Antibiotic Use in Children with Otitis Media and Sore Throat: NICE Guidelines and Cochrane Review

The National Institute for Health and Care Excellence (NICE) guidelines recommend immediate antibiotic prescribing for children with otorrhoea and acute otitis media, as well as for children under 2 years with bilateral otitis media, those who are systemically unwell, have signs of complications, or have pre-existing co-morbidities. For children with acute sore throat and three or more Centor criteria, antibiotics may be considered due to the likelihood of a group A β-haemolytic streptococcus infection. However, a Cochrane review found that antibiotics provide only a small benefit for acute otitis media in children, and the possible adverse reactions must be weighed against this benefit. A pragmatic approach is to provide a prescription for antibiotics but advise parents to wait and see if it is necessary to have it dispensed based on worsening or prolonged symptoms.

Understanding Laryngomalacia: A Common Condition in Young Babies

Laryngomalacia, also known as congenital laryngeal stridor, is a condition that affects many young babies. It is caused by delayed maturation of the cartilage in the larynx, which leads to collapse of the supraglottic larynx during inspiration. This results in a noisy respiration and an inspiratory stridor, which is typically more noticeable when the baby is in a supine position, feeding, crying, sleeping, or during intercurrent illness.

While there may be gastro-oesophageal reflux, the child is otherwise well and there is no associated upper respiratory discharge. However, infants with laryngomalacia may have difficulty coordinating the ‘suck-swallow-breathe’ sequence needed for feeding due to their airway obstruction.

It is important to note that respiratory distress is uncommon, and if there is tachypnoea, it is only mild and there is no reduction in oxygen saturation. Additionally, a barking cough is not a typical symptom of laryngomalacia. The classic symptom is inspiratory stridor, which may be increased when the child has an upper respiratory infection.

While symptoms may initially worsen, they typically resolve by 18-24 months without the need for treatment. However, if the stridor is worsening, other diagnoses should be considered. Overall, understanding laryngomalacia can help parents and caregivers better recognize and manage this common condition in young babies.

Asplenia and Splenic Dysfunction: Important Considerations for Vaccinations

A surprising answer for many, the medical conditions that require additional vaccines may not be what you expect. While immunosuppression and diabetes are common guesses, patients with asplenia or splenic dysfunction (such as those with coeliac disease or sickle cell) should receive Men ACWY, Pneumococcal, and influenza vaccines in addition to the routine schedule.

It’s important to note that asplenia and splenic dysfunction are not rare conditions. In fact, one in a hundred patients may have coeliac disease, whether diagnosed or not. Additionally, those with complement disorders (including those receiving complement inhibitor therapy) should also receive the Meningococcal ACWY vaccine.

Overall, it’s crucial for healthcare professionals to consider these conditions when determining a patient’s vaccination schedule. By doing so, we can help protect those who may be at higher risk for vaccine-preventable diseases.

The child has temporary lactose intolerance due to a deficiency in enzymes caused by viral gastroenteritis. It is recommended to avoid lactose-containing foods for two weeks to one month, after which lactose can be reintroduced to the diet. If symptoms recur, a specialist should be consulted. Antibiotics such as metronidazole and ciprofloxacin are not effective in treating this condition. Symptoms should resolve spontaneously with a lactose-free diet. Primary lactase deficiency is a common genetic condition that can be managed by determining the amount of lactose that can be tolerated and taking it in divided portions throughout the day.

Understanding Epstein’s Pearl

Epstein’s pearl is a type of cyst that is present in the mouth from birth. It is commonly found on the hard palate, but can also be seen on the gums. Parents may mistake it for a tooth that is about to erupt. However, there is no need for concern as it tends to resolve on its own within a few weeks. Treatment is not usually required.

In summary, Epstein’s pearl is a harmless cyst that is commonly found in the mouth of newborns. It is important for parents to be aware of its presence and not mistake it for a dental issue. With time, it will naturally disappear without any intervention.

