[
  {
    "article_id": 161,
    "article_title": "Severe Dehydration",
    "section_id": "7d085f689c72447183f70ed72af34006",
    "section_title": "Management",
    "variant": "clinical",
    "imperatives": 5,
    "content": "## Immediate resuscitation phase\n\n**Vascular access:** Establish a large-bore intravenous catheter. If IV access cannot be obtained, use intraosseous access.\n\n**Initial fluid bolus:** Administer 20 mL/kg of isotonic fluid (normal saline or lactated Ringer solution) over approximately 20 minutes.\n\n**Fluid choice:**\n- Use **normal saline or lactated Ringer solution** for initial resuscitation\n- In children with isolated vomiting and probable metabolic alkalosis, use **normal saline** (avoid lactated Ringer solution or Plasma-Lyte)\n- Lactated Ringer solution or Plasma-Lyte may be preferable to normal saline in shock as balanced solutions\n\n**Reassessment and repeat boluses:** Monitor vital signs closely. Repeat boluses of 20 mL/kg may be needed. The child may require multiple boluses administered as rapidly as possible. Up to 20–100 mL/kg total may be required to restore plasma volume and pulses.\n\n**Monitoring:** Assess for return of normal pulse and state of consciousness. Monitor for hypotension and orthostatic vital sign changes. Evaluate peripheral perfusion and mental status.\n\n**Urine output:** Monitor urine output; normal output is approximately 1 mL/kg/h. If the patient does not void after 3 fluid boluses, insert a bladder catheter.\n\n**Escalation:** Any child requiring more than 40 mL/kg as a bolus should be urgently reviewed for need of vasopressor or inotropic support and consideration of intensive care.\n\n## Laboratory assessment\n\n**Electrolytes:** Determine serum electrolyte levels, BUN, and creatinine.\n\n**Potassium:** Do not give intravenous potassium until urine output is established.\n\n## Deficit replacement phase\n\nOnce shock is reversed and mental status is satisfactory, replace the remaining fluid deficit over 12–24 hours using isotonic fluid. Add dextrose and potassium to ongoing fluids as appropriate.\n\n## Transition to oral rehydration\n\nWhen the child's condition has stabilized and mental status is satisfactory, initiate oral rehydration therapy. Maintain the intravenous line until oral intake is adequate.\n\n**Alternative:** Consider enteral hydration via nasogastric tube for patients who refuse oral intake but do not have ongoing vomiting.\n\n## Poor response to resuscitation\n\nLack of response to initial resuscitation or persistently poor perfusion despite multiple boluses suggests an underlying problem such as [[178|septic shock]], toxic shock syndrome, [[100|myocarditis]], myocardiopathy, or pericarditis. Treat with broad-spectrum antibiotics and vasopressors, and transfer to an intensive care unit."
  },
  {
    "article_id": 162,
    "article_title": "Sickle Cell Disease",
    "section_id": "4968825e7035401d8690db51237900ab",
    "section_title": "Management",
    "variant": "clinical",
    "imperatives": 2,
    "content": "### Assessment and Initial Evaluation\n\nChildren presenting with suspected or known sickle cell disease require rapid assessment for acute complications, as life-threatening conditions can develop quickly. Obtain a detailed history of pain location and severity, fever, respiratory symptoms, and any recent infections or triggers. Perform a thorough physical examination including vital signs, assessment for acute chest syndrome (chest pain, dyspnea, cough with pulmonary consolidation), splenic enlargement, and signs of sepsis.\n\n### Diagnostic Approach\n\nFor newly identified cases or confirmatory diagnosis:\n- Hemoglobin electrophoresis\n- High-performance liquid chromatography (HPLC)\n- Immunologic tests\n- Molecular genetic testing\n\nNote: If the child has received a blood transfusion, delay testing until more than 90 days after transfusion.\n\n### Comprehensive Care Framework\n\nAll children with sickle cell disease require coordinated comprehensive care through a medical home with appropriate expertise. This includes:\n\n- **Ongoing education** for patient and family regarding disease management, pain recognition, and when to seek emergency care\n- **Periodic comprehensive evaluations** to monitor for complications\n- **Disease-specific health maintenance services** tailored to prevent and detect complications early\n- **Psychosocial support** to address the emotional and social impact of chronic illness\n- **Genetic counseling** for family members\n\n### Acute Illness Management\n\nTimely and appropriate treatment of acute complications is critical. Recognize that acute presentations may include:\n- Vaso-occlusive pain crises (musculoskeletal and abdominal)\n- Acute chest syndrome\n- Splenic sequestration\n- Bacterial [[226|sepsis]] or [[147|meningitis]]\n- Stroke\n- Priapism\n\nRapid assessment and intervention are essential as complications can become life-threatening within hours."
  },
  {
    "article_id": 163,
    "article_title": "Trisomy 18",
    "section_id": "c28c25d8d2144aaf86981658cbf02089",
    "section_title": "Clinical Management",
    "variant": "clinical",
    "imperatives": 4,
    "content": "**Prenatal Recognition**\n\nIncreased nuchal translucency on early prenatal ultrasound may raise suspicion for trisomy 18. Combined screening protocols incorporating maternal age, nuchal translucency, and maternal serum markers enable early detection.\n\n**Postnatal Assessment**\n\nAt birth, examine for characteristic dysmorphic features: overlapping fingers in clenched fist, short sternum, rocker-bottom feet, prominent occiput, and low-set ears. Document reduced birth weight and small placenta. Assess for signs of fetal distress.\n\n**Cardiac Evaluation**\n\nCongenital heart disease is present in the majority of cases. Obtain echocardiography to identify structural lesions (VSD, PDA, ASD, polyvalvular disease). Monitor for signs of heart failure and pulmonary hypertension.\n\n**Feeding and Nutrition**\n\nPoor feeding is common. Nasogastric tube feeding is often necessary. Growth charts specific to trisomy 18 should be used for monitoring.\n\n**Respiratory Support**\n\nCentral apnea and hypoventilation are major causes of mortality. Provide respiratory monitoring and support as clinically indicated.\n\n**Diagnostic Confirmation**\n\nG-banded karyotype analysis is the study of choice to confirm diagnosis and determine recurrence risk. This is particularly important if translocation is suspected, as recurrence risk is higher for translocation carriers and depends on the chromosomes involved and the sex of the carrier parent."
  },
  {
    "article_id": 165,
    "article_title": "Congenital Hypothyroidism",
    "section_id": "61950c9d1c424d62844325d2438e9bc1",
    "section_title": "Management",
    "variant": "clinical",
    "imperatives": 1,
    "content": "**Diagnosis and Initial Assessment**\n\nIdentify infants at risk through newborn screening programs. Congenital [[171|hypothyroidism]] should be considered in any infant presenting with significant constipation, prolonged jaundice, hypotonia, or hypothermia.\n\nConfirm diagnosis with TSH measurement ideally after 48 hours of age (minimum 24 hours). TSH elevation above a threshold of 20 μL indicates congenital hypothyroidism. In suspected central hypothyroidism, clinical suspicion is required as TSH-based screening may miss these cases.\n\n**Treatment Initiation**\n\nBegin levothyroxine replacement therapy as quickly as possible after diagnosis, with the goal of initiating treatment by 2 weeks of age. The passages do not provide specific dosing information for levothyroxine.\n\n**Monitoring and Follow-up**\n\nMonitor for resolution of clinical manifestations. Neonatal cholestasis, if present, typically resolves with appropriate hormone supplementation. Assess for associated [[115|congenital anomalies]], particularly cardiac anomalies, and evaluate hearing. In infants with central hypothyroidism or pan-hypopituitarism, screen for adrenal insufficiency, as delayed treatment may lead to severe consequences including death."
