[
  {
    "article_id": 3,
    "article_title": "Bronchiolitis",
    "section_id": "7b628719fb3b73c83cc15cc85b609866",
    "section_title": "Evaluation",
    "variant": "long",
    "imperatives": 1,
    "content": "The diagnosis is clinical. Routine chest radiographs and viral testing are not needed for typical cases. Work of breathing, hydration and feeding, and oxygen saturation are assessed."
  },
  {
    "article_id": 7,
    "article_title": "Iron deficiency anemia",
    "section_id": "2901c7c7d343ca4046f31c90a9ab35f8",
    "section_title": "Management",
    "variant": "long",
    "imperatives": 1,
    "content": "Oral iron is given with dietary counselling; the response is rechecked after several weeks. A source of blood loss is sought when the history does not fit."
  },
  {
    "article_id": 9,
    "article_title": "Asthma in children",
    "section_id": "63c86ba94fab1ce63c424c49c7ceb1bd",
    "section_title": "Acute exacerbation",
    "variant": "long",
    "imperatives": 1,
    "content": "Inhaled short-acting beta agonists, systemic corticosteroids and oxygen are given as needed. The response is reassessed, and care is escalated for poor responders."
  },
  {
    "article_id": 10,
    "article_title": "Developmental milestones",
    "section_id": "20d61ca5b22813039798ff34f31a6f0a",
    "section_title": "Next steps",
    "variant": "long",
    "imperatives": 1,
    "content": "Diagnosis is confirmed with a standardised tool, hearing and vision are checked, and referral to early intervention services is made while the evaluation proceeds."
  },
  {
    "article_id": 84,
    "article_title": "Normal Child Development",
    "section_id": "4eb9f87531bc40a295e052615de3cd61",
    "section_title": "Key points",
    "variant": "short",
    "imperatives": 1,
    "content": "- WHO growth standards are used for children birth to 2 years; CDC charts for ages 2–19 years; condition-specific charts for genetic syndromes\n- Normal growth is fastest in the fetal period; slows gradually through infancy and childhood; accelerates during puberty\n- First year: infants gain ~25 cm length and triple birth weight; achieve two-thirds adult brain size by age 2½–3 years\n- After age 2 years, growth velocity is 4–6 cm/year; shifting percentile channels after age 2 is abnormal\n- Development progresses cephalocaudal (head to toe) and centrifugal (proximal to distal)\n- Walking typically achieved by 12 months (range 9–17 months); independent sitting by 6 months; crawling by 8 months\n- By age 2–3 years, children progress from total dependence to mobile, verbal, independent individuals\n- Normal values defined as within 2 standard deviations of population mean (~95% of children)\n- [[115|Congenital anomalies]] classified as production problems (permanent) or packaging problems (usually resolve)"
  },
  {
    "article_id": 85,
    "article_title": "Pediatric Surgery",
    "section_id": "f1716492d9c64912a2111fb71871a875",
    "section_title": "Management of Blunt Pancreatic Trauma",
    "variant": "clinical",
    "imperatives": 3,
    "content": "**Assessment:**\n\n- Emergency ultrasound is performed for rapid evaluation in acute trauma\n- Advanced imaging (computed tomography) is obtained for injury classification and severity assessment\n\n**Management approach:**\n\n- Nonoperative management is favored in children with blunt pancreatic trauma when feasible\n- Close observation and imaging surveillance are implemented during the nonoperative period\n- Operative intervention is reserved for complications or failure of conservative management\n\n**Rationale:** Nonoperative management preserves pancreatic tissue and function while avoiding unnecessary surgery in the pediatric population."
  },
  {
    "article_id": 85,
    "article_title": "Pediatric Surgery",
    "section_id": "186b0296d76d471faa27d0f9409a3194",
    "section_title": "Management of Neonatal Surgical Emergencies",
    "variant": "clinical",
    "imperatives": 3,
    "content": "**Immediate actions upon presentation:**\n\n1. **Exposed viscera are protected** — Nonadherent dressings are applied and changed as needed to prevent contamination and drying\n2. **The bowel is decompressed** — A nasogastric tube is placed for decompression\n3. **Careful positioning** — Positioning is maintained to minimize volvulus and bowel ischemia risk\n4. **Monitoring is established** — Close clinical observation is implemented for signs of deterioration\n5. **Pediatric surgery is consulted immediately** — Specialist input is not delayed\n\n**Preoperative optimization:**\n\n- Metabolic abnormalities, particularly [[321|hypoglycemia]], are corrected\n- Access is established for parenteral nutrition, which is prepared\n- Chest radiography and echocardiography are obtained to assess for cardiopulmonary abnormalities\n- Physiological readiness for general anesthesia is assessed — the neonate may not be cleared for surgery if significant cardiopulmonary abnormalities are present\n\n**Key principle:** Operative intervention is delayed if necessary to optimize the neonate's medical condition and ensure physiological stability before surgical reduction and repair are attempted."