Sepsis in Newborns: Apnoeic Episodes and Potential Consequences

Sepsis is a common issue in newborns, often presenting as apnoeic episodes. In the initial stages, the fontanelle may appear normal. The most frequent cause of sepsis in newborns is group B Streptococcus, which can be acquired during or after delivery. Unfortunately, the mortality rate for infants with sepsis is between 5-15%. Even those who survive may experience long-term consequences such as learning difficulties, speech problems, visual impairment, or neural deafness. Additionally, meningomyelocele is a risk factor for the introduction of meningeal infection.

To confirm the suspected IgE mediated allergy diagnosis, an atopy patch test is utilized.

Cow’s milk protein intolerance/allergy (CMPI/CMPA) is a condition that affects approximately 3-6% of children and typically presents in formula-fed infants within the first 3 months of life. However, it can also occur in exclusively breastfed infants, although this is rare. Both immediate (IgE mediated) and delayed (non-IgE mediated) reactions can occur, with CMPA usually used to describe immediate reactions and CMPI for mild-moderate delayed reactions. Symptoms of CMPI/CMPA include regurgitation and vomiting, diarrhea, urticaria, atopic eczema, colic symptoms such as irritability and crying, wheezing, chronic cough, and rarely, angioedema and anaphylaxis.

Diagnosis of CMPI/CMPA is often based on clinical presentation, such as improvement with cow’s milk protein elimination. However, investigations such as skin prick/patch testing and total IgE and specific IgE (RAST) for cow’s milk protein may also be performed. If symptoms are severe, such as failure to thrive, referral to a pediatrician is necessary.

Management of CMPI/CMPA depends on whether the child is formula-fed or breastfed. For formula-fed infants with mild-moderate symptoms, extensive hydrolyzed formula (eHF) milk is the first-line replacement formula, while amino acid-based formula (AAF) is used for infants with severe CMPA or if there is no response to eHF. Around 10% of infants with CMPI/CMPA are also intolerant to soy milk. For breastfed infants, mothers should continue breastfeeding while eliminating cow’s milk protein from their diet. Calcium supplements may be prescribed to prevent deficiency while excluding dairy from the diet. When breastfeeding stops, eHF milk should be used until the child is at least 12 months old and for at least 6 months.

The prognosis for CMPI/CMPA is generally good, with most children eventually becoming milk tolerant. In children with IgE-mediated intolerance, around 55% will be milk tolerant by the age of 5 years, while in children with non-IgE mediated intolerance, most will be milk tolerant by the age of 3 years. However, a challenge is often performed in a hospital setting as anaphylaxis can occur.

Understanding Bronchiolitis in Infants

Bronchiolitis is a common chest condition that affects infants, particularly those aged one to six months. It is caused by respiratory syncytial virus in about 80% of cases. The condition typically starts with a coryzal illness and progresses to a dry cough, shortness of breath, and wheezing. Infants may be admitted to the hospital due to respiratory distress and difficulty feeding.

During examination, doctors may observe a dry cough, shortness of breath, respiratory distress, fine end-inspiratory crackles, wheezing, tachycardia, and cyanosis or pallor. However, not all infants with bronchiolitis require hospital admission. GPs should assess the child’s respiratory distress and feeding/hydration status to determine if they can be managed in the community with advice on when to seek review.

In summary, bronchiolitis is a potentially serious condition that requires prompt medical attention. Understanding its symptoms and severity can help parents and healthcare providers make informed decisions about the best course of treatment for affected infants.

Severe asthma exacerbation is characterized by the following: difficulty in completing full sentences, use of accessory muscles, respiratory rate of 40 breaths/ min, and a heart rate of 140 breaths/ min.

Assessing the severity of asthma attacks in children is crucial for effective management. The 2016 BTS/SIGN guidelines provide criteria for assessing the severity of asthma in general practice. These criteria include measuring SpO2 levels, PEF (peak expiratory flow) rates, heart rate, respiratory rate, use of accessory neck muscles, and other symptoms such as breathlessness, agitation, altered consciousness, and cyanosis.

A severe asthma attack is characterized by a SpO2 level below 92%, PEF rates between 33-50% of the best or predicted, being too breathless to talk or feed, and a high heart and respiratory rate. On the other hand, a life-threatening asthma attack is indicated by a SpO2 level below 92%, PEF rates below 33% of the best or predicted, a silent chest, poor respiratory effort, use of accessory neck muscles, agitation, altered consciousness, and cyanosis.

