[ { "article_id": 384, "article_title": "Nocturnal Enuresis", "section_id": "e1028e16cc754d8ea340d7f5e049eadc", "section_title": "Taking the history and exam", "variant": "clinical", "imperatives": 2, "content": "The history specifically covers the number of wet nights per week, the longest stretch of dryness ever achieved, evening fluid intake, daytime voiding frequency and symptoms (urgency, straining, weak stream, dribbling), constipation, and snoring or mouth breathing. The family is directly asked about a parental history of childhood bedwetting, since this is rarely volunteered but carries strong prognostic value (40% risk with one affected parent, 70% with both). On exam, hypertension or [[246|growth failure]] (chronic renal disease) is checked for, and a genital exam is performed for meatal stenosis or labial fusion, along with an abdominal exam for an enlarged bladder or kidneys. Urinalysis and culture are sent to exclude infection, and urine specific gravity is noted to screen for a concentrating defect. In a previously dry child with new-onset enuresis, abuse or a new emotional stressor is considered as a possible trigger and screened for accordingly." }, { "article_id": 385, "article_title": "Laryngomalacia", "section_id": "4b28950e8c7e4385ab0f1e1c9a597112", "section_title": "Diagnosing and Triaging the Infant with Stridor", "variant": "clinical", "imperatives": 3, "content": "Laryngomalacia is suspected in an infant with inspiratory stridor beginning in the first 2-6 weeks of life that worsens with crying, feeding, agitation, and supine positioning, and improves prone and at rest - this pattern, together with normal oxygen saturation and a normal chest radiograph, supports an upper-airway (supraglottic) source rather than lower respiratory disease. Diagnosis is confirmed with awake flexible fiberoptic laryngoscopy, looking for the omega-shaped epiglottis, short aryepiglottic folds, and inspiratory prolapse of the arytenoid mucosa/cuneiform cartilage. Early airway examination (rather than waiting) is obtained in infants presenting under 4 weeks of age or with severe obstruction, since these presentations warrant ruling out an alternative cause. If stridor sounds wet, is accompanied by cough with feeds, or there is a history of recurrent respiratory illness or pneumonia, evaluation for dysphagia with a contrast swallow study or FEES is warranted, since laryngomalacia can impair suck-swallow-breath coordination. For infants with moderate to severe obstruction, complete bronchoscopy is performed, since 15-60% have a synchronous airway anomaly that would otherwise be missed." }, { "article_id": 385, "article_title": "Laryngomalacia", "section_id": "e89f5ae3972348529b2e809ced4f8f60", "section_title": "Managing the Expected Course and Recognizing Red Flags", "variant": "clinical", "imperatives": 1, "content": "Families are reassured that most laryngomalacia is mild, self-limited, and managed expectantly with positioning and treatment of any coexisting GERD, with symptoms typically peaking by about 6 months, improving from 7-9 months, and resolving completely by 12-18 months in the majority of infants. Reflux is screened for and treated, since GERD/laryngopharyngeal reflux can worsen severity and prolong the clinical course. Surgical evaluation (supraglottoplasty) is pursued for stridor at rest with retractions and increased work of breathing, or for chronic signs such as failure to thrive, [[311|obstructive sleep apnea]], hypoxemia, or severe dyspnea - these more severe presentations occur in only about 10-22% of cases. If stridor worsens or persists beyond the expected improving trajectory instead of following the typical course, reassessment for an alternate or coexisting diagnosis (such as an enlarging subglottic hemangioma, vocal cord paralysis, or subglottic stenosis) is warranted rather than continuing to attribute symptoms to uncomplicated laryngomalacia." }, { "article_id": 386, "article_title": "Parasitic Infection", "section_id": "f340f79e114147bcb7788a213a573987", "section_title": "Deciding whom and how to test", "variant": "clinical", "imperatives": 1, "content": "Before parasitic testing is ordered in a child with diarrhea, pretest probability is considered: more than 90% of stool O&P exams in the US are negative, and helminths are rarely the cause of diarrhea. Broad parasitic workup is reserved for children with a specific risk factor — travel to or residence in an endemic area, daycare attendance with a known outbreak, exposure to contaminated water (well water, a pool, a stream), or pet/animal contact — rather than ordering an O&P reflexively on every child with loose stools. When protozoal infection (Giardia, Cryptosporidium, Entamoeba) is genuinely suspected, molecular (PCR-based) stool testing is favored over traditional O&P microscopy, since these are now the more accurate and commonly used diagnostic approach for these organisms." }, { "article_id": 386, "article_title": "Parasitic Infection", "section_id": "3acff6c343784f84b6ca98df03fa7df4", "section_title": "Recognizing and managing giardiasis specifically", "variant": "clinical", "imperatives": 1, "content": "Giardiasis is suspected in a child with diarrhea and a history of exposure to potentially contaminated water (well water, a stream, or even a treated pool, since Giardia resists chlorination), daycare attendance, or a household contact with similar symptoms — remembering that 25% of infected individuals are asymptomatic, so an asymptomatic carrier in the household can be the ongoing