The average age for girls to begin puberty is 11.The first sign of puberty in girls is usually that their breasts begin to develop.It’s normal for breast buds to sometimes be very tender or for one breast to start to develop several months before the other one.Pubic hair also starts to grow, and some girls may notice more hair on their legs and arms.After a year or so of puberty beginning, and for the next couple of years:girls’ breasts continue to grow and become fuller.Around 2 years after beginning puberty, girls usually have their first period,pubic hair becomes coarser and curlierunderarm hair begins to grow. From the time their periods start, girls grow 5 to 7.5cm (2 to 3 inches) annually over the next year or two, then reach their adult height.After about 4 years of puberty in girls:breasts become adult-likepubic hair has spread to the inner thighgenitals should now be fully developedgirls stop growing taller.

Croup is the most common aetiology for hoarseness, cough, and onset of acute stridor in febrile children. Symptoms of coryza may be absent, mild, or marked. The vast majority of children with croup recover without consequences or sequelae.

NICE does not recommend the use of antibiotics or tonsillectomy in this case. Paracetamol/Ibuprofen are indicated as they provide antipyretic action and analgesia. Indications for tonsillectomy are 5 or more episodes of acute sore throat/year, symptoms present for at least 2 years, symptoms are severe enough to disrupt a child’s social life. Indications for antibiotics are features of marked systemic upset secondary to the acute sore throat, unilateral peritonsillitis, history of rheumatic fever, an increased risk from acute infection, acute tonsillitis with 3 or more of the following: history of fever, tonsillar exudates, no cough and tender anterior cervical lymphadenopathy.

ABC : Airway, breathing, circulation is the order of assessment in any patient that is unconscious and apnoeic.

Precocious puberty is the development of secondary sexual characteristics before the age of 8 in females, and 9 in males. The first sign of early puberty in females is breast enlargement, followed by the appearance of pubic and axillary hair, and finally menarche, 2-3 years after the onset of thelarche. Precocious puberty is caused by the premature activation of the hypothalamic-pituitary-gonadal axis where FSH and LH levels are raised. Less common is the gonadotrophin independent form, which is due to excess sex hormones, but low FSH and LH levels.

Pyloric stenosis affects infants, typically in the second to fourth weeks of life and is caused most commonly by hypertrophy and thickening of the pylorus. It usually presents with projectile vomiting and failure to thrive. The infant usually has a normal appetite. Features include: ‘projectile’ vomiting, typically 30 minutes after a feed, constipation and dehydration may also be present and a palpable mass may be present in the upper abdomen.

Three physical changes – breast budding, pubic hair growth, and axillary hair growth in the order mentioned precede menarche. These changes are due to oestrogen, a hormone essential for pubertal development.The various pubertal changes in males include:-Testicular growth: It is the first sign of puberty occurring at around 12 years of age (Range = 10 – 15 years).- Testicular volume: An increase in the volume of testicles to 4 ml indicates the onset of pubertyThe various pubertal changes in females include:- The first sign is breast development at around 11.5 years of age (range = 9-13 years)- Followed by the onset of height spurt reaching the maximum in puberty (at 12 years of age)- The final change that occurs is termed menarche at 13 (11-15) years of age.Some of the other pubertal changes include:- Gynecomastia may develop in boys- Asymmetrical breast growth may occur in girls- Diffuse enlargement of the thyroid gland

The average amount of energy required by a well preterm baby in a thermo-neutral environment is 50/kcal/kg to maintain essential body functions while it takes about 70 kcal/kg/day for optimal growth. It is important to ensure that enough proteins are given per calorie to limit catabolism and promote cell building. Caloric need usually increases when the baby is ill.

Most cases of Prader-Willi syndrome are not inherited, particularly those caused by a deletion in the paternal chromosome 15 or by maternal uniparental disomy. These genetic changes occur as random events during the formation of reproductive cells (eggs and sperm) or in early embryonic development. Affected people typically have no history of the disorder in their family.Rarely, a genetic change responsible for Prader-Willi syndrome can be inherited. For example, it is possible for a genetic change that abnormally inactivates genes on the paternal chromosome 15 to be passed from one generation to the next.Prader-Willi syndrome is a complex genetic condition that affects many parts of the body. In infancy, this condition is characterized by weak muscle tone (hypotonia), feeding difficulties, poor growth, and delayed development. Beginning in childhood, affected individuals develop an insatiable appetite, which leads to chronic overeating (hyperphagia) and obesity. Some people with Prader-Willi syndrome, particularly those with obesity, also develop type 2 diabetes (the most common form of diabetes).

Guidelines suggest that when hypothermia manifests in the context of a shockable rhythm, it might get harder to defibrillate. Therefore, defibrillation is recommended to occur at temperatures below 30°C, and to be limited in three shocks.

