age, strict return to (or maintenance of) phenylalanine restriction before and throughout pregnancy is emphasized, since maternal PKU can cause fetal harm irrespective of the fetus's own genetic status."},
    {"title": "Diagnosis", "content": "Every newborn receives screening in the first few days of life, and testing is specifically repeated by the second week of life for any infant screened before 24 hours of age, since delayed detection risks irreversible neurologic damage that begins to occur by about 8 weeks of age. Plasma phenylalanine and phenylalanine:tyrosine ratio testing is pursued; a urine ferric chloride test can be a rapid adjunct in the emergency setting when the characteristic odor prompts suspicion. Classic PKU is differentiated from the rarer biopterin-related variants by checking urinary pterins and blood dihydropteridine reductase activity, since these variants need additional treatment with neurotransmitter precursors beyond diet alone — missing this distinction means diet alone will not prevent neurologic damage in these patients."},
    {"title": "Management", "content": "Once PKU is confirmed, a phenylalanine-restricted diet with a phenylalanine-free medical formula is initiated as soon as possible, and referral is made to a metabolic disease clinic and a nutritionist experienced in PKU for ongoing, careful dietary monitoring — the treatment is lifelong, not just an infant/childhood intervention. Continued breastfeeding is supported if the family wishes, but only with close specialty clinic oversight to balance breast milk's phenylalanine content against formula and dietary needs. Families are counseled explicitly that aspartame-containing products must be avoided completely, since this common sweetener is a hidden phenylalanine source. Treated children are monitored with phenylalanine level testing coordinated by the metabolic clinic to confirm control is achieved early (ideally by 3–4 weeks of age) and sustained over time, since both the timing and the consistency of control drive long-term cognitive outcome."},
]

NEW[319] = [
    {"title": "Clinical paths", "content": "Whether the puncture occurred through a shoe, particularly a sneaker, is specifically asked about, since this raises specific concern for Pseudomonas infection and should influence empiric antibiotic selection if infection develops. Prompt reassessment is warranted if [[353|cellulitis]] develops after a puncture wound, and the workup is escalated if signs of infection persist beyond the expected course, since this may indicate a retained foreign body or deep infection ([[227|septic arthritis]], chondritis, [[175|osteomyelitis]]) requiring surgical debridement. For animal or human bite puncture wounds, wound severity and location are assessed (hand/face carry higher risk)."},
    {"title": "Diagnosis", "content": "A plain radiograph is obtained for puncture wounds, especially those over the metatarsophalangeal joints or other weight-bearing areas, to look for a radiopaque foreign body (glass, metal) or bony penetration; if suspicion for a retained foreign body remains despite a negative plain film, ultrasound, CT, or MRI is pursued, since organic material is often radiolucent. For purulent cellulitis/abscess, ultrasound is used to confirm a drainable collection when exam is unclear."},
    {"title": "Management", "content": "For a straightforward foot puncture wound, thorough irrigation is performed, [[266|tetanus]] prophylaxis is updated as indicated by the child's immunization history, and a course of antibiotics is considered per local practice; families are counseled that the majority of these wounds heal without complication using this approach. Cellulitis after a puncture wound is treated with IV antibiotics, with surgical drainage added if an abscess forms, and a 10–14 day systemic antibiotic course covering S. aureus and Pseudomonas is given for deep infection. I&D is performed for mild-to-moderate purulent disease, and TMP-SMX is added or IV vancomycin with I&D is used based on abscess size, extent of cellulitis, and systemic signs (fever, hypotension) or immunocompromise. For animal or human bite wounds, amoxicillin-clavulanate prophylaxis is given for 5 days when the wound is moderate/severe, the patient is immunocompromised, or there is possible penetration of the periosteum or joint capsule or significant edema — prophylaxis should not be withheld on these higher-risk bite wounds while waiting to see if infection develops."},
]

