[
  {
    "article_id": 340,
    "article_title": "Varicella Zoster",
    "section_id": "1c223d0dc611477da2d7ec9912ada1b6",
    "section_title": "Recognizing and confirming varicella at the bedside",
    "variant": "clinical",
    "imperatives": 1,
    "content": "Varicella is suspected in a child with a brief prodrome of low-grade fever and malaise followed by a pruritic rash appearing in successive crops — typically about three — spreading centrifugally from the trunk and scalp outward, with lesions at multiple stages (papule, vesicle with a red halo, cloudy fluid, crust) present simultaneously. Diagnosis is usually clinical with an exposure history; if confirmation is needed, PCR or direct fluorescent antibody of vesicular fluid or a scab scraping is used. In a vaccinated child, breakthrough varicella is kept in mind if the rash looks milder or atypical. An initial leukopenia followed by lymphocytosis and mildly elevated liver enzymes is expected if labs are drawn."
  },
  {
    "article_id": 341,
    "article_title": "Toxoplasmosis",
    "section_id": "31138f0bd2874f069d4b8107814c39e8",
    "section_title": "Evaluating a Neonate with Suspected Congenital Toxoplasmosis",
    "variant": "clinical",
    "imperatives": 2,
    "content": "Congenital toxoplasmosis is considered in any infant with hepatosplenomegaly, microcephaly or macrocephaly, abnormal tone, seizures, or intrauterine growth restriction, and specifically in any infant under 1 year with undiagnosed neurologic disease, especially when retinal lesions are present. A normal newborn exam does not exclude infection - most infected infants look normal at birth - so CSF analysis, a dilated eye exam, and CNS imaging are pursued when suspicion is raised by maternal history or other findings. On imaging, diffuse intracranial calcifications and hydrocephalus are sought; periventricular calcification on head CT should prompt toxoplasmosis serology alongside consideration of rubella, CMV, and herpes simplex. Hydrocephalus may be the only sign of congenital toxoplasmosis and typically requires shunt placement regardless of other findings. Confirmed [[155|congenital infection]] is treated with pyrimethamine, sulfadiazine, and folinic acid."
  },
  {
    "article_id": 341,
    "article_title": "Toxoplasmosis",
    "section_id": "0b8955719a3745f9b07c351982a61200",
    "section_title": "Ocular and Later-Presenting Disease",
    "variant": "clinical",
    "imperatives": 1,
    "content": "In an older child or adolescent presenting with visual symptoms, ocular toxoplasmosis is evaluated with T. gondii IgG/IgM serology plus dilated eye examination looking for focal necrotizing retinochoroiditis adjacent to a chorioretinal scar; PCR of aqueous humor can confirm the diagnosis but is rarely needed. Families are counselled that congenitally infected children who appear normal in infancy remain at risk for [[343|visual impairment]], [[114|learning disability]], or [[248|hearing loss]] emerging later, often in the second or third decade of life, so long-term ophthalmologic and developmental follow-up is warranted even after an initially reassuring newborn evaluation."
  },
  {
    "article_id": 342,
    "article_title": "Absence Seizure",
    "section_id": "7f1518823a324882a2b3fcd67f85bec5",
    "section_title": "Recognizing absence seizures at the bedside or in clinic",
    "variant": "clinical",
    "imperatives": 2,
    "content": "Absence seizures are suspected in a child, typically 4-12 years old, with brief (a few seconds to about 20 seconds) episodes of staring or behavioral arrest, abrupt in onset and offset, without aura or postictal confusion, sometimes with subtle eye flutter, lip smacking, or other automatisms. Because episodes are often missed by the child and family, specific questioning about frequent daydreaming, inattention, or new school performance problems is warranted, since these can be the presenting complaint. Diagnosis is confirmed with EEG showing the classic 3-Hz generalized spike-and-slow-wave discharge; hyperventilation for 3-4 minutes is a simple office and EEG-lab maneuver that reliably provokes the seizure and supports the diagnosis. A normal neurologic exam and normal intelligence are expected in typical CAE — a finding of true falls, myoclonus, or developmental regression should instead raise concern for atypical absence or another [[206|epilepsy]] syndrome and prompt neurology referral."
  },
  {
    "article_id": 342,
    "article_title": "Absence Seizure",
    "section_id": "9b98be29f46d44a09d5bb3106cce99a5",
    "section_title": "Starting and monitoring treatment",
    "variant": "clinical",
    "imperatives": 3,
    "content": "Ethosuximide is started as first-line therapy for confirmed absence seizures; valproate or lamotrigine are reasonable alternatives. Carbamazepine is avoided, as it can worsen absence seizures. Families are counselled that the prognosis is excellent — over 90% of children become seizure-free with treatment, with remission typically by age 12 — but that seizures can occur many times a day until controlled, which can affect learning and carries some injury risk in the interim. If a child presents in a prolonged confused or dreamy state lasting hours, absence status epilepticus is considered and treated with a benzodiazepine."