  },
  {
    "article_id": 86,
    "article_title": "Infant Of Diabetic Mother",
    "section_id": "eafc800c32b64043b41e7b1032c31362",
    "section_title": "Management at the Bedside",
    "variant": "clinical",
    "imperatives": 9,
    "content": "**Immediate actions at delivery:**\n- The infant is evaluated immediately for birth trauma and major malformations\n- Blood glucose and hematocrit are obtained in the nursery\n- A focused physical examination of heart, kidneys, lungs, and extremities is performed\n- Jitteriness, tremors, convulsions, apnea, weak cry, and poor sucking are watched for\n- Any signs of [[151|respiratory distress]] in the delivery room are addressed immediately\n\n**First 24 hours:**\n- Blood glucose is monitored closely throughout the first 24 hours\n- Early feeding is initiated to help prevent [[321|hypoglycemia]]\n- Hypoglycemia is screened for and [[151|respiratory distress]] is assessed\n- Signs of cardiac disease (cardiomegaly on chest X-ray, murmur, signs of heart failure) are watched for\n- Abdominal distension and meconium passage (small left colon syndrome) are checked for\n\n**First 48 hours:**\n- Observation for jaundice continues\n- Renal, cardiac, neurologic, and gastrointestinal abnormalities are assessed for\n- Jitteriness after 24 hours is monitored for (may indicate [[368|hypocalcemia]] or hypomagnesemia rather than [[321|hypoglycemia]])\n- Signs of [[151|respiratory distress]] from immature lungs are watched for\n\n**Note:** Hypoglycemia typically resolves within 1–2 days as pancreatic insulin secretion decreases. The passages provided do not specify glucose targets, monitoring intervals, or treatment protocols for hypoglycemia."
  },
  {
    "article_id": 87,
    "article_title": "Pediatric Orthopedics",
    "section_id": "f3e8b7c89a37401ab48e27cc4d9bd7fa",
    "section_title": "Clinical Assessment and Management",
    "variant": "clinical",
    "imperatives": 1,
    "content": "**Initial Evaluation**\n\nWhen a child presents with an orthopedic problem:\n\n1. **History**: Age of onset, whether congenital or acquired, and whether the condition is progressive or stable are determined\n2. **Physical examination**: Any deformities are measured and documented using standardized reference values for normal rotational and angular measurements\n3. **Functional assessment**: Pain, functional limitations, or gait abnormalities are evaluated for\n\n**Decision-Making**\n\n- **Reassurance and observation**: Many lower extremity rotational and angular variations resolve spontaneously during childhood growth and require only parental education and periodic follow-up\n- **Specialist referral**: Referral to a pediatric orthopedic surgeon is made when:\n  - Detailed evaluation beyond primary care scope is needed\n  - Deformity is progressive despite observation\n  - Significant functional impairment is present\n  - Surgical intervention may be indicated\n  - Diagnostic uncertainty exists\n\n**Follow-up**\n\nFor conditions managed conservatively, periodic reassessment is arranged to monitor for progression and ensure appropriate development. Baseline measurements are documented to allow comparison at subsequent visits."
  },
  {
    "article_id": 88,
    "article_title": "Adolescent Depression",
    "section_id": "a9fdbf56972c4d719a21d2127f13d1dc",
    "section_title": "Assessment and Initial Management",
    "variant": "clinical",
    "imperatives": 4,
    "content": "**Screening and Identification**\n\nScreening for adolescent depression is performed routinely in primary care settings. Assessment explores the cardinal features: sadness, irritability, and loss of interest or pleasure in activities. Associated symptoms including changes in school performance, social withdrawal, sleep and appetite disturbance, and nonspecific physical complaints are evaluated for. Functional impairment across home, school, and peer relationships is assessed.\n\n**Risk Assessment**\n\nAll depressed adolescents require evaluation for suicide risk. Specific risk factors are identified: history of bullying (victim or perpetrator), substance use, coexisting psychiatric conditions, chaotic home environment, and recent humiliation or perceived failure. Any psychotic symptoms such as hallucinations or paranoid ideation are documented.\n\n**Treatment Considerations**\n\nManagement typically involves antidepressant medication, psychotherapy (including cognitive behaviour therapy, interpersonal therapy, or family therapy), or combination treatment. Approximately 50% of depressed youth in primary care decline pharmacotherapy, and adherence challenges are common. The evidence regarding antidepressant efficacy and safety is discussed with adolescents and families. Adequate treatment duration and dosing are ensured to achieve expected benefit, as many adolescents discontinue treatment prematurely.\n\n**Referral**\n\nReferral to [[94|mental health]] specialists is considered for severe depression, psychotic features, significant suicide risk, or when initial management in primary care is unsuccessful."
  },
  {
    "article_id": 91,
    "article_title": "Pediatric Metabolic Disorders",
    "section_id": "6dd0b0e0995f4e52a7a75ae14e6fe11a",
    "section_title": "Management of Neonatal Metabolic Disturbances",
    "variant": "clinical",
    "imperatives": 7,
    "content": "**Hypoglycemia**\n- Blood glucose is assessed urgently in at-risk infants (intrauterine growth restriction, infants of diabetic mothers)\n- Early treatment initiation is critical to prevent [[315|seizures]]\n- Duration of [[321|hypoglycemia]] and time to treatment are key determinants of neurological outcome\n\n**[[368|Hypocalcemia]]**\n- Infants are screened for [[368|hypocalcemia]] when low birthweight, born to diabetic mothers, asphyxiated, affected by DiGeorge syndrome, or born to mothers with hyperparathyroidism\n- Serum magnesium is assessed concurrently, as hypomagnesemia frequently accompanies hypocalcemia\n- Magnesium deficiency is corrected to facilitate calcium correction\n\n**[[170|Hyponatremia]]**\n- Fluid management practices are reviewed\n- Syndrome of inappropriate antidiuretic hormone secretion is evaluated for\n- Fluid intake and osmolarity are adjusted as indicated\n\n**Hypernatremia**\n- Feeding adequacy in breastfed infants is assessed\n- Correct formula dilution in formula-fed infants is verified\n- Underlying [[99|dehydration]] is addressed\n\n**Pyridoxine Dependency**\n- [[315|Seizures]] resistant to standard anticonvulsants are recognized as a clinical clue\n- Pyridoxine dependency is considered in infants with intrauterine convulsions\n- Specific treatment with pyridoxine may be indicated based on clinical suspicion and diagnostic confirmation"
  },
  {
    "article_id": 92,
    "article_title": "Hypertension",
    "section_id": "2a2fc8ba92f44e69955f601124700e02",
    "section_title": "Management",
    "variant": "clinical",
    "imperatives": 3,
    "content": "**Incidental Hypertension**\n\nManagement includes:\n- Pain control\n- Measures to calm the patient\n- Serial blood pressure monitoring\n\n**Diagnostic Approach**\n\n1. Blood pressure is measured by auscultation (not oscillatory devices) using an appropriately sized cuff for the patient's arm circumference\n2. Elevation is confirmed at three separate visits before hypertension is diagnosed\n3. In athletes with persistently elevated BP:\n   - Family history of hypertension is asked about\n   - Use of stimulants (caffeine, nicotine, ephedrine) or anabolic steroids is asked about\n   - In those <25 years with upper extremity hypertension, lower extremity BP is checked to exclude coarctation of the aorta\n4. 24-hour ambulatory blood pressure monitoring is considered to exclude white coat hypertension\n\n**Treatment**\n\nTarget blood pressure: less than the 90th percentile for sex, age, and height, or less than 130/80 mm Hg, whichever is lower.\n\nFirst-line approach: nutritional changes proven to treat hypertension. Pharmacological treatment is considered for those not responding to lifestyle modification."
