It is important to distinguish between upper and lower urinary tract infections as the choice and duration of antibiotic treatment differ. Localising symptoms can guide treatment in primary care. In young children with confirmed UTI, clinicians may be tempted to treat for 5 or 7 days simply because of their age, but there are clear guidelines on this. A urine specimen should be collected for culture and sensitivity testing before starting antibacterial therapy, especially in children under 3 years of age, those with suspected upper urinary-tract infection, complicated infection, or recurrent infection, and pregnant women. Treatment should not be delayed while waiting for results, and the chosen antibacterial should reflect current local bacterial sensitivity. Uncomplicated lower urinary tract infections in children over 3 months of age can be treated with various antibiotics for 3 days, while acute pyelonephritis in children over 3 months of age can be treated with a first-generation cephalosporin or co-amoxiclav for 7-10 days. Children under 3 months of age should be transferred to hospital and treated initially with intravenous antibacterials until the infection responds.

Urinary Tract Infection in Children: Symptoms, Diagnosis, and Treatment

Urinary tract infections (UTIs) are more common in boys until 3 months of age, after which the incidence is substantially higher in girls. At least 8% of girls and 2% of boys will have a UTI in childhood. The presentation of UTIs in childhood depends on age. Infants may experience poor feeding, vomiting, and irritability, while younger children may have abdominal pain, fever, and dysuria. Older children may experience dysuria, frequency, and haematuria. Features that may suggest an upper UTI include a temperature of over 38ºC and loin pain or tenderness.

According to NICE guidelines, a urine sample should be checked in a child if there are any symptoms or signs suggestive of a UTI, with unexplained fever of 38°C or higher (test urine after 24 hours at the latest), or with an alternative site of infection but who remain unwell (consider urine test after 24 hours at the latest). A clean catch is the preferable method for urine collection. If not possible, urine collection pads should be used. Invasive methods such as suprapubic aspiration should only be used if non-invasive methods are not possible.

Infants less than 3 months old should be referred immediately to a paediatrician. Children aged more than 3 months old with an upper UTI should be considered for admission to the hospital. If not admitted, oral antibiotics such as cephalosporin or co-amoxiclav should be given for 7-10 days. Children aged more than 3 months old with a lower UTI should be treated with oral antibiotics for 3 days according to local guidelines, usually trimethoprim, nitrofurantoin, cephalosporin, or amoxicillin. Parents should be asked to bring the children back if they remain unwell after 24-48 hours. Antibiotic prophylaxis is not given after the first UTI but should be considered with recurrent UTIs.

Oral lesions typically manifest before palm and sole lesions in cases of hand, foot and mouth disease.

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.

NICE Guidance on Depression in Children and Young People

NICE has released guidance on how to manage depression in children and young people. For those presenting with mild depression, a ‘watchful waiting’ approach should be taken, with a further assessment arranged two weeks later. If the depression persists after up to four weeks of watchful waiting, psychological therapies such as individual non-directive supportive therapy, group cognitive behavioural therapy, or guided self-help can be offered for a limited period of around two to three months. Antidepressant medication should not be used at this stage. If the mild depression remains unresponsive to psychological therapies after two to three months, referral to tier 2-3 CAMHS can be made for further assessment and management. This guidance aims to provide a structured approach to managing depression in children and young people, ensuring that appropriate interventions are offered at the right time.

MMR Vaccination and Immunoglobulin Therapy

The MMR vaccination is not recommended for individuals with a history of anaphylaxis, concurrent febrile illness, neomycin and gelatin allergy. However, a family history of atopy is not relevant. The MMR vaccine is typically administered at around one year of age in the NHS vaccination schedule and there is no benefit in giving separate vaccines for measles, mumps, and rubella. It is important to note that the MMR vaccine contains live attenuated strains of these viruses, while vaccines for diseases such as diphtheria and tetanus are killed vaccines.

In regards to immunoglobulin therapy, there is no indication for children with epilepsy. It is important to consult with a healthcare professional to determine the appropriate course of treatment for any medical condition.

Managing Asthma in Children: NICE Guidelines

The National Institute for Health and Care Excellence (NICE) released guidelines in 2017 for the management of asthma in children aged 5-16. These guidelines follow a stepwise approach, with treatment options based on the severity of the child’s symptoms. For newly-diagnosed asthma, short-acting beta agonists (SABA) are recommended. If symptoms persist or worsen, a combination of SABA and paediatric low-dose inhaled corticosteroids (ICS) may be used. Leukotriene receptor antagonists (LTRA) and long-acting beta agonists (LABA) may also be added to the treatment plan.

For children under 5 years old, clinical judgement plays a greater role in diagnosis and treatment. The stepwise approach for this age group includes an 8-week trial of paediatric moderate-dose ICS for newly-diagnosed asthma or uncontrolled symptoms. If symptoms persist, a combination of SABA and paediatric low-dose ICS with LTRA may be used. If symptoms still persist, referral to a paediatric asthma specialist is recommended.

It is important to note that NICE doesn’t recommend changing treatment for patients with well-controlled asthma simply to adhere to the latest guidelines. Additionally, maintenance and reliever therapy (MART) may be used for combined ICS and LABA treatment, but only for LABAs with a fast-acting component. The definitions for low, moderate, and high-dose ICS have also changed, with different definitions for children and adults.

The NHS will provide the HPV vaccine to all 12- and 13-year-olds in school year 8 starting from September 2019. Typically, the vaccine is administered in two injections, with the second dose given 6 to 12 months after the first (during school year 8 or year 9). However, individuals who receive the vaccine after the age of 15 will require three doses, as they do not have the same response to two doses as younger individuals.

The human papillomavirus (HPV) is a known carcinogen that infects the skin and mucous membranes. There are numerous strains of HPV, with strains 6 and 11 causing genital warts and strains 16 and 18 linked to various cancers, particularly cervical cancer. HPV infection is responsible for over 99.7% of cervical cancers, and testing for HPV is now a crucial part of cervical cancer screening. Other cancers linked to HPV include anal, vulval, vaginal, mouth, and throat cancers. While there are other risk factors for developing cervical cancer, such as smoking and contraceptive pill use, HPV vaccination is an effective preventative measure.

The UK introduced an HPV vaccine in 2008, initially using Cervarix, which protected against HPV 16 and 18 but not 6 and 11. This decision was criticized due to the significant disease burden caused by genital warts. In 2012, Gardasil replaced Cervarix as the vaccine used, protecting against HPV 6, 11, 16, and 18. Initially given only to girls, boys were also offered the vaccine from September 2019. The vaccine is offered to all 12- and 13-year-olds in school Year 8, with the option for girls to receive a second dose between 6-24 months after the first. Men who have sex with men under the age of 45 are also recommended to receive the vaccine to protect against anal, throat, and penile cancers.