  },
  {
    "article_id": 343,
    "article_title": "Visual Impairment",
    "section_id": "8a6f28c28f9b48059c9299642fc388a2",
    "section_title": "Early Detection in Primary Care",
    "variant": "clinical",
    "imperatives": 1,
    "content": "Visual behavior is screened at every well-child visit, since early detection of significant visual impairment - and of conditions that risk permanent vision loss if untreated - is one of the primary care clinician's most important responsibilities here. By 3-6 months of age, persisting wandering nystagmus or poor visual regard/tracking should prompt urgent ophthalmology referral. In the first 1-2 years, persistent excessive tearing and eye redness, significant strabismus, and leukocoria (white pupillary reflex) are treated as red flags requiring prompt evaluation. Amblyopia - the most common cause of unilateral, preventable, permanent visual impairment in developed countries, affecting up to 5% of the population - is often insidious and will not be caught without systematic vision screening, so parental observation alone is not relied upon to exclude it."
  },
  {
    "article_id": 343,
    "article_title": "Visual Impairment",
    "section_id": "d809141ab0c444ed8e2d4d75ed746195",
    "section_title": "Working Up Nystagmus or Suspected Cortical Visual Impairment",
    "variant": "clinical",
    "imperatives": 1,
    "content": "When abnormal eye movements are evaluated, they are characterized as rhythmic/swinging versus nonrhythmic, with waveform, direction, amplitude, frequency, velocity, and symmetry between the two eyes described, noting any associated nonocular muscle movement - vertical nystagmus in particular raises concern for a posterior fossa lesion. If an infant has poor eye contact, fails to fixate and follow, is unresponsive to visual threat, or shows wandering/roving eye movements with a normal eye exam (normal pupillary responses and eye movements on structural exam), cortical visual impairment from perinatal hypoxia, prematurity, hydrocephalus, congenital CNS anomaly, trauma, [[379|intracranial hemorrhage]], or periventricular leukomalacia is considered. Referral to ophthalmology is made to determine etiology, and electroretinogram, visual evoked potential testing, brain imaging, and genetics/neurology consultation are pursued as indicated. Once a vision-impairing condition without medical or surgical treatment is identified, early referral for tailored educational intervention, environmental modification, low-vision devices, and family support services is arranged rather than delaying care while awaiting a precise etiologic diagnosis."
  },
  {
    "article_id": 344,
    "article_title": "Acrocyanosis",
    "section_id": "76bdc099d8df4a0eb8dd814180a499f7",
    "section_title": "Distinguishing benign acrocyanosis from a concerning presentation",
    "variant": "clinical",
    "imperatives": 1,
    "content": "The distribution is examined first: acrocyanosis is confined to the hands, feet, and perioral/circumoral area, with the tongue, mucous membranes, and trunk remaining pink — this alone distinguishes it from central cyanosis, which involves the skin, lips, and tongue and needs prompt cardiorespiratory evaluation. Proper lighting is used, and diagnosis is confirmed with pulse oximetry rather than visual assessment alone, since visual assessment is not a reliable indicator of true oxygen saturation. Acrocyanosis in a newborn is expected in the first 6-24 hours of life (up to 1-2 days, or 24-48 hours with cold stress) and resolves with warming; in an older, normothermic infant, hypovolemia is considered. When a caregiver reports an alarming episode with crying, vomiting, coughing, or breath-holding, a careful history is taken and mental status change is observed for — true acrocyanosis occurs without major mental status change and the child otherwise looks well, whereas seizure, apnea, arrhythmia, or a congenital heart defect need to be excluded when the story or exam does not fit this pattern."
  },
  {
    "article_id": 344,
    "article_title": "Acrocyanosis",
    "section_id": "ef4a066c4dcd4809aca232bc82ddae05",
    "section_title": "Management",
    "variant": "clinical",
    "imperatives": 1,
    "content": "No treatment is needed for benign acrocyanosis beyond warming the infant if it is cold-triggered. Supplemental oxygen is reserved for documented desaturation below target range on pulse oximetry, not for blue-looking extremities with normal saturation. If cyanosis extends beyond the classic distribution, persists beyond the first few minutes of life, or is accompanied by poor perfusion, mottling, or a change in mental status, prompt evaluation for cardiorespiratory disease is warranted: oxygen desaturation is documented with pulse oximetry, and pre/postductal saturations, chest radiography, ECG, hyperoxia testing, and echocardiography are considered to distinguish a cardiac from a noncardiac or pulmonary cause. If acrocyanosis appears in an adolescent, especially with other signs of autonomic dysfunction (orthostatic symptoms, cold limbs, excessive sweating), it is considered in that broader context rather than assuming a purely neonatal or cold-exposure cause."
  },
  {
    "article_id": 345,
    "article_title": "Acne Vulgaris",
    "section_id": "05ce8a18878242b3b784dbd8d9864343",
    "section_title": "Distinguishing Acne by Age of Presentation",
    "variant": "clinical",
    "imperatives": 1,
    "content": "In a neonate with facial pustules in the first 2-4 weeks of life, neonatal cephalic pustulosis (comedones are absent) is favored when the picture is small, uniform dusky-pink papules/pustules on the face and scalp - but bacterial, viral, or fungal causes are still actively excluded, and other neonatal mimics such as milia, [[207|erythema toxicum neonatorum]], transient neonatal pustulosis, and sebaceous gland hyperplasia are considered. Neonatal acne is managed with routine cleansing alone, and caregivers are reassured it resolves spontaneously within about 1-3 months without scarring. In an infant presenting between about 6 weeks and 1 year of age with open comedones and papules/pustules on the cheeks and chin, infantile acne is diagnosed - a true acne with a course that can last 1-2 years and a meaningful scarring risk (up to 25% of cases), so treatment is started rather than only observing. Hormonal/endocrine workup is reserved for infantile acne that is unusually severe or persistent, or accompanied by other signs of androgen or cortisol excess; routine hormonal testing is not needed otherwise."