  },
  {
    "article_id": 95,
    "article_title": "Pediatric Infectious Disease",
    "section_id": "31e32fc0272844d0a38be2e795c4a761",
    "section_title": "Clinical Assessment and Management",
    "variant": "clinical",
    "imperatives": 8,
    "content": "**Initial Evaluation**\n\n- A detailed history including exposure history, incubation period considerations, and symptom timeline is obtained\n- A thorough physical examination documenting clinical manifestations is performed\n- Risk factors including immunocompromised status, underlying chronic conditions, or group care attendance are identified\n\n**Diagnostic Approach**\n\n- Pathogen-specific diagnostic tests are ordered based on clinical presentation and suspected organism\n- Incubation period is considered in timing of diagnostic testing\n- Findings are documented to guide organism identification\n\n**Treatment Considerations**\n\n- Antimicrobial therapy is selected based on identified or suspected organism\n- Age-appropriate dosing is used and route of administration is specified\n- Supportive care is provided, tailored to the infection type and severity\n- Complications and treatment response are monitored for\n\n**Special Populations**\n\n- Children with congenital heart disease or other chronic conditions may require modified prevention and treatment approaches\n- Immunocompromised hosts warrant specialized management strategies\n- Consultation with pediatric infectious disease specialists is considered for complex cases"
  },
  {
    "article_id": 97,
    "article_title": "Neonatal Hypoglycemia",
    "section_id": "6998c375c537476881ee43210f694ad5",
    "section_title": "Bedside Management",
    "variant": "clinical",
    "imperatives": 4,
    "content": "**Initial Assessment**\n\n1. [[321|hypoglycemia]] is confirmed: capillary glucose screening below 40 mg/dL is verified by laboratory serum or plasma glucose measurement\n2. In any sick infant, critical blood and urine samples are collected before treatment is started, to guide diagnosis\n3. Symptoms are assessed for: altered consciousness, poor feeding, apnea, cyanosis, hypothermia, hypotonia, tremor, or [[315|seizures]]\n\n**Treatment Approach**\n\n**For asymptomatic or mildly symptomatic infants:**\n- Early enteral feeding is initiated with human milk or standard infant formula (30–60 mL per feed)\n- Expected glucose rise: 20–30 mg/dL within the first hour\n- Frequent feeding is continued to maintain glucose homeostasis\n\n**For symptomatic hypoglycemia or failure of enteral feeding:**\n- Rapid intravenous correction is provided\n- 10% dextrose (D10W) is used intravenously\n- Treatment continues until normal glucose homeostasis is established and adequate substrate supply is secured\n\n**Monitoring and Targets**\n\n- First 48 hours: blood glucose is maintained >50 mg/dL\n- After 48 hours: blood glucose is maintained >60 mg/dL if intravenous glucose is required\n- Once blood glucose is stabilized, normal feedings resume\n- Infants unable to maintain preprandial glucose >50 mg/dL by 48 hours or >60 mg/dL after 48 hours require investigation for persistent [[321|hypoglycemia]] before discharge\n\n**Special Considerations**\n\n- Breastfed newborns have lower blood glucose and higher ketone concentrations compared to formula-fed infants\n- Suspected congenital hyperinsulinism requires genetic analysis and may require diazoxide or other medications for long-term control"
  },
  {
    "article_id": 98,
    "article_title": "Allergic Rhinitis",
    "section_id": "59dead8b70cb48d7914afa6a4aaf46e6",
    "section_title": "Management",
    "variant": "clinical",
    "imperatives": 2,
    "content": "**Assessment**\n\nA detailed history of symptom onset, frequency, duration, and seasonal pattern is obtained. Potential allergen exposures (indoor and outdoor) are identified. Impact on sleep, school performance, and quality of life is assessed to determine severity classification. Physical examination of the nasal mucosa is performed, noting turbinate swelling and colour (red or pale pink-purple).\n\n**Pharmacological Treatment**\n\nFirst-line agents:\n- **Intranasal corticosteroids** — primary treatment option\n- **Antihistamines** — available in oral and intranasal formulations\n- **Leukotriene antagonists** — alternative or adjunctive therapy\n- **Decongestants** — for symptomatic relief\n- **Ipratropium nasal spray** — adjunctive therapy\n\n**Non-pharmacological Measures**\n\n- Nasal saline rinses wash away allergens\n- Allergen avoidance and environmental control (removing or reducing exposure to identified triggers)\n- For seasonal allergens, outdoor exposure is minimised during high pollen periods\n- For perennial indoor allergens, dust mite control measures are implemented and animal dander sources are removed where possible\n\n**Monitoring**\n\nResponse to treatment is assessed and therapy is adjusted based on symptom control and impact on quality of life. Treatment of nasal inflammation reduces associated asthma symptoms and emergency department visits in children with concurrent asthma."
