[
  {
    "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. Assess work of breathing, hydration and feeding, and oxygen saturation."
  },
  {
    "article_id": 7,
    "article_title": "Iron deficiency anemia",
    "section_id": "2901c7c7d343ca4046f31c90a9ab35f8",
    "section_title": "Management",
    "variant": "long",
    "imperatives": 1,
    "content": "Oral iron with dietary counselling; recheck the response after several weeks. Look for a source of blood loss 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 as needed. Reassess the response and escalate for poor responders."
  },
  {
    "article_id": 10,
    "article_title": "Developmental milestones",
    "section_id": "20d61ca5b22813039798ff34f31a6f0a",
    "section_title": "Next steps",
    "variant": "long",
    "imperatives": 1,
    "content": "Confirm with a standardised tool, check hearing and vision, and refer to early intervention services while the evaluation proceeds."
  },
  {
    "article_id": 84,
    "article_title": "Normal Child Development",
    "section_id": "4eb9f87531bc40a295e052615de3cd61",
    "section_title": "Key points",
    "variant": "short",
    "imperatives": 1,
    "content": "- Use WHO growth standards 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- Perform emergency ultrasound for rapid evaluation in acute trauma\n- Obtain advanced imaging (computed tomography) 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- Implement close observation and imaging surveillance during the nonoperative period\n- Reserve operative intervention 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. **Protect exposed viscera** — Apply nonadherent dressings and change as needed to prevent contamination and drying\n2. **Decompress the bowel** — Place a nasogastric tube for decompression\n3. **Position carefully** — Maintain positioning to minimize volvulus and bowel ischemia risk\n4. **Establish monitoring** — Implement close clinical observation for signs of deterioration\n5. **Consult pediatric surgery immediately** — Do not delay specialist input\n\n**Preoperative optimization:**\n\n- Correct metabolic abnormalities, particularly [[321|hypoglycemia]]\n- Establish access for and prepare parenteral nutrition\n- Obtain chest radiography and echocardiography to assess for cardiopulmonary abnormalities\n- Assess physiological readiness for general anesthesia — the neonate may not be cleared for surgery if significant cardiopulmonary abnormalities are present\n\n**Key principle:** Delay operative intervention if necessary to optimize the neonate's medical condition and ensure physiological stability before attempting surgical reduction and repair."
  },
  {
    "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- Evaluate infant immediately for birth trauma and major malformations\n- Obtain blood glucose and hematocrit in the nursery\n- Perform focused physical examination of heart, kidneys, lungs, and extremities\n- Observe for jitteriness, tremors, convulsions, apnea, weak cry, and poor sucking\n- Address any signs of [[151|respiratory distress]] in the delivery room immediately\n\n**First 24 hours:**\n- Monitor blood glucose closely throughout the first 24 hours\n- Initiate early feeding to help prevent [[321|hypoglycemia]]\n- Screen for hypoglycemia and assess for [[151|respiratory distress]]\n- Observe for signs of cardiac disease (cardiomegaly on chest X-ray, murmur, signs of heart failure)\n- Check for abdominal distension and meconium passage (small left colon syndrome)\n\n**First 48 hours:**\n- Continue observation for jaundice\n- Assess for renal, cardiac, neurologic, and gastrointestinal abnormalities\n- Monitor for jitteriness after 24 hours (may indicate [[368|hypocalcemia]] or hypomagnesemia rather than [[321|hypoglycemia]])\n- Observe for signs of [[151|respiratory distress]] from immature lungs\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**: Determine age of onset, whether congenital or acquired, and whether the condition is progressive or stable\n2. **Physical examination**: Measure and document any deformities using standardized reference values for normal rotational and angular measurements\n3. **Functional assessment**: Evaluate for pain, functional limitations, or gait abnormalities\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**: Refer to a pediatric orthopedic surgeon 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, arrange periodic reassessment to monitor for progression and ensure appropriate development. Document baseline measurements 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 should be performed routinely in primary care settings. Assessment should explore the cardinal features: sadness, irritability, and loss of interest or pleasure in activities. Evaluate for associated symptoms including changes in school performance, social withdrawal, sleep and appetite disturbance, and nonspecific physical complaints. Assess for functional impairment across home, school, and peer relationships.