It is important for healthcare professionals to be familiar with these criteria to ensure prompt and appropriate management of asthma attacks in children. Early recognition of the severity of an asthma attack can help prevent complications and reduce the risk of hospitalization or death.

Patellofemoral pain syndrome is a common knee condition that affects a large number of individuals. It typically develops slowly and starts off as mild and sporadic, but can eventually become severe and persistent. The pain is alleviated by taking a break and exacerbated by activities like kneeling, running, or jumping.

Knee Problems in Children and Young Adults

Knee problems are common in children and young adults, and can be caused by a variety of conditions. Chondromalacia patellae is a condition that affects teenage girls and is characterized by softening of the cartilage of the patella. This can cause anterior knee pain when walking up and down stairs or rising from prolonged sitting. However, it usually responds well to physiotherapy.

Osgood-Schlatter disease, also known as tibial apophysitis, is often seen in sporty teenagers. It causes pain, tenderness, and swelling over the tibial tubercle. Osteochondritis dissecans can cause pain after exercise, as well as intermittent swelling and locking. Patellar subluxation can cause medial knee pain due to lateral subluxation of the patella, and the knee may give way. Patellar tendonitis is more common in athletic teenage boys and causes chronic anterior knee pain that worsens after running. It is tender below the patella on examination.

It is important to note that referred pain may come from hip problems such as slipped upper femoral epiphysis. Understanding the key features of these common knee problems can help with early diagnosis and appropriate treatment.

Understanding Child Tax Credits

Child tax credits are a form of financial assistance provided to families to help with the expenses of raising children. To be eligible for child tax credits, certain criteria must be met. Firstly, the age of the child is taken into consideration. Children under the age of 16 can be claimed for until the 31st of August following their 16th birthday. Additionally, children under the age of 20 who are in approved education or training can also be claimed for.

Secondly, responsibility for the child is also a factor in determining eligibility. If the child lives with you all the time, or if they normally live with you and you are their primary caregiver, you may be eligible for child tax credits. Other indicators of responsibility include the child keeping their toys and clothes at your home, you paying for their meals and giving them pocket money, or if they live in an EEA country or Switzerland but are financially dependent on you.

In summary, child tax credits are a helpful resource for families with children. By meeting the age and responsibility criteria, families can receive financial assistance to help with the costs of raising children.

Hydrocoele in Infants

A hydrocoele is a condition where there is an accumulation of fluid around the testicle within the tunica vaginalis. This condition is common in infants and is usually asymptomatic. The swelling is smooth and fluctuant, and the testis cannot be felt separately. Transillumination is used to confirm the diagnosis.

In most cases, hydrocoeles resolve spontaneously within the first year of life as the processus vaginalis gradually becomes obliterated. Therefore, watchful waiting is usually recommended, and the hydrocoele can be reviewed after the first year of life. However, if the hydrocoele persists, it can be assumed that the processus vaginalis will not close spontaneously, and surgical referral is necessary.

Polio Vaccination and Neurological Conditions

The Department of Health’s ‘Green Book’ provides guidelines for polio vaccination and neurological conditions. According to the book, stable pre-existing neurological conditions such as spina bifida and congenital brain abnormalities do not prevent polio vaccination. However, if a child has an unstable or deteriorating neurological condition, vaccination should be deferred, and the child should be referred to a specialist for further assessment and advice. This includes children with uncontrolled epilepsy.

It is important to note that a family history of seizures or epilepsy doesn’t prevent immunization. However, if there is a personal or family history of febrile seizures, there is an increased risk of these occurring after any fever, including post-immunization. In such cases, immunization should proceed as recommended, with advice on the prevention and management of fever beforehand.

Bartter’s syndrome is a genetic disorder that typically follows an autosomal recessive pattern of inheritance. It results in severe hypokalemia due to a malfunction in the absorption of chloride at the Na+ K+ 2Cl- cotransporter in the ascending loop of Henle. Unlike other endocrine causes of hypokalemia, such as Conn’s, Cushing’s, and Liddle’s syndrome, Bartter’s syndrome is associated with normotension.