  },
  {
    "article_id": 166,
    "article_title": "Cyanotic Heart Disease",
    "section_id": "e02e258d2a734457b791f1b450657906",
    "section_title": "Management of the acutely ill cyanotic infant",
    "variant": "clinical",
    "imperatives": 12,
    "content": "**Initial assessment:**\n- Perform rapid clinical evaluation to determine if congenital heart disease is the cause\n- Obtain pulse oximetry, chest radiography, and electrocardiography\n- Perform careful neurological examination to identify complications (hypoxaemic spells, stroke, brain abscess)\n\n**If signs of [[285|congestive heart failure]] or cardiogenic shock are present:**\n- Recognise that survival depends on maintaining ductus arteriosus patency\n- Initiate early infusion of prostaglandin E1 (alprostadil) under carefully controlled monitoring\n- Arrange emergent cardiology consultation\n- Consider inhaled nitrous oxide or extracorporeal membrane oxygenation in severe cases\n\n**If well-appearing but investigations abnormal:**\n- Refer urgently to paediatric cardiologist\n- Arrange echocardiography for further evaluation\n- Admit for therapy and cardiac evaluation if acutely ill\n\n**Ongoing management of cyanotic patients:**\n- Monitor for polycythaemia\n- Avoid [[99|dehydration]]; consider decreasing or temporarily discontinuing diuretics during [[273|acute gastroenteritis]] or excessively hot weather\n- Avoid high altitudes and sudden thermal environmental changes\n- Treat iron deficiency\n- Monitor for rhythm disturbances and sudden cardiac death risk"
  },
  {
    "article_id": 167,
    "article_title": "Familial Hypercholesterolemia",
    "section_id": "1e85823f897d45d191cdb479ea428716",
    "section_title": "Management",
    "variant": "clinical",
    "imperatives": 7,
    "content": "**Screening and Diagnosis**\n\n1. Identify candidates: children with family history of FH, family history of premature coronary heart disease, or severely elevated cholesterol in a parent\n2. Measure fasting lipid profile including total cholesterol and LDL cholesterol\n3. Confirm diagnosis if LDL cholesterol persistently >160 mg/dL (>4.144 mmol/L) or >190 mg/dL (>4.921 mmol/L) with supporting family or clinical history\n4. Perform genetic testing to confirm pathogenic variant in *LDLR*, *APOB*, or *PCSK9*\n\n**Initial Management**\n\n1. Counsel on dietary modification: reduce total and saturated fat consumption\n2. Recommend at least 1 hour of physical activity daily\n3. Ensure diet provides appropriate energy for normal growth and sufficient micronutrients\n4. Encourage weight management in obese patients\n5. Expect dietary changes alone to lower LDL cholesterol by 5–15%\n\n**Pharmacological Treatment**\n\n1. Initiate statin therapy when dietary measures are insufficient\n2. Statins are the preferred agents for LDL cholesterol reduction\n3. Treatment target: reduce LDL cholesterol by 50% or achieve levels below 130 mg/dL (3.367 mmol/L)\n4. Consider starting statin therapy at age 10 years in children with confirmed FH to achieve long-term cardiovascular risk reduction comparable to unaffected siblings"
  },
  {
    "article_id": 168,
    "article_title": "Gastroenteritis",
    "section_id": "84b71a4062064fdaa3257602d2ee2f41",
    "section_title": "Management",
    "variant": "clinical",
    "imperatives": 2,
    "content": "**Assessment**\n\nObtain a clinical history and perform examination to identify severity and complications. Consider differential diagnoses including surgical emergencies (intussusception, appendicitis), systemic infections (septicaemia, meningitis), and metabolic disorders.\n\n**Rehydration**\n\nOral rehydration is the mainstay of treatment for most cases. This is typically sufficient for mild to moderate gastroenteritis.\n\n**Antimicrobial Therapy**\n\nAntimicrobials are indicated only for:\n- Severe diarrhea\n- Wound infection\n- Septicaemia\n\nFor suspected Vibrio species infection causing severe diarrhea:\n- Doxycycline or ciprofloxacin\n- Doxycycline can be used for short durations (21 days or less) without regard to patient age\n\nFor Vibrio septicaemia with or without haemorrhagic bullae, or wound infections:\n- Third-generation cephalosporin plus either doxycycline or ciprofloxacin\n- Alternative: trimethoprim-sulfamethoxazole plus an aminoglycoside\n\nWound infections may also require surgical débridement of necrotic tissue if present.\n\n**Monitoring**\n\nMost cases resolve within 4–5 days. Monitor for complications including reactive arthritis and neurological symptoms (particularly with Campylobacter infection)."
  },
  {
    "article_id": 169,
    "article_title": "Group B Streptococcus Infection",
    "section_id": "0ba275bf8f124cea9713eb4de0f12a9d",
    "section_title": "Management",
    "variant": "clinical",
    "imperatives": 7,
    "content": "**Diagnosis and Initial Assessment**\n\n- Obtain blood culture and cerebrospinal fluid (CSF) culture from any neonate or infant with suspected GBS infection\n- Perform Gram stain and culture on 5% sheep blood agar; look for narrow-zone beta-hemolysis\n- Confirm diagnosis by Lancefield group B antigen detection (latex agglutination) or biochemical testing (bacitracin resistance, CAMP factor production, bile esculin negative, trimethoprim-sulfamethoxazole resistance)\n- Check white blood cell count and immature-to-total neutrophil ratio\n\n**Treatment**\n\n- Administer parenteral antibiotics for a full 10-day course\n- Do not shorten duration or switch to oral antibiotics in uncomplicated cases, as outcome data supporting such approaches are lacking\n\n**Special Considerations**\n\n- Birth mates of a multiple birth index case with early- or late-onset GBS disease should be observed carefully\n- Evaluate birth mates and treat empirically for suspected systemic infection if signs of illness develop\n- Continue full-course treatment in birth mates with confirmed GBS infection"
  },
  {
    "article_id": 170,
    "article_title": "Hyponatremia",
    "section_id": "675983fdfb2640b4aff6f4bc7d5d5cd1",
    "section_title": "Management",
    "variant": "clinical",
    "imperatives": 1,
    "content": "**Step 1: Assess Volume Status**\n\nDetermine clinically whether the patient is hypovolemic, euvolemic, or hypervolemic using history, physical examination (including weight changes), vital signs, and laboratory data (serum electrolytes, blood urea nitrogen, creatinine, uric acid, urine sodium, specific gravity, osmolality).\n\n**Step 2: Determine Correction Rate**\n\nThe rise in serum sodium should not exceed 0.5 mEq/L per hour or 6–8 mEq/L per 24 hours unless the patient demonstrates central nervous system symptoms (seizures, altered mental status, coma) that warrant more rapid initial correction.\n\n**Step 3: Calculate Deficit and Plan Replacement**\n\nHalf of the sodium deficit is replenished in the first 8 hours of therapy, and the remainder is given over the following 16 hours. Maintenance and replacement fluids should also be provided. Deficit plus maintenance calculations often approximate 5% dextrose with 0.45% or higher saline.\n\n**Step 4: Manage by Volume Status**\n\n**Hypovolemic hyponatremia:** First restore intravascular volume with normal saline boluses of 20 mL/kg as needed to correct the volume deficit. Then provide hypotonic fluids to further replace the water deficit. Note that even normal saline (osmolality 308 mEq/L) is hypotonic relative to hypertonic serum and allows gradual sodium reduction.\n\n**Hypervolemic hyponatremia:** Restrict both sodium and water intake and correct the underlying disorder. If due to water intoxication (characterized by maximally dilute urine with specific gravity <1.003), restrict water.\n\n**Step 5: Monitor and Avoid Complications**\n\nAvoid overly rapid correction, which can cause osmotic demyelination syndrome, cerebral dehydration, and seizures. Monitor serum sodium regularly to ensure correction remains within safe limits."