\n\n**Risk Assessment**\n\nAll depressed adolescents require evaluation for suicide risk. Identify specific risk factors: history of bullying (victim or perpetrator), substance use, coexisting psychiatric conditions, chaotic home environment, and recent humiliation or perceived failure. Document any psychotic symptoms such as hallucinations or paranoid ideation.\n\n**Treatment Considerations**\n\nManagement typically involves antidepressant medication, psychotherapy (including cognitive behaviour therapy, interpersonal therapy, or family therapy), or combination treatment. Be aware that approximately 50% of depressed youth in primary care decline pharmacotherapy, and adherence challenges are common. Discuss the evidence regarding antidepressant efficacy and safety with adolescents and families. Ensure adequate treatment duration and dosing to achieve expected benefit, as many adolescents discontinue treatment prematurely.\n\n**Referral**\n\nConsider referral to [[94|mental health]] specialists 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- Assess blood glucose 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- Screen for [[368|hypocalcemia]] in low birthweight infants, infants of diabetic mothers, asphyxiated infants, infants with DiGeorge syndrome, and those born to mothers with hyperparathyroidism\n- Assess serum magnesium concurrently, as hypomagnesemia frequently accompanies hypocalcemia\n- Correct magnesium deficiency to facilitate calcium correction\n\n**[[170|Hyponatremia]]**\n- Review fluid management practices\n- Evaluate for syndrome of inappropriate antidiuretic hormone secretion\n- Adjust fluid intake and osmolarity as indicated\n\n**Hypernatremia**\n- Assess feeding adequacy in breastfed infants\n- Verify correct formula dilution in formula-fed infants\n- Address underlying [[99|dehydration]]\n\n**Pyridoxine Dependency**\n- Recognize [[315|seizures]] resistant to standard anticonvulsants as a clinical clue\n- Consider pyridoxine dependency 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\nManage with:\n- Pain control\n- Measures to calm the patient\n- Serial blood pressure monitoring\n\n**Diagnostic Approach**\n\n1. Measure blood pressure by auscultation (not oscillatory devices) using an appropriately sized cuff for the patient's arm circumference\n2. Confirm elevation at three separate visits before diagnosing hypertension\n3. In athletes with persistently elevated BP:\n   - Enquire about family history of hypertension\n   - Ask about use of stimulants (caffeine, nicotine, ephedrine) or anabolic steroids\n   - In those <25 years with upper extremity hypertension, check lower extremity BP to exclude coarctation of the aorta\n4. Consider 24-hour ambulatory blood pressure monitoring 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 should be 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- Obtain detailed history including exposure history, incubation period considerations, and symptom timeline\n- Perform thorough physical examination documenting clinical manifestations\n- Identify risk factors including immunocompromised status, underlying chronic conditions, or group care attendance\n\n**Diagnostic Approach**\n\n- Order pathogen-specific diagnostic tests based on clinical presentation and suspected organism\n- Consider incubation period in timing of diagnostic testing\n- Document findings to guide organism identification\n\n**Treatment Considerations**\n\n- Select antimicrobial therapy based on identified or suspected organism\n- Use age-appropriate dosing and specify route of administration\n- Provide supportive care tailored to the infection type and severity\n- Monitor for complications and treatment response\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- Consider consultation with pediatric infectious disease specialists 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. Confirm [[321|hypoglycemia]]: Capillary glucose screening below 40 mg/dL should be verified by laboratory serum or plasma glucose measurement\n2. In any sick infant, collect critical blood and urine samples before starting treatment to guide diagnosis\n3. Assess for symptoms: 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- Initiate early enteral feeding 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- Continue frequent feeding to maintain glucose homeostasis\n\n**For symptomatic hypoglycemia or failure of enteral feeding:**\n- Provide rapid intravenous correction\n- Use 10% dextrose (D10W) intravenously\n- Continue until normal glucose homeostasis is established and adequate substrate supply is secured\n\n**Monitoring and Targets**\n\n- First 48 hours: maintain blood glucose >50 mg/dL\n- After 48 hours: maintain blood glucose >60 mg/dL if intravenous glucose is required\n- Once blood glucose is stabilized, resume normal feedings\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\nObtain a detailed history of symptom onset, frequency, duration, and seasonal pattern. Identify potential allergen exposures (indoor and outdoor). Assess impact on sleep, school performance, and quality of life to determine severity classification. Perform physical examination of the nasal mucosa, 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 to wash away allergens\n- Allergen avoidance and environmental control (remove or reduce exposure to identified triggers)\n- For seasonal allergens, minimise outdoor exposure during high pollen periods\n- For perennial indoor allergens, implement dust mite control measures and remove animal dander sources where possible\n\n**Monitoring**\n\nAssess response to treatment and adjust therapy 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- Obtain detailed history: duration of illness, frequency and character of vomiting/diarrhoea, urine output, preillness weight, recent oral intake\n- Examine vital signs, general appearance, oral mucosa, respiratory pattern, eyes (sunken appearance, tears), skin turgor, and capillary refill\n- Calculate fluid deficit: percentage dehydration × weight (kg) × 10 mL\n\n**Ongoing care:**\n- Reassess physical examination and vital signs continually\n- Monitor urine output closely\n- Quantify and replace ongoing losses\n- Individualise therapy based on dehydration type and severity\n\n**Admission criteria:**\n- [[161|Severe dehydration]] (>10% in infants; >6% in older children)\n- Unable to keep up with ongoing losses\n- Persistently hypoglycaemic\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. Consider myocarditis 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- Obtain immediate cardiology consultation to direct further workup and management\n- Establish hemodynamic monitoring to detect worsening cardiac function or shock\n- Perform serial physical examinations, 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- Observe patients with mild disease 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- Treat with appropriate medications\n- Consider temporary or permanent pacing for persistent arrhythmias\n- Consider implantable cardioverter-defibrillator 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, use WHO standards. For children aged 2 to 19 years, use CDC growth charts. For children with genetic conditions (Down syndrome, Turner syndrome, Noonan syndrome), use condition-specific growth charts. Any deviation from expected centiles or the normal sequence of development requires further assessment.\n\n**Motor Development Assessment**\n\nExamine gross motor skills by observing head control, ability to lift shoulders when prone, rolling, sitting balance, crawling, standing, and walking. Assess fine motor skills including visual tracking, reaching, grasping, and pincer grasp development. Compare findings 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, assess for vocalization beyond crying, visual tracking, reaching attempts, arm support, and head lifting. By 6 months of adjusted age, assess for sitting with support, head control, and arm positioning."
  },
  {
    "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- Use WHO standards 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 should be 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. Identify clinical signs: tachypnoea, grunting, nasal flaring, subcostal and intercostal retractions, and cyanosis.\n\n**Diagnostic confirmation**\n\nObtain a chest radiograph to confirm diagnosis. Look for poor lung expansion with homogenous ground-glass appearance and air bronchograms.\n\n**Supportive care**\n\nProvide supplemental oxygen as needed to maintain adequate oxygenation and reduce cyanosis.\n\n**Respiratory support**\n\nSevere cases require positive pressure ventilation. Initiate based on clinical severity and blood gas abnormalities (progressive hypoxaemia and hypercarbia).\n\n**Surfactant replacement therapy**\n\nAdminister exogenous surfactant in severe cases. This is a key intervention that has significantly improved survival rates.\n\n**Monitoring**\n\nContinuously monitor oxygenation, ventilation status, and acid–base balance. Assess response to therapy and adjust support 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- Plot weight, length/height, and head circumference on WHO growth charts for children <2 years\n- For premature infants, use gestation-corrected age:\n  - Weight: correct until 24 months\n  - Head circumference: correct until 18 months\n  - Length/height: correct until 40 months\n- Ensure standing height is recorded as height, not recumbent length\n- Identify crossing of percentile lines over 3–6 months or values below 3rd–5th percentile\n\n**Comprehensive Evaluation**\n\nAssessment must address multiple domains:\n- **Medical evaluation**: Identify organic causes (malabsorption, maldigestion, increased metabolic demand, ineffective calorie use)\n- **Nutritional assessment**: Quantify current intake and identify deficiencies\n- **Psychosocial evaluation**: Assess family circumstances, feeding practices, parental knowledge, and emotional factors\n- **Developmental assessment**: Screen for concurrent [[82|developmental delay]]\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 must be 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- Use WHO growth charts for children <2 years; apply gestation correction 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** (choose one option below, then add additional agents):\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- Perform wet mount of vaginal