  },
  {
    "article_id": 99,
    "article_title": "Dehydration",
    "section_id": "fae0d19dd26e4fc497ff037f0a9971bc",
    "section_title": "Management",
    "variant": "clinical",
    "imperatives": 3,
    "content": "**Assessment and monitoring:**\n- A detailed history is obtained: duration of illness, frequency and character of vomiting/diarrhoea, urine output, preillness weight, recent oral intake\n- Vital signs, general appearance, oral mucosa, respiratory pattern, eyes (sunken appearance, tears), skin turgor, and capillary refill are examined\n- Fluid deficit is calculated: percentage dehydration × weight (kg) × 10 mL\n\n**Ongoing care:**\n- Physical examination and vital signs are reassessed continually\n- Urine output is monitored closely\n- Ongoing losses are quantified and replaced\n- Therapy is individualised based on dehydration type and severity\n\n**Admission criteria:**\n- [[161|Severe dehydration]] (>10% in infants; >6% in older children)\n- Inability to keep up with ongoing losses\n- Persistent hypoglycaemia\n- Appropriate outpatient care cannot be provided\n- Aetiology unclear and further workup required"
  },
  {
    "article_id": 100,
    "article_title": "Myocarditis",
    "section_id": "f55dd6337b0c42a688248b02dc5d65fc",
    "section_title": "Clinical features",
    "variant": "long",
    "imperatives": 1,
    "content": "Presentation is highly variable and often subtle, requiring a high index of suspicion. Early symptoms mimic nonspecific viral illness and include fever, lethargy, poor feeding, vomiting, diaphoresis, pallor, shortness of breath, and rhinorrhea. Older children may report fatigue, dyspnea, or chest pain. Unopposed vomiting without diarrhea may be a presenting feature.\n\nPhysical examination commonly reveals tachypnea, hepatomegaly, fever, and crackles. Cardiac findings include tachycardia disproportionate to fever, gallop rhythm, or arrhythmias. Severe disease presents with signs of congestive heart failure including jugular venous distention, hepatomegaly, and pulmonary edema with rales. Findings may become more obvious after fluid administration, emphasizing the importance of serial examinations between fluid boluses.\n\nMyocarditis may be mistaken for common illnesses such as [[3|bronchiolitis]], sepsis, or dehydration. Myocarditis is considered in all patients recently evaluated for respiratory and gastrointestinal symptoms, especially with abnormal vital signs or tachycardia out of proportion to hydration status."
  },
  {
    "article_id": 100,
    "article_title": "Myocarditis",
    "section_id": "19caeae19bb948eba23f20e91a24daeb",
    "section_title": "Management",
    "variant": "clinical",
    "imperatives": 5,
    "content": "**Immediate actions:**\n- Immediate cardiology consultation is obtained to direct further workup and management\n- Hemodynamic monitoring is established to detect worsening cardiac function or shock\n- Serial physical examinations are performed, particularly between fluid boluses, as findings may become more obvious after fluid administration\n\n**Diagnostic workup:**\n- Electrocardiography (abnormal in >90% of cases)\n- High-sensitivity troponin T (highly sensitive for acute myocarditis)\n- Creatine phosphokinase level\n- Echocardiography to assess ventricular function and identify pericardial effusion\n- Chest radiography to evaluate for cardiomegaly\n\n**Supportive care:**\n- Treatment remains largely supportive unless a treatable infectious pathogen is identified\n- Patients with mild disease are observed for developing signs of [[285|congestive heart failure]]\n\n**Management of congestive heart failure** (under pediatric cardiologist guidance):\n- Diuretics\n- Angiotensin-converting enzyme inhibitors\n- Angiotensin II receptor antagonists\n- Beta-blockers\n\n**Management of arrhythmias:**\n- Arrhythmias are treated with appropriate medications\n- Temporary or permanent pacing is considered for persistent arrhythmias\n- Implantable cardioverter-defibrillator is considered for appropriate indications"
  },
  {
    "article_id": 101,
    "article_title": "Normal Development",
    "section_id": "496b02dbf6ac4e0bbbf28adf277bb78f",
    "section_title": "Clinical Assessment of Development",
    "variant": "clinical",
    "imperatives": 1,
    "content": "**Growth Monitoring**\n\nRegular measurement and plotting of length/height and weight on appropriate growth charts is fundamental to clinical practice. For children from birth to 2 years, WHO standards are used. For children aged 2 to 19 years, CDC growth charts are used. For children with genetic conditions (Down syndrome, Turner syndrome, Noonan syndrome), condition-specific growth charts are used. Any deviation from expected centiles or the normal sequence of development requires further assessment.\n\n**Motor Development Assessment**\n\nGross motor skills are examined by observing head control, ability to lift shoulders when prone, rolling, sitting balance, crawling, standing, and walking. Fine motor skills including visual tracking, reaching, grasping, and pincer grasp development are assessed. Findings are compared to age-appropriate milestones, noting that normal ranges exist around mean ages (e.g., walking: mean 12 months, normal range 9–17 months).\n\n**Early Intervention Referral**\n\nFormal developmental surveillance should include referral to early intervention programs, particularly for extremely low birth weight infants. Routine screening tests alone are not sensitive enough to detect subtle neurodevelopmental abnormalities. The Individuals with Disabilities Education Act Part C guarantees early intervention services for eligible infants and young children. By 3 months of adjusted age, vocalization beyond crying, visual tracking, reaching attempts, arm support, and head lifting are assessed for. By 6 months of adjusted age, sitting with support, head control, and arm positioning are assessed for."