  },
  {
    "article_id": 171,
    "article_title": "Hypothyroidism",
    "section_id": "fca2e6451ecb4c818796f166a14ef554",
    "section_title": "Management",
    "variant": "clinical",
    "imperatives": 3,
    "content": "**Diagnostic Approach**\n\n1. Measure serum TSH and free T4 levels\n   - Elevated TSH with low/low-normal free T4 indicates primary hypothyroidism\n   - Normal or low TSH with low free T4 suggests central hypothyroidism\n\n2. Obtain anti-thyroid antibodies (anti-thyroperoxidase and anti-thyroglobulin) if autoimmune thyroiditis suspected\n\n3. Consider thyroid ultrasound to confirm presence of thyroid tissue, particularly in congenital cases\n\n4. In central hypothyroidism, assess for additional pituitary hormone deficiencies and evaluate for midline defects\n\n**Neonatal Screening**\n\nAll newborns require thyroid function testing. If not performed at birth, screening should occur at the first clinical encounter (e.g., vaccination visit). Standard neonatal screening programs typically measure TSH to detect primary hypothyroidism; many do not detect central hypothyroidism.\n\n**Monitoring After Treatment Initiation**\n\nFollow growth velocity as a key indicator of adequate thyroid hormone replacement. Normal growth velocity should resume following initiation of therapy."
  },
  {
    "article_id": 172,
    "article_title": "Knee Injury",
    "section_id": "742b0b3ef5fd4346ae068162e56058c7",
    "section_title": "Management",
    "variant": "clinical",
    "imperatives": 8,
    "content": "**Initial Assessment**\n\n1. Obtain detailed history of mechanism of injury, as this guides diagnosis\n2. Assess timing of swelling: rapid swelling within hours suggests hemarthrosis and serious internal injury\n3. Perform physical examination, recognizing that reliable assessment of ligamentous stability may not be possible with significant swelling\n\n**Imaging**\n\n- Obtain radiographs to exclude fractures, particularly physeal injuries in younger children\n- Arrange magnetic resonance imaging for evaluation of soft tissue and bony injuries when available\n- Plan outpatient orthopedic referral for repeat clinical evaluation once swelling has improved\n\n**Immobilization**\n\n- Use immobilizers for patients with significant pain with movement\n- Avoid prolonged immobilization without repeat evaluation due to risk of quadriceps atrophy\n\n**Bracing and Rehabilitation**\n\n- Apply functional knee brace to enhance proprioception and control terminal extension\n- Permit full knee motion within the brace within a few days\n- Allow weight bearing\n- Initiate strengthening program\n- Continue bracing until pain and range of motion improve and subjective instability resolves\n- Functional brace required for return to competition\n\n**Return to Activity**\n\n- Most isolated, low-grade medial collateral ligament injuries: return to play in 3–5 weeks\n- Return to sports for other injuries is variable and depends on severity of tear and associated injuries"
  },
  {
    "article_id": 173,
    "article_title": "Neonatal Conjunctivitis",
    "section_id": "e54005b05e3646c69fecccce6c876635",
    "section_title": "Management",
    "variant": "clinical",
    "imperatives": 4,
    "content": "**Immediate assessment:**\n- Perform emergency Gram stain to rule out [[185|gonorrhea]]\n- Obtain aerobic, anaerobic, and viral cultures\n- Refer all cases to ophthalmology\n- Document timing of symptom onset and character of discharge\n\n**Diagnostic testing:**\n- Giemsa staining from conjunctival scrapings for chlamydia\n- Direct immunofluorescence antibody testing for chlamydia\n\n**Treatment by organism:**\n\n| Organism | Treatment |\n|----------|----------|\n| *Neisseria gonorrhoeae* | Intravenous penicillin or third-generation cephalosporin + topical antibiotics + saline irrigation |\n| *Chlamydia trachomatis* | Oral azithromycin (topical drops not effective as monotherapy) |\n| *Pseudomonas* | Systemic aminoglycoside + saline irrigation + gentamicin ophthalmic ointment |\n| *Staphylococcus* | Parenteral methicillin + saline irrigation |\n| Chemical (prophylaxis-related) | Supportive care; resolves by 48 hours |\n\n**Important notes:**\n- Topical treatment alone is insufficient for infectious conjunctivitis because it does not clear nasopharyngeal carriage\n- Treatment of maternal contacts is required for chlamydial cases: mothers of infected infants and mothers' sexual partners should be treated for *C. trachomatis*"
  },
  {
    "article_id": 174,
    "article_title": "Neonatal Infection",
    "section_id": "14fcd86af7a64999bd914fd7ffc5c58b",
    "section_title": "Management Approach",
    "variant": "clinical",
    "imperatives": 2,
    "content": "**Initial Assessment**\n\nMaintain high clinical suspicion for neonatal infection in any symptomatic newborn. Obtain detailed maternal history including:\n- Maternal genital infections (herpes simplex virus, [[185|gonorrhea]])\n- Maternal fever or [[355|chorioamnionitis]]\n- Duration of rupture of membranes\n- Maternal antibiotic prophylaxis status\n\n**Diagnostic Evaluation**\n\nFor suspected systemic infection:\n- Blood culture (before antibiotics)\n- Complete blood count\n- Liver function tests (abnormalities suggest herpes simplex virus or enteroviral infection)\n- Cerebrospinal fluid examination and culture if [[147|meningitis]] suspected\n- Enteroviral polymerase chain reaction from cerebrospinal fluid in neonates with [[226|sepsis]] signs and elevated liver enzymes\n\nFor skin lesions:\n- Potassium hydroxide preparation (candidiasis shows budding yeast with pseudohyphae)\n- Bacterial culture as indicated\n\nFor suspected herpes simplex virus:\n- Consider in any neonate with abnormal liver function tests\n- Viral culture and polymerase chain reaction from affected sites\n\n**Specific Infection Management**\n\n**Neonatal Candidiasis (skin):** Topical antifungal medications are effective for diaper dermatitis and oral thrush. If difficult to treat, evaluate for immunosuppression.\n\n**Gonococcal Ophthalmia Neonatorum:** In-hospital evaluation and treatment are recommended.\n\n**Impetigo:** Treat as indicated for *Staphylococcus aureus* or group A streptococcus infection.\n\n**General Principles**\n\nBecause 60–80% of mothers transmitting herpes simplex virus have no prior genital infection history, clinical suspicion cannot rely on maternal history alone. Enteroviral infections are more severe in neonates than older children and may rapidly progress to meningitis, hepatitis, or [[100|myocarditis]]; maintain low threshold for investigation and treatment."