  },
  {
    "article_id": 345,
    "article_title": "Acne Vulgaris",
    "section_id": "35217a55c17f47889a4f397b829b170d",
    "section_title": "Treating Acne Across Severity",
    "variant": "clinical",
    "imperatives": 3,
    "content": "Typical adolescent acne is started on topical therapy - a retinoid, benzoyl peroxide, and/or a topical antibiotic - as first line. For infantile acne, a topical retinoid (tretinoin cream or adapalene gel) combined with benzoyl peroxide is used as the initial regimen. Escalation to oral therapy occurs for severe or recalcitrant disease at either age: oral erythromycin (or azithromycin in infants) for more severe or refractory cases, with oral tetracyclines avoided in young children because of tooth discoloration. Oral isotretinoin is reserved for the most severe, scarring, or nodular disease at any age. Adolescents and families are counselled early about the risk of scarring and the emotional impact of acne, since both are recognized complications that argue for prompt, adequate treatment rather than a wait-and-see approach in more than mild disease."
  },
  {
    "article_id": 346,
    "article_title": "Alopecia Areata",
    "section_id": "fac910dc4b704e0cbc39d8ad1c05bfd8",
    "section_title": "Bedside evaluation",
    "variant": "clinical",
    "imperatives": 3,
    "content": "Any child with patchy [[370|hair loss]] is examined for the characteristic features of alopecia areata: sharply circumscribed, smooth, round or oval patches of complete hair loss with otherwise normal-looking underlying skin, and exclamation-point hairs (short, tapered, easily plucked) at the margin. Nail pitting, striations, or leukonychia are checked for. Because inflammation is not a feature of alopecia areata, the presence of scaling, crusting, redness, pruritus, or regional lymphadenopathy should raise suspicion for [[339|tinea capitis]] instead, and warrants mycologic examination for Trichophyton tonsurans. Atopy is asked about and, since alopecia areata can rarely accompany other autoimmune conditions ([[290|Hashimoto thyroiditis]], [[270|type 1 diabetes]], Addison disease, vitiligo, ulcerative colitis), further evaluation is pursued only if the history or exam suggests one of these — most children with alopecia areata have no other autoimmune disease. Extent is assessed: single small patch versus multifocal or ophiasis-pattern loss versus progression toward alopecia totalis or universalis, since more extensive disease and childhood onset both predict a worse prognosis."
  },
  {
    "article_id": 346,
    "article_title": "Alopecia Areata",
    "section_id": "75de564ee3994f889a56e61be9d5f44f",
    "section_title": "Counseling and treatment",
    "variant": "clinical",
    "imperatives": 2,
    "content": "Topical corticosteroids are started as first-line therapy for localized alopecia areata, with referral to dermatology for consideration of other treatments if the response is inadequate, since no therapy has strong evidence of outperforming placebo. Families are counselled that about half of children regrow hair completely within about 12 months, though relapse is common, and that regrowing hairs are often initially grey before regaining color. Expectations are set based on prognostic features present: localized, later-onset disease in an older child, adolescent, or young adult carries the best prognosis, while childhood onset, an ophiasis pattern, coexisting atopy, or widespread hair loss predicts a more guarded course, including possible progression to alopecia totalis or universalis."
  },
  {
    "article_id": 347,
    "article_title": "Acute Pancreatitis",
    "section_id": "cd5cba5add804681a10516e38351eda2",
    "section_title": "Follow-Up After the Acute Episode",
    "variant": "clinical",
    "imperatives": 2,
    "content": "Families are counselled that pediatric outcomes with conservative management are favorable, with mortality under 0.4%, but that recurrent acute pancreatitis occurs in up to 10% of children after a first episode. If a child has a second episode, or any features suggesting genetic risk (family history, PRSS1/SPINK1/CFTR-associated conditions), a structured etiologic work-up is pursued rather than assuming idiopathic disease, since children with PRSS1 mutations in particular can progress to chronic pancreatitis more quickly. Chronic pancreatitis is considered - with evaluation for exocrine insufficiency (fat malabsorption, [[354|chronic diarrhea]]) and endocrine insufficiency (diabetes symptoms) - in a child with recurrent pancreatic-type pain and imaging showing pancreatic calcification or a dilated duct; pancreatic biopsy is not the standard diagnostic step in children as it can be in adults."
  },
  {
    "article_id": 347,
    "article_title": "Acute Pancreatitis",
    "section_id": "e4e88eb877d84e4c93272cb46e38756a",
    "section_title": "Recognizing and Confirming Acute Pancreatitis",
    "variant": "clinical",
    "imperatives": 1,
    "content": "In a child with sudden-onset epigastric pain radiating to the back, worsened by food and accompanied by vomiting, amylase and lipase are checked and abdominal imaging is obtained (ultrasound first-line, CT or MRI as needed). The diagnosis is confirmed when at least 2 of 3 criteria are met: consistent pain, amylase/lipase at least 3 times the upper limit of normal, and imaging consistent with pancreatitis - enzyme elevation alone is not relied upon, since nonpancreatic causes of hyperamylasemia exist. A history targeted at the common pediatric causes is taken: recent blunt abdominal trauma, biliary disease/gallstones (particularly relevant with rising adolescent obesity), multisystem illness such as HUS or [[254|inflammatory bowel disease]], and medication exposure - specifically valproic acid, L-asparaginase, 6-mercaptopurine, and azathioprine - as well as alcohol use in adolescents. Most children are hemodynamically stable with nonspecific symptoms and can be managed conservatively, but the minority with necrotizing or hemorrhagic disease who present in shock or with jaundice and need immediate stabilization must be recognized."