The condition usually manifests in childhood and may present with symptoms such as failure to thrive, polyuria, polydipsia, weakness, and hypokalemia.

Hypertension, or high blood pressure, can also affect children. To measure blood pressure in children, it is important to use a cuff size that is approximately 2/3 the length of their upper arm. The 4th Korotkoff sound is used to measure diastolic blood pressure until adolescence, when the 5th Korotkoff sound can be used. Results should be compared to a graph of normal values for their age.

In younger children, secondary hypertension is the most common cause, with renal parenchymal disease accounting for up to 80% of cases. Other causes of hypertension in children include renal vascular disease, coarctation of the aorta, phaeochromocytoma, congenital adrenal hyperplasia, and essential or primary hypertension, which becomes more common as children get older. It is important to identify the underlying cause of hypertension in children in order to provide appropriate treatment and prevent complications.

Febrile seizures are most common in children between 6 months and 6 years old, with the highest incidence at 18 months. They are associated with fever and affect 2-4% of European children. While tonic-clonic movements are typical during febrile seizures, complex febrile seizures may present with focal or myoclonic features. If a seizure lasts longer than 15 minutes, it is considered complex and may require hospitalization. Signs of meningeal irritation, such as neck stiffness and Kernig’s sign, suggest a possible CNS infection and require further evaluation. Recurrence of seizures within 24 hours or during the same illness may indicate a complex febrile seizure.

Management of Constipation in a 12-Month-Old Child

This 12-month-old child has presented with constipation. Referral for specialist assessment or further investigation is not necessary at this stage, as there are no red flags in the history or examination. Treatment should be initiated in primary care.

A rectal examination is not necessary for the primary care assessment. A thorough history and examination, as discussed in the stem, is sufficient to make an accurate diagnosis and identify the presence of any impaction.

The first-line treatment for constipation is laxative treatment. A good first-line agent is macrogol polyethylene glycol 3350 with electrolytes (Movicol® Paediatric Plain). If there is a lack of effect, a stimulant laxative such as senna can be added to the treatment. In addition to laxative use, the patient and carers should be advised on lifestyle factors such as diet, including adequate fluid intake.

Behavioural interventions, such as scheduled toileting, encouragement, and reward systems, may be appropriate depending on the age of the patient. Advice on exercise in older children may also be helpful. However, dietary interventions should not be used alone as a first-line treatment. Early use of a laxative is indicated and is the most appropriate option.

Hand foot and mouth disease is the correct answer. The patient’s history reveals a mild illness with symptoms such as systemic upset, sore throat, and fever, followed by the appearance of oral ulcers and lesions on the hands and feet. It is worth noting that the lesions may also be present in the groin or buttocks area. The rash is characterized by scattered erythematous macules and papules, usually with a central greyish vesicle measuring around 25 mm.

Hand, Foot and Mouth Disease: A Contagious Condition in Children

Hand, foot and mouth disease is a viral infection that commonly affects children. It is caused by intestinal viruses from the Picornaviridae family, particularly coxsackie A16 and enterovirus 71. This condition is highly contagious and often occurs in outbreaks in nurseries.

The clinical features of hand, foot and mouth disease include mild systemic upset such as sore throat and fever, followed by the appearance of oral ulcers and vesicles on the palms and soles of the feet.

Symptomatic treatment is the only management option available, which includes general advice on hydration and analgesia. It is important to note that there is no link between this disease and cattle, and children do not need to be excluded from school. However, the Health Protection Agency recommends that children who are unwell should stay home until they feel better. If there is a large outbreak, it is advisable to contact the agency for assistance.

Plagiocephaly has become more prevalent due to campaigns promoting the practice of placing babies on their backs while sleeping to reduce the risk of sudden infant death syndrome (SIDS). This condition causes unilateral flattening of the occipital region of the skull, resulting in the forehead and ear on the same side being pushed forward, giving the head a parallelogram appearance. However, most cases of plagiocephaly improve by the age of 3-5 years as the child adopts a more upright posture. The use of helmets is not typically recommended, as a randomized controlled trial showed no significant difference between groups. One simple solution is to turn the baby’s cot around to encourage them to look in the opposite direction and relieve pressure on the affected side. Other methods include supervised tummy time during the day, supported sitting, and changing the position of toys and mobiles in the cot to shift the child’s focus. It is important to ensure that all advice given is consistent with SIDS prevention guidelines.