Injection site reactions are common with HPV vaccines. It should be noted that parents may not be able to prevent their daughter from receiving the vaccine, as information given to parents and available on the NHS website makes it clear that the vaccine may be administered against parental wishes.

Fluid intake should be limited for children from 1 hour before to 8 hours after administering desmopressin.

Managing Nocturnal Enuresis in Children

Nocturnal enuresis, also known as bedwetting, is a common condition in children. It is defined as the involuntary discharge of urine during sleep in children aged 5 years or older who have not yet achieved continence. There are two types of nocturnal enuresis: primary and secondary. Primary enuresis occurs when a child has never achieved continence, while secondary enuresis occurs when a child has been dry for at least 6 months before.

When managing nocturnal enuresis, it is important to look for possible underlying causes or triggers such as constipation, diabetes mellitus, or recent onset urinary tract infections. General advice includes monitoring fluid intake and encouraging regular toileting patterns, such as emptying the bladder before sleep. Lifting and waking techniques and reward systems, such as star charts, can also be effective.

The first-line treatment for nocturnal enuresis is an enuresis alarm, which has a high success rate. These alarms have sensor pads that detect wetness and wake the child up when they start to wet the bed. If an enuresis alarm is not effective or not acceptable to the family, desmopressin can be used for short-term control, such as for sleepovers. It is important to note that reward systems should be given for agreed behavior rather than dry nights, such as using the toilet to pass urine before sleep. By following these management strategies, children with nocturnal enuresis can achieve continence and improve their quality of life.

Slipped Upper Epiphysis: Symptoms, Diagnosis, and Treatment

Slipped upper epiphysis is a condition that commonly affects overweight boys aged 10-15 and is associated with obesity and hypothyroidism. Patients often present with pain, which may be referred to the knee, and a thorough examination of the hips is necessary. Reduced range of movement of abduction and internal rotation, leg shortening, and external rotation with hip flexion are key findings that support the diagnosis.

Slipped epiphysis can be classified as acute, chronic, or acute on chronic, and as unstable or stable. Unstable cases require urgent surgical repair due to the risk of avascular necrosis, while stable cases are usually treated with in situ screw fixation. Prophylactic fixation of the contralateral hip may also be considered.

If the slipped epiphysis is chronic and stable, an x-ray is the first line investigation, but U&Es, serum TFTs, and serum growth hormone may also be considered. Perthes disease, trochanteric bursitis, and osteomyelitis are differential diagnoses that should be considered. Perthes disease typically affects a younger age group, while trochanteric bursitis is more common in older adults. Osteomyelitis may present with pain, fever, inflammation, and acute tenderness, but a bone scan or MRI may be necessary for diagnosis.

In summary, slipped upper epiphysis is a condition that requires careful examination and diagnosis. Treatment depends on the classification of the condition and may involve surgical repair or in situ screw fixation. Differential diagnoses should also be considered to ensure accurate diagnosis and appropriate treatment.

Types of Juvenile Arthritis and Their Symptoms

Juvenile arthritis is a condition that affects children and adolescents, causing joint pain, swelling, and stiffness. There are different types of juvenile arthritis, each with its own set of symptoms. It is important to identify the type of arthritis a child has in order to provide appropriate treatment.

Juvenile psoriatic arthritis is a type of arthritis that should be considered if a child has arthritic symptoms along with dactylitis, nail pitting, or nail onycholysis, even if there is no personal or family history of psoriasis. This is because arthritis can occur before psoriasis develops.

Enthesis-related JIA should be considered if the arthritis is associated with inflammation at the site of a tendon or ligament insertion, such as heel pain.

Oligoarticular JIA should be considered if the arthritis is affecting up to four joints for over six months, often presenting with joint swelling and stiffness but with no or mild pain.

Septic arthritis and Systemic JIA are usually associated with fever and do not explain the nail pitting or dactylitis.

In summary, identifying the type of juvenile arthritis a child has is crucial for proper treatment. Symptoms such as dactylitis, nail pitting, and inflammation at the site of a tendon or ligament insertion can help differentiate between different types of juvenile arthritis.

Pediatric Urinary Tract Conditions: Causes and Symptoms

Recurrent urinary infections in children can be caused by various conditions that lead to urinary stasis. One of the most common causes is vesicoureteric reflux (VUR), which occurs in 41% of cases. VUR is found in about 1% of normal infants and can resolve over several years, but it is a risk factor for pyelonephritis and renal scarring. Other causes of recurrent urinary infections include renal calculi, obstructive uropathy, poor urine flow, impaired immune or renal function, and sexual abuse.

Posterior urethral valves, a less common condition than VUR, can cause urinary tract infections, diurnal enuresis, voiding pain or dysfunction, and an abnormal urinary stream. Bilateral polycystic kidney disease, which rarely causes major symptoms during childhood, can lead to progressive kidney failure and present with loin pain, haematuria, UTIs, and stones. Neurogenic bladder, caused by spina bifida, spinal trauma, or tumour, can cause urine leakage and retention, and is less common than VUR. Renal calculi, caused by metabolic abnormalities or unknown factors, are less common in childhood than VUR and may present with urinary infections.

In summary, recurrent urinary infections in children can be caused by various conditions, each with its own set of symptoms and risk factors. Early diagnosis and treatment are crucial to prevent complications and ensure proper kidney function.

As per the Children Act 1989, families are restricted to fostering a maximum of three children.

Foster care is a system in which children who cannot live with their birth families are placed with foster families who provide them with a safe and nurturing environment. According to Schedule 7 of the Children Act 1989, there is a limit of three foster children per family. Additionally, all children in long-term foster care require a medical examination every six months to ensure their physical and emotional well-being. This system aims to provide children with stability and support while their birth families work towards resolving any issues that led to their placement in foster care.

If a child remains drowsy for more than an hour, it is unlikely that they are experiencing a ‘simple’ febrile convulsion. A tonic-clonic seizure is a common occurrence and should not cause concern. Additionally, the presence of a confirmed infection focus, such as otitis media, should provide reassurance rather than necessitating hospitalization.

Febrile convulsions are seizures that occur in otherwise healthy children when they have a fever. They are most common in children between the ages of 6 months and 5 years, affecting around 3% of children. Febrile convulsions usually occur at the onset of a viral infection when the child’s temperature rises rapidly. The seizures are typically brief, lasting less than 5 minutes, and are usually tonic-clonic in nature.