  },
  {
    "article_id": 175,
    "article_title": "Osteomyelitis",
    "section_id": "cfdd8afff0484d5fb9dbd7f5c8f30c68",
    "section_title": "Management",
    "variant": "clinical",
    "imperatives": 1,
    "content": "**Recognition and Initial Assessment**\n\nThe goal of treatment is prompt recognition of osteomyelitis in the febrile child presenting with bone pain. Obtain a focused history including trauma, preceding infection, and risk factors ([[162|sickle cell disease]], prior surgery, immunocompromise). Examine for point tenderness over the metaphysis, swelling, erythema, warmth, and range of motion limitation.\n\n**Diagnostic Testing**\n\n1. **Blood cultures** — obtain before antibiotics (positive in ~50% of cases)\n2. **Complete blood count** — assess for elevated white blood cell count\n3. **Acute phase reactants** — erythrocyte sedimentation rate, C-reactive protein, or procalcitonin\n4. **Plain radiographs** — of the suspected site; may be negative early but should be obtained\n5. **Bone biopsy or aspiration** — attempt prior to antibiotics if child is nontoxic and immunocompetent; provides organism identification and susceptibility testing\n6. **MRI** — the preferred imaging modality; demonstrates early edema, subperiosteal abscess, and contiguous infections; should guide surgical drainage if abscess is suspected\n\n**Antibiotic Therapy**\n\nInitiate empiric antibiotics promptly after cultures are obtained. The passages do not provide specific antibiotic regimens, dosing, or routes. Tailor therapy based on:\n- Organism identification and susceptibility\n- Local resistance patterns\n- Patient age and renal function\n- Presence of risk factors ([[162|sickle cell disease]], immunocompromise, puncture wounds, bites)\n\nMacrolides are less effective than other antibiotics and are recommended only for patients who cannot tolerate cephalosporins, penicillins, or tetracyclines.\n\n**Monitoring**\n\nRepeat acute phase reactants (erythrocyte sedimentation rate or C-reactive protein) to monitor treatment effectiveness."
  },
  {
    "article_id": 177,
    "article_title": "Primary Dysmenorrhea",
    "section_id": "51d28f409a714b0199af57d090d8212d",
    "section_title": "Management",
    "variant": "clinical",
    "imperatives": 2,
    "content": "**Assessment**\n\nObtain detailed menstrual and sexual history with HEEADSSS psychosocial screening. Pelvic examination may be deferred in non-sexually active adolescents with a presentation consistent with primary [[137|dysmenorrhea]]. If examination is performed, it should be normal.\n\n**First-line treatment: NSAIDs**\n\nStart NSAIDs 1–2 days before the expected onset of menses and continue through day 2–3 of bleeding. Use age and weight-appropriate doses:\n- Ibuprofen: every 6–8 hours\n- Naproxen: twice daily\n- Mefenamic acid: as an alternative\n\nAcetaminophen-containing products are not as effective as NSAIDs for dysmenorrhea.\n\n**Second-line treatment: Hormonal contraception**\n\nFor adolescents who do not respond to NSAIDs after appropriate use, or who prefer hormonal management:\n- Combination oral contraceptive pills improve symptoms in 90% of young women\n- Maximum therapeutic benefit may take 3 cycles to achieve\n- NSAIDs and oral contraceptives used together can provide enhanced relief\n\n**Adjunctive measures**\n\nCounsel patients to avoid smoking and caffeine. Consider alternative treatments with evidence of effectiveness: omega-3 polyunsaturated fatty acids, vitamin E, vitamin B1, and magnesium.\n\n**When to suspect secondary dysmenorrhea**\n\nIf symptoms do not improve after 6 months of appropriate NSAIDs and/or hormonal management, suspect secondary dysmenorrhea caused by endometriosis or other pelvic pathology and investigate further. Red flags include pain at menarche, intercycle pain, severe dysmenorrhea, or family history of endometriosis."
  },
  {
    "article_id": 178,
    "article_title": "Septic Shock",
    "section_id": "e5d9c893ab7f4599ac85ad1dc9d12716",
    "section_title": "Management: First 15 Minutes",
    "variant": "clinical",
    "imperatives": 3,
    "content": "**Immediate actions (0–5 minutes):**\n- Establish intravenous access; if unsuccessful, establish intraosseous line\n- Maintain or restore airway and breathing\n- Initiate continuous cardiac monitoring\n\n**Within 15 minutes:**\n- Administer fluid bolus: **10–20 mL/kg isotonic crystalloid or balanced/buffered solution**\n- Attend to airway and establish intravascular access if not already done\n- Diagnose and correct [[321|hypoglycemia]]\n- Diagnose and correct [[368|hypocalcemia]]\n- Draw blood cultures and laboratory studies\n- Administer empiric broad-spectrum antibiotics\n\n**Fluid resuscitation strategy:**\n- Deliver repeat fluid boluses as needed up to **40–60 mL/kg total** in the first 15–60 minutes\n- Observe for signs of fluid overload (increased work of breathing, rales, cardiac gallop, hepatomegaly); stop if these develop"
  },
  {
    "article_id": 178,
    "article_title": "Septic Shock",
    "section_id": "35b2908f27d04fec8b45728ad6a00c9e",
    "section_title": "Management: First Hour and Beyond",
    "variant": "clinical",
    "imperatives": 1,
    "content": "**Resuscitation endpoints to achieve:**\n- Heart rate: age-appropriate threshold\n- Blood pressure: age-appropriate normal\n- Capillary refill: ≤2 seconds\n- No difference between peripheral and central pulses\n- Warm extremities\n- Urine output: >1 mL/kg per hour\n- Normal mental status\n- Cardiac index: 3.3–6.0 L/min/m²\n- Superior vena cava oxygen saturation: ≥70%\n- Perfusion pressure (MAP − CVP): 55 ± 1.5 × age in years\n\n**Vasoactive agents:**\n- Start vasoactive agents as needed if resuscitation endpoints are not achieved with fluids alone\n\n**Ongoing assessment:**\n- Patients responsive to fluid may be observed in the pediatric intensive care unit\n- Cardiac output measurement can be performed invasively or noninvasively to guide therapy\n- Continue to maximize oxygen and glucose delivery"
  },
  {
    "article_id": 179,
    "article_title": "Sleep Disorder",
    "section_id": "56fdaabd970a442988af929342929e56",
    "section_title": "Clinical Assessment and Management",
    "variant": "clinical",
    "imperatives": 1,
    "content": "**Initial Assessment**\n\nObtain a detailed sleep history from the child and parent or caregiver, including sleep onset time, nighttime awakenings, morning wake time, daytime sleepiness, snoring, witnessed apneas, and movements during sleep. Document behavioral and environmental factors such as bedtime routine, bedroom environment (presence of electronics), caffeine intake, and consistency of sleep schedule.\n\nIdentify associated medical, psychiatric, or neurodevelopmental conditions. In children with ADHD, depression, anxiety, or [[117|autism spectrum disorder]], specifically assess for sleep disturbance as part of the clinical evaluation.\n\n**Diagnostic Considerations**\n\nFor suspected [[311|obstructive sleep apnea]], polysomnography may be indicated based on clinical presentation and risk factors. Videography can document excessive nocturnal movements in suspected restless sleep disorder.\n\n**Management Approach**\n\nBegin with behavioral interventions addressing sleep hygiene: establish consistent bedtimes and wake times, implement a structured bedtime routine, remove electronics from the bedroom, and eliminate caffeine intake.\n\nFor children with autism spectrum disorder or depression presenting with [[377|insomnia]], cognitive behavioral therapy is an evidence-based treatment option. Melatonin or medications may be considered in autism-associated insomnia when behavioral interventions are insufficient.\n\nIn restless sleep disorder associated with low serum iron levels, iron supplementation should be considered, with symptomatic improvement expected following treatment.\n\nFor medication-related sleep disturbance in ADHD, review timing and type of stimulant or nonstimulant medication with consideration for dose adjustment or alternative agents in consultation with the prescribing clinician.\n\nAddress underlying psychiatric conditions (depression, anxiety, bipolar disorder) with appropriate pharmacotherapy and psychotherapy as indicated, which may improve associated sleep disturbance."