source. Because pets are rarely a source of human Giardia infection (due to host-specific strain differences), exposure history focuses on water sources, daycare, and person-to-person contact rather than the family dog or cat. When antiparasitic treatment is selected for any confirmed parasitic infection, FDA approval status and pediatric-specific indications are verified before prescribing, since the antiparasitic drug landscape includes agents with limited approval or that are available only through the CDC." }, { "article_id": 387, "article_title": "Metabolic Acidosis", "section_id": "1e84d21ac02d4c9387502c8f07b6c0f0", "section_title": "Treating Metabolic Acidosis Safely", "variant": "clinical", "imperatives": 3, "content": "Treatment is directed first at correcting the underlying cause - rehydration and treatment of the precipitating illness, rather than bicarbonate, resolves most cases. Fluid balance is corrected in infants with a dilutional component to their acidosis. For chronic acidosis from ongoing bicarbonate loss, bicarbonate supplementation is added directly to feeds. Reflexive intravenous sodium bicarbonate bolus for acute acidosis is avoided: it is reserved for severely unstable, persistently acidotic infants who have failed other measures, and only when the infant is intubated/ventilated or breathing well enough spontaneously to clear the resulting CO2 load, given the risks of volume overload, [[379|intracranial hemorrhage]], hypernatremia, worsened respiratory acidosis, impaired oxygen delivery, and paradoxical intracellular acidosis. Families are counselled that chronic acidosis causes reversible [[246|growth failure]], and that adequate correction (for example, in [[284|chronic kidney disease]] with bicarbonate or citrate) is important specifically for growth and bone health, not simply for normalizing a lab value." }, { "article_id": 387, "article_title": "Metabolic Acidosis", "section_id": "5405a368a9624d99ad929d0820395970", "section_title": "Working Up a Child with Metabolic Acidosis", "variant": "clinical", "imperatives": 2, "content": "BUN, creatinine, glucose, urinalysis, and electrolytes are obtained as baseline studies, and the anion gap is calculated to narrow the differential. In an acutely ill child, diarrhea (stool bicarbonate loss), shock/lactic acidosis (perfusion is assessed carefully - dehydration, blood loss, sepsis, and heart disease can all present this way), and DKA (glucose, urine ketones and glucose are checked) are considered the most common acute causes. In a child with ketosis and only mild acidosis (bicarbonate above 18 mEq/L) attributed to poor intake, a concurrent illness such as gastroenteritis is actively sought, since starvation ketosis alone rarely explains significant acidosis. Metabolic acidosis with seizures or depressed sensorium in an infant is treated as a possible inborn error of metabolism until proven otherwise, with accompanying hypoglycemia or hyperammonemia checked for, while meningitis/sepsis with lactic acidosis is considered the more common explanation when neurologic signs and acidosis coexist without a metabolic-disease history. In a child with failure to thrive and chronic acidosis, evaluation for renal insufficiency or renal tubular acidosis is undertaken, including Fanconi syndrome-associated type II RTA (normoglycemia with glycosuria) and adrenal insufficiency (acidosis with hypoglycemia). Medication exposure and possible [[338|toxic ingestion]] (ethylene glycol, methanol) are always asked about, since these are treatable causes with excellent response to specific therapy when identified promptly." }, { "article_id": 388, "article_title": "Phenylketonuria (Pku)", "section_id": "88b65950e89c43a59856007042c376ab", "section_title": "Ongoing management and special scenarios", "variant": "clinical", "imperatives": 1, "content": "Confirmed PKU is managed with a lifelong phenylalanine-restricted diet under the guidance of a metabolic clinic and a nutritionist experienced in PKU, aiming for good phenylalanine control by 3-4 weeks of age and sustained control thereafter to maximize neuropsychological outcome. Continued breastfeeding is supported where desired, but phenylalanine levels are monitored closely given ongoing intake from breast milk. Patients and families are counselled to avoid aspartame. For a newborn of a mother with known PKU, phenylalanine levels are measured once enteral feeding is established, and early quantitative amino acid analysis is considered rather than relying on routine newborn screening alone, given the child's elevated background risk (about 1 in 80) and the possibility of in-utero phenylalanine-related effects (microcephaly, congenital heart disease, intellectual disability) even in a heterozygous, unaffected infant if maternal phenylalanine control was inadequate during pregnancy." }, { "article_id": 389, "article_title": "Neurofibromatosis Type 1", "section_id": "df36bd1819ae4e289b05eeca9100e744", "section_title": "Diagnosing NF1 in a Child", "variant": "clinical", "imperatives": 2, "content": "The 2-of-7 criteria are applied systematically: 6 or more cafe-au-lait macules (over 5 mm prepubertal, over 15 mm postpubertal), 2 or more neurofibromas of any type or 1 plexiform neurofibroma, axillary/inguinal freckling, optic pathway glioma, 2 or more Lisch nodules, a distinctive osseous lesion, or a first-degree relative with NF1. Cafe-au-lait macules are expected from birth, freckling by adolescence in about 75% of cases, and Lisch nodules on slit-lamp exam in about 75% of prepubescent children