There are three types of febrile convulsions: simple, complex, and febrile status epilepticus. Simple febrile convulsions last less than 15 minutes and are generalised seizures. Complex febrile convulsions last between 15 and 30 minutes and may be focal seizures. Febrile status epilepticus lasts for more than 30 minutes. Children who have had their first seizure or any features of a complex seizure should be admitted to paediatrics.

Following a seizure, parents should be advised to call an ambulance if the seizure lasts longer than 5 minutes. Regular antipyretics have not been shown to reduce the chance of a febrile seizure occurring. If recurrent febrile convulsions occur, benzodiazepine rescue medication may be considered, but this should only be started on the advice of a specialist, such as a paediatrician. Rectal diazepam or buccal midazolam may be used.

The overall risk of further febrile convulsions is 1 in 3, but this varies depending on risk factors for further seizure. These risk factors include age of onset under 18 months, fever below 39ºC, shorter duration of fever before the seizure, and a family history of febrile convulsions. Children with no risk factors have a 2.5% risk of developing epilepsy, while those with all three risk factors have a much higher risk of developing epilepsy, up to 50%.

Henoch-Schonlein Purpura (HSP)

Henoch-Schonlein purpura (HSP) is a vasculitic condition that commonly affects children between the ages of 3 and 10. The core clinical features of HSP include a characteristic skin rash, joint pain, periarticular oedema, renal involvement, and abdominal pain. Renal involvement can lead to hypertension, haematuria, and proteinuria, which can result in nephrotic and nephritic syndromes. Therefore, urine dipstick testing is crucial in aiding the clinical diagnosis and guiding management and follow-up. Regular follow-up is necessary in the convalescent period as HSP can lead to chronic renal problems in some patients. PatientPlus provides HSP guidelines that offer a comprehensive overview of the clinical features, patient assessment, and management.

MMR Vaccine Administration Guidelines

The MMR vaccine can be administered at any age, but it is recommended to consult with your local Health Protection Team if the child is under 1 year of age. In case of exposure to measles, mumps, or rubella, most individuals can receive post-exposure prophylaxis with the MMR vaccine within three days, provided that the vaccine is not contraindicated. However, the response to MMR vaccine in infants under 6 months of age is not optimal, and it is not recommended as post-exposure prophylaxis in this age group.

For children under 6 months of age, pregnant women, and immunocompromised individuals, human normal immunoglobulin should be considered if the MMR vaccine cannot be given. It is important to follow the recommended guidelines for MMR vaccine administration to ensure the best protection against these diseases.

Management of a Child with Sore Throat

This child doesn’t exhibit any life-threatening symptoms or signs of bacterial tonsillitis. The presence of fever and tonsillar exudate suggests a viral sore throat, which doesn’t require antibiotics. It is important to explain to the parents that antibiotics are unlikely to help and may contribute to bacterial resistance. Instead, regular analgesia and fluids should be given, and safety-netting advice provided. Antibiotics may be prescribed immediately for certain groups, such as those with three or more Centor criteria, systemic illness, or pre-existing comorbidities. It is also important to inform parents about the average length of the illness. As a GP who helped develop the NICE guidelines, I recommend following these management strategies for children with sore throat.

If there is a suspicion of cow’s milk protein allergy mediated by IgE, it is recommended to refer the child to secondary care for skin prick or IgE specific antigen blood testing. However, non-IgE mediated cow’s milk protein allergy can be managed in primary care. To begin with, a trial of cow’s milk exclusion for 2-4 weeks should be attempted. In the case of exclusively breastfed babies, the mother should exclude cow’s milk from her diet. For bottle-fed babies, the first line of treatment is a trial of extensively hydrolysed formula.

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, extensively 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.

If a child has scarlet fever, they can go back to school after 24 hours of starting antibiotics. The symptoms described are typical of scarlet fever, including a strawberry tongue and a rough-textured rash with small red spots on the palate called Forchheimer spots. Charlotte doesn’t need to be hospitalized but should take a 10-day course of phenoxymethylpenicillin. According to NICE, the child should stay away from school, nursery, or work for at least 24 hours after starting antibiotics. It is also important to advise parents to take measures to prevent cross-infection, such as frequent handwashing, avoiding sharing utensils and towels, and disposing of tissues promptly.

Scarlet fever is a condition caused by erythrogenic toxins produced by Group A haemolytic streptococci, usually Streptococcus pyogenes. It is more common in children aged 2-6 years, with the highest incidence at 4 years. The disease is spread through respiratory droplets or direct contact with nose and throat discharges. The incubation period is 2-4 days, and symptoms include fever, malaise, headache, sore throat, ‘strawberry’ tongue, and a rash that appears first on the torso and spares the palms and soles. Scarlet fever is usually a mild illness, but it may be complicated by otitis media, rheumatic fever, acute glomerulonephritis, or rare invasive complications.

To diagnose scarlet fever, a throat swab is usually taken, but antibiotic treatment should be started immediately, rather than waiting for the results. Management involves oral penicillin V for ten days, while patients with a penicillin allergy should be given azithromycin. Children can return to school 24 hours after starting antibiotics, and scarlet fever is a notifiable disease. Desquamation occurs later in the course of the illness, particularly around the fingers and toes. The rash is often described as having a rough ‘sandpaper’ texture, and children often have a flushed appearance with circumoral pallor. Invasive complications such as bacteraemia, meningitis, and necrotizing fasciitis are rare but may present acutely with life-threatening illness.

Ankle Injuries in Children and the Ottawa Ankle Rules

The history of ankle injuries in children suggests a forced internal rotation at the ankle joint, which can cause a sprain of the lateral ligaments. This type of injury requires supportive strapping, analgesia, and graduated mobilization. However, ankle sprains are less common in children than adults because their ligaments are stronger than their growth plates. As a result, the growth plate tends to fracture before the ligament tears.

In some cases, Salter-Harris Type 1 fractures and ligament tears may not show up on radiographs. Therefore, it is important to consider the patient’s history, such as tenderness over the ligament rather than bone and whether the patient is weight-bearing.

The Ottawa ankle rules are helpful in assisting GPs in the management of ankle injuries in adults and determining the need for an x-ray. A recent study published in the BMJ showed that the Ottawa ankle rules are highly accurate at excluding ankle fractures after a sprain injury. By following these guidelines, healthcare professionals can provide appropriate care for ankle injuries in children and adults.

Kawasaki disease is indicated by a high fever lasting more than 5 days, along with red palms that peel and a strawberry tongue. Symptoms of this condition also include conjunctivitis and cracked lips. It is important to note that Stevens-Johnson syndrome typically involves erythema multiforme with mucosal involvement, while the other conditions listed would not present in this manner.