  },
  {
    "article_id": 348,
    "article_title": "Asthma Exacerbation",
    "section_id": "02ae412eb17f4aa890ecbbecdd739ed6",
    "section_title": "Rapid assessment and initial treatment",
    "variant": "clinical",
    "imperatives": 1,
    "content": "On presentation with a possible exacerbation, the severity of obstruction and the risk of further deterioration are rapidly assessed, watching for wheezing, respiratory distress, tachypnea, and accessory muscle use, and asking about early warning signs the family may have already noticed (cough, chest tightness, retractions, audible wheeze). Frequent bronchodilator treatments and a course of systemic (oral or intravenous) corticosteroid are started, which resolves most exacerbations. Response is tracked with SpO2: a level below 92% after an hour of therapy is a good predictor that hospitalization will be needed. Exacerbations can follow two patterns — a days-long course from progressive inflammation and mucus plugging, versus an abrupt, asphyxial pattern from extreme airway hyperresponsiveness with a very high initial arterial CO2 — so a rapid or recent onset should not be falsely reassuring. Any ongoing irritant or allergen exposure contributing to the episode is identified and removed."
  },
  {
    "article_id": 349,
    "article_title": "Anemia",
    "section_id": "2ce74e93797b4afb85b69b85d1203fc4",
    "section_title": "In short",
    "variant": "short",
    "imperatives": 1,
    "content": "- Anemia is defined statistically as hemoglobin or hematocrit more than 2 standard deviations below the age- and sex-specific mean; by definition this classifies about 2.5% of a healthy population as anemic.\n- Definitions are age-dependent: one source gives Hb under 100 g/L in postneonatal infants and under 110 g/L from 1-12 years; another (WHO nutritional-anemia criteria) gives Hb under 11 g/dL for ages 6 months-6 years and under 12 g/dL for ages 6-14 years.\n- Black children have lower average hemoglobin values than white children, so racial reference ranges matter; children with [[166|cyanotic heart disease]] or chronic respiratory insufficiency normally run higher hemoglobin and can be \"functionally anemic\" even at a hemoglobin still within the broader normal range.\n- Anemia is classified by mean corpuscular volume (microcytic, normocytic, macrocytic) and by mechanism: decreased bone marrow production, increased red cell destruction (hemolysis), or blood loss (relatively uncommon as a cause in children) - some cases, like anemia of prematurity, involve a combination.\n- Globally, anemia affects an estimated 25% of the population; in some national survey data, anemia prevalence in children under 5 has approached 70%.\n- Yearly screening is performed in high-risk children: history of prematurity/low birth weight, lead exposure, exclusive breastfeeding without supplemental iron beyond 4 months, a diet lacking iron-fortified foods, feeding problems, or poor growth.\n- History is central to diagnosis: diet, growth, chronic disease/malabsorption/blood-loss symptoms, jaundice (including neonatal jaundice) or family history of anemia/jaundice/gallbladder disease/splenectomy (suggesting hemolysis), and ethnicity (relevant to hemoglobinopathies and G6PD deficiency) are asked about.\n- Clinical presentation depends on age, severity, cause, and rapidity of onset; gradual-onset anemia can be relatively asymptomatic due to compensatory plasma volume expansion and increased cardiac contractility, so many cases are found incidentally on screening or during evaluation for an unrelated acute illness.\n- Severe anemia requires rapid evaluation and treatment to prevent hypoxia, [[285|congestive heart failure]], end-organ damage, and death; stabilization should be guided primarily by clinical presentation rather than the lab value alone, since chronic blood loss can be relatively well tolerated at a low hemoglobin due to compensation and should not by itself be the sole indication for transfusion."
  },
  {
    "article_id": 349,
    "article_title": "Anemia",
    "section_id": "3c426cc341404e439f5b4996df7c131d",
    "section_title": "Working Up the Anemic Child",
    "variant": "clinical",
    "imperatives": 3,
    "content": "The finding is confirmed against age- and sex-specific reference ranges before proceeding, since a hemoglobin that looks low by adult standards may be entirely normal for the child's age. A focused history is taken covering diet (milk intake, iron-fortified foods), growth and feeding history, symptoms of chronic disease, malabsorption, or blood loss, personal or family history of jaundice (including neonatal jaundice), gallbladder disease, splenomegaly, or splenectomy, and the child's ethnic background (relevant to hemoglobinopathies and G6PD deficiency). The reticulocyte count and MCV are used to classify the anemia by mechanism (decreased production vs. increased destruction vs. blood loss) and by red cell size (microcytic, normocytic, macrocytic) before a broader panel of specific tests is ordered. Yearly screening is applied in high-risk children: prematurity or low birth weight, lead exposure, exclusive breastfeeding without supplemental iron past 4 months, a diet without iron-fortified foods, feeding difficulties, or poor growth."