after age 3 - so a young child may only show cafe-au-lait spots initially. When a child has 6 or more cafe-au-lait macules but no other criterion yet, NF1 is not dismissed - the child is followed clinically, since about 95% eventually meet full diagnostic criteria (usually by 8-10 years of age). Referral to ophthalmology for slit-lamp exam and screening is made whenever NF1 is suspected or diagnosed, given the risk of Lisch nodules and, more importantly, optic pathway glioma (occurring in 15-20% of NF1 children, usually before age 6), which can cause visual loss or [[222|precocious puberty]]. In counseling families, both parents are evaluated carefully, since about half of cases are inherited (autosomal dominant, nearly full penetrance) and half are new mutations - this distinction matters for genetic counseling of the family." }, { "article_id": 389, "article_title": "Neurofibromatosis Type 1", "section_id": "ef116cbeacf44ce39c39e135f0ff37ec", "section_title": "Monitoring for Complications", "variant": "clinical", "imperatives": 1, "content": "Expectations are set that NF1 manifestations emerge over time rather than all at once, and that about two-thirds of patients have a mild course while the remaining third face a range of unpredictable complications - so periodic, structured monitoring (rather than one-time reassurance) is the right model of care. [[114|Learning disability]] is actively screened for and addressed, since it affects 30-60% of children with NF1 and is a major driver of quality of life, independent of physical manifestations. Signs of vascular dysplasia (moyamoya arteriopathy, in 3-7% of children) are watched for if new neurologic symptoms develop, and optic pathway and brainstem gliomas in NF1 tend to behave more indolently than in children without NF1, which can inform a more conservative initial approach to management in consultation with neuro-oncology." }, { "article_id": 390, "article_title": "Polycystic Ovary Syndrome", "section_id": "b9abf72de27f49cfab8b4b87dbe5ce09", "section_title": "Diagnosing PCOS in the adolescent", "variant": "clinical", "imperatives": 1, "content": "In an adolescent at least 2 years post-menarche with irregular cycles (under 21 or over 45 days in years 1-3 post-menarche, or under 21/over 35 days or fewer than 8 cycles/year beyond that, or any cycle over 90 days), evaluation is made for both hyperandrogenism (clinical: hirsutism, moderate-to-severe acne, male-pattern alopecia; biochemical: elevated free/total testosterone, DHEA-S, androstenedione) and other causes of irregular cycles (thyroid dysfunction, hyperprolactinemia) are excluded before PCOS is diagnosed — this evaluation is done before oral contraceptives are started for the irregular cycles, since starting hormonal therapy first can mask the underlying picture. Pelvic ultrasound is not relied upon in this age group: polycystic-appearing ovaries are a normal finding in many adolescents from ongoing pubertal anovulatory cycles, so the adult ultrasound criterion should not be applied. True virilization (clitoromegaly, voice change, rapidly progressive hirsutism) is specifically watched for — this is not consistent with PCOS and should prompt evaluation for a more severe androgen-excess condition instead." }, { "article_id": 391, "article_title": "Oligohydramnios", "section_id": "9e9d5a8799bf474c82bfb4319334ec29", "section_title": "Counseling and Coordinating Care", "variant": "clinical", "imperatives": 1, "content": "Because severe oligohydramnios from bilateral renal agenesis or severe renal dysplasia carries an extremely high mortality risk (respiratory insufficiency from pulmonary hypoplasia), antenatal counseling is coordinated with maternal-fetal medicine and neonatology as soon as significant oligohydramnios with a suspected renal cause is identified, so families understand the prognosis before delivery. For infants who survive the immediate perinatal period, the broader pattern of associated anomalies (cardiac defects, GI atresias, imperforate anus, Pierre Robin sequence) is screened for rather than assuming an isolated renal or pulmonary problem. Developmental dysplasia of the hip is screened for in any infant with a history of oligohydramnios, since intrauterine crowding increases this risk; most minor ultrasound findings between 6 weeks and 4 months resolve with observation, but referral to orthopedics is made if clinical instability (positive Barlow test) persists." }, { "article_id": 392, "article_title": "Post-Concussion Syndrome", "section_id": "3d3b763cd611435da491ad477a43305a", "section_title": "Initial assessment after a head injury", "variant": "clinical", "imperatives": 3, "content": "Any child with a blow to the head, face, neck, or body is evaluated for the five symptom categories of [[200|concussion]]: somatic (headache, dizziness, nausea, light/noise sensitivity, fatigue), vestibular, cognitive (amnesia, confusion, difficulty concentrating), emotional (irritability, anxiety), and sleep-related. Loss of consciousness occurs in fewer than 5% of concussions and does not predict severity or recovery time, so its absence should not be reassuring nor its presence alarming on its own. Laboratory workup (CBC, electrolytes, glucose, toxicology, coagulation studies) is reserved for significant [[139|head trauma]] or altered consciousness, rather than routine concussion presentations. Risk factors for prolonged recovery — female sex, [[308|migraine]] history, prior concussion, family/social stressors, a neurodevelopmental disorder, or psychiatric illness — are specifically asked about, since initial symptom burden combined with these factors helps anticipate which children are more likely to develop persistent postconcussion symptoms." }, { "article_id": 392, "article_title": "Post-Concussion Syndrome", "section_id": "c568716d734d429e8d077ba3c2643044", "section_title": "Managing recovery and return to activity", "variant": "clinical", "imperatives": 3, "content": "Management starts with cognitive and physical rest, favoring a reduction rather than complete elimination of activity, with the plan individualized to the child's specific symptom spectrum. A stepwise, progressive return-to-activity program is used for both school and sport, advancing physical and cognitive demands gradually while monitoring for symptom recurrence at each stage — advancement does not continue if symptoms return. Athletes and families are counselled that a second head injury before full recovery from the first risks second impact syndrome, a catastrophic and sometimes fatal complication, so strict avoidance of return to play until complete symptom resolution is essential. Referral for formal neuropsychological or neurobehavioral testing is made when recovery extends beyond the usual 7-10 day window or symptoms are substantially interfering with school or daily function. For athletes with a history of multiple concussions, especially those from progressively lesser force, taking longer to resolve, or showing a change from baseline, a more conservative eligibility decision is favored for continued contact or collision sport participation." }, { "article_id": 393, "article_title": "Peanut Allergy", "section_id": "f126142b9c5d4609b83c43106ff44cb8", "section_title": "Deciding When and How to Introduce Peanut", "variant": "clinical", "imperatives": 1, "content": "Every infant is stratified by [[288|eczema]] severity and egg-allergy status before deciding on peanut introduction timing. For an infant with severe eczema, egg allergy, or both, referral for peanut-specific IgE and/or skin prick testing (with an oral food challenge if results are indeterminate) is strongly considered before peanut is introduced, aiming for introduction as early as 4-6 months once safety is established; a skin prick wheal of 0-2 mm is interpreted as low risk (introduce at home or in a supervised office feeding), 3-7 mm as moderate-to-severe risk (refer to a specialist or arrange supervised office feeding), and 8 mm or more as very likely allergic (continue management with a specialist) - the same risk tiers apply to peanut-specific IgE using the 0.35 kUA/L cutoff. For an infant with mild-to-moderate eczema, peanut-containing foods are introduced around 6 months without needing prior testing. For an infant with no eczema or known food allergy, peanut-containing foods are introduced whenever age-appropriate, per family preference and cultural practice. Families are not counselled to delay peanut introduction as a preventive strategy, even with a strong family history of allergy - the evidence (LEAP trial) instead supports early, regular introduction (at least 6 g of peanut protein over 3+ meals weekly in high-risk infants) as protective, cutting allergy risk from about 17% to about 3% by age 5 in that population." }, { "article_id": 393, "article_title": "Peanut Allergy", "section_id": "54930440f3cf4d70bd30840db87bd012", "section_title": "Managing a Reaction and Ongoing Care", "variant": "clinical", "imperatives": 2, "content": "Any presentation of rash, swelling, and wheezing after peanut exposure is treated as [[143|anaphylaxis]]: epinephrine is given promptly, along with antihistamines and systemic corticosteroids, and observation for a late-onset (biphasic) reaction occurs before discharge. After stabilization, a complete allergy evaluation and allergist referral are arranged for any child suspected of having peanut allergy - history alone is not relied upon given the risk of both under- and overdiagnosis. The family is equipped with a written avoidance plan, instruction on careful food-label reading, an epinephrine auto-injector to be carried at all times, and a medical alert bracelet. Families are counselled that most children with peanut allergy do not outgrow it, and that any resolution occurs almost exclusively within the first 5 years of life - so ongoing allergist follow-up and periodic reassessment (rather than a one-time diagnosis) is the appropriate long-term model of care." }, { "article_id": 394, "article_title": "Primary Amenorrhea", "section_id": "5605fffcf1d646cd9354ab368c10f974", "section_title": "Deciding when to evaluate", "variant": "clinical", "imperatives": 2, "content": "The proactive evaluation thresholds are applied rather than waiting until age 16: referral or workup is begun for a girl with no menses by age 15 despite normal growth and secondary sexual characteristics, no menses more than 3 years after thelarche onset, or no secondary sexual characteristics at all by age 13. Evaluation is prompt, regardless of age, if delayed secondary sexual development accompanies the amenorrhea or if cyclic pelvic pain is present alongside primary amenorrhea, since the latter suggests an outflow tract obstruction (imperforate hymen, transverse vaginal septum) with trapped menstrual blood that needs timely surgical attention. In a competitive female athlete, any positive menstrual-history screening question (absent menarche by 15, menarche not within 5 years of initial breast development) is treated as a trigger for further endocrine and gynecologic evaluation, with