secretions to assess for white blood cells and to identify or exclude trichomonas or [[239|bacterial vaginosis]]\n- Test for gonococcal and chlamydial cervical infection\n- Perform serological testing for HIV and syphilis\n- Consider imaging (transvaginal ultrasound or MRI) if diagnosis 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- Keep the bedroom clean and dust-free; wet mopping of floors is encouraged\n- Use light plain cloth sheets rather than heavy tapestry as curtains\n- Periodically clean carpets, stuffed furniture, loose clothing, and hangings\n- Use light bed materials and air them regularly\n- Discourage contact with animal pets if the child is sensitive to their fur\n- Avoid exposure to tobacco smoke\n- Adolescent patients should 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- Obtain nucleic acid amplification testing (NAAT) on urine or vaginal/endocervical swabs to confirm diagnosis\n- Do not perform test of cure; positive results persist for up to 3 weeks after treatment\n- Plan retesting at 3 months even in asymptomatic patients due to high reinfection risk\n\n**Clinical assessment:**\n\n- Screen sexually active adolescents and young adults\n- In prepubertal girls, assess for vaginal discharge, vaginal bleeding, vulvar pruritus, pain, or erythema\n- In adolescent girls, evaluate for symptoms of cervical and urethral infection (pelvic/abdominal pain, spotting, irregular vaginal bleeding)\n- Test for coinfection with _Neisseria gonorrhoeae_\n- In neonates born to infected mothers, examine for conjunctivitis or signs of [[150|pneumonia]]\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- Confirm tachypnea (respiratory rate 80–100 breaths/min) with shallow, rapid breathing\n- Assess for chest retractions (typically minimal or absent)\n- Evaluate for cyanosis\n- Obtain maternal history: mode of delivery, labor analgesia/anesthesia, gestational diabetes, [[107|asthma]], [[92|hypertension]]\n\n**Diagnostic Workup**\n- Obtain chest radiograph to identify characteristic findings: bilateral streaky opacities, hyperinflation, possible pleural fluid\n- Exclude other diagnoses: maternal [[355|chorioamnionitis]], maternal infection, meconium staining, premature rupture of membranes, [[226|sepsis]]\n- Clinical judgment essential as radiographs cannot reliably differentiate TTN from neonatal [[150|pneumonia]]\n\n**Supportive Care**\n- Provide normal newborn care and feeding support\n- Administer oxygen for mild cyanosis as needed\n- Maintain normal oral feeding when infant is stable\n- Monitor respiratory status and clinical improvement\n- Do not use furosemide or inhaled racemic epinephrine (no proven benefit)\n\n**Follow-up**\n- Expect symptom resolution 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- Investigate prolonged tachypnea (>72 hours) or deteriorating clinical status 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. Confirm diagnosis and severity\n   - Assess hemodynamic status and degree of [[349|anemia]]\n   - Categorize as mild, moderate, or severe\n\n2. Exclude life-threatening causes\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   - Screen for sexually transmitted infections in at-risk patients\n\n3. Consider additional investigations\n   - Pelvic ultrasound if structural pathology 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- Maintain menstrual calendar (paper or smartphone app) 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. **Confirm the child's weight** and include it in all verbal and written orders.\n2. **Use closed-loop communication**: state the drug name, dose with units, route, and child's weight; ask the recipient to repeat back the intended dose.\n3. **For oral liquid medications**, prescribe and administer using **millilitres only**. Do not use teaspoons or tablespoons. Provide the child's carer with a **syringe marked in metric units** rather than a household spoon.\n4. **For high-risk drugs** (such as epinephrine in neonatal emergencies), ensure that **only one concentration is available** in the clinical area. For neonatal resuscitation, stock only the **dilute epinephrine solution (0.1 mg/mL)**; the concentrated solution (1 mg/mL) should not be present, as accidental use causes a 10-fold overdose.\n5. **Verify the concentration** by showing the medication box to another team member before preparation.\n6. **Check the prepared dose** against a weight-based reference chart or table.\n7. **Avoid ambiguous abbreviations** and ensure prescriptions state both the drug name and its concentration (not volume alone).\n8. **Verify intravenous line patency** before injecting any medication, and confirm endotracheal tube position before administering drugs 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, determine whether it is an isolated finding or part of a multiple malformation syndrome, 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, perform thorough clinical assessment to exclude occult major defects. The presence of multiple minor findings significantly increases the probability of identifying significant underlying anomalies. Document all findings 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\nIdentify signs of shock early, as prompt intervention significantly improves outcomes. Assess tissue perfusion, mental status, and hemodynamic parameters continuously.