NEW[320] = [
    {"title": "Clinical paths", "content": "When a child is missing school 2–3 days per week for 2 or more weeks, school refusal is first distinguished from truancy and from ordinary illness-related absenteeism: confirmation that the parent is aware the child is at home rules out truancy, and the characteristic pattern of somatic symptoms confined to weekday, term-time mornings that resolve by midday, without underlying organic explanation, is sought. Bullying (traditional and cyber) and violence or fear of violence at school are always asked about directly, given how commonly these contribute to school-associated refusal and how serious the downstream emotional consequences can be. Suicidal ideation is asked about directly given documented cases among school refusers, and any positive response is treated as requiring immediate, serious follow-up rather than downplaying it as anxiety."},
    {"title": "Diagnosis", "content": "A sensitive, holistic history-taking approach is used — the first conversation itself begins building the therapeutic alliance needed to shift the family away from avoidant behavior — and child-related factors (age-appropriate fears, temperament, academic performance), family factors (parental illness, family stress, overdependency dynamics), and school factors (bullying, violence, academic pressure) are systematically explored rather than assuming a single cause. Screening is done for anxiety disorders (especially separation anxiety in younger children), depression, oppositional defiant disorder, panic disorder, and agoraphobia, recognizing that 20–30% of affected children will not meet criteria for any specific psychiatric diagnosis — a normal screen does not exclude school refusal as the correct diagnosis."},
    {"title": "Management", "content": "Management is tailored to age and underlying dynamic: for a younger child with separation-anxiety-driven refusal, work is directed toward gently increasing tolerance of separation from parents (for example, practicing overnight stays with relatives or friends) while a prompt, early return to school rather than prolonged time at home is arranged, since delay tends to entrench the avoidance pattern. The family and the school are engaged collaboratively in a shared plan, cognitive-behavioral therapy and relaxation techniques are involved, and, when an anxiety or depressive disorder is present, SSRIs are considered as part of a comprehensive treatment plan. Physician involvement itself is framed as marking a turning point that signals to the child and family the seriousness of the symptoms and the need to change the avoidant pattern, and families are counseled explicitly about the meaningful long-term risks (school non-completion, later psychiatric care, disrupted independence) of unaddressed school refusal to support engagement with treatment rather than continued accommodation of avoidance."},
]

NEW[321] = [
    {"title": "Clinical paths", "content": "Hypoglycemia is suspected in any infant or child with autonomic signs (shakiness, sweating, pallor, dizziness) or neuroglycopenic signs (irritability, lethargy, confusion, seizures); neonates and infants are frequently asymptomatic or show only subtle findings such as cyanosis, apnea, hypothermia, hypotonia, jitteriness, or poor feeding."},
    {"title": "Diagnosis", "content": "A blood glucose below 60 mg/dL (3.3 mmol/L) confirms hypoglycemia in infants and children outside the first 72 hours of life. Whenever the glucose is below 50 mg/dL (2.8 mmol/L), a critical sample is obtained before treating, since this is the point at which a diagnostic fasting or provocative test would also be stopped. A simultaneous insulin level above 2 µU/mL at a glucose below 60 mg/dL, together with low ketones and low lactate, points to hyperinsulinism; absent ketonemia and ketonuria with an appropriately suppressed insulin instead points to a fatty acid oxidation defect. In a patient with known diabetes, hypoglycemia is defined at a higher threshold, below 70 mg/dL, and does not need this same critical-sample workup."},
    {"title": "Management", "content": "Hypoglycemia is treated immediately once recognized or confirmed, with the goal of restoring and keeping glucose above 70 mg/dL — a target that matters most in hyperinsulinism, where the child cannot fall back on ketones as brain fuel while glucose is low. In a child with diabetes, this means prompt carbohydrate treatment, and patients and families are taught to always carry a source of carbohydrate along with a glucose meter when away from home, aiming to normalize glucose quickly without giving so much carbohydrate that it rebounds into hyperglycemia. Diazoxide can be used for hyperinsulinism, including the syndromic hyperinsulinism of [[323|Beckwith-Wiedemann syndrome]]. Beyond the initial glucose correction, long-term management turns on identifying the underlying cause, since that determines the definitive treatment and the risk of recurrence."},
]

