Infant Weight Loss and Monitoring

It is normal for infants to experience weight loss during the early days of life. However, if an infant loses more than 10% of their birth weight, it is important to assess for dehydration, underlying illness, and feeding problems. Monitoring the infant closely is also recommended, but weighing should not be done more frequently than daily according to NICE guidelines. If there is evidence of illness or failure to respond to feeding support, referral to paediatric services should be considered.

Supplementation with infant formula may result in the cessation of breastfeeding, so it is advised to support the mother to continue breastfeeding. The RCGP recommends testing for normality and sometimes, monitoring or reassurance may be the answer to questions related to infant weight loss. By closely monitoring and addressing any concerns, infants can return to their birth weight by 3 weeks of age.

Identifying Red Flags in Febrile Children

Febrile illness in children can be a cause of concern for parents and healthcare providers. While most cases are self-limiting and resolve without complications, some may require urgent medical attention. It is important to identify red flags that indicate a potentially serious underlying condition.

Factors that may increase family anxiety include a history of serious illness or death due to feverish illness, other illnesses affecting the child or family members, and parental instinct. Parents should not ignore their intuition and seek medical advice if they are concerned.

While there are no set rules about how long a fever should last, parents should seek further advice if their child has been febrile for five days without resolution. In infants aged 0-3 months, a temperature of >38°C is a red flag, while a temperature of >39°C in infants aged 3-6 months is an amber flag. After six months of age, the temperature alone is no longer an indicator of intermediate or high risk.

Reduced fluid intake, dry mucous membranes, reduced urine output, and reduced skin turgor are amber warning signs that require medical attention. A blanching erythematous rash is likely to indicate a viral infection and is not a cause for concern. However, non-blanching petechiae and patches in a sick child suggest meningococcal disease and require urgent medical attention.

In conclusion, identifying red flags in febrile children is crucial for timely diagnosis and management of potentially serious conditions. Parents should seek medical advice if they are concerned about their child’s health.

Understanding Innocent Murmurs in Children

Innocent murmurs are common in children and are usually harmless. They are short in duration, soft, systolic, and typically located at the left sternal border. Innocent murmurs may change with the child’s position or respiration, but they do not usually radiate and are without symptoms in the patient.

It is important to note that a grade 4/6 murmur is loud with a thrill and is usually pathological. Murmurs that are only diastolic in nature or pansystolic in nature are also usually pathological. The presence of abnormal heart sounds is another indication of a pathological murmur.

If an innocent murmur is suspected, it should disappear when the child has recovered from a febrile illness. If the murmur persists when the child is well, further investigation is warranted.

Understanding the characteristics of innocent murmurs can help healthcare professionals differentiate between harmless murmurs and those that require further investigation.

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.

Measles Treatment and Complications

If a person has been exposed to measles within the past 72 hours, the measles vaccine is the preferred treatment option. This vaccine can provide lifelong immunity, although it is not 100% effective in preventing the disease. If the vaccine is not an option, immune globulin can be given within six days of exposure.

Complications from measles are common, with one-third of those infected experiencing issues such as pneumonia, otitis media, and diarrhea. However, the most serious complication is the development of subacute sclerosing pan-encephalitis.

Measles typically begins with coryzal symptoms, followed by the appearance of a rash several days later.

Route and Timing of Immunisations in the UK

The UK routine immunisation schedule includes various vaccines that are administered through different routes. One of these is the rotavirus vaccine, which is the only vaccine given orally. It is given to infants at 8 and 12 weeks of age. On the other hand, the polio vaccine used to be administered orally in the past, but it is no longer part of the routine UK immunisation schedule. It is important to follow the recommended route and timing of immunisations to ensure their effectiveness in protecting against diseases.

Diagnosing UTI in Children

UTI can be challenging to diagnose in children, especially in preverbal ones. While offensive smelling urine is a rare symptom, general symptoms such as fever, poor feeding, and vomiting are more common. Therefore, obtaining a urine sample is crucial for accurate diagnosis. NICE recommends obtaining a clean catch urine sample for urine collection. If this is not possible, collection pads are advised. However, it is important to note that cotton wool balls, gauze, and sanitary towels should not be used.