low energy availability considered alongside other causes." }, { "article_id": 395, "article_title": "Short Bowel Syndrome", "section_id": "11addc9c02c3488ebbc99b8d7b58b6e2", "section_title": "Nutritional management and monitoring", "variant": "clinical", "imperatives": 1, "content": "Total parenteral nutrition is started in the immediate postoperative period to meet caloric, fluid, and electrolyte needs while the bowel is insufficient, but enteral feeding is introduced as early as feasible, since this maximizes enteric hormonal stimulation and promotes bowel adaptation (elongation, hypertrophy, and slowed peristalsis) rather than leaving the bowel unstimulated. Recovery can take years, sometimes requiring TPN for the first several years of life, and a multidisciplinary short bowel program is involved early, given the substantial survival benefit these programs and improved catheter/PNALD management have demonstrated (over 90% survival in recent series). The specific prognostic factors are tracked over time — residual bowel adaptive potential, infection frequency, and the function of other organs — to guide the pace of weaning from parenteral nutrition and to identify children who may eventually need consideration for intestinal transplantation." }, { "article_id": 396, "article_title": "Pneumothorax", "section_id": "cf991b066d864f5785585af8120ecb90", "section_title": "Identifying the Underlying Cause", "variant": "clinical", "imperatives": 1, "content": "In a tall, thin adolescent male presenting with sudden chest pain and dyspnea without trauma, primary spontaneous pneumothorax is considered, with smoking, vaping, or drug use (marijuana, cocaine, MDMA) asked about, and CT imaging for apical blebs is considered if recurrence or diagnostic uncertainty exists; an underlying connective tissue disorder (Marfan syndrome, Ehlers-Danlos syndrome) is also considered if there are supporting physical features or family history. In a child with known asthma, cystic fibrosis, or another chronic lung disease presenting with pneumothorax, it is classified as secondary spontaneous pneumothorax, and the underlying disease is addressed alongside the acute air leak. Iatrogenic causes (recent central line placement, intubation, biopsy, or mechanical ventilation) are considered in any hospitalized child who develops sudden respiratory decline. In an adolescent female with recurrent spontaneous pneumothorax temporally linked to menstruation, the rare diagnosis of catamenial pneumothorax is considered and appropriate referral made, since standard management alone will not address the underlying diaphragmatic defect. Even a small, seemingly stable pneumothorax in a child should prompt admission for observation given its potential to progress." }, { "article_id": 397, "article_title": "Substance Intoxication", "section_id": "261c6d1e99c84e3fa3da5dbc9bbbb93c", "section_title": "Initial stabilization and history-taking", "variant": "clinical", "imperatives": 1, "content": "Airway, breathing, circulation, and mental status assessment are prioritized immediately in any child with suspected substance intoxication, before a detailed history or diagnostic workup is pursued. Once stabilized, a comprehensive history is gathered from witnesses, family, and friends about the nature of the substance, timing, and circumstances, recognizing that a clear history is often unavailable and that toxicology screening does not always clarify the picture — a high index of suspicion is maintained regardless. Passive or environmental exposure (transplacental, breast milk, inhalation, or presence where drugs are used or manufactured) is considered in an infant or young child with unexplained intoxication signs, and substance use or withdrawal is considered in any adolescent with chronic, persistent irritability. Examination for pallor (hemolysis) or cyanosis (methemoglobinemia) is performed as clues to specific toxic mechanisms, and evaluation for ataxia and metabolic derangement (hypoglycemia, [[170|hyponatremia]], hyperammonemia) is done alongside the standard exam." }, { "article_id": 398, "article_title": "Polytrauma", "section_id": "8ba05693e1e34e48ba5967c98a2acf2e", "section_title": "In short", "variant": "short", "imperatives": 1, "content": "- Polytrauma is trauma to more than one area of the body, generally reserved for moderate-to-severe injury requiring multiple interventions across specialties (e.g., head plus orthopedic plus abdominal plus plastic surgery, including burns).\n- Trauma is the leading cause of morbidity and mortality in children in the developed world, and blunt trauma is the most common mechanism of injury in children.\n- Multisystem injury is the rule rather than the exception in children - internal injury must always be suspected when the mechanism warrants it, even without visible external trauma.\n- Children's unique anatomy increases vulnerability: a relatively larger cranium means more space between brain and skull, so bridging veins have less support, and thinner musculature/padding gives organs less protection.\n- Children have a remarkable capacity to maintain systolic blood pressure despite 25-30% acute blood loss, so normal blood pressure does not exclude significant hemorrhage; [[211|hypovolemic shock]] from acute blood loss is the most common cause of shock in pediatric trauma patients, and hemorrhagic shock is defined by cardiac output failing to meet tissue metabolic demand, not by any specific blood pressure number.