Scabies is a dermatological condition caused by infestation of the Sarcoptes Scaibie. The tiny mite, often unseen by the naked human eye, is able to burrow into the stratum corneum where it lays its eggs, causing irritation and a rash related to the immune response against the mite and its eggs, saliva and faeces. On examination, the pathognomic small burrows are often seen on the skin along with small red papules and scratch marks; granulomatous nodules may also be seen especially in darker skin types. Other clinical subtypes such as bullous, and Norwegian (crusted) also exist. Common areas of infection include the hands, wrists, and the interdigital spaces. Infestation can also occur on the genital area, the buttocks, feet, ankles, flexor surfaces. First line treatment is with permethrin 5% dermal cream. It is important that all members of the household are also treated at the same time, and that contaminated bedding, clothes and furniture is adequately disinfected. Scabies is usually associated with overcrowded conditions.

The most probable diagnosis for this patient would be a duplex kidney with an ectopic ureter inserting below the bladder neck. Rationale: The Weigert-Myer law states that the upper moiety ureter inserts inferior and medial to the lower moiety ureter. Other options:- Horseshoe kidney would display as a single pelvic kidney on an ultrasound scan.- Ureterocele would be a cystic lesion within the bladder or may prolapse at birth. – Continence should not be affected by polycystic kidney disease. – The overactive bladder would cause frequency and urgency, neither of which is mentioned in the history.

Findings described are suggestive of Waterhouse-Friderichsen syndrome which develops secondary to meningococcaemia. The reported incidence of Addison’s disease is 4 in 100,000. It affects both sexes equally and is seen in all age groups. It tends to show clinical symptoms at the time of metabolic stress or trauma. The symptoms are precipitated by acute infections, trauma, surgery or sodium loss due to excessive perspiration.

Graves disease is an autoimmune disorder in which patients present with thyrotoxicosis and related ophthalmopathy, and dermopathy. Many affected patients experience hyperthyroidism. Peak incidence of graves disease is after the 3rd decade of life and is more common in women than in men. Graves susceptibility is association with HLA-DR3. Clinical features of Graves disease include an increased metabolic rate, heat intolerance, irritability, weight loss despite increasing appetite, diarrhoea palpitations, chemosis, acropachy and onycholysis.

The main problem with infants having gastroenteritis is dehydration. So they should be admitted to the hospital for IV fluids if they are not tolerating oral fluids.

According to APLS, your next step should be one of the following: synchronous DC shock, amiodarone, or cardiology advice for alternative antiarrhythmics.

Somatropin is a recombinant human growth hormone used to treat growth failure conditions associated with natural growth hormone deficiencies. According to the UK National Institute for Health and Care Excellence, these conditions include, Prader-Willi syndrome, Noonan syndrome, short stature Homeobox (SHOX) gene deficiency, Turner’s syndrome, chronic renal insufficiency and children who are small for gestational age. Treatment of short stature in achondroplasia has not seen any significant changes with somatotropin.

Recommended regimens3 NRTI (e.g., zidovudine, lamivudine, abacavir) OR2 NRTI (e.g., lamivudine + abacavir) AND1 NNRTI (e.g., efavirenz) OR1 PI (e.g., lopinavir) OR1 INI (e.g., raltegravir)

HbA1c stands for glycated haemoglobin. In patients with haemolytic diseases associated with a shortened RBC survival, HbA1c levels can be unusually low despite controlled diabetes mellitus.These haemolytic diseases can include glucose-6-phosphate dehydrogenase deficiency and sickle cell anaemia.HbA1c:It is a measure of non-enzymatic glycation which occurs due to haemoglobin’s exposure to plasma glucose. As plasma glucose increases so does HbA1c.The level of HbA1c quantitively assesses the control of diabetes mellitus over the last 120 days (as this is the life span of a red blood cell).Haemoglobin type A is separated on cation exchange chromatographyOther subsections include HbA1O, HbA1a, HbA1b.According to the updated NICE recommendations (2015):The target level of HbA1c in children with T1DM is 48 mmol/mol (6.5%) or lower. It is monitored every three months. Better control is associated with fewer long term complications

People with Systemic Juvenile Idiopathic Arthritis (also known as Stills disease) can have recurrent fevers, a macular rash, joint pain, joint deformities, an enlarged liver and/or spleen, and can occasionally have polyserositis, lung involvement or pericardial effusions. Rheumatoid factor and antinuclear antibodies are usually negative. Treatment is with non-steroidal anti-inflammatory drugs (NSAIDs) and the prognosis is better than for adult rheumatoid arthritis.In pauciarticular Still’s disease, antinuclear antibodies are present. Large joints are affected and most patients develop classic features of seronegative spondylarthritis.

Based on the clinical scenario provided, the most probable nerve injured in this patient would be the trochlear nerve. The trochlear nerve has a relatively long intracranial course, and this makes it vulnerable to injury in head trauma. Head trauma is the most frequent cause of acute fourth nerve palsy. A 4th nerve palsy is the most common cause of vertical diplopia. The diplopia is at its worst when the eye looks medially which it usually does as part of the accommodation reflex when walking downstairs.