  },
  {
    "article_id": 181,
    "article_title": "Vaginal Infection",
    "section_id": "d50827ab7d994608beb469fb1f8f73cd",
    "section_title": "Management",
    "variant": "clinical",
    "imperatives": 1,
    "content": "**Initial Assessment**\n\n1. Obtain history of discharge characteristics, duration, associated symptoms, and hygiene practices\n2. Examine for perianal redness, introital inflammation, and discharge appearance\n3. Collect vaginal discharge for wet preparation and KOH microscopy using a cotton swab inserted into the vagina while avoiding hymenal contact\n4. In sexually active adolescents or suspected sexual abuse: obtain urine for NAATs (*Chlamydia*, *Neisseria gonorrhoeae*); consider VDRL/RPR, HIV testing, and HSV testing if lesions present\n\n**Diagnostic Interpretation**\n\n| Finding | Likely Diagnosis |\n|---------|------------------|\n| Clue cells, few leukocytes, *Lactobacillus* outnumbered by mixed flora | Bacterial vaginosis |\n| Leukocytes, yeast, mycelia, or pseudomycelia (40–80% of cases) | Candida vulvovaginitis |\n| Motile trichomonds (50–70% of symptomatic patients) | *Trichomonas* vaginitis |\n| Normal epithelial cells, *Lactobacillus* predominates | Physiologic discharge |\n\n**Treatment by Organism**\n\n**[[239|Bacterial vaginosis]]:**\n- Metronidazole 500 mg orally twice daily for 7 days, OR\n- Metronidazole gel 0.75% one full applicator intravaginally daily for 5 days, OR\n- Clindamycin 300 mg orally twice daily for 7 days\n\n**Vulvovaginal candidiasis:**\n- Fluconazole 150 mg orally once, OR\n- Intravaginal azole cream (multiple formulations available)\n\n**[[402|Trichomoniasis]]:**\n- Metronidazole 2 g orally once, OR\n- Tinidazole 2 g orally once\n\n**Supportive Care (All Cases)**\n\n- Recommend sitz baths\n- Advise front-to-back wiping technique\n- Encourage frequent urination opportunities\n- Instruct on regular washing with warm water without excessive scrubbing\n- Recommend loose-fitting clothes and white cotton underwear, well rinsed after washing\n- Advise avoidance of bubble baths and irritant products\n\n**Follow-up**\n\n- Review adherence to hygiene measures at follow-up visit\n- If no improvement despite appropriate treatment and adherence, reassess diagnosis and consider sexual abuse, foreign body, or referral to pediatric gynecology"
  },
  {
    "article_id": 182,
    "article_title": "Acute Cerebellar Ataxia",
    "section_id": "db435671a5684fbea60609353c637719",
    "section_title": "Management",
    "variant": "clinical",
    "imperatives": 1,
    "content": "**Assessment and Investigation**\n\n1. **History and examination**: Document timing of symptom onset, preceding viral illness, and current neurological status. Confirm normal mental status, normal strength, normal sensation, and normal reflexes to support the diagnosis.\n\n2. **Lumbar puncture**: Perform to exclude [[147|meningitis]] and other CNS infections. Expect normal or near-normal opening pressure, protein, and glucose. Mild lymphocytic pleocytosis (10–30/mm³) is acceptable; significant elevation in white blood cell count or protein suggests alternative diagnosis.\n\n3. **Brain MRI**: Obtain as imaging modality of choice. Normal MRI supports diagnosis of acute cerebellar ataxia and indicates more favorable prognosis. T2 hyperintensities suggest cerebellitis rather than simple ataxia.\n\n**Treatment**\n\nAcute cerebellar ataxia is self-limiting. There is no evidence that corticosteroids or other immune therapy alters outcome. Management is supportive:\n\n- Reassurance and observation\n- Management of nausea and vomiting as needed\n- Safety precautions during the acute phase\n- Monitoring for improvement, which typically begins within weeks\n\n**Red Flags Requiring Escalation**\n\nIf the child develops signs of increased intracranial pressure, focal neurological signs, meningismus with fever, or progressive encephalopathy, consider alternative diagnoses (cerebellitis with MRI abnormalities, posterior fossa tumor, cerebellar abscess, or acute disseminated encephalomyelitis). These conditions may require more aggressive intervention including steroids or neurosurgical consultation."
  },
  {
    "article_id": 184,
    "article_title": "Cystic Fibrosis",
    "section_id": "2d87f4b30f674aa39443f17589e4811a",
    "section_title": "Management",
    "variant": "clinical",
    "imperatives": 4,
    "content": "### Assessment\n\nRoutinely assess nutritional parameters as part of standard care. Monitor for decline in growth, which may indicate worsening pulmonary status, onset of cystic fibrosis-related diabetes, or cystic fibrosis-related liver disease.\n\n### Nutritional Support\n\nChildren over 2 years of age (including adolescents) should achieve energy intake at levels of **110% to 200% above usual requirements** in healthy children to achieve age-appropriate weight gain. Implement a combination of approaches:\n- Calorie boosting\n- Nutritional supplements\n- Behavioural interventions\n\nThe goal is to maintain normal weight and height for age, as normal growth is associated with better lung function and survival.\n\n### Management of Pulmonary Exacerbations\n\nPulmonary exacerbations present with cough, chest congestion, dyspnoea, tachypnoea, and may include fever. Rhonchi and/or rales may be diffuse or localised. Sputum viscosity or colour may change. Investigate with lung function testing (FEV₁) and chest radiography to assess for worsening.\n\n### Management of Acute Complications\n\n**Distal ileal obstruction syndrome:** Presents with abdominal pain, distention, and emesis without fever. Obtain abdominal radiography to confirm diagnosis.\n\n**[[396|Pneumothorax]]:** Presents with acute onset ipsilateral chest pain, shortness of breath, and ipsilateral decreased or absent breath sounds. Confirm with chest radiography.\n\n**Cystic fibrosis-related diabetes:** Screen for weight loss or poor weight gain, polydipsia, polyuria, and glycosuria. Measure glucose and haemoglobin A₁c levels; perform glucose tolerance testing if indicated.\n\n### Coordination of Care\n\nWhen possible, coordinate management of a patient with cystic fibrosis with the staff of the cystic fibrosis centre where the child receives routine care."
  },
  {
    "article_id": 185,
    "article_title": "Gonorrhea",
    "section_id": "94f5f559d9c94e66aca17ce6905af7b8",
    "section_title": "Management",
    "variant": "clinical",
    "imperatives": 5,
    "content": "**Assessment and Evaluation**\n\n- Obtain careful sexual history including pharyngeal and anorectal exposure\n- Send blood cultures in neonatal cases to evaluate for disseminated infection ([[226|sepsis]], arthritis, [[147|meningitis]])\n- Test all patients for concurrent syphilis, HIV, and *Chlamydia trachomatis* infection\n- In prepubertal children with genital, rectal, or pharyngeal infection, conduct thorough epidemiologic investigation and consider sexual abuse\n\n**Treatment of Uncomplicated Infections (Adolescents)**\n\nDual therapy is recommended for uncomplicated gonococcal infections of the cervix, urethra, rectum, and pharynx:\n- **Ceftriaxone** intramuscularly, once\n- **Azithromycin** orally, once\n\n**Neonatal Disease**\n\n- Hospitalize infants with clinical evidence of ophthalmia neonatorum or scalp abscess\n- Treat in consultation with an infectious disease specialist\n- Evaluate for disseminated infection\n\n**Post-Treatment Counseling**\n\n- Instruct patients to abstain from sexual activity for 7 days after treatment and until all sexual partners are adequately treated\n- Provide same-day treatment linkage if medications unavailable at initial visit\n- Identify and treat all sexual contacts; expedited partner treatment (prescriptions without examination) increases success\n- Administer medication on-site with direct observation when possible"
  },
  {
    "article_id": 186,
    "article_title": "Group A Streptococcal Pharyngitis",
    "section_id": "8348d0a757df43f8a8805ffa91224203",
    "section_title": "Management",
    "variant": "clinical",
    "imperatives": 2,
    "content": "**Diagnosis and Initial Assessment**\n\nConfirm GAS pharyngitis clinically based on sudden sore throat, tonsillar inflammation, and cervical lymphadenopathy, particularly in children aged 5–15 years. Note that throat culture may be negative if infection has localized to cervical lymph nodes.\n\n**Antimicrobial Therapy**\n\nInitiate a standard pharyngitis antibiotic regimen. The passages do not specify drug names, doses, or routes, so these should be determined from current local guidelines and formularies.\n\n**Timing**\n\nBegin treatment promptly to reduce acute morbidity and prevent complications. Patients become non-contagious 24 hours after starting appropriate antimicrobial therapy.\n\n**Management of [[194|Acute Rheumatic Fever]]**\n\nIf ARF develops:\n- Eradicate GAS with the standard pharyngitis antibiotic regimen\n- Treat acute manifestations (arthritis, valvulitis, heart failure) according to clinical presentation\n- Provide education to parents and patient\n- Initiate secondary prophylaxis to prevent future GAS infections\n\n**Note on [[369|Glomerulonephritis]]**\n\nAntimicrobial therapy does not prevent acute glomerulonephritis after pharyngitis or pyoderma, so treatment decisions should not be based on this goal."