  },
  {
    "article_id": 101,
    "article_title": "Normal Development",
    "section_id": "971ce0cc477d461f94044a4b25f7dad1",
    "section_title": "Key points",
    "variant": "short",
    "imperatives": 1,
    "content": "- Normal development is defined as values within 2 standard deviations of the mean, representing ~95% of the population range\n- Development encompasses motor, cognitive, language, social, and behavioral domains reflecting nervous system maturation\n- Growth is fastest in the fetal period and infancy; average length gain is ~25 cm in year 1 and ~10 cm in year 2\n- After age 2 years, growth velocity is relatively constant at 4–6 cm/year; shifting percentile channels after age 2 is abnormal\n- WHO standards are used for children birth to 2 years and CDC growth charts for ages 2–19 years\n- Gross motor milestones: sitting by 6 months, walking by 12 months (range 9–17 months), running by 15 months\n- Fine motor development includes horizontal tracking by 1 month and refined pincer grasp by 9–12 months\n- Early developmental surveillance is essential, particularly for extremely low birth weight infants, to detect subtle neurodevelopmental abnormalities\n- Production problems (malformations, dysplasias) do not spontaneously resolve; packaging problems (deformations from mechanical causes) typically do\n- Condition-specific growth charts are used for genetic conditions such as Down syndrome, Turner syndrome, and Noonan syndrome"
  },
  {
    "article_id": 102,
    "article_title": "Respiratory Distress Syndrome",
    "section_id": "58c0a8f1d22646718579816ad252c47f",
    "section_title": "Management",
    "variant": "clinical",
    "imperatives": 3,
    "content": "**Recognition and initial assessment**\n\nPrompt recognition of respiratory distress and early intervention prevent progression to respiratory failure and cardiorespiratory arrest. Clinical signs are identified: tachypnoea, grunting, nasal flaring, subcostal and intercostal retractions, and cyanosis.\n\n**Diagnostic confirmation**\n\nA chest radiograph is obtained to confirm diagnosis. Poor lung expansion with homogenous ground-glass appearance and air bronchograms is looked for.\n\n**Supportive care**\n\nSupplemental oxygen is provided as needed to maintain adequate oxygenation and reduce cyanosis.\n\n**Respiratory support**\n\nSevere cases require positive pressure ventilation. It is initiated based on clinical severity and blood gas abnormalities (progressive hypoxaemia and hypercarbia).\n\n**Surfactant replacement therapy**\n\nExogenous surfactant is administered in severe cases. This is a key intervention that has significantly improved survival rates.\n\n**Monitoring**\n\nOxygenation, ventilation status, and acid–base balance are continuously monitored. Response to therapy is assessed and support is adjusted accordingly."
  },
  {
    "article_id": 104,
    "article_title": "Failure To Thrive",
    "section_id": "83a0c5cbbdb94f2e8115d2c9a3b2e079",
    "section_title": "Clinical Assessment and Management",
    "variant": "clinical",
    "imperatives": 1,
    "content": "**Growth Chart Plotting**\n\nAccurate serial measurement and plotting are the foundation of assessment:\n- Weight, length/height, and head circumference are plotted on WHO growth charts for children <2 years\n- For premature infants, gestation-corrected age is used:\n  - Weight: corrected until 24 months\n  - Head circumference: corrected until 18 months\n  - Length/height: corrected until 40 months\n- Standing height is recorded as height, not recumbent length\n- Crossing of percentile lines over 3–6 months or values below 3rd–5th percentile is identified\n\n**Comprehensive Evaluation**\n\nAssessment addresses multiple domains:\n- **Medical evaluation**: Organic causes (malabsorption, maldigestion, increased metabolic demand, ineffective calorie use) are identified\n- **Nutritional assessment**: Current intake is quantified and deficiencies are identified\n- **Psychosocial evaluation**: Family circumstances, feeding practices, parental knowledge, and emotional factors are assessed\n- **Developmental assessment**: Concurrent [[82|developmental delay]] is screened for\n\n**Multidisciplinary Management**\n\nEffective intervention requires coordinated input from:\n- Pediatrician or primary care provider\n- Registered dietitian\n- Social worker or family support specialist\n- Developmental specialist as indicated\n\nManagement is sustained beyond acute phases and tailored to address the specific medical, nutritional, and psychosocial factors contributing to [[246|growth failure]] in each child and family."