Understanding Kawasaki Disease

Kawasaki disease is a rare type of vasculitis that primarily affects children. It is important to identify this disease early on as it can lead to serious complications such as coronary artery aneurysms. The disease is characterized by a high-grade fever that lasts for more than five days, which is resistant to antipyretics. Other features include conjunctival injection, bright red, cracked lips, strawberry tongue, cervical lymphadenopathy, and red palms and soles that later peel.

Diagnosis of Kawasaki disease is based on clinical presentation as there is no specific diagnostic test available. Management of the disease involves high-dose aspirin, which is one of the few indications for aspirin use in children. Intravenous immunoglobulin is also used as a treatment option. Echocardiogram is the initial screening test for coronary artery aneurysms instead of angiography.

Complications of Kawasaki disease include coronary artery aneurysm, which can be life-threatening. Early recognition and treatment of Kawasaki disease can prevent serious complications and improve outcomes for affected children.

Screening and Diagnostic Tests for Newborns

Newborns undergo several tests to ensure their health and development. These tests include auscultation of the heart, examination for developmental dysplasia of the hip, congenital cataracts, and undescended testicles. However, some heart murmurs may not be detected until the ductus arteriosus closes early in life. A hearing test, specifically the automated otoacoustic emission test, is often performed before discharge from the hospital or during the first 4-5 weeks of life. The cover test for squint is not usually done during the newborn stage as it requires the child to fixate on an object held away from the eyes. Blood-spot screening for conditions such as congenital hypothyroidism, phenylketonuria, cystic fibrosis, and sickle cell disease is ideally carried out at five days. A urine test is a diagnostic test rather than a screening test at this age and is usually done if a urinary infection is suspected.

Screening and Diagnostic Tests for Newborns

If parents take their child to the A&E department instead of a GP on a regular basis, it could be an indication of child abuse. This is because they may assume that seeing a different doctor each time will decrease the likelihood of any suspicions being raised.

Recognizing Child Abuse: Signs and Symptoms

Child abuse is a serious issue that can have long-lasting effects on a child’s physical and emotional well-being. It is important to recognize the signs and symptoms of child abuse in order to protect vulnerable children. One way that abuse may come to light is through a child’s own disclosure. However, there are other factors that may indicate abuse, such as inconsistencies in a child’s story or repeated visits to emergency departments. Children who appear frightened or withdrawn may also be experiencing abuse, exhibiting a state of frozen watchfulness.

Physical signs of abuse can also be indicative of maltreatment. Bruising, fractures (especially in the metaphyseal area or posterior ribs), and burns or scalds are all possible signs of abuse. Additionally, a child who is failing to thrive or who has contracted a sexually transmitted infection may be experiencing abuse. It is important to be aware of these signs and to report any concerns to the appropriate authorities. By recognizing and addressing child abuse, we can help protect vulnerable children and promote their safety and well-being.

Understanding Rickets: Causes and Symptoms

Rickets is a condition that affects bone development in children, caused by a severe deficiency of vitamin D. This vitamin is essential for bone mineralization, and without it, bones become soft and weak, leading to deformities and impaired growth. In adults, the condition is known as osteomalacia and can cause bone pain and tenderness.

The most common cause of rickets is a dietary deficiency of vitamin D, which can be compounded by inadequate exposure to sunlight. Other risk factors include having dark skin and following a vegetarian diet. Oily fish and cod liver oil are the best food sources of vitamin D.

Hyperparathyroidism, cystic fibrosis, nephrotic syndrome, and juvenile idiopathic arthritis are all potential causes of bone abnormalities, but they are not typically associated with rickets. Hyperparathyroidism and nephrotic syndrome can cause bone-related issues, but they are not commonly associated with rickets. Cystic fibrosis and other malabsorption diseases can lead to vitamin D deficiency, but they typically present with other symptoms such as recurrent chest infections. Juvenile idiopathic arthritis causes joint pain and swelling, rather than bony deformities.

In summary, rickets is a condition caused by a severe deficiency of vitamin D, which can lead to bone deformities and impaired growth in children. It is important to ensure adequate vitamin D intake through diet and sunlight exposure to prevent this condition.

Best Antibiotic Choice for Children

When it comes to choosing an antibiotic for children, it’s important to consider their age and potential side effects. In this circumstance, Amoxicillin would be the best choice due to its effectiveness and safety profile. Quinolones and tetracyclines should be avoided in childhood, while co-trimoxazole has limited indications and nitrofurantoin would not be effective. It’s crucial to consult with a healthcare professional before administering any medication to children.

As of July 1st, 2016, the vaccination schedule underwent a change that eliminated the meningitis C vaccination at 12 weeks of age. Consequently, children will receive the meningitis C vaccine when they turn 1 year old and again at 14 years old.

The UK immunisation schedule recommends certain vaccines at different ages. At birth, the BCG vaccine is given if the baby is at risk of tuberculosis. At 2, 3, and 4 months, the ‘6-1 vaccine’ (diphtheria, tetanus, whooping cough, polio, Hib and hepatitis B) and oral rotavirus vaccine are given, along with Men B and PCV at specific intervals. At 12-13 months, the Hib/Men C, MMR, PCV, and Men B vaccines are given. At 3-4 years, the ‘4-in-1 Preschool booster’ (diphtheria, tetanus, whooping cough and polio) and MMR vaccines are given. At 12-13 years, the HPV vaccination is given, and at 13-18 years, the ‘3-in-1 teenage booster’ (tetanus, diphtheria and polio) and Men ACWY vaccines are given. Additionally, the flu vaccine is recommended annually for children aged 2-8 years.

It is important to note that the meningitis ACWY vaccine has replaced meningitis C for 13-18 year-olds due to an increased incidence of meningitis W disease in recent years. The ACWY vaccine is also offered to new students up to the age of 25 years at university. GP practices will automatically send letters inviting 17-and 18-year-olds in school year 13 to have the Men ACWY vaccine, while students going to university or college for the first time should contact their GP to have the vaccine before the start of the academic year.

The Men C vaccine used to be given at 3 months but has now been discontinued as there are almost no cases of Men C disease in babies or young children in the UK. All children will continue to be offered the Hib/Men C vaccine at one year of age, and the Men ACWY vaccine at 14 years of age to provide protection across all age groups.

Confidential Medical Records for Adolescents

When it comes to disclosing confidential medical records of a 15-year-old adolescent, it is important to consider their maturity level. If they are deemed ‘Gillick’ competent, then their decision to disclose or withhold their medical record should be respected. However, practitioners must carefully review any third-party information and any information that may cause harm to an individual’s physical or mental health. If necessary, this information can be withheld under the Data Protection Act 1998. It is crucial to handle confidential medical records with care to protect the privacy and well-being of adolescents.