Turner’s syndrome is the likely diagnosis for a patient with short stature and primary amenorrhoea. Hypothyroidism may also cause these symptoms, but the presence of a high-arched palate makes it less likely. While gonadal dysgenesis (46, XX) can cause primary amenorrhoea, it doesn’t typically present with the characteristic dysmorphic features seen in Turner’s syndrome.

Understanding Turner’s Syndrome

Turner’s syndrome is a genetic condition that affects approximately 1 in 2,500 females. It is caused by the absence of one sex chromosome (X) or a deletion of the short arm of one of the X chromosomes. This condition is identified as 45,XO or 45,X.

The features of Turner’s syndrome include short stature, a shield chest with widely spaced nipples, a webbed neck, a bicuspid aortic valve (present in 15% of cases), coarctation of the aorta (present in 5-10% of cases), primary amenorrhea, cystic hygroma (often diagnosed prenatally), a high-arched palate, a short fourth metacarpal, multiple pigmented naevi, lymphoedema in neonates (especially in the feet), and elevated gonadotrophin levels. Hypothyroidism is also more common in individuals with Turner’s syndrome, as well as an increased incidence of autoimmune diseases such as autoimmune thyroiditis and Crohn’s disease.

In summary, Turner’s syndrome is a chromosomal disorder that affects females and is characterized by various physical features and health conditions. Early diagnosis and management can help individuals with Turner’s syndrome lead healthy and fulfilling lives.

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.

Possible causes of microcytic anaemia in a 9-month-old child

Microcytic anaemia is a condition characterized by a low level of haemoglobin (Hb) in red blood cells, along with small cell size. In a 9-month-old child, this can be caused by various factors. One possible cause is overconsumption of cow’s milk, which is low in iron but high in calories. This can lead to a lack of appetite and subsequent deficiencies in vitamins and minerals, especially iron. Another possible cause is folic acid deficiency, which typically results in megaloblastic anaemia rather than microcytic anaemia. Calorie deficit is unlikely in a child with a high weight percentile. Inflammatory bowel disease is rare in infancy and not supported by the given information. Finally, it is worth noting that a normal physiological fall in Hb occurs after birth, but by 6 months of age, the Hb level should be within the range of 110-140 g/l. Treatment for microcytic anaemia may involve dietary education and oral iron supplementation.

Understanding Vitamin D Deficiency

Vitamin D deficiency is a common health concern that can lead to various health problems. To investigate suspected Vitamin D deficiency, doctors often use the 25-hydroxyvitamin D blood test. However, it’s important to note that a high alkaline phosphatase level may indicate rickets, but it can still be normal despite significant Vitamin D deficiency. Additionally, Vitamin D deficiency can impair the absorption of dietary calcium and phosphorus, but these levels may still appear normal despite the deficiency.

When the parathyroid calcium sensing receptors detect low levels of calcium, the body produces parathyroid hormone. While this hormone can be used to diagnose Vitamin D deficiency, it’s an expensive test that is not usually necessary. Overall, understanding the signs and symptoms of Vitamin D deficiency and getting regular check-ups can help prevent and treat this common health issue.

It is recommended to consider prescribing calcium supplements and vitamin D for breastfeeding mothers whose babies have or are suspected to have CMPI. This is to prevent deficiency while they exclude dairy from their diet, which puts them at risk of deficiency. Soya milk is not advised for infants due to its phyto-oestrogen content, and lactase enzyme products are not relevant as lactose intolerance is a different condition. Lactulose is also not indicated based on the given history.

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.

Common Myths and Facts about Safe Sleeping for Babies

There are many misconceptions about safe sleeping for babies that can put them at risk of Sudden Infant Death Syndrome (SIDS). Here are some common myths and facts to help parents ensure their baby is sleeping safely.

Myth: It’s okay to smoke around the baby.
Fact: Smoking during and after pregnancy increases the risk of SIDS. Passive smoking also significantly increases the risk of SIDS, and the risk increases further when both parents smoke.