  },
  {
    "article_id": 104,
    "article_title": "Failure To Thrive",
    "section_id": "dff3fdb5f7c5473fad179ba222651ff6",
    "section_title": "Key points",
    "variant": "short",
    "imperatives": 1,
    "content": "- Failure to thrive describes inadequate growth: weight or weight-for-height below the 3rd–5th percentile, or crossing down two major percentile lines over 3–6 months\n- Most common cause is inadequate calorie intake, often with associated psychosocial difficulties\n- The condition reflects [[214|malnutrition]] resulting from complex interaction of medical, nutritional, emotional, and social factors\n- Affects 5–10% of children in primary care; accounts for 5–10% of tertiary referrals and ~1% of hospital admissions\n- WHO growth charts are used for children <2 years; gestation correction is applied until 24 months for weight, 18 months for head circumference, 40 months for length/height in premature infants\n- Early malnutrition spares height and head circumference initially; prolonged malnutrition causes decline in all parameters\n- Thorough psychosocial evaluation is essential; the organic/nonorganic dichotomy is obsolete\n- Malnutrition impairs growth, immune function, and long-term cognitive and socioaffective development\n- Management is multidisciplinary and sustained, aiming for a thriving child in a thriving family"
  },
  {
    "article_id": 106,
    "article_title": "Pelvic Inflammatory Disease",
    "section_id": "00c69c40a3904e87a5423a7efa7005be",
    "section_title": "Management",
    "variant": "clinical",
    "imperatives": 3,
    "content": "**First-line antibiotic regimens** (one option below is selected, then additional agents are added):\n\n**Option 1:**\n- Ceftriaxone 250 mg IM once\n\n**Option 2:**\n- Cefoxitin 2 g IM plus probenecid 1 g orally, both in a single dose concurrently\n\n**Option 3:**\n- Other parenteral third-generation cephalosporin (ceftizoxime or cefotaxime)\n\n**PLUS:**\n- Doxycycline 100 mg orally twice daily for 14 days\n\n**WITH or WITHOUT:**\n- Metronidazole 500 mg orally twice daily for 14 days\n\n**Diagnostic workup:**\n- A wet mount of vaginal secretions is performed to assess for white blood cells and to identify or exclude trichomonas or [[239|bacterial vaginosis]]\n- Gonococcal and chlamydial cervical infection are tested for\n- Serological testing for HIV and syphilis is performed\n- Imaging (transvaginal ultrasound or MRI) is considered if diagnosis is uncertain or to evaluate for complications such as tubo-ovarian abscess"
  },
  {
    "article_id": 107,
    "article_title": "Asthma",
    "section_id": "9572ca31a5fe41fd99132ca970592429",
    "section_title": "Prevention and Environmental Management",
    "variant": "long",
    "imperatives": 3,
    "content": "Several measures can reduce the risk of asthma exacerbations:\n- The bedroom is kept clean and dust-free; wet mopping of floors is encouraged\n- Light plain cloth sheets are used rather than heavy tapestry as curtains\n- Carpets, stuffed furniture, loose clothing, and hangings are cleaned periodically\n- Light bed materials are used and aired regularly\n- Contact with animal pets is discouraged if the child is sensitive to their fur\n- Exposure to tobacco smoke is avoided\n- Adolescent patients are advised to refrain from smoking\n\nDietary restriction is usually not necessary, as food allergy is not the cause in most cases. Allergen mitigation strategies such as air purifiers, HEPA filters, and pillow and mattress covers may be considered."
  },
  {
    "article_id": 108,
    "article_title": "Chlamydia Infection",
    "section_id": "2e4f96072e5f4a26954bb92accde8a60",
    "section_title": "Diagnosis and Management",
    "variant": "clinical",
    "imperatives": 3,
    "content": "**Diagnostic approach:**\n\n- Nucleic acid amplification testing (NAAT) on urine or vaginal/endocervical swabs is obtained to confirm diagnosis\n- Test of cure is not performed; positive results persist for up to 3 weeks after treatment\n- Retesting is planned at 3 months even in asymptomatic patients due to high reinfection risk\n\n**Clinical assessment:**\n\n- Sexually active adolescents and young adults are screened\n- In prepubertal girls, vaginal discharge, vaginal bleeding, vulvar pruritus, pain, or erythema are assessed for\n- In adolescent girls, symptoms of cervical and urethral infection (pelvic/abdominal pain, spotting, irregular vaginal bleeding) are evaluated for\n- Coinfection with _Neisseria gonorrhoeae_ is tested for\n- In neonates born to infected mothers, conjunctivitis or signs of [[150|pneumonia]] are examined for\n\n**Note:** The reference passages do not provide specific antibiotic dosing regimens or routes of administration for treatment."
  },
  {
    "article_id": 109,
    "article_title": "Transient Tachypnea Of Newborn",
    "section_id": "37747c7e1c544588b9f23fc3903b68b6",
    "section_title": "Bedside Management",
    "variant": "clinical",
    "imperatives": 9,
    "content": "**Initial Assessment**\n- Tachypnea (respiratory rate 80–100 breaths/min) with shallow, rapid breathing is confirmed\n- Chest retractions (typically minimal or absent) are assessed for\n- Cyanosis is evaluated for\n- Maternal history is obtained: mode of delivery, labor analgesia/anesthesia, gestational diabetes, [[107|asthma]], [[92|hypertension]]\n\n**Diagnostic Workup**\n- A chest radiograph is obtained to identify characteristic findings: bilateral streaky opacities, hyperinflation, possible pleural fluid\n- Other diagnoses are excluded: maternal [[355|chorioamnionitis]], maternal infection, meconium staining, premature rupture of membranes, [[226|sepsis]]\n- Clinical judgment is essential as radiographs cannot reliably differentiate TTN from neonatal [[150|pneumonia]]\n\n**Supportive Care**\n- Normal newborn care and feeding support are provided\n- Oxygen is administered for mild cyanosis as needed\n- Normal oral feeding is maintained when the infant is stable\n- Respiratory status and clinical improvement are monitored\n- Furosemide or inhaled racemic epinephrine is not used (no proven benefit)\n\n**Follow-up**\n- Symptom resolution is expected by 12–24 hours in most infants; 74% resolve by 48 hours\n- Respiratory symptoms typically disappear by 3 days\n- Radiographic resolution occurs within 24–48 hours\n- In healthy asymptomatic infants, follow-up radiographs are not necessary\n- Prolonged tachypnea (>72 hours) or deteriorating clinical status is investigated with further evaluation"