The fully formed pincer grip is the latest fine motor development that can be expected at 12 months old. While finger pointing typically develops around 9 months old, there is no indication that the child in question has achieved this milestone yet. The palmar grasp, which is typically present at 6 months old, was only achieved at 9 months old, suggesting a potential developmental delay. Passing an object from one hand to another should be present at 6 months old but was only achieved at 12 months old. Reaching for an object is expected at 3 months old in normal development.

Fine Motor and Vision Developmental Milestones

Fine motor and vision developmental milestones are important indicators of a child’s growth and development. At three months, a baby can reach for objects and hold a rattle briefly if given to their hand. They are visually alert, particularly to human faces, and can fix and follow to 180 degrees. By six months, they can hold objects in a palmar grasp and pass them from one hand to another. They become visually insatiable, looking around in every direction. At nine months, they can point with their finger and develop an early pincer grip. By 12 months, they have a good pincer grip and can bang toys together.

In terms of bricks, a 15-month-old can build a tower of two, while an 18-month-old can build a tower of three. A two-year-old can build a tower of six, and a three-year-old can build a tower of nine. When it comes to drawing, an 18-month-old can make circular scribbles, while a two-year-old can copy a vertical line. A three-year-old can copy a circle, a four-year-old can copy a cross, and a five-year-old can copy a square and triangle.

It’s important to note that hand preference before 12 months is abnormal and may indicate cerebral palsy. These milestones serve as a guide for parents and caregivers to monitor a child’s development and ensure they are meeting their milestones appropriately.

Understanding Infant Bowel Movements: Breastfed Babies and Constipation

Breastfed infants tend to have more frequent bowel movements than formula-fed babies, but there is a wide range of normal variation. It is common for breastfed babies to have frequent bowel movements up to six weeks of age due to the gastro-colic reflex. However, it is also normal for breastfed babies to go several days without a bowel movement, sometimes up to 7-10 days. When a bowel movement does occur after a longer period of time, it may be a blow-out of normal consistency and should not cause concern as long as it appears painless.

It is important to note that simple straining to pass stool is also normal and doesn’t necessarily indicate constipation. However, if there are worrying signs such as difficulty with feeding, failure to gain weight, or signs of discomfort, medical attention should be sought.

It is not necessary to give a macrogol laxative unless a diagnosis of constipation is made. Additionally, introducing baby food containing fruit and vegetables is not appropriate for exclusively breastfed infants. Prune juice may help with constipation, but it is not recommended for infants until they are weaned at 4-6 months.

Overall, as long as the baby is well and examination is normal, there is no need for urgent referral to hospital. However, if constipation appears during the first few weeks of life, it may be a sign of a more serious condition such as Hirschsprung’s disease, which requires medical attention.

Hepatitis B Vaccination for Newborns

Babies born to mothers with hepatitis B require immediate vaccination to prevent the transmission of the virus. Within 24 hours of birth, the newborn should receive the first dose of the hepatitis B vaccine. Subsequent doses should be given at 4, 8, 12, and 16 weeks of age, with the final dose administered when the child is 1-year-old. This vaccination schedule is crucial in protecting the child from developing chronic hepatitis B infection, which can lead to liver damage and other serious health complications. By following this vaccination schedule, parents can ensure the health and well-being of their newborn.

Hereditary diseases can have an earlier age of onset in successive generations due to genetic anticipation, particularly in trinucleotide repeat disorders such as Huntington’s disease and Myotonic dystrophy (which have a CTG repeat sequence). However, genetic anticipation is not observed in Duchenne muscular dystrophy (an X-linked recessive condition), Marfan syndrome (an autosomal dominant condition), or Homocystinuria (inherited in an autosomal recessive manner).

Trinucleotide repeat disorders are genetic conditions that occur due to an abnormal number of repeats of a repetitive sequence of three nucleotides. These expansions are unstable and may enlarge, leading to an earlier age of onset in successive generations, a phenomenon known as anticipation. In most cases, an increase in the severity of symptoms is also observed. It is important to note that these disorders are predominantly neurological in nature. Examples of such disorders include Fragile X, Huntington’s, myotonic dystrophy, Friedreich’s ataxia, spinocerebellar ataxia, spinobulbar muscular atrophy, and dentatorubral pallidoluysian atrophy. It is interesting to note that Friedreich’s ataxia is an exception to the rule and doesn’t demonstrate anticipation.

Calculation of Propranolol Dose

When calculating the dose of propranolol, it is important to consider the patient’s weight and the daily dose required. For example, if the patient weighs 12 kg and requires a daily dose of 0.5 mg/kg, the total daily dose would be 6 mg TDS.

To determine the amount of propranolol needed, it is important to know the concentration of the medication. In this case, the concentration is 5 mg/5 ml, which can be simplified to 1 mg/1 ml. Therefore, the total daily dose of 6 mg would be equivalent to 6 ml TDS.

It is important to accurately calculate the dose of propranolol to ensure the patient receives the appropriate amount of medication for their condition. By considering the patient’s weight and the medication concentration, healthcare professionals can determine the correct dosage for their patients.

Differential Diagnosis for Respiratory Symptoms in Infants

Respiratory symptoms in infants can be caused by a variety of conditions, and it is important to consider the differential diagnosis to provide appropriate treatment. Here are some common conditions and their typical symptoms:

Bronchiolitis: This acute infection of the lower respiratory tract is most common in infants between two and six months old. Symptoms include difficulty feeding, low-grade fever, coryza, cough, dyspnoea, wheezing, and respiratory distress.

Croup: This inflammation of the upper airways is usually caused by a respiratory virus and affects children from three months to three years old. Symptoms include a barking cough, stridor, and wheeze.

Asthma: This condition is rarely diagnosed in infants due to the lack of a clear diagnostic test. Symptoms overlap with common childhood illnesses and include coughing, wheezing, and difficulty breathing.

Heart failure: This should be considered in infants with feeding and breathing difficulties, but typically presents with symptoms since birth.

Pneumonia: This is another possible diagnosis for respiratory symptoms in infants, but examination findings such as reduced air entry and dull percussion note would support this diagnosis.

In summary, a thorough evaluation of symptoms and examination findings is necessary to determine the appropriate diagnosis and treatment for respiratory symptoms in infants.

Treatment Recommendations for Childhood Eczema

Topical tacrolimus and pimecrolimus should only be used in children with eczema who have not responded to other treatments. antihistamines are not typically recommended for childhood eczema unless there is a specific issue with itching. However, emollients should be applied generously and can even be covered with a local bandage during the initial stages of treatment. It is important to follow these guidelines to effectively manage childhood eczema and provide relief for the child.