Myth: The ideal room temperature for a baby is 20-24°C.
Fact: This temperature might be uncomfortably warm; the ideal room temperature is 16–20 °C.

Myth: Babies should sleep in the same room as their parents for the first year of life.
Fact: Infants should share the same room, but not the same bed, as their parents for the first six months to decrease the risk of SIDS.

Myth: Place the baby on their front to sleep.
Fact: Babies should be placed on their backs to sleep, with feet touching the end of the cot, so that they cannot slip under the covers. The use of pillows is not recommended.

Myth: The use of pacifiers is not recommended.
Fact: The use of pacifiers while settling the baby to sleep reduces the risk of cot death.

Gemma has been diagnosed with labial adhesion, which typically resolves on its own without the need for treatment unless there are issues with urination. If urination problems arise, a topical oestrogen cream may be used. Since Gemma is not experiencing any urination problems, no treatment is necessary, and her symptoms are expected to resolve naturally. There is no need to refer her to social services as labial adhesions do not necessarily indicate safeguarding concerns, and there is no other information in her medical history to suggest such concerns. Additionally, genetic testing or a referral to a paediatric surgeon is not necessary as this condition is common and usually resolves on its own.

Labial Adhesions: Causes, Symptoms, and Treatment

Labial adhesions refer to the fusion of the labia minora in the middle, which is commonly observed in girls aged between 3 months and 3 years. This condition can be treated conservatively, and spontaneous resolution usually occurs around puberty. It is important to note that labial adhesions are different from an imperforate hymen.

Symptoms of labial adhesions include problems with urination, such as pooling in the vagina. Upon examination, thin semitranslucent adhesions covering the vaginal opening between the labia minora may be seen, which can sometimes cover the vaginal opening completely.

Conservative management is usually appropriate for most cases of labial adhesions. However, if there are associated problems such as recurrent urinary tract infections, oestrogen cream may be tried. If this fails, surgical intervention may be necessary.

In summary, labial adhesions are a common condition in young girls that can cause problems with urination. While conservative management is usually effective, medical intervention may be necessary in some cases.

Pulmonary Embolism in Nephrotic Syndrome

Pulmonary embolus is a rare but potentially life-threatening condition that may be missed due to its rarity. However, its presentation in children is similar to that in adults, with symptoms such as hypotension, tachycardia, pleuritic chest pain, and possibly haemoptysis. In children with nephrotic syndrome, the risk of pulmonary embolism is increased due to abnormalities in clotting factors and hypercoagulability. Therefore, it is important for healthcare providers to be aware of this potential complication and consider it in the differential diagnosis of children with nephrotic syndrome presenting with respiratory symptoms. Proper diagnosis and management can prevent serious consequences and improve outcomes for these patients.

For a child with croup, a single dose of oral dexamethasone (0.15 mg/kg) should be taken immediately regardless of the severity of the illness. Croup typically begins with cold-like symptoms and progresses to a barking cough with a seal-like sound. The severity of croup can be determined by the presence of symptoms such as stridor, recessions, and distress. In this case, the child has mild croup and hospital admission is not necessary. Nebulized adrenaline is only recommended for children with severe symptoms, while a salbutamol inhaler is not effective for croup. Antibiotics are not useful for treating croup as it is a viral illness. Steroids, such as dexamethasone, have been shown to alleviate symptoms and reduce the need for hospitalization.

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.

Fraser Guidelines and Young People’s Competence to Consent to Contraceptive Advice or Treatment

The Fraser guidelines provide a framework for assessing young people’s competence to consent to contraceptive advice or treatment. According to these guidelines, a young person is considered competent if they understand the doctor’s advice, cannot be persuaded to inform their parents, are likely to start or continue having sexual intercourse with or without contraceptive treatment, are at risk of physical or mental harm without treatment, and require advice or treatment in their best interests without parental consent.

However, there can be considerable differences in the maturity of teenagers seeking contraception, and it is important to consider whether the failure of the consultation is due to the doctor’s communication skills or the young person’s anxiety. For instance, a young person who is not sexually active may not understand the importance of contraception and may need education or counselling to help them make informed decisions about their sexual health.