NEW[322] = [
    {"title": "Clinical paths", "content": "Examination is performed in a warm room with warm hands. Inspection for scrotal asymmetry is done - a hypoplastic hemiscrotum suggests the testis has never descended. With the child supine or sitting, an attempt is made to guide the testis down the inguinal canal into the scrotum. If successful, it is held in the scrotum for 30 seconds to fatigue the cremaster: a retractile testis remains down, a true undescended testis springs back up. Bilateral non-palpable testes in a newborn phenotypic male require prompt evaluation for a disorder of sex development, since the infant may be a virilized genetic female with salt-wasting [[136|congenital adrenal hyperplasia]] - a potentially life-threatening diagnosis. Separately, an acutely tender groin mass with an empty ipsilateral scrotum in a boy with a known undescended testis should prompt immediate consideration of [[231|testicular torsion]] (as well as incarcerated inguinal hernia or acute hydrocele of the cord) and prompt surgical evaluation."},
    {"title": "Diagnosis", "content": "Scrotal ultrasound has no role in locating a non-palpable testis - it does not change management and is reserved for a painful or mass-like scrotum. The same urgent evaluation is warranted for a neonate with hypospadias plus an undescended testis: the risk of an underlying disorder of sex development is about 15% when the testis is palpable and rises to about 50% when it is non-palpable."},
    {"title": "Management", "content": "If the testis has not descended by 6 months of age (corrected for gestational age), referral for surgery is made rather than waiting further, since spontaneous descent essentially does not occur after this point. A UDT found together with an inguinal hernia should go to surgery at the time of diagnosis, not be deferred to 6 months. Bilateral non-palpable testes and hypospadias with an undescended testis both prompt urgent evaluation for a disorder of sex development, and an acutely tender groin mass in a boy with a known undescended testis prompts prompt surgical evaluation for possible testicular torsion."},
]

NEW[323] = [
    {"title": "Clinical paths", "content": "In a newborn with macrosomia, macroglossia, an omphalocele or umbilical hernia, hemihyperplasia, visceromegaly, or characteristic linear ear creases, blood glucose is checked promptly and monitored closely, since [[97|neonatal hypoglycemia]] from pancreatic beta-cell hyperplasia is common and clinically important in BWS. Hyperinsulinism affects about half of BWS infants; most cases are mild, resolve within the first several weeks of life, and respond to diazoxide."},
    {"title": "Diagnosis", "content": "If hypoglycemia proves severe or persistent and unresponsive to diazoxide, paternal uniparental isodisomy of 11p is considered as the underlying mechanism, which can require treatment into adulthood or lifelong. At diagnosis, screening for nephrourological malformations is done with clinical evaluation and renal ultrasound. An elevated or rising AFP or an abnormal ultrasound finding warrants prompt further evaluation, since early detection at an earlier tumor stage significantly improves outcomes."},
    {"title": "Management", "content": "Because of the marked predisposition to embryonal tumors — chiefly Wilms tumor, hepatoblastoma, and adrenocortical carcinoma, with hepatoblastoma risk reported at roughly 2280-fold the general population — children with BWS require structured, ongoing surveillance rather than a one-time workup. Recommended monitoring is serum alpha-fetoprotein every 3 months (protocols describe this through age 3-4 years) together with abdominal ultrasound every 3 to 4 months until about age 7-8 years; one source describes AFP and abdominal/renal sonograms every 4 months for a child under surveillance. A 2018 international consensus statement recommends tailoring the exact surveillance protocol to the specific genetic or epigenetic mechanism identified. Because tumor risk is concentrated in the first 8 years of life and uncommon thereafter, surveillance can generally be relaxed beyond that age."},
]