\n\n**Fluid Resuscitation**\n\nFor pediatric [[178|septic shock]], initiate resuscitation with balanced fluids. This approach is associated with improved survival compared to alternative fluid strategies.\n\n**Hemodynamic Support**\n\nProvide hemodynamic support tailored to the type and severity of shock. Follow American College of Critical Care Medicine clinical practice parameters for pediatric and neonatal septic shock to guide the intensity and type of support required.\n\n**Advanced Life Support**\n\nAdhere to Pediatric Advanced Life Support guidelines. Use age- and weight-appropriate dosing for resuscitation medications as outlined in current guidelines.\n\n**Monitoring for Complications**\n\nScreen regularly for delirium using 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, ensure the transport team has specialized pediatric knowledge and appropriate equipment. Consider telemedicine support 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, conduct a complete physical examination 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- Use the patient's communication assist devices or comfort items during examination and care\n- If the presenting complaint relates to pain or agitation, pay specific attention to organ systems that may be involved\n- Be aware of common comorbidities that may require hospitalization in patients with autism spectrum disorder\n- Recognize that 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, obtain a detailed behavior history from parents and caregivers, as children rarely self-report these concerns. Assess the onset, duration, and settings in which behaviors occur. Screen for any acute changes in behavior, particularly if accompanied by physical symptoms or abnormal vital signs, as medical conditions may contribute to or complicate the presentation.\n\nConsider the differential diagnosis, 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\nConfirm that symptoms 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. Document the specific behaviors observed and reported. Determine age of onset (before or after age 10 years), as this significantly affects prognosis and management planning.\n\n**Risk Stratification**\n\nIdentify children at increased risk for substance abuse and trauma-related injuries. Assess for suicidal ideation and homicidal risk, particularly in high-risk patients. Evaluate for comorbid psychiatric conditions and medical contributors.\n\n**Management Approach**\n\nBecause children do not typically seek help independently, engage parents and caregivers as active partners in treatment planning. Behavioral management counseling services, including in-home behavior management counseling, should be considered. Coordinate care across school, home, and community settings, as symptoms may be confined to specific environments. Address any identified medical or psychiatric comorbidities. For acute agitation or aggression requiring emergency department evaluation, manage according to acute behavioral emergency protocols while investigating underlying medical or psychiatric triggers."
  },
  {
    "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\nBegin with a systematic history 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\nConduct systematic neurologic examination adapted to developmental stage:\n- Assess level of consciousness and behavior\n- Evaluate cranial nerves (II–XII)\n- Test motor function: tone, strength, spontaneous movement\n- Assess reflexes and compare symmetry\n- Evaluate coordination and gait (if age-appropriate)\n- Perform sensory testing as tolerated\n- Look for abnormal movements or posturing\n- Measure head circumference in infants and young children\n\n**When to Pursue Further Investigation**\n\nConsider neuroimaging (cranial ultrasound or MRI) 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\nConsider specialized testing (nerve conduction studies, electromyography, genetic/metabolic panels) 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\nConduct a structured interview and mental status examination in all patients presenting with suspected psychiatric emergencies. Assess for hallucinations and psychotic symptoms through careful questioning about perceptual experiences and thought content.\n\n**Risk Stratification**\n\nIdentify patients at high risk for psychiatric boarding (prolonged medical ward stays) 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\nArrange prompt psychiatric evaluation for patients requiring inpatient admission. Coordinate with psychiatric services to minimize boarding time on medical wards. Document clinical indicators that necessitate psychiatric hospitalization versus outpatient follow-up.\n\n**Special Populations**\n\nFor children and adolescents following disasters or traumatic events, implement a public [[94|mental health]] approach through the emergency department. Provide crisis support and connect families to ongoing mental health resources in the community."
  }
]