  },
  {
    "article_id": 350,
    "article_title": "Bacteremia",
    "section_id": "7cf386ba301b402dab904df9bcb24a7b",
    "section_title": "Recognizing the child at risk for bacteremia",
    "variant": "clinical",
    "imperatives": 1,
    "content": "Occult or overt bacteremia is considered in a febrile child, particularly one under 2 years old with fever over 39°C and no clear source, with special attention paid to lethargy, irritability, altered mental status, tachycardia out of proportion to the fever, tachypnea or labored breathing, a bulging or depressed fontanel, nuchal rigidity, petechiae, or abdominal/flank tenderness — any of which raises concern for serious bacterial illness. Bacteremia in infants is often not accompanied by fever, and in newborns can instead present with apnea, bradycardia, respiratory dysfunction, temperature instability (fever or hypothermia), or abdominal distention. Vulnerable hosts are identified specifically — asplenic children, those with central venous catheters, neutropenic children, and those with short gut — since they carry substantially higher bacteremia risk and may have a confounding baseline tachycardia that complicates triage."
  },
  {
    "article_id": 350,
    "article_title": "Bacteremia",
    "section_id": "7a7365e8693d4f8784aaacafdbf3cf4a",
    "section_title": "Workup and empiric management",
    "variant": "clinical",
    "imperatives": 1,
    "content": "Blood cultures are obtained and vital signs are assessed carefully against age-appropriate normal ranges, since abnormal ranges vary substantially across childhood and subtle deviations can be missed without this context. Empiric antibiotic choice is based on the most likely regional organisms for the child's age (S. pneumoniae, Staphylococcus, and H. influenzae predominate under age 2) and known local antibiotic resistance patterns, with quick adjustment if a specific risk factor points elsewhere — for example, a central venous catheter raising suspicion for coagulase-negative staphylococci, or travel/endemic exposure raising suspicion for typhoidal or nontyphoidal Salmonella or Brucella. Most children with pneumococcal bacteremia recover spontaneously, but the roughly 3-5% who develop meningitis or the additional 5% who develop another focal infection, most often pneumonia, are monitored for closely."
  },
  {
    "article_id": 351,
    "article_title": "Asymptomatic Proteinuria",
    "section_id": "474ae13ecc03421b8ab102d0e28aec73",
    "section_title": "Red Flags Requiring Prompt Referral",
    "variant": "clinical",
    "imperatives": 3,
    "content": "Conservative management is not appropriate when proteinuria is accompanied by edema, hypertension, hematuria, systemic complaints (rash, fever, arthralgia), or a significant family history of [[369|glomerulonephritis]] or renal failure - referral to nephrology is made and renal function is assessed (BUN, creatinine, electrolytes). Total protein, albumin, cholesterol, and triglycerides are checked if [[310|nephrotic syndrome]] (proteinuria plus hypoalbuminemia, edema, and hyperlipidemia) is suspected. Complement (C3, C4) and streptococcal serology (Streptozyme, ASO, antihyaluronidase, anti-DNase B) are checked when post-streptococcal glomerulonephritis is possible (typically 4 days to 3 weeks after streptococcal pharyngitis or impetigo, with low C3/C4), and ANA testing (with low C3 and C4) is considered when SLE is a concern, particularly if hypertension or hematuria coexist. For a child followed with persistent asymptomatic isolated proteinuria who is otherwise stable, annual monitoring is arranged, with escalation to renal biopsy discussion if proteinuria exceeds 1 g/day or persists beyond 12 months."
  },
  {
    "article_id": 352,
    "article_title": "Cervicitis",
    "section_id": "748fe0684fa54d749272315e4e871a6c",
    "section_title": "Bedside recognition and workup",
    "variant": "clinical",
    "imperatives": 2,
    "content": "Cervicitis is considered in any sexually active adolescent with purulent vaginal discharge, intermenstrual or postcoital bleeding, or dyspareunia — but cervicitis is frequently asymptomatic and can be found incidentally on exam. The two defining signs are sought: a purulent or mucopurulent endocervical exudate, and endocervical friability with sustained bleeding after gentle swab passage through the cervical os. In a younger adolescent, care is taken to distinguish these findings from normal cervical ectopy so inflammation is not overdiagnosed. The absence of fever or significant pain is typical of isolated cervicitis; if either is present, PID or HSV infection is evaluated for instead. Noninfectious causes are kept in mind too — a retained tampon, IUD, or irritation from contraceptive cream or douching can all produce a similar picture."
  },
  {
    "article_id": 352,
    "article_title": "Cervicitis",
    "section_id": "c58715d1fcc747a3863d29d2c900f439",
    "section_title": "Empiric treatment and counseling",
    "variant": "clinical",
    "imperatives": 1,
    "content": "In a sexually active patient with findings consistent with cervicitis, empiric treatment for [[185|gonorrhea]] and chlamydia is started while confirmatory testing is pending, since these are the most frequently identified pathogens. Screening for other sexually transmitted infections is done at the same visit, evaluation for [[106|pelvic inflammatory disease]] is undertaken if there is fever, significant pain, or other concerning features, and counseling on safe sexual practices is provided given the risks of ascending infection (PID, infertility, chronic pelvic pain, ectopic pregnancy), transmission to partners, and increased HIV acquisition risk with exposure. If a foreign body or irritant (tampon, IUD, contraceptive cream, douche) is identified as the likely cause, it is removed or discontinued as part of management."