\n- The ABCDE sequence (airway, breathing, circulation, disability, exposure) should be followed for initial assessment in every child with polytrauma; airway is the top priority since choking kills faster than any other threat, and the cervical spine should always be protected in a child with polytrauma.\n- Length-based tools are used for rapid weight estimation to guide drug doses and equipment sizing in a child whose actual weight is unknown.\n- Persistent shock despite initial resuscitation should prompt consideration of neurogenic shock, cardiac contusion, or cardiac tamponade, not just ongoing hemorrhage.\n- Continuous monitoring after initial resuscitation is mandatory to detect further deterioration, and management should follow a multidisciplinary approach with a single team leader; a Pediatric Trauma Score below 0 is associated with a very poor prognosis and should prompt transport to the nearest appropriate facility.\n- Polytrauma can have significant psychological and social impact on the developing brain, contributing to considerable morbidity; psychological and social support during and after resuscitation is an important part of care. Improved emergency medical services, transport systems, and trauma facilities have significantly reduced trauma-related mortality in developed countries." }, { "article_id": 398, "article_title": "Polytrauma", "section_id": "babf30bc86ae408981da6339f65f8db0", "section_title": "Initial Assessment of the Polytrauma Patient", "variant": "clinical", "imperatives": 1, "content": "Every child with polytrauma is approached using the ABCDE sequence, with airway prioritized above all else, since airway compromise kills faster than any other injury - assessment is made for obstruction from positioning, blood, teeth, vomitus, or foreign material, and level of consciousness, maxillofacial injury, and stridor or cyanosis are evaluated. The cervical spine is protected throughout the assessment and stabilization process in every child with polytrauma, regardless of the apparent primary injury site. A length-based tool is used to estimate weight quickly for accurate drug dosing and equipment sizing rather than waiting for an actual weight. Internal injury is actively suspected whenever the mechanism of injury is severe enough to cause it, even in the complete absence of external signs of trauma, given children's thinner protective musculature and padding. A normal blood pressure does not rule out significant blood loss - children can lose 25-30% of their circulating volume while maintaining a normal systolic pressure - so other perfusion markers (heart rate, capillary refill, mental status) are relied upon rather than blood pressure alone to assess for hemorrhagic shock." }, { "article_id": 398, "article_title": "Polytrauma", "section_id": "74290fee4e8a4519998f2f8b624bb19c", "section_title": "Managing Shock and Coordinating Ongoing Care", "variant": "clinical", "imperatives": 1, "content": "If a child remains in shock despite adequate initial fluid/blood resuscitation, the differential is broadened beyond ongoing hemorrhage to include neurogenic shock, cardiac contusion, and cardiac tamponade, and investigated accordingly rather than simply escalating volume resuscitation. Care is organized under a single multidisciplinary team leader when multiple specialties (neurosurgery, orthopedics, general/trauma surgery, plastic surgery) are involved, and continuous monitoring is maintained after initial resuscitation, since deterioration can occur even after apparent stabilization. The Pediatric Trauma Score is used to help gauge severity and, for very low scores, rapid transport to the nearest facility is prioritized over transfer to a more specialized but more distant center. Psychological and social support is built into the care plan from the time of resuscitation onward, recognizing that polytrauma can affect the developing brain and contribute to long-term morbidity beyond the physical injuries themselves." }, { "article_id": 399, "article_title": "Posterior Urethral Valves", "section_id": "3c50c7209a0643a1974d8983c8909015", "section_title": "Managing PUV and Its Renal Consequences", "variant": "clinical", "imperatives": 2, "content": "Endoscopic fulguration of the valves is arranged as early as feasible once the diagnosis is confirmed; cutaneous vesicostomy or another temporary diversion is reserved for very small infants in whom endoscopic treatment is not practical. Renal function (creatinine, BUN) and electrolytes are checked at diagnosis, and evaluation for vesicoureteral reflux is performed, since about half of neonates with PUV have VUR - prophylactic antibiotics are considered for higher-grade (3-5) reflux in infants and young children, weighing this against the risks of prolonged antibiotic exposure. Expectations are set with families that unilateral disease with contralateral renal sparing carries a better prognosis than bilateral involvement, and that even after technically successful valve ablation, about 30% of patients progress to chronic or end-stage renal disease because of underlying renal dysplasia established before birth - so long-term nephrology follow-up is needed regardless of surgical success. Nephrectomy is considered for a kidney with severely impaired function that does not improve with temporary nephrostomy, or that is a source of severe hypertension or recurrent infection." }, { "article_id": 399, "article_title": "Posterior Urethral Valves", "section_id": "42fe89b771884ff3aedc12cb01f21b2b", "section_title": "Recognizing and Confirming PUV", "variant": "clinical", "imperatives": 