  },
  {
    "article_id": 110,
    "article_title": "Abnormal Uterine Bleeding",
    "section_id": "5f8b2184753f4f7980b860e96bfb8716",
    "section_title": "Management",
    "variant": "clinical",
    "imperatives": 3,
    "content": "**Initial Assessment**\n\n1. Diagnosis and severity are confirmed\n   - Hemodynamic status and degree of [[349|anemia]] are assessed\n   - Severity is categorized as mild, moderate, or severe\n\n2. Life-threatening causes are excluded\n   - Urine hCG (pregnancy test) in all patients\n   - Complete blood count including platelets and reticulocyte count\n   - Coagulation studies: prothrombin time, partial thromboplastin time, von Willebrand panel (especially if bleeding began at menarche or is severe)\n   - Thyroid function tests (free T4, TSH)\n   - Sexually transmitted infections are screened for in at-risk patients\n\n3. Additional investigations are considered\n   - Pelvic ultrasound if structural pathology is suspected\n   - Follicle-stimulating hormone, luteinizing hormone, prolactin as clinically indicated\n\n**Treatment**\n\n- Acute management typically consists of hormonal therapy tailored to severity and etiology\n- High-dose estrogen therapy requires concurrent antiemetic medication\n- A menstrual calendar (paper or smartphone app) is maintained to monitor response to therapy"
  },
  {
    "article_id": 112,
    "article_title": "Medication Error",
    "section_id": "279e2dbab5ab4794a8fcae75960f9a10",
    "section_title": "Preventing medication errors at the bedside",
    "variant": "clinical",
    "imperatives": 1,
    "content": "**Before prescribing or preparing any medication:**\n\n1. **The child's weight is confirmed** and included in all verbal and written orders.\n2. **Closed-loop communication is used**: the drug name, dose with units, route, and child's weight are stated; the recipient is asked to repeat back the intended dose.\n3. **For oral liquid medications**, prescribing and administration use **millilitres only**. Teaspoons or tablespoons are not used. The child's carer is given a **syringe marked in metric units** rather than a household spoon.\n4. **For high-risk drugs** (such as epinephrine in neonatal emergencies), it is ensured that **only one concentration is available** in the clinical area. For neonatal resuscitation, only the **dilute epinephrine solution (0.1 mg/mL)** is stocked; the concentrated solution (1 mg/mL) should not be present, as accidental use causes a 10-fold overdose.\n5. **The concentration is verified** by showing the medication box to another team member before preparation.\n6. **The prepared dose is checked** against a weight-based reference chart or table.\n7. **Ambiguous abbreviations are avoided** and prescriptions state both the drug name and its concentration (not volume alone).\n8. **Intravenous line patency is verified** before any medication is injected, and endotracheal tube position is confirmed before drugs are administered via that route."
  },
  {
    "article_id": 115,
    "article_title": "Congenital Anomalies",
    "section_id": "4a49f2d263fa46c5a26f4abf8d508e33",
    "section_title": "Management",
    "variant": "clinical",
    "imperatives": 1,
    "content": "**Immediate Assessment**\n\nInfants with congenital anomalies require early recognition and systematic evaluation. Upon identification of any anomaly, whether it is an isolated finding or part of a multiple malformation syndrome is determined, as this distinction guides further investigation and prognosis.\n\n**Genetic Testing**\n\nInfants with congenital anomalies warrant genetic testing. Testing strategies include:\n- Karyotyping to identify large chromosomal abnormalities\n- Fluorescence in situ hybridization (FISH) for classic microdeletion syndromes such as 22q11\n- Chromosomal microarray for comprehensive genetic assessment\n\n**Life-Threatening Anomalies Requiring Immediate Intervention**\n\nThe following anomalies require immediate medical or surgical therapy for postnatal survival:\n- Congenital heart disease\n- Tracheoesophageal fistula\n- Congenital diaphragmatic hernia\n- Choanal atresia\n- [[302|Intestinal obstruction]]\n\nThese conditions necessitate delivery room preparation and coordination with surgical services.\n\n**Clinical Evaluation Strategy**\n\nWhen multiple minor anomalies are identified, thorough clinical assessment is performed to exclude occult major defects. The presence of multiple minor findings significantly increases the probability of identifying significant underlying anomalies. All findings are documented systematically by organ system to facilitate syndrome recognition and genetic counseling."
  },
  {
    "article_id": 116,
    "article_title": "Pediatric Critical Care",
    "section_id": "bfc0cd6d50414d1b92793ab44a8ac120",
    "section_title": "Management Approach",
    "variant": "clinical",
    "imperatives": 3,
    "content": "**Recognition and Initial Assessment**\n\nSigns of shock are identified early, as prompt intervention significantly improves outcomes. Tissue perfusion, mental status, and hemodynamic parameters are assessed continuously.\n\n**Fluid Resuscitation**\n\nFor pediatric [[178|septic shock]], resuscitation with balanced fluids is initiated. This approach is associated with improved survival compared to alternative fluid strategies.\n\n**Hemodynamic Support**\n\nHemodynamic support is provided, tailored to the type and severity of shock. American College of Critical Care Medicine clinical practice parameters for pediatric and neonatal septic shock are followed to guide the intensity and type of support required.\n\n**Advanced Life Support**\n\nPediatric Advanced Life Support guidelines are adhered to. Age- and weight-appropriate dosing is used for resuscitation medications as outlined in current guidelines.\n\n**Monitoring for Complications**\n\nRegular screening for delirium uses validated assessment tools such as the Cornell Assessment of Pediatric Delirium, which provides rapid observational screening in the PICU setting.\n\n**Transport Considerations**\n\nWhen interfacility transport is necessary, the transport team must have specialized pediatric knowledge and appropriate equipment. Telemedicine support is considered to facilitate consultation during transfer."