Reye’s syndrome is a risk associated with the use of aspirin in children, therefore it should not be administered to them.

To avoid the risk of morphine toxicity and respiratory depression, the MHRA recommends that codeine should not be given to children under the age of 12.

Codeine, a commonly used pain medication, can have different effects on patients due to genetic variations in the CY62D6 component of the P450 enzyme system. Some patients may be more sensitive to the effects of codeine, which can lead to serious adverse events. A recent review found that paediatric patients, particularly those from southern European countries, the Middle East, and Africa, have a higher incidence of rapid codeine metabolism. This has led to reports of morphine toxicity in children, especially those with a history of obstructive sleep apnoea. As a result, the MHRA now advises that codeine should only be used in children over 12 years of age for pain that is not controlled by other medications. Additionally, breastfeeding mothers should avoid using codeine due to the potential effects of morphine toxicity on their babies.

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.

Calculating the Correct Dose of Trimethoprim for a Child

When administering medication to a child, it is important to calculate the correct dose based on their weight. In this case, the child weighs 20 kg and requires a dose of 4 mg/kg of trimethoprim twice daily. This equates to a total daily dose of 80 mg.

The trimethoprim solution available is 50 mg/5 ml, which can be simplified to 10 mg in 1 ml. To calculate the correct dose, we need to determine how many milliliters of the solution contain 80 mg of trimethoprim.

By dividing 80 mg by 10 mg/ml, we get a total of 8 ml. Therefore, the child should take 8 ml of the trimethoprim solution twice daily to receive the correct dose. It is important to always double-check calculations and measurements to ensure the safety and effectiveness of medication administration.

Understanding Sydenham’s Chorea: A Common Cause of Acute Chorea Worldwide

Sydenham’s chorea, also known as St Vitus’ dance, is a neurological manifestation of rheumatic fever and remains the most common cause of acute chorea worldwide. While it was commonly seen in the 1930s, it occurs less frequently in the UK today. This condition can occur with or without symptoms of rheumatic fever and is usually self-limiting. Improvement occurs over about two weeks, but total recovery can take up to nine months, and may recur in some patients.

In this scenario, the short time course of the chorea and the girl’s age are useful diagnostically. It is important to note that psychological changes may precede or accompany the choreiform movements, as demonstrated by the girl’s emotional lability.

It is important to consider other potential causes of chorea, such as cerebral tumour, cerebrovascular accident, Guillain–Barré syndrome, and Huntington’s chorea. However, in this case, these conditions are unlikely as they do not fit with the girl’s symptoms and age.

Many referrals for orthopaedic outpatient care from general practitioners are actually normal variants. The defining characteristics of normal variants are that they are always symmetrical, painless, and improve with age.

Genu varum, or bow legs, is a normal variant from birth until about 2 years of age. Referral should be considered if genu varum is asymmetrical or persists beyond 3 years of age. Severe cases may be indicative of vitamin D deficiency. Genu valgus, or knock knees, is a normal variant between 3-6 years of age. Again, referral should be considered if the valgus is severe or persists, and vitamin D deficiency may be a factor. Flat feet are a normal variant until age 3, and most cases resolve by age 8 as the foot arch develops. Arches should appear when the infant stands on their tip toes, and the foot should be flexible and painless. Painful rigid flat feet should always be referred and may suggest tarsal coalition.

In-toeing has three main causes: metatarsus adductus (a congenital foot deformity), internal tibial torsion (feet internally rotated), and femoral anteversion (feet and knees internally rotated). The vast majority of cases resolve by around 8 years of age.

Paediatric Orthopaedics: Common Conditions and Treatments

Developmental dysplasia of the hip is a condition that is usually diagnosed in infancy through screening tests. It may be bilateral, and when it is unilateral, there may be leg length inequality. As the disease progresses, the child may limp and experience early onset arthritis. This condition is more common in extended breech babies. Treatment options include splints and harnesses or traction, and in later years, osteotomy and hip realignment procedures may be needed. In cases of arthritis, a joint replacement may be necessary, but it is best to defer this if possible as it will likely require revision. Initially, there may be no obvious changes on plain films, and ultrasound gives the best resolution until three months of age. On plain films, Shenton’s line should form a smooth arc.

Perthes Disease is characterized by hip pain, which may be referred to the knee, and usually occurs between the ages of 5 and 12. Bilateral disease occurs in 20% of cases. Treatment involves removing pressure from the joint to allow for normal development and physiotherapy. If diagnosed and treated promptly, the condition is usually self-limiting. X-rays will show a flattened femoral head, and in untreated cases, the femoral head will eventually fragment.

Slipped upper femoral epiphysis is typically seen in obese male adolescents. Pain is often referred to the knee, and limitation to internal rotation is usually seen. Knee pain is usually present two months prior to hip slipping, and bilateral disease occurs in 20% of cases. Treatment involves bed rest and non-weight bearing to avoid avascular necrosis. If severe slippage or risk of it occurring is present, percutaneous pinning of the hip may be required. X-rays will show the femoral head displaced and falling inferolaterally, resembling a melting ice cream cone. The Southwick angle gives an indication of disease severity.

Although febrile seizures are frequent, it is crucial to have a pediatrician confirm the diagnosis and exclude any serious underlying condition. Therefore, according to NICE clinical knowledge summaries, if a child experiences their initial febrile seizure, they must be promptly hospitalized and assessed by a pediatrician.

It would be inappropriate to merely reassure the mother or postpone the evaluation until the following day. An antibiotic allergy would not typically trigger a seizure.

Febrile convulsions are seizures that occur in otherwise healthy children when they have a fever. They are most common in children between the ages of 6 months and 5 years, affecting around 3% of children. Febrile convulsions usually occur at the onset of a viral infection when the child’s temperature rises rapidly. The seizures are typically brief, lasting less than 5 minutes, and are usually tonic-clonic in nature.

There are three types of febrile convulsions: simple, complex, and febrile status epilepticus. Simple febrile convulsions last less than 15 minutes and are generalised seizures. Complex febrile convulsions last between 15 and 30 minutes and may be focal seizures. Febrile status epilepticus lasts for more than 30 minutes. Children who have had their first seizure or any features of a complex seizure should be admitted to paediatrics.

Following a seizure, parents should be advised to call an ambulance if the seizure lasts longer than 5 minutes. Regular antipyretics have not been shown to reduce the chance of a febrile seizure occurring. If recurrent febrile convulsions occur, benzodiazepine rescue medication may be considered, but this should only be started on the advice of a specialist, such as a paediatrician. Rectal diazepam or buccal midazolam may be used.