2, "content": "Bilateral hydronephrosis in a male infant, whether identified prenatally or postnatally, is treated as an urgent indication to exclude posterior urethral valves. In a neonate with a palpable [[235|abdominal mass]], hypertension, urinary ascites, or unexplained renal failure, PUV is included in the differential and a voiding cystourethrogram, the key diagnostic study, is obtained, looking for a dilated/elongated posterior urethra, thickened trabeculated bladder, bladder neck hypertrophy, and [[271|vesicoureteral reflux]]. Parental report of a weak urinary stream is not relied upon to trigger evaluation, since most children with PUV are not brought in for this symptom specifically - suspicion is maintained based on the broader clinical picture (vomiting, poor weight gain, abdominal distention, recurrent UTI) since more than half of cases are not diagnosed until several months of age. In an older boy with incontinence, recurrent UTI, or unexplained renal impairment, previously unrecognized PUV is considered as part of the work-up." }, { "article_id": 400, "article_title": "Thrombocytopenia", "section_id": "bf69bd6e478448a7bf2b807310fe1aa3", "section_title": "Evaluating the well child with new bruising or petechiae", "variant": "clinical", "imperatives": 2, "content": "In an otherwise healthy 1- to 10-year-old presenting with sudden bruising, petechiae, or mucosal bleeding 1-4 weeks after a viral illness or vaccination, a CBC and peripheral smear are obtained: isolated thrombocytopenia with large platelets, normal white count and hemoglobin, normal PT/PTT, and no hepatosplenomegaly or lymphadenopathy is classic for ITP and needs no further testing initially. Pseudothrombocytopenia is ruled out first if the count seems inconsistent with the clinical picture, by redrawing in a citrate or heparin tube rather than EDTA. New medications (sulfonamides, vancomycin, valproic acid, phenytoin, carbamazepine, heparin) are specifically asked about as a cause of drug-induced thrombocytopenia, which should improve within 1-2 days of stopping the offending drug. If pancytopenia, anemia, organomegaly, lymphadenopathy, or an abnormal PT/PTT accompanies the thrombocytopenia, the workup is broadened (bone marrow exam, direct Coombs, ANA) to evaluate for leukemia, autoimmune disease, hemolytic uremic syndrome, or a marrow failure syndrome rather than assuming simple ITP." }, { "article_id": 400, "article_title": "Thrombocytopenia", "section_id": "ab61ba55ca4b45c7bf8b6bd221b7c585", "section_title": "Managing ITP and counseling on risk", "variant": "clinical", "imperatives": 2, "content": "For classic ITP without significant bleeding, observation with serial platelet counts is a reasonable initial approach, since 60-75% resolve within 2-4 months regardless of treatment. Active treatment (IVIG, corticosteroids, or other agents) is reserved for significant bleeding or very low platelet counts, and platelet transfusion is used to manage an acute bleeding crisis. Families are counselled that [[379|intracranial hemorrhage]], while the most serious complication, occurs in under 1% of ITP cases; warning signs (severe headache, neurologic change) are nonetheless emphasized given the roughly one-third mortality when ICH does occur. In a menstruating adolescent with ITP, close monitoring for heavy menstrual bleeding occurs if the platelet count falls below 10,000/µL. If thrombocytopenia persists beyond 3-6 months, additional testing (HIV, hepatitis C, H. pylori, ANA, anticardiolipin antibodies) is pursued rather than continuing to assume self-limited acute ITP. In a newborn with thrombocytopenia, maternal history (preeclampsia, autoimmune disease, medications) is evaluated alongside neonatal causes (alloimmunization, [[155|congenital infection]], sepsis, NEC), and hematology is consulted if thrombocytopenia persists beyond 10 days of life." }, { "article_id": 401, "article_title": "Tinea Versicolor", "section_id": "0d025eec252e4245bbf1ed37a7487142", "section_title": "Recognizing tinea versicolor at the bedside", "variant": "clinical", "imperatives": 2, "content": "Tinea versicolor is suspected in an adolescent or young adult with multiple small, oval, scaly patches on the upper chest, back, or upper arms that vary in color (white, pink, tan, or reddish-brown) and notably fail to tan with sun exposure, appearing lighter than surrounding skin in summer. In an infant or young child, facial involvement is looked for instead, particularly the bilateral temples. Diagnosis is confirmed with a Wood's lamp (yellowish-brown fluorescence) or KOH prep of a skin scraping, expecting the classic \"spaghetti and meatballs\" pattern of short hyphae and spore clusters. It is distinguished from vitiligo (which shows depigmentation rather than fine scale and a positive KOH), pityriasis alba, seborrheic dermatitis, and pityriasis rosea based on distribution, scale character, and KOH findings; secondary syphilis is considered in a sexually active adolescent with an atypical or resistant presentation." }, { "article_id": 401, "article_title": "Tinea Versicolor", "section_id": "91923882960f47a9947c8f453225cc2b", "section_title": "Treatment and counseling on recurrence", "variant": "clinical", "imperatives": 2, "content": "Treatment starts with selenium sulfide 2.5% suspension or zinc pyrithione shampoo applied to the entire affected area (and surrounding skin) and left on overnight, repeated in 1 week and then monthly to prevent recurrence; the patient is warned about potential skin irritation from this regimen. Alternatively, a