  },
  {
    "article_id": 353,
    "article_title": "Cellulitis",
    "section_id": "593d2f4569f54758b2e6b4be25965635",
    "section_title": "Evaluating a Child with Suspected Cellulitis",
    "variant": "clinical",
    "imperatives": 3,
    "content": "Exposure history that narrows the likely pathogen is assessed: recent animal bite (Pasteurella, Capnocytophaga), penetrating trauma (S. aureus), fresh or saltwater exposure (Aeromonas or Vibrio, respectively), fish/swine/poultry contact (Streptococcus iniae or Erysipelothrix), neutropenia (Pseudomonas and other gram-negatives are considered), or acute varicella (S. pyogenes superinfection). In an infant under 3 months with cellulitis, full evaluation for invasive infection - blood culture and, usually, lumbar puncture - is undertaken given the risk of group B streptococcal [[350|bacteremia]] and meningitis at this age. In toddlers with facial or buccal cellulitis, especially if unvaccinated, H. influenzae type b and S. pneumoniae are considered; a blue-red, dusky appearance to the skin is characteristic of H. influenzae buccal cellulitis. Fever is not expected to be present - only 10-20% of children with cellulitis are febrile - and blood cultures are usually unrevealing in a well-appearing, immunocompetent child. Bedside ultrasound is used when an abscess is suspected clinically, since distinguishing a drainable collection from simple cellulitis changes management."
  },
  {
    "article_id": 353,
    "article_title": "Cellulitis",
    "section_id": "643e12d6dd234e0dbf725477b9547145",
    "section_title": "In short",
    "variant": "short",
    "imperatives": 1,
    "content": "- Cellulitis is an acute infection of the dermis/subcutaneous tissue causing erythema, edema, warmth, and pain, with poorly defined borders (unlike erysipelas, a more superficial infection with well-demarcated, raised, beefy-red borders, usually from group A strep).\n- The most common causes overall are Staphylococcus aureus (including MRSA) and Streptococcus pyogenes (GAS); the lower extremities and feet are the most frequently affected sites.\n- Only 10-20% of children with cellulitis develop fever; regional adenopathy is common, but blood cultures are rarely positive in well-appearing, immunocompetent hosts.\n- Exposure-specific pathogens: cat/dog bites - Pasteurella species, Capnocytophaga canimorsus; penetrating trauma - S. aureus; freshwater immersion - Aeromonas hydrophila; saltwater immersion - Vibrio species; fish exposure - Streptococcus iniae; swine/poultry/fish - Erysipelothrix rhusiopathiae; periorbital/facial - H. influenzae, S. pneumoniae; neutropenia - Pseudomonas aeruginosa; acute varicella - S. pyogenes.\n- Infants under 3 months are at risk from group B strep, which can cause [[350|bacteremia]] and [[147|meningitis]]; cellulitis in a neonate should prompt full evaluation for invasive infection including blood culture (and usually lumbar puncture).\n- Buccal cellulitis from H. influenzae classically shows a blue-red, dusky skin discoloration.\n- Outpatient oral treatment for mild-to-moderate cellulitis in infants/children over 2 months (without fever, lymphadenopathy, or other constitutional signs): dicloxacillin or a first-generation cephalosporin (cephalexin); clindamycin is used if MRSA is suspected. Trimethoprim-sulfamethoxazole is an option but does not reliably cover S. pyogenes.\n- Initial parenteral therapy is considered for: immunocompromised patients, toxic appearance, rapidly progressive lesions, facial or circumferential involvement, or crepitance/violaceous skin.\n- Needle aspirate from the center of a cellulitic lesion yields a pathogen in only 5-40% of cases (punch biopsy has a higher yield); bedside ultrasound can help distinguish abscess from simple cellulitis."
  },
  {
    "article_id": 354,
    "article_title": "Chronic Diarrhea",
    "section_id": "10f0b031b49f4351870b24c9635ef5b6",
    "section_title": "Initial bedside approach",
    "variant": "clinical",
    "imperatives": 2,
    "content": "The pattern is established first: loose or watery stools more than 3 times a day, lasting more than 2 weeks, deviating from the child's prior stool pattern. Whether this looks like small-bowel disease (large-volume stool, no blood/mucus) or large-bowel disease (small-volume stool with blood/mucus) is determined, and growth parameters are checked to see whether failure to thrive accompanies the diarrhea, since this substantially changes the differential. Specific questioning covers nighttime awakening to pass stool — a sign favoring an organic over a functional cause — and diet (excessive juice or carbohydrate intake, low fat intake), medication use (laxatives, antacids), and stressors, since these point toward the common, benign functional entities: toddler's diarrhea in a 6-month-to-5-year-old with normal growth, or [[374|irritable bowel syndrome]] in an older child or adolescent, especially a girl, with symptoms worse after eating or under stress. In a child under 3, systemic causes are not overlooked — a urinary tract infection is checked for first, since it is the most important systemic cause in this age group, along with [[310|nephrotic syndrome]], sepsis, or an inciting medication."