The overall risk of further febrile convulsions is 1 in 3, but this varies depending on risk factors for further seizure. These risk factors include age of onset under 18 months, fever below 39ºC, shorter duration of fever before the seizure, and a family history of febrile convulsions. Children with no risk factors have a 2.5% risk of developing epilepsy, while those with all three risk factors have a much higher risk of developing epilepsy, up to 50%.

The primary screening test for infant hearing is now the Newborn Hearing Screening Programme, which is replacing distraction testing. Midwives rarely conduct visits beyond 4 weeks in their daily routine.

Child Health Surveillance in the UK

Child health surveillance in the UK involves a series of checks and tests to ensure the well-being of children from before birth to Preschool age. During the antenatal period, healthcare professionals ensure that the baby is growing properly and check for any maternal infections that may affect the baby. After birth, a clinical examination is conducted, and the newborn hearing screening programme is carried out to detect any hearing problems. The mother is also given a Personal Child Health Record.

Within the first month, a heel-prick test is conducted to check for hypothyroidism, PKU, metabolic diseases, cystic fibrosis, and medium-chain acyl Co-A dehydrogenase deficiency (MCADD). A midwife visit may also be conducted within the first four weeks. In the following months, health visitor input is provided, and a GP examination is conducted at 6-8 weeks. Routine immunisations are also given during this time.

Preschool children are screened for vision problems through a national orthoptist-led programme. Ongoing monitoring of growth, vision, and hearing is conducted, and health professionals provide advice on immunisations, diet, and accident prevention. Although midwife visits are supposed to occur up to four weeks after birth, in practice, health visitors usually take over at two weeks. Overall, child health surveillance in the UK aims to ensure that children receive the necessary care and support for their physical and developmental well-being.

The Barlow manoeuvre involves an attempt to dislocate the femoral head of a newborn.

Developmental dysplasia of the hip (DDH) is a condition that affects 1-3% of newborns and is more common in females, firstborn children, and those with a positive family history or breech presentation. It used to be called congenital dislocation of the hip (CDH). DDH is more often found in the left hip and can be screened for using ultrasound in infants with certain risk factors or through clinical examination using the Barlow and Ortolani tests. Other factors to consider include leg length symmetry, knee level when hips and knees are flexed, and restricted hip abduction in flexion. Ultrasound is typically used to confirm the diagnosis, but x-rays may be necessary for infants over 4.5 months old. Management options include the Pavlik harness for younger children and surgery for older ones. Most unstable hips will stabilize on their own within 3-6 weeks.

Pertussis-Containing Vaccines: Who Should Not Receive Them?

There are very few people who cannot receive pertussis-containing vaccines. However, if there is any doubt, it is important to seek advice from a consultant paediatrician, local Screening and Immunisation team, or consultant in Health Protection rather than withholding the vaccine.

There are only two situations where the vaccine should not be given. Firstly, if an individual has had a confirmed anaphylactic reaction to a previous dose of a pertussis-containing vaccine. Secondly, if an individual has had a confirmed anaphylactic reaction to neomycin, streptomycin, or polymyxin B, which may be present in trace amounts. In these cases, it is important to avoid the vaccine and seek alternative options.

Regardless of severity, a one-time oral dose of dexamethasone (0.15 mg/kg) should be taken immediately for croup.

Croup is a respiratory infection that affects young children, typically those between 6 months and 3 years old. It is most common in the autumn and is caused by parainfluenza viruses. The main symptom is stridor, which is caused by swelling and secretions in the larynx. Other symptoms include a barking cough, fever, and cold-like symptoms. The severity of croup can be graded based on the child’s symptoms, with mild cases having occasional coughing and no audible stridor at rest, and severe cases having frequent coughing, prominent stridor, and significant distress or lethargy. Children with moderate or severe croup should be admitted to the hospital, especially if they are under 6 months old or have other airway abnormalities. Diagnosis is usually made based on clinical symptoms, but a chest x-ray can show subglottic narrowing. Treatment typically involves a single dose of oral dexamethasone or prednisolone, and emergency treatment may include high-flow oxygen or nebulized adrenaline.

Developmental Milestones in Social Behaviour, Feeding, Dressing, and Play

Developmental milestones are important markers in a child’s growth and development. In terms of social behaviour and play, there are several milestones that parents and caregivers can look out for. At six weeks, a baby may start to smile, which develops into laughter by three months. At six months, they become less shy, but by nine months, they may exhibit shyness. Additionally, babies at this age tend to put everything in their mouths.

In terms of feeding, a six-month-old may start to put their hand on the bottle while being fed. By 12-15 months, they can drink from a cup and use a spoon, which develops over a three-month period. At two years, they become competent with a spoon and don’t spill with a cup, and by three years, they can use a spoon and fork. Finally, at five years, they can use a knife and fork.

When it comes to dressing, a child may start to help with getting dressed and undressed at 12-15 months. By 18 months, they can take off shoes and hats but may not be able to replace them. At two years, they can put on hats and shoes, and by four years, they can dress and undress independently, except for laces and buttons.

Lastly, in terms of play, a nine-month-old may start to play peek-a-boo and wave bye-bye. By 12 months, they may play pat-a-cake, and at 18 months, they can play contentedly alone. At two years, they may play near others but not necessarily with them, and by four years, they can play with other children. These milestones can help parents and caregivers track a child’s development and ensure they are meeting age-appropriate goals.

Understanding Infantile Spasms

Infantile spasms, also known as West syndrome, is a form of epilepsy that typically occurs in infants between 4 to 8 months old, with a higher incidence in male infants. This condition is often associated with an underlying serious medical condition and has a poor prognosis.

The characteristic feature of infantile spasms is the salaam attack, which involves the flexion of the head, trunk, and arms followed by the extension of the arms. These attacks last only 1-2 seconds but can be repeated up to 50 times. Infants with this condition may also experience progressive mental handicap.

To diagnose infantile spasms, an EEG is typically performed, which may show hypsarrhythmia in two-thirds of infants. A CT scan may also be done, which can reveal diffuse or localized brain disease in 70% of cases, such as tuberous sclerosis.

Unfortunately, infantile spasms carry a poor prognosis. However, there are treatment options available. Vigabatrin is now considered first-line therapy, and ACTH is also used.