topical antifungal cream is prescribed twice daily for 1-2 weeks, or a single 400 mg dose of oral fluconazole for a simpler regimen in an adolescent or adult. Patients are counselled that pigmentary changes (light or dark patches) can take weeks to months to fully resolve even after the infection itself has cleared, since this reflects residual pigment abnormality rather than persistent infection — this is expected and not treatment failure. Since Malassezia is normal skin flora and recurrence is common, advice is given on minimizing predisposing factors (excess heat, humidity, sweating, occlusive clothing) where practical." }, { "article_id": 402, "article_title": "Trichomoniasis", "section_id": "b2663dd3e50348ca96126fb691178d9e", "section_title": "Treatment and follow-up", "variant": "clinical", "imperatives": 1, "content": "Self-limited neonatal trichomonal infection acquired perinatally is not treated, since this generally resolves on its own. For postpubertal patients with confirmed infection, treatment follows current CDC guidelines, and sexual partners are treated simultaneously to prevent reinfection — the single biggest driver of ongoing transmission. Retesting is scheduled 3 months after treatment given the high reinfection rate, rather than assuming a single treatment course is sufficient. Mycoplasma genitalium and [[239|bacterial vaginosis]] are kept in mind as alternative or coexisting causes of persistent symptoms if a patient does not respond as expected to trichomoniasis treatment." }, { "article_id": 403, "article_title": "Urethritis", "section_id": "9358b9457fd445fabf55a1615a625a58", "section_title": "Evaluating dysuria with discharge or blood spotting", "variant": "clinical", "imperatives": 1, "content": "In a child with dysuria accompanied by urethral discharge or blood spotting on the underwear, urethritis is considered and a urethral smear and urine culture are obtained as part of the workup, since infectious causes—though less common in children than adults—still need to be identified when present. Trauma, chemical exposure (bubble baths, soaps), and the possibility of a foreign body are specifically asked about, since these are recognized noninfectious causes of urethritis in children. In a girl with dysuria and gross [[187|hematuria]] or blood spotting, careful examination is made for urethral prolapse (complete protrusion of urethral mucosa beyond the meatus), especially if she is young or from a lower socioeconomic background, and prompt treatment (sitz baths, antibiotics, topical estrogen, or surgical referral if needed) is given to avoid progression to mucosal necrosis. In a child with a weak urinary stream or recurrent urinary symptoms, urethral stricture is considered and voiding cystourethrogram or cystoscopy is pursued for diagnosis." }, { "article_id": 404, "article_title": "Vulvovaginitis", "section_id": "2761d6433781411ab809bf2d712177c8", "section_title": "Evaluating a Prepubertal Girl with Vulvovaginal Symptoms", "variant": "clinical", "imperatives": 2, "content": "A detailed history is taken covering hygiene technique (front-to-back wiping), exposure to chemical irritants (bubble baths, soaps, detergents, pools/hot tubs), tight clothing, recent diarrhea, and perianal or nighttime itching, and the possibility of a foreign body is gently asked about, recognizing a young child may not recall or disclose this. On exam, visible discharge is distinguished from irritation/erythema alone - visible discharge raises the likelihood of a specific infectious cause to about 50%, whereas irritation without discharge more often reflects nonspecific vulvovaginitis from the combination of unestrogenized mucosa, absent labial protection, and alkaline pH that predisposes all prepubertal girls. A culture with sensitivities is obtained using a moistened cotton or urethral (Calgiswab) swab when a specific infectious cause is suspected, particularly with blood-tinged/serosanguineous discharge (raising concern for group A streptococcus or Shigella) or a history of recent respiratory illness or diarrhea. A diagnosis of nonspecific vaginitis is reserved for after other identifiable causes have been reasonably excluded, since many of these children have already had prior evaluations and treatment failures." }, { "article_id": 404, "article_title": "Vulvovaginitis", "section_id": "589877b8a98849a3858d99cd55734dde", "section_title": "Recognizing Red Flags and Treating by Cause", "variant": "clinical", "imperatives": 2, "content": "Any prepubertal child with a sexually transmitted pathogen identified on vulvovaginal culture, or with [[106|pelvic inflammatory disease]], is treated as a sexual abuse concern requiring a full evaluation - this association is close to universal at this age. Candida vulvovaginitis is considered only when a predisposing factor is present (diabetes, recent systemic antibiotics or steroids) in a prepubertal, diaper-free child, since Candida is otherwise an uncommon cause at this age despite being a frequent culprit in diaper dermatitis and in postpubertal vulvovaginitis; diagnosis is confirmed with KOH prep/wet mount and treated with topical azole antifungals or, in adolescents, a single dose of oral fluconazole. For nonspecific vulvovaginitis, the majority of cases, first-line management focuses entirely on hygiene counseling (front-to-back wiping, wet wipes, gentle genital cleansing, avoiding perfumed soaps and other irritants) before escalating to antimicrobial therapy, since most children improve with these measures alone." } ]