  },
  {
    "article_id": 356,
    "article_title": "Cryptorchidism",
    "section_id": "e68c38ef0442491d9e222c941789019d",
    "section_title": "Newborn evaluation",
    "variant": "clinical",
    "imperatives": 2,
    "content": "On identifying an [[322|undescended testis]] in a newborn, whether it is unilateral or bilateral and whether the testis is palpable is determined first. Bilateral nonpalpable undescended testes in an apparently normal male newborn should never be assumed benign until the possibility of a fully virilized female with salt-losing [[136|congenital adrenal hyperplasia]] has been excluded, given the potentially fatal consequences of missing this diagnosis. Any cryptorchidism, unilateral or bilateral, occurring with hypospadias — especially severe hypospadias — should prompt evaluation for a disorder of sexual development, including karyotype. In infants aged 2-6 months, LH, FSH, inhibin B, and testosterone can help establish whether functional testicular tissue is present; beyond that age, an HCG stimulation test serves the same purpose. Imaging (ultrasound, CT, MRI) is reserved for localizing a testis suspected to be in the inguinal region — these modalities are unreliable for finding an intra-abdominal testis, and ultrasound has no role in simply searching for a nonpalpable testis. Renal ultrasound is ordered only if true congenital monorchism is suspected, since this specific entity (not cryptorchidism generally) is linked to ipsilateral renal agenesis."
  },
  {
    "article_id": 356,
    "article_title": "Cryptorchidism",
    "section_id": "55fbac33b85b4db28ae1f5e8f18c7de8",
    "section_title": "Timing referral and surgery",
    "variant": "clinical",
    "imperatives": 2,
    "content": "Because spontaneous descent is very unlikely beyond 6 months of corrected age (though about a third to half of cryptorchid testes will have descended spontaneously by around 3 months), referral to a surgical specialist is made if descent has not occurred by 6 months of corrected age. Orchiopexy between 6 and 18 months of age is the goal to best preserve fertility potential; if the child presents later, orchiopexy is still pursued before puberty, since this timing reduces the future risk of testicular malignancy even though it may not fully normalize fertility. An inguinal or scrotal approach is chosen for a palpable testis, and additional surgical evaluation is planned for a nonpalpable one. Hormonal therapy to induce descent is not offered, since it lacks proven long-term effectiveness. Families are counselled on the long-term stakes of delayed or missed treatment: roughly 33% reduced fertility with unilateral and 66% with bilateral disease, and a 5- to 10-fold increase in adult testicular cancer risk, with testicular histologic changes possible from as early as 6 months of age."
  },
  {
    "article_id": 357,
    "article_title": "Chronic Sinusitis",
    "section_id": "5eafa38faa5a4c3db73cc58381e0d973",
    "section_title": "Distinguishing Chronic Sinusitis from Recurrent Viral Illness",
    "variant": "clinical",
    "imperatives": 2,
    "content": "In a child with persistent cough (often worse lying supine) and rhinorrhea, whether symptoms have ever fully resolved within the typical 10-14 day course of a viral URI is determined first - if symptoms have persisted beyond 90 days (or 12 weeks) without a clear symptom-free interval, chronic sinusitis or chronic rhinosinusitis is favored over a string of separate viral illnesses. Chronic sinusitis is expected to look milder than acute bacterial sinusitis: fever is uncommon and the exam is often normal, so a lack of classic sinus tenderness or fever does not exclude the diagnosis. Predisposing conditions are screened for - cystic fibrosis (especially with nasal polyps), primary ciliary dyskinesia, immunoglobulin deficiency, [[98|allergic rhinitis]], and GERD - since these change management and prognosis. Sinus imaging (plain films or CT) is not relied upon to make the diagnosis in uncomplicated cases, since opacification, mucosal thickening, and air-fluid levels are also seen with the common cold."
  },
  {
    "article_id": 357,
    "article_title": "Chronic Sinusitis",
    "section_id": "247bbcaec5d44627b9b882db61fdb0fe",
    "section_title": "Treating Chronic or Recurrent Sinusitis",
    "variant": "clinical",
    "imperatives": 2,
    "content": "Supportive care is started - saline nasal irrigation, hydration, and acetaminophen or ibuprofen for discomfort - and over-the-counter cold medications or decongestants are avoided in children under 12. Because chronic sinusitis (especially lasting beyond a year) has a different microbiology than typical acute disease, including S. aureus and anaerobes alongside nontypeable H. influenzae and viridans streptococci, empiric antimicrobial therapy is initiated for recurrent acute or chronic sinusitis, with reassessment if there is no improvement. Referral to otolaryngology for endoscopic examination (with or without cultures) is made when a child fails to improve on empiric therapy; in most refractory cases, adenoidectomy is considered as a next step before CT scanning of the sinuses or sinus surgery are pursued. Any signs suggesting orbital or intracranial extension - periorbital swelling, visual change, severe headache, or altered mental status - are watched for and urgently evaluated, since sinusitis complications (orbital [[353|cellulitis]], brain abscess, epidural/subdural empyema, cavernous sinus thrombosis) occur more often in children than in adults and require prompt escalation of care."
  },
  {
    "article_id": 358,
    "article_title": "Drug Overdose",
    "section_id": "abd1005997204309ba4e5790d0511822",
    "section_title": "Managing suspected opioid overdose and dosing safety",
    "variant": "clinical",
    "imperatives": 2,
    "content": "Intravenous naloxone 0.1 mg/kg (maximum 2 mg) is given for suspected opiate toxicity — pupillary dilation after administration supports the diagnosis, which can be confirmed with urine or serum testing for opiates. Any opioid-naive child who has ingested more than 5 mg of methadone, or any dose of an extended-release opioid, is treated with close observation, since methadone's long duration of action makes even small doses dangerous. When dosing any medication for a child, adult \"maximal safe dose\" references can overdose a smaller pediatric patient — age- or weight-based pediatric dosing (Young's, Fried's, or Clark's rule) is used rather than extrapolating adult doses directly, and liquid medication conversions from ingredient amount to volume are double-checked. If a child has been on round-the-clock opioid dosing for several days, the possibility of dependence and withdrawal on cessation is anticipated, even though specific pediatric withdrawal-management guidance is limited."