For pre-pubertal girls with vulvovaginitis and no red flags, general measures should be attempted before further investigations. The most appropriate measure is providing hygiene advice, which includes wiping from front to back, maintaining hand hygiene, wearing loose cotton underwear, and avoiding irritants such as soaps, bubble baths, and laundry detergents. Vinegar baths and barrier creams may also be helpful. Clotrimazole pessary, oral metronidazole, and oral trimethoprim are not recommended for this age group and scenario. It is important to note that vulvovaginitis in young girls often resolves on its own as they grow older.

Gynaecological Problems in Children: Vulvovaginitis

In children, gynaecological problems are not uncommon, and vulvovaginitis is the most prevalent disorder. This condition is often caused by poor hygiene, tight clothing, lack of labial fat pads protecting the vaginal orifice, and lack of protective acid secretion found in the reproductive years. Bacterial or fungal organisms may be responsible for the infection, and in rare cases, sexual abuse may present as vulvovaginitis. If there is a bloody discharge, it is essential to consider a foreign body.

It is not recommended to perform vaginal examinations or vaginal swabs on children. Instead, referral to a paediatric gynaecologist is appropriate for persistent problems. Most newborn girls have some mucoid white vaginal discharge, which usually disappears by three months of age.

The management of vulvovaginitis includes advising the child about hygiene, using soothing creams, and applying topical antibiotics or antifungals. In resistant cases, oestrogen cream may be necessary. It is crucial to seek medical attention if the symptoms persist or worsen.

The recurrence rate of Down’s syndrome is typically 1 in 100.

Down’s Syndrome: Epidemiology and Genetics

Down’s syndrome is a genetic disorder that is caused by the presence of an extra copy of chromosome 21. The risk of having a child with Down’s syndrome increases with maternal age, with a 1 in 1,500 chance at age 20 and a 1 in 50 or greater chance at age 45. This can be remembered by dividing the denominator by 3 for every extra 5 years of age starting at 1/1,000 at age 30.

There are three main types of Down’s syndrome: nondisjunction, Robertsonian translocation, and mosaicism. Nondisjunction accounts for 94% of cases and occurs when the chromosomes fail to separate properly during cell division. Robertsonian translocation, which usually involves chromosome 14, accounts for 5% of cases and occurs when a piece of chromosome 21 attaches to another chromosome. Mosaicism, which accounts for 1% of cases, occurs when there are two genetically different populations of cells in the body.

The risk of recurrence for Down’s syndrome varies depending on the type of genetic abnormality. If the trisomy 21 is a result of nondisjunction, the chance of having another child with Down’s syndrome is approximately 1 in 100 if the mother is less than 35 years old. If the trisomy 21 is a result of Robertsonian translocation, the risk is much higher, with a 10-15% chance if the mother is a carrier and a 2.5% chance if the father is a carrier.

Childhood Development Milestones

At around 16 months, a child should be able to walk without assistance, with the average age for achieving this milestone being 12 months. Additionally, they should be able to assist with dressing themselves at this age. However, building a tower of four cubes and scribbling with a pencil are not expected until around two years old. By this age, the child should also understand the meaning of no and be able to appropriately state mama and dada. These are important developmental milestones to keep in mind as a child grows and develops.

Conditions That Necessitate Surgical Intervention

1. Hirschsprung’s Disease:
   • Description: Hirschsprung’s disease is a congenital condition characterized by the absence of ganglion cells in a segment of the colon, leading to bowel obstruction due to a lack of peristalsis in the affected area.
   • Surgical Intervention: Surgery is required to remove the aganglionic segment of the colon. This is typically done through a procedure called a pull-through surgery, where the diseased segment is removed, and the healthy bowel is connected to the anus.

Conditions That May or May Not Require Surgical Intervention

2. Tongue Tie (Ankyloglossia):
   • Description: Tongue tie occurs when the lingual frenulum (the band of tissue under the tongue) is too short or tight, restricting tongue movement.
   • Surgical Intervention: A frenotomy or frenuloplasty may be performed if the tongue tie significantly affects breastfeeding, speech, or oral hygiene. However, not all cases require surgery, and some may resolve as the child grows.

Conditions That Typically Do Not Require Surgical Intervention in Newborns

3. Umbilical Hernia:
   • Description: An umbilical hernia is a protrusion of the intestine or other tissue through a weakness in the abdominal muscles near the belly button.
   • Management: Most umbilical hernias in newborns close spontaneously by the age of 1-3 years. Surgery is usually only considered if the hernia persists beyond this age or if complications arise (e.g., incarceration or strangulation).
4. Non-retractile Prepuce (Phimosis):
   • Description: Non-retractile prepuce is common in newborns and infants, where the foreskin cannot be retracted over the glans penis.
   • Management: This is typically physiological and resolves naturally as the child grows. Surgery, such as circumcision, is generally only considered if there are recurrent urinary tract infections or other complications.
5. Capillary Haemangioma (Infantile Hemangioma):
   • Description: Capillary hemangiomas are benign vascular tumors that appear as red or purple skin lesions in newborns.
   • Management: Most infantile hemangiomas do not require surgical intervention and tend to regress spontaneously over time. Surgery or other treatments may be considered if the hemangioma causes complications, such as obstruction of vision or airway, ulceration, or bleeding.

Summary

• Surgical intervention is necessary for Hirschsprung’s disease in the newborn period.
• Tongue tie may require surgery if it affects feeding or speech, but many cases do not.
• Umbilical hernia, non-retractile prepuce, and capillary hemangioma generally do not require immediate surgical intervention in newborns unless complications occur.

Childhood Illnesses Caused by Adenovirus

Adenovirus is a common cause of childhood illnesses, including upper respiratory tract infections, otitis media, acute bronchiolitis, obliterative bronchiolitis, pneumonia, diarrhea, meningitis, encephalitis, hepatitis, urinary tract infections, and nonspecific febrile illnesses. It is important to note that adenovirus is not the cause of glandular fever, Kawasaki disease, roseola infantum, or scarlet fever. Glandular fever is caused by Epstein-Barr virus, the exact cause of Kawasaki disease is unknown, roseola infantum is caused by human herpesvirus 6, and scarlet fever is due to Streptococcus pyogenes infection. It is important for parents and caregivers to be aware of the symptoms of these illnesses and seek medical attention if necessary.

Speech Delay in Children: Possible Causes and Exclusions

Speech delay is a common issue that affects 3-10% of all children, with boys being 3-4 times more likely to experience it than girls. One possible cause of speech delay in older children is elective mutism, which can be assessed through proper diagnosis. However, before progressing to other investigations, it is important to exclude deafness as a possible cause. Other factors that should be excluded include social and environmental deprivation, disorders of metabolism, and degenerative nervous diseases, which are rare possibilities. By identifying and addressing the underlying cause of speech delay, children can receive the necessary support and intervention to improve their communication skills.