  },
  {
    "article_id": 187,
    "article_title": "Hematuria",
    "section_id": "6c6983a9fe4d4ca9a192f5d6b4e23470",
    "section_title": "In short",
    "variant": "short",
    "imperatives": 2,
    "content": "- Hematuria is defined as ≥5 red blood cells per high-power field on spun urine; occurs in 4–6% of school-aged children\n- Confirm dipstick-positive urine with microscopy; distinguish true hematuria from haemoglobinuria or myoglobinuria\n- [[8|Urinary tract infection]] is the most common cause; [[369|glomerulonephritis]] and trauma are the most common serious causes\n- Glomerular hematuria produces brown or tea-colored urine, often with proteinuria, casts, and [[92|hypertension]]\n- Non-glomerular hematuria produces red urine, typically without proteinuria; common causes include stones, hypercalciuria, and [[162|sickle cell disease]]\n- All children require: urine microscopy and culture, protein and calcium excretion, renal ultrasound, and blood tests (urea, electrolytes, creatinine, calcium, phosphate, albumin, FBC, platelets, coagulation screen, sickle cell screen)\n- If glomerular hematuria suspected, add: ESR, complement levels, anti-DNA antibodies\n- Admit if severe pain, heart failure, hypertension, renal insufficiency, or generalized oedema present"
  },
  {
    "article_id": 187,
    "article_title": "Hematuria",
    "section_id": "e0ed7f16009a40cb88a9af5b24f0e195",
    "section_title": "Management",
    "variant": "clinical",
    "imperatives": 2,
    "content": "**Initial assessment**\n\n1. Confirm hematuria with urine microscopy of fresh, spun urine showing red blood cells; dipstick alone is insufficient\n2. Obtain focused history: painless vs painful, intermittent vs persistent, gross vs microscopic; trauma history; family history of hematuria or renal disease\n3. Examine for signs of systemic disease: [[92|hypertension]], oedema, flank mass, perineal bruising (consider abuse), signs of heart failure\n\n**Investigations for all children with hematuria**\n\n- Urine microscopy with phase contrast and culture\n- Urine protein and calcium excretion\n- Kidney and urinary tract ultrasound\n- Blood tests: urea, electrolytes, creatinine, calcium, phosphate, albumin, full blood count, platelets, coagulation screen, sickle cell screen\n\n**Additional investigations if glomerular hematuria suspected**\n\nGlomerular hematuria is suggested by brown or tea-colored urine, deformed red cells, casts, and proteinuria.\n\n- Erythrocyte sedimentation rate\n- Complement levels (C3, C4)\n- Anti-DNA antibodies\n\n**Admission indications**\n\nAdmit if hematuria is associated with:\n- Severe abdominal or flank pain\n- [[285|Congestive heart failure]] or fluid overload with oliguria or anuria\n- [[92|Hypertension]]\n- Renal insufficiency\n- Generalized oedema (anasarca)"
  },
  {
    "article_id": 188,
    "article_title": "Hemolytic Anemia",
    "section_id": "730ce279a90e4cd6a4e56e70cb6b2f85",
    "section_title": "Management",
    "variant": "clinical",
    "imperatives": 3,
    "content": "**Initial Assessment**\n\nRecognize hemolytic anemia in any child presenting with unexplained low haemoglobin accompanied by reticulocytosis. Typical features include pallor, jaundice, dark urine, fatigue, and splenomegaly. Symptoms may develop suddenly or evolve over days to weeks.\n\n**Immediate Stabilization**\n\nThe goal is to stabilize the haemoglobin level and maintain sufficient oxygen-carrying capacity and cardiac output. Early recognition and intervention for uncompensated anemia is critical.\n\n**Transfusion Indications**\n\n- **Severe [[349|anemia]] with cardiovascular compromise**: Transfuse when haemoglobin <5 g/dL\n- **Reticulocytopenia**: Transfuse in the presence of reticulocytopenia\n\n**Warm Autoimmune Hemolytic Anemia**\n\n1. **First-line treatment**: Corticosteroids (prednisone)\n2. **Second-line options**: Splenectomy or rituximab\n3. **Transfusion**: Reserve for severe [[349|anemia]] with cardiovascular compromise or reticulocytopenia\n\n**Cold Autoimmune Hemolytic Anemia**\n\n- Advise cold avoidance\n\n**Life-Threatening Autoimmune Hemolysis**\n\n- Urgently consult hematology\n- Consider high-dose steroids, intravenous immunoglobulin, plasmapheresis, or exchange transfusion as indicated\n- Long-term management may include splenectomy or immunosuppressant medications\n\n**Neonatal Hemolytic Disease**\n\n- Intensive phototherapy\n- Exchange transfusion\n\n**Nonimmune Hemolytic Anemia**\n\n- Observation and supportive care\n- Remove offending agent if identified\n- Prevent renal damage from significant hemolysis\n- For small-vessel disease (e.g., thrombotic thrombocytopenic purpura): prompt plasma exchange can be lifesaving\n- Treat underlying disorder (e.g., collagen vascular disease, renal failure in haemolytic-uraemic syndrome)\n\n**Inherited Hemolytic Anemias**\n\n- Careful long-term monitoring\n- Occasional transfusions as needed\n- Hematology consultation for management planning"
  },
  {
    "article_id": 189,
    "article_title": "Hemolytic Disease Of The Newborn",
    "section_id": "0c01923863224778a86ebaa72248610a",
    "section_title": "Management",
    "variant": "clinical",
    "imperatives": 4,
    "content": "**Initial Assessment**\n\n1. Obtain blood group and direct Coombs test on cord blood or infant blood\n2. Perform peripheral blood smear to identify spherocytes, schistocytes, and nucleated red blood cells\n3. Measure hemoglobin, hematocrit, and reticulocyte count\n4. Establish baseline total serum bilirubin level\n5. Monitor for signs of hemolysis: jaundice within first 6 hours, pallor, hepatosplenomegaly\n\n**Ongoing Monitoring**\n\nInfants with Rh disease require surveillance for:\n- [[400|Thrombocytopenia]] (from liver dysfunction or disseminated intravascular coagulation)\n- [[321|Hypoglycemia]] (secondary to pancreatic islet cell hyperplasia)\n- Direct [[130|hyperbilirubinemia]] (from hepatocellular damage)\n\n**Therapeutic Interventions**\n\n**Exchange Transfusion**\n- Removes antibody-coated red blood cells\n- Replaces with uncoated donor red blood cells lacking the sensitizing antigen\n- Prolongs intravascular red blood cell survival\n- Reduces bilirubin concentration\n\n**Intravenous Immunoglobulin (IVIG)**\n- Indicated if total serum bilirubin is rising despite intensive phototherapy\n- Indicated if total serum bilirubin is within 2 to 3 mg/dL of the exchange transfusion threshold\n- Decreases the need for exchange transfusion in Rh and ABO incompatibility\n- Specific dosing not provided in available guidelines"
  },
  {
    "article_id": 190,
    "article_title": "Inhalation Injury",
    "section_id": "414a0f2d0bde4be3823d01eb4eae50be",
    "section_title": "In short",
    "variant": "short",
    "imperatives": 1,