Congenital heart defects are common (40-50%); they are frequently observed in patients with Down syndrome who are hospitalized (62%) and are a common cause of death in this aneuploidy in the first 2 years of life.The most common congenital heart defects are the following:- Endocardial cushion defect (43%), which results in atrioventricular septal defect (AVSD)/AV canal defect- Ventricular septal defect (32%)- Secundum atrial septal defect (10%)- Tetralogy of Fallot (6%)- Isolated patent ductus arteriosus (4%).About 30% of patients have more than one cardiac defect. The most common secondary lesions are patent ductus arteriosus (16%), atrial septal defect, and pulmonic stenosis (9%). About 70% of all endocardial cushion defects are associated with Down syndrome.Valve abnormalities, such as mitral valve prolapse or aortic regurgitation may develop in up to 40-50% of adolescents and adults who were born without structural heart disease.

Miliaria is a common skin disease caused by blockage and/or inflammation of eccrine sweat ducts. Miliaria is frequently seen in hot, humid or tropical climates, in patients in the hospital, and in the neonatal period. Miliaria is also known as sweat rash.Based on the level of the sweat duct obstruction, miliaria is divided into three subtypes:- Miliaria crystallina (sudamina), caused by obstruction of the sweat ducts close to the surface of the skin (epidermis);- Miliaria rubra, caused by obstruction of the sweat ducts deeper in the epidermis;- Miliaria profunda (tropical anhidrosis), the result of sweat leaking into the middle layer of skin (dermis).Miliaria crystallina appears as 1-2 mm superficial clear blisters that easily break. The blisters can look like beads of sweat. There is no inflammation. The blisters are usually seen widely spread on the head, neck, and upper trunk.Miliaria rubra is the most common type of miliaria results in red, 2-4 mm, non-follicular papules and papulovesicles. They are very itchy. Background erythema is often present. In children, miliaria affects the skin folds of the neck, axilla or groin. In adults, miliaria often affects the upper trunk, scalp, neck and flexures, particularly areas of friction with clothing. Miliaria pustulosa is a variant of milia rubra in which there are pustules.Miliaria profunda describes asymptomatic deep papules. The flesh-coloured, 1-3 mm diameter papules usually arise on the trunk and extremities.Mild Topical steroids can be used as a treatment

In boys, the first manifestation of puberty is testicular enlargement; the normal age for initial signs of puberty is 9 to 14 years in males. Pubic hair in boys generally appears 18 to 24 months after the onset of testicular growth and is often conceived as the initial marker of sexual maturation by male adolescents.

In people with juvenile myoclonic epilepsy, symptoms can be brought on by: -Sleep deprivation-Psychological stress-Alcohol and drug use-Noncompliance of medication-Flickering lights such as strobe lights -Menses-Time of day – usually mornings

Hydrocephalus is a serious medical condition resulting from excessive accumulation of cerebrospinal fluid in the brain leading to abnormal pressure build-up inside the brain. Hydrocephalus can be categorized into two types according to the flow of CSF between the ventricles. When the CSF flows freely between the ventricles, but is blocked after it exits the ventricular system, the hydrocephalus is said to be a communicating hydrocephalus. When the flow of CSF within the ventricles is blocked, the resulting hydrocephalus is termed as obstructive, or non-communicating. The communicating hydrocephalus is caused by insufficient reabsorption of CSF in the subarachnoid space, which is also observed in cases of bacterial meningitis, in which inflammatory process leads to the thickening of the leptomeninges and thereby reduces CSF reabsorption. Arnold Chiari malformation is associated with obstructive hydrocephalus due to blocked ventricles. Congenital aqueduct stenosis causes the blockage of third and lateral ventricles. Congenital atresia of the foramen of Monro leads to blocked lateral ventricles and thus results in obstructive hydrocephalus. Tumour of the posterior fossa is associated with blockage of the fourth ventricle outflow.

The Chi-squared test would have been a useful test to compare the proportions in the scenario. However, due to the small sample size, Fisher’s exact test can be applied to analyse the significance of the difference. Adequate information is not given to determine what sample sizes were used to test the efficacy of the treatment, and to tell whether the treatment should be discontinued without further analysis on the data.

Scabies infection in neonates typically manifests as nodular eruptions involving the face, neck, scalp, palms, and soles in contrast to the predominant involvement of the hands, wrists, elbows, and ankles in adults. Differential diagnoses for the nodular eruption in neonates are broad, and scabies often is misdiagnosed as Langerhans cell histiocytosis, urticaria pigmentosa, or another pruritic, bullous, or lymphoproliferative dermatosis. Histopathology of the reactive nodules usually is not diagnostic, because scabetic organisms are often unidentified and histologic findings are nonspecific. Furthermore, because of the atypical presentation, scabies in children is often missed until persons in close contact with the child present with similar symptoms. Thus, a thorough history and close follow-up are crucial to avoid misdiagnosis and unnecessary aggressive treatment. Moreover, synchronized treatment of patients and their close contacts is needed to ensure the success of therapy, considering that relapse is 2-3 times more frequent in children and infants

Intussusception is the most suggested case here based on the child’s symptoms. The urgent course of treatment is to bring the child to a paediatric surgical unit. If air reduction attempts fail, surgery will have to be done. Risk factors for intussusception include viral infection and intestinal lymphadenopathy.

Language/Communication milestones of 2 years old:Points to things or pictures when they are named Knows names of familiar people and body parts Says sentences with 2 to 4 words Follows simple instructions Repeats words overheard in conversation Points to things in a book