  },
  {
    "article_id": 117,
    "article_title": "Autism Spectrum Disorder",
    "section_id": "f04486a240774edb953fc98e3011ce9f",
    "section_title": "Clinical Management",
    "variant": "clinical",
    "imperatives": 2,
    "content": "**Hospitalization and Physical Examination**\n\nWhen a child with autism spectrum disorder requires hospitalization, a complete physical examination is conducted, as these patients remain at risk for the full range of pathology. The examination may be tailored based on the history obtained and the patient's current status.\n\n**Key Clinical Considerations:**\n\n- The patient's communication assist devices or comfort items are used during examination and care\n- If the presenting complaint relates to pain or agitation, specific attention is paid to organ systems that may be involved\n- Common comorbidities that may require hospitalization in patients with autism spectrum disorder are recognized\n- Physical and neurologic examinations are typically completely normal in autism spectrum disorder\n\n**Intervention Approach**\n\nBest practice management includes:\n\n1. Systematic assessment of the child's existing skills\n2. Selection of individualized, measurable goals based on objective assessment\n3. Use of assessment-based, empirically supported instructional methods to build, generalize, and maintain skills and reduce problem behaviors\n4. Inclusion of specific intervention content addressing impairments in social communication and restricted and repetitive behavioral patterns"
  },
  {
    "article_id": 118,
    "article_title": "Behavioral Disorder",
    "section_id": "d50dd5d957a04404aae06b6090c1b7c0",
    "section_title": "Assessment and Management",
    "variant": "clinical",
    "imperatives": 5,
    "content": "**Initial Assessment**\n\nWhen a child presents with suspected [[286|conduct disorder]] or acute behavioral disturbance, a detailed behavior history is obtained from parents and caregivers, as children rarely self-report these concerns. The onset, duration, and settings in which behaviors occur are assessed. Any acute changes in behavior are screened for, particularly if accompanied by physical symptoms or abnormal vital signs, as medical conditions may contribute to or complicate the presentation.\n\nThe differential diagnosis is considered, which includes anxiety, adjustment reactions, depression, mania, medical illness (including delirium), pervasive developmental disorders, psychosis, and trauma. A thorough medical evaluation is warranted to exclude organic causes of behavioral change.\n\n**Diagnostic Evaluation**\n\nSymptoms are confirmed to meet criteria: at least 3 of 15 conduct disorder criteria present in the past 12 months, with at least one in the past 6 months. The specific behaviors observed and reported are documented. Age of onset (before or after age 10 years) is determined, as this significantly affects prognosis and management planning.\n\n**Risk Stratification**\n\nChildren at increased risk for substance abuse and trauma-related injuries are identified. Suicidal ideation and homicidal risk are assessed for, particularly in high-risk patients. Comorbid psychiatric conditions and medical contributors are evaluated for.\n\n**Management Approach**\n\nBecause children do not typically seek help independently, parents and caregivers are engaged as active partners in treatment planning. Behavioral management counseling services, including in-home behavior management counseling, should be considered. Care is coordinated across school, home, and community settings, as symptoms may be confined to specific environments. Any identified medical or psychiatric comorbidities are addressed. For acute agitation or aggression requiring emergency department evaluation, management follows acute behavioral emergency protocols while underlying medical or psychiatric triggers are investigated."
  },
  {
    "article_id": 119,
    "article_title": "Pediatric Neurology",
    "section_id": "9e7a3e4a055d48f780c23e914309fb84",
    "section_title": "Clinical Assessment at the Bedside",
    "variant": "clinical",
    "imperatives": 7,
    "content": "**History Taking**\n\nA systematic history is taken focusing on:\n- Timing and mode of symptom onset (acute vs. gradual)\n- Course of illness (stable, progressive, or fluctuating)\n- Antenatal history: maternal infections, drug exposure, complications\n- Perinatal history: delivery method, need for resuscitation, Apgar scores\n- Neonatal history: birth weight, [[321|hypoglycemia]], [[368|hypocalcemia]], jaundice, feeding difficulties, early activity abnormalities\n- Developmental history: achievement of motor and cognitive milestones, any regression\n- Family history of neurologic or genetic disorders\n\n**Physical Examination**\n\nA systematic neurologic examination adapted to developmental stage is conducted:\n- Level of consciousness and behavior are assessed\n- Cranial nerves (II–XII) are evaluated\n- Motor function is tested: tone, strength, spontaneous movement\n- Reflexes are assessed and symmetry is compared\n- Coordination and gait are evaluated (if age-appropriate)\n- Sensory testing is performed as tolerated\n- Abnormal movements or posturing are looked for\n- Head circumference is measured in infants and young children\n\n**When to Pursue Further Investigation**\n\nNeuroimaging (cranial ultrasound or MRI) is considered when:\n- Abnormal neurologic findings on examination\n- [[82|Developmental delay]] or regression\n- Suspected structural brain abnormality\n- History of significant perinatal insult\n\nSpecialized testing (nerve conduction studies, electromyography, genetic/metabolic panels) is considered based on clinical presentation and suspected diagnosis."
  },
  {
    "article_id": 120,
    "article_title": "Pediatric Psychiatry",
    "section_id": "7124245af69c4bdbaa8b9260f264003a",
    "section_title": "Assessment and Management",
    "variant": "clinical",
    "imperatives": 2,
    "content": "**Initial Evaluation**\n\nA structured interview and mental status examination are conducted in all patients presenting with suspected psychiatric emergencies. Hallucinations and psychotic symptoms are assessed for through careful questioning about perceptual experiences and thought content.\n\n**Risk Stratification**\n\nPatients at high risk for psychiatric boarding (prolonged medical ward stays) are identified early in the emergency department course. Predictors include acute suicidal ideation, suicide attempts, and acute psychotic symptoms. Early identification allows for timely psychiatric consultation and disposition planning.\n\n**Coordination of Care**\n\nPrompt psychiatric evaluation is arranged for patients requiring inpatient admission. Coordination with psychiatric services minimizes boarding time on medical wards. Clinical indicators that necessitate psychiatric hospitalization versus outpatient follow-up are documented.\n\n**Special Populations**\n\nFor children and adolescents following disasters or traumatic events, a public [[94|mental health]] approach is implemented through the emergency department. Crisis support is provided and families are connected to ongoing mental health resources in the community."
  }
]