    "content": "- Inhalation injury occurs in 20–30% of children with severe burns and accounts for up to 90% of burn-related mortality\n- Suspect inhalation injury with history of confined-space fire exposure, decreased consciousness, carbonaceous sputum, singed nasal hairs, or voice changes\n- Children's small airways mean 1 mm of circumferential oedema reduces diameter by 2 mm and increases resistance 16-fold (versus 3-fold in adults)\n- Thermal injury predominantly affects upper airway; steam and chemical products injure lower airways\n- Acute [[102|[[151|respiratory distress]] syndrome]] typically develops 24–48 hours after injury\n- Chest X-ray may be normal initially despite significant pulmonary injury\n- Mild cases: supplemental oxygen, albuterol for wheezing, racemic epinephrine for stridor\n- Significant injury: early intubation and mechanical ventilation with positive end-expiratory pressure\n- Early inhaled anticoagulants (within 2–4 hours) may reduce obstructive fibrin formation\n- Steroids are generally not recommended for airway injury in burn patients\n- Reduced lung function persists for 3–8 years after injury"
  },
  {
    "article_id": 190,
    "article_title": "Inhalation Injury",
    "section_id": "4fea3e0017fc41bcaff6d4e4e4a5b660",
    "section_title": "Management at the bedside",
    "variant": "clinical",
    "imperatives": 1,
    "content": "**Initial assessment (ABC approach)**\n\n1. **Airway evaluation first** — Inhalation of hot gas causes rapid local oedema and loss of airway patency. Lower the threshold for intubation in children because small airway diameter makes them vulnerable to rapid compromise.\n\n2. **Recognise concomitant poisoning** — Screen for carbon monoxide and cyanide exposure, which contribute significantly to morbidity and early death.\n\n3. **Obtain arterial blood gas** — Measure carboxyhemoglobin level. Do not rely on pulse oximetry, as oxygen saturation values are often falsely elevated.\n\n**Mild inhalational injury**\n\n- Supplemental oxygen\n- Albuterol nebuliser treatment if wheezing is present\n- Racemic epinephrine nebuliser treatment if stridor is present\n- Close monitoring for deterioration\n- Steroids are generally not recommended\n\n**Significant inhalational injury**\n\n- **Early intubation** — Perform promptly if there is any evidence of airway burns or oedema, or if [[151|respiratory distress]] develops\n- **Mechanical ventilation** — Use positive end-expiratory pressure to reduce pulmonary oedema from vascular leak\n- **Inhaled anticoagulant** — Consider within 2–4 hours of injury (e.g. tissue plasminogen activator or heparin) to prevent obstructive fibrin formation\n- **Non-invasive ventilation** — Continuous positive airway pressure devices may benefit awake, cooperative patients with lesser pulmonary involvement and few facial burns\n- **Fluid management** — Careful attention to fluid balance\n- **Antibiotics** — As needed for superinfection\n\n**Serial endoscopy**\n\nIf clinical assessment is uncertain, experienced physician should perform serial endoscopy to visualise laryngeal soft-tissue changes. If oedema is present, splint the airway open by intubation.\n\n**Admission criteria**\n\nAdmit to intensive care if unstable airway, respiratory distress, severe hypoxia, ongoing blood loss, or other severe injuries are present."
  },
  {
    "article_id": 192,
    "article_title": "Pediatric Oncology",
    "section_id": "bdf80184a0094a87be7eef5bfdc40b31",
    "section_title": "Clinical Approach",
    "variant": "clinical",
    "imperatives": 1,
    "content": "**Initial Assessment**\n\nWhen evaluating a pediatric oncology patient presenting to clinical care:\n\n1. **History taking** — Explore the patient and parents' perspective on the cause of symptoms and current clinical status. Obtain a detailed medication history documenting all current medications (chemotherapy agents, antibiotics, antiemetics, and supportive care medications) and their timing, as side effects may contribute to presenting symptoms.\n\n2. **Differential diagnosis** — Include malignant processes in the differential diagnosis of common childhood complaints. Recognize that oncologic emergencies require prompt identification.\n\n3. **Psychosocial context** — Acknowledge the extreme stress a cancer diagnosis places on families and provide care with appropriate compassion and professionalism.\n\n**Ongoing Management**\n\nLong-term follow-up care of pediatric cancer survivors should incorporate:\n\n- Exposure-based health screening guidelines to provide a framework for high-quality supervision\n- Ongoing dialogue with pediatric oncology subspecialists regarding changes in follow-up recommendations\n- Monitoring for late effects including hematologic, infectious, neurologic, cardiovascular, hepatic, and gastrointestinal complications\n- Pain and symptom control throughout treatment and in terminal care"
  },
  {
    "article_id": 193,
    "article_title": "Acute Abdomen",
    "section_id": "3d17bc4ddd90461abe9e4866971238d6",
    "section_title": "Bedside Management",
    "variant": "clinical",
    "imperatives": 2,
    "content": "**Initial Assessment**\n\n1. **History**: Characterise the pain (onset, duration, location, progression), associated symptoms (vomiting—bilious or nonbilious, diarrhoea, fever), recent exposures (sick contacts, travel), and relevant past medical history.\n\n2. **Physical Examination**:\n   - Assess general appearance and toxicity\n   - Palpate abdomen using flat surface of fingers (not fingertips)\n   - Evaluate for guarding, distension, tenderness (location and severity)\n   - Auscultate bowel sounds\n   - Examine right lower quadrant specifically (McBurney's point)\n   - Inspect skin for petechiae or purpura\n   - Assess for signs of [[99|dehydration]] or [[226|sepsis]]\n\n3. **Initial Investigations**:\n   - Full blood count\n   - C-reactive protein level\n   - Plain vertical abdominal X-ray\n   - Abdominal ultrasonography\n\n**Management Strategy**\n\n**For patients appearing toxic or with findings concerning for surgical abdomen** (bilious vomiting, guarding, significant tenderness, absent bowel sounds):\n- Keep nothing by mouth\n- Establish intravenous access\n- Obtain urgent surgical consultation\n- Defer antibiotics pending surgical evaluation\n\n**For nontoxic patients with atypical presentations**:\n- Keep nothing by mouth\n- Defer antibiotics until diagnosis is more certain\n- Conduct serial abdominal examinations\n- Repeat laboratory studies (full blood count, C-reactive protein) as dictated by clinical suspicion\n- Arrange early surgical consultation if clinical concern persists\n\n**Key Principle**: Maintain a low threshold for early surgical consultation, particularly in infants and young children where diagnostic difficulty is greatest and rapid progression of pathology can occur."