Common Skull Problems in Children

Plagiocephaly is a condition where a child’s head becomes parallelogram-shaped. This condition has become more prevalent in recent years, possibly due to the success of the ‘Back to Sleep’ campaign. This campaign encourages parents to place their infants on their backs to sleep, reducing the risk of sudden infant death syndrome (SIDS). However, prolonged time spent on the back of the head can lead to flattening of the skull. Plagiocephaly can be corrected with physical therapy or the use of a special helmet.

Craniosynostosis is a condition where the skull bones fuse prematurely, leading to an abnormal head shape. This condition can cause pressure on the brain and may require surgery to correct. It is important to diagnose and treat craniosynostosis early to prevent potential developmental delays or neurological problems.

A possible diagnosis for an unexplained enlarged abdominal mass in children is Wilms tumour, which is the most common renal malignancy in this age group. It typically presents as a unilateral mass in the abdomen. Therefore, it is crucial to arrange an urgent paediatric review within 48 hours for assessment and imaging, in accordance with NICE guidelines.

Delaying diagnosis by opting for an ultrasound scan within 2 weeks or a routine referral to paediatrics is not recommended. While a renal function test will be performed in secondary care, it will not alter the management of the patient.

It is worth noting that sickle cell disease can be diagnosed using haemoglobin electrophoresis, and it may present with splenomegaly (a left-sided mass). However, in the case of an unexplained enlarged abdominal mass in children, Wilms tumour should be considered as a potential diagnosis and prompt action should be taken.

Wilms’ Tumour: A Common Childhood Malignancy

Wilms’ tumour, also known as nephroblastoma, is a prevalent type of cancer in children, with a median age of diagnosis at 3 years old. It is often associated with Beckwith-Wiedemann syndrome, hemihypertrophy, and a loss-of-function mutation in the WT1 gene on chromosome 11. The most common presenting feature is an abdominal mass, which is usually painless, but other symptoms such as haematuria, flank pain, anorexia, and fever may also occur. In 95% of cases, the tumour is unilateral, and metastases are found in 20% of patients, most commonly in the lungs.

If a child presents with an unexplained enlarged abdominal mass, it is crucial to arrange a paediatric review within 48 hours to rule out Wilms’ tumour. The management of this cancer typically involves nephrectomy, chemotherapy, and radiotherapy if the disease is advanced. Fortunately, the prognosis for Wilms’ tumour is good, with an 80% cure rate.

Histologically, Wilms’ tumour is characterized by epithelial tubules, areas of necrosis, immature glomerular structures, stroma with spindle cells, and small cell blastomatous tissues resembling the metanephric blastema. Overall, early detection and prompt treatment are essential for a successful outcome in children with Wilms’ tumour.

It is recommended to treat asymptomatic household contacts of patients with threadworms, even if they show no symptoms. In this case, the appropriate treatment would be Mebendazole and hygiene measures for the patient and his parents, but not for his three-month-old sister who is too young for the medication. While a sample can be sent to confirm the diagnosis, empirical treatment is appropriate in most cases. Advising on hygiene and fluid intake alone would not be sufficient to treat the threadworm infection. Permethrin is not a suitable treatment for threadworms, as it is used for scabies.

Threadworms: A Common Infestation Among Children in the UK

Infestation with threadworms, also known as pinworms, is a prevalent condition among children in the UK. The infestation occurs when individuals swallow eggs present in their environment. Although around 90% of cases are asymptomatic, some possible features include perianal itching, especially at night, and vulval symptoms in girls.

Diagnosis can be made by applying Sellotape to the perianal area and sending it to the laboratory for microscopy to see the eggs. However, most patients are treated empirically, and this approach is supported in the CKS guidelines.

The recommended management for threadworm infestation is a combination of anthelmintic with hygiene measures for all members of the household. Mebendazole is used as a first-line treatment for children over six months old, with a single dose given unless the infestation persists. By following these guidelines, individuals can effectively manage and prevent the spread of threadworms.