  },
  {
    "article_id": 359,
    "article_title": "Facial Nerve Palsy",
    "section_id": "312f28eefdd84227a472a40851e69caf",
    "section_title": "When to test for Lyme and how to manage",
    "variant": "clinical",
    "imperatives": 2,
    "content": "In a Lyme-endemic area, Lyme serology is obtained for any child with isolated facial nerve palsy, even without other systemic symptoms, since facial palsy can be the only presenting sign; bilateral facial weakness favors Lyme over Bell palsy, and fever, malaise, headache, myalgia, or arthralgia preceding the palsy also favor Lyme. If serology is initially negative but suspicion is high, titers are repeated later, since sensitivity increases with time from infection. Lumbar puncture is reserved for evidence of meningoencephalitis (severe headache, nuchal rigidity) — its routine use for isolated facial palsy with Lyme risk alone is controversial. Confirmed Lyme-associated facial palsy is treated with oral antibiotics for 14-21 days. For Bell palsy without an identified cause, symptomatic care and corneal protection (lubricating drops, eye patch) are provided rather than steroids or acyclovir, which have not been shown to improve pediatric outcomes; families are counselled that up to 90% of children recover fully, but referral for further workup is made if recurrence occurs or if there is no improvement after 2-3 months."
  },
  {
    "article_id": 360,
    "article_title": "Dilated Cardiomyopathy",
    "section_id": "2782a8115bf0455a8aa90610fa0814f1",
    "section_title": "Managing Heart Failure in DCM",
    "variant": "clinical",
    "imperatives": 2,
    "content": "For acute decompensated heart failure, diuretics, inotropic support (milrinone, or dopamine/dobutamine per center practice), and afterload reduction/vasodilators are used, and [[121|pediatric cardiology]] is involved early given the potential need for mechanical circulatory support. Once a child is stabilized into compensated heart failure, transition is made to an ACE inhibitor (or ARB) and a beta-blocker such as carvedilol, with diuretics as needed. Endomyocardial biopsy is reserved for cases where a specific infectious or inflammatory cause needs confirmation, since it is rarely required and most commonly shows nonspecific mononuclear infiltrates when performed. Families are counselled that myocarditis-associated presentations often improve spontaneously and that over a third of children show significant improvement in cardiac function over time, while also being prepared for the possibility that transplantation, with or without a bridging mechanical circulatory support device, remains a possible outcome for children who do not recover adequate function."
  },
  {
    "article_id": 361,
    "article_title": "Foreign Body Ingestion",
    "section_id": "ab75ebf6065545bba7c8382788d1df43",
    "section_title": "Bedside assessment of a suspected ingestion",
    "variant": "clinical",
    "imperatives": 2,
    "content": "In any child with a suspected or witnessed foreign body ingestion, a thorough history is taken and a careful examination performed, evaluating for respiratory distress, oropharyngeal injury, and signs of perforation such as subcutaneous emphysema or peritoneal signs — noting that up to 50% of children are asymptomatic despite true ingestion. Specific questioning covers dysphagia, refusal to eat, drooling, gagging, vomiting, or a foreign-body sensation, which suggest esophageal impaction; the mouth, oropharynx, neck, chest, and abdomen are examined in any child with swallowing difficulty. The urgency and approach to removal are based on the object's nature, location, and size, the timing of ingestion, presence of symptoms, and NPO status — coins and most small objects can often be observed for spontaneous passage, but batteries and multiple magnets require urgent attention given their higher risk of serious complications even though they are ingested less often than coins. A foreign body lodged in the esophagus is treated as an emergency because of perforation and sepsis risk."
  },
  {
    "article_id": 361,
    "article_title": "Foreign Body Ingestion",
    "section_id": "d4eb25363f3c4f5eabf6b2ec03d00ee1",
    "section_title": "Distinguishing ingestion from aspiration, and managing each",
    "variant": "clinical",
    "imperatives": 1,
    "content": "If a child presents with sudden-onset choking, stridor, or wheezing, foreign body aspiration is presumed until proven otherwise, even though the classic witnessed-choking history is not always present — an unwitnessed aspiration can mimic croup, [[3|bronchiolitis]], or asthma with nonspecific cough, stridor, or wheezing, so suspicion for airway foreign body is maintained with any sudden-onset respiratory symptom. In infants, liquids are the most common cause of choking; in toddlers and older children, small objects and foods such as grapes, nuts, hot dogs, and candy are typical. For acute, severe airway obstruction in a conscious child, abdominal thrusts are used. For a suspected esophageal foreign body, prompt evaluation and, if needed, endoscopic removal (about 10-20% of cases) are arranged — surgery is rarely needed (under 1%). A nasal foreign body is considered in any child with persistent unilateral, foul-smelling rhinorrhea, and is removed in the office with appropriate equipment when feasible, with general anesthesia reserved for difficult cases. In a child with recurrent food impaction and dysphagia, eosinophilic esophagitis is evaluated for, which is found in the large majority of such presentations."
  }
]