  },
  {
    "article_id": 194,
    "article_title": "Acute Rheumatic Fever",
    "section_id": "4cb70dccf419424794378ad7a6d112dd",
    "section_title": "Management",
    "variant": "clinical",
    "imperatives": 7,
    "content": "**Initial Assessment**\n\n- Obtain detailed history of preceding pharyngitis (even if not recalled by patient or family)\n- Perform thorough cardiac examination, auscultating for systolic murmur at apex (mitral regurgitation) or early diastolic murmur (aortic regurgitation)\n- Assess for other manifestations: migratory joint pain/swelling, subcutaneous nodules, erythema marginatum, neurological signs (chorea)\n\n**Investigations**\n\n- Measure inflammatory markers: erythrocyte sedimentation rate (ESR) and C-reactive protein (CRP)\n- Obtain antistreptolysin O (ASO) and anti-DNase B titers\n- Perform 12-lead electrocardiogram to assess for heart block\n- Obtain chest radiograph to evaluate for cardiomegaly, pulmonary edema, or pericardial effusion\n- **Arrange echocardiography at a qualified center** in all suspected cases to assess for carditis, valvular regurgitation, myocardial dysfunction, and pericardial effusion\n\n**Cardiac Evaluation**\n\nAll patients require thorough cardiac evaluation and echocardiography. Approximately 5–10% of patients develop severe [[100|myocarditis]] with heart failure requiring aggressive treatment.\n\n**Secondary Prevention**\n\nFor patients with confirmed ARF, initiate long-term chemoprophylaxis:\n\n| Drug | Dose | Route | Frequency |\n|------|------|-------|----------|\n| Penicillin G benzathine | 1.2 million units | Intramuscular | Every 4 weeks |\n| Penicillin G benzathine | 600,000 units | Intramuscular | Every 4 weeks (for lower body weight) |\n\n**Primary Prevention**\n\nPrompt diagnosis and treatment of acute GAS pharyngitis in the emergency department is the most effective means of preventing rheumatic heart disease and ARF development."
  },
  {
    "article_id": 195,
    "article_title": "Atopic Dermatitis",
    "section_id": "c151ced731b2484c8f1e88c48a2874b9",
    "section_title": "Management",
    "variant": "clinical",
    "imperatives": 1,
    "content": "### Skin Care Foundation\n\nBegin with basic skin care measures for all patients:\n- Avoid irritants and proven allergens\n- Maintain skin hydration with regular moisturizers of good quality\n- Wet skin for 5–10 minutes twice daily\n\n### Topical Corticosteroids (First-Line)\n\nUse topical corticosteroids as first-line therapy in patients requiring more than moisturizer alone.\n\n**Low potency:**\n- Hydrocortisone 1%, 2.5%\n- Desonide 0.05%\n\n**Moderate potency:**\n- Hydrocortisone valerate 0.2%\n- Mometasone furoate 0.1%\n- Triamcinolone 0.1%\n- Fluocinolone 0.1%\n\n### Topical Calcineurin Inhibitors (Second-Line)\n\nTacrolimus is approved for patients 2 years of age or older as second-line treatment.\n\n### Systemic Therapy\n\nFor severe disease:\n- Cyclosporine\n- Ultraviolet therapy\n\n### Infection Management\n\n**Bacterial superinfection:** Oral antibiotics are required when superinfection occurs but are not indicated for routine prophylactic use.\n\n**Herpes simplex/[[288|eczema]] herpeticum:** Initiate acyclovir treatment. If periorbital skin or nasal tip involvement is present, obtain ophthalmologic consultation. Severe cases may require hospitalization for intravenous antiviral therapy.\n\n**Candida coinfection:** Use topical nystatin, clotrimazole, or miconazole.\n\n**Tinea corporis:** Treat with topical antifungal agents.\n\n**[[339|Tinea capitis]]:** Requires systemic antifungal therapy.\n\n**Malassezia-related scaling:** Antifungal shampoos may help reduce scaling.\n\n### Antihistamines\n\nSedating antihistamines help most with itching. Note that topical calcineurin inhibitors can cause stinging and burning sensations on application.\n\n### Patient and Family Education\n\nInform families that there is no immediate cure; treatment aims to control the disease. Weeks of effective control may be followed by sudden severe relapse. Careful attention to aggravating factors (dry skin, sweating, stress, secondary infection) is essential."
  },
  {
    "article_id": 196,
    "article_title": "Atrioventricular Septal Defect",
    "section_id": "240170089f4f48b8a0a18ff777b9a9d5",
    "section_title": "Management",
    "variant": "clinical",
    "imperatives": 6,
    "content": "**Initial Assessment**\n\n1. Identify clinical context: newborn with Down syndrome or signs of heart failure (poor feeding, tachypnoea, hepatomegaly) at 2–3 weeks of life\n2. Perform physical examination: assess for loud pulmonary component of S2; note that murmur may be absent in neonates\n3. Obtain 12-lead ECG: look for extreme left axis deviation and superior axis\n\n**Diagnostic Confirmation**\n\n4. Arrange urgent echocardiography (gold standard):\n   - Apical four-chamber view to visualize common atrioventricular valve spanning atrial and ventricular defects\n   - Colour Doppler to assess regurgitation jets and left-to-right shunting\n   - Measure chamber sizes and assess right atrial enlargement\n5. Obtain chest radiograph to assess for cardiomegaly, pulmonary vascularity, and venous congestion\n\n**Medical Management (Acute Phase)**\n\n6. Treat heart failure:\n   - Restrict fluid intake\n   - Administer diuretics as needed\n   - Optimize nutrition and monitor growth\n7. Monitor for complications including pulmonary [[92|hypertension]]\n\n**Definitive Treatment**\n\n8. Refer for surgical repair at 3–6 months of age\n   - Procedure involves separating the common valve into mitral and tricuspid components\n   - Closure of atrial and ventricular septal defects"
  },
  {
    "article_id": 197,
    "article_title": "Breastfeeding Difficulty",
    "section_id": "0ad6ed3e99d74b0b90374850e19f41ba",
    "section_title": "Management",
    "variant": "clinical",
    "imperatives": 6,
    "content": "**Assessment and Initial Evaluation**\n\n1. **Determine the source of difficulty** through history and observation:\n   - Maternal: nipple pain, engorgement, inadequate milk supply, or systemic illness\n   - Infant: poor latch, ankyloglossia, nasal congestion, or systemic illness\n\n2. **Evaluate infant for illness** if presenting with decreased feeding interest accompanied by lethargy, fever, vomiting, diarrhea, cough, or difficulty breathing—refer to pediatrician\n\n3. **Assess latch and positioning** to identify poor technique as cause of nipple pain or inadequate milk transfer\n\n**Management of Specific Problems**\n\n**Nipple pain and trauma:**\n- Correct positioning and latch technique\n- Lubricate and cover nipple wounds to promote healing\n- Continue breastfeeding with corrected latch\n- Refer to certified lactation consultant if severe or persistent\n- Pain medication safe during breastfeeding may be offered if needed\n\n**Engorgement:**\n- Increase feeding frequency\n- Perform manual pumping or expression before feedings to soften breast and improve latch\n\n**Infant nasal congestion:**\n- Clear nasal passages with bulb syringe prior to feeding\n\n**Feeding frequency and duration:**\n- Recommend at least 8–12 feedings per day when infant shows early feeding cues\n- Target approximately 10–45 minutes per feeding\n- Do not exceed 1 hour per feeding\n- Prioritize adequate infant intake over feeding duration\n\n**Referral and Support**\n\n- Refer to certified lactation consultant for severe nipple pain, suspected latch problems, or inadequate milk transfer\n- Refer to pediatrician for infant illness, suspected ankyloglossia, or [[104|failure to thrive]]\n- Connect mother with family support, peer support networks, and reliable breastfeeding information resources\n- For mothers with opioid use disorder, provide trauma-informed counseling and support"
  }
]