In such cases, a specialist young people’s service may be able to provide the necessary support, such as counselling, education, or youth work interventions, to help the young person understand the risks and benefits of contraception and make an informed decision about their sexual health. By providing young people with the information and support they need, healthcare professionals can help them make responsible choices about their sexual health and reduce the risk of physical and mental harm.

Treatment Ladder for Asthma in a 9-Year-Old Child

Here we have a 9-year-old child with asthma who is currently on a regular inhaled corticosteroid (ICS) + long acting beta2 agonist (LABA) combination inhaler and salbutamol as needed. Despite some improvement with the regular inhaled ICS+LABA, the child is still requiring salbutamol quite frequently.

To guide treatment titration, the British Thoracic Society treatment ladder is the best recognized guideline in the UK. Based on this, the next step would be to trial a leukotriene receptor antagonist. If the addition of the LABA had not yielded any clinical benefit, then it should be stopped. However, since it has proved to be somewhat helpful, it should be continued.

In summary, the treatment ladder for asthma in a 9-year-old child involves gradually increasing the level of medication until symptoms are controlled. The addition of a leukotriene receptor antagonist may be the next step in this process.

Developmental Milestones in Speech and Hearing

As children grow and develop, they reach various milestones in their speech and hearing abilities. These milestones are important indicators of a child’s progress and can help parents and caregivers identify any potential issues early on.

At three months old, a baby will begin to quieten down when they hear their parents’ voices and turn towards sounds. They may also start to make high-pitched squeals. By six months, they will begin to produce double syllables such as adah and erleh.

At nine months, a baby will typically say mama and dada and understand the word no. By 12 months, they will know and respond to their own name and understand simple commands like give it to mummy.

Between 12 and 15 months, a baby will know about 2-6 words and understand more complex commands. By two years old, they will be able to combine two words and point to parts of their body. They will also have a vocabulary of around 200 words by 2 1/2 years old.

At three years old, a child will begin to talk in short sentences and ask what and who questions. They will also be able to identify colors and count to 10. By four years old, they will start asking why, when, and how questions.

Overall, these milestones provide a helpful guide for parents and caregivers to track a child’s speech and hearing development. If there are any concerns, it is important to seek advice from a healthcare professional.

Differential diagnosis of a child with faltering growth and respiratory symptoms

Cystic fibrosis, coeliac disease, α1-antitrypsin deficiency, asthma, and hypothyroidism are among the possible conditions that may cause faltering growth and respiratory symptoms in children. In the case of cystic fibrosis, dysfunction of the exocrine glands affects multiple organs, leading to chronic respiratory infection, pancreatic enzyme insufficiency, and related complications. The diagnosis of cystic fibrosis is often made in infancy, but can vary in age and may involve meconium ileus or recurrent chest infections. Coeliac disease, on the other hand, typically develops after weaning onto cereals that contain gluten, and may cause faltering growth but not respiratory symptoms. α1-Antitrypsin deficiency, which can lead to chronic obstructive pulmonary disease later in life, is less likely in a young child. Asthma, a common condition that affects the airways and causes wheeze or recurrent nocturnal cough, usually doesn’t affect growth. Hypothyroidism, a disorder of thyroid hormone deficiency, is screened for in newborns but doesn’t cause respiratory symptoms after birth. Therefore, based on the combination of faltering growth and respiratory symptoms, cystic fibrosis is the most likely diagnosis in this scenario.

Pertussis: A Contagious Disease

Pertussis, also known as whooping cough, is a highly contagious respiratory disease caused by the bacterium Bordetella pertussis. The incubation period lasts for 7-10 days, after which the child becomes maximally infectious during the first 7-14 days of the illness, known as the catarrhal phase. Although antibiotics do not have a significant effect on symptoms, they can reduce the period of infectivity.

In children over two years old, a whoop may not always be present, but apnoeic episodes are common in infants. The bacterium is challenging to culture, but the use of PCR has improved diagnostic accuracy. While the annual death rate in the United Kingdom is low, pertussis is not a trivial disease, and vaccination is strongly recommended.

NICE Guidelines for Children with Pneumonia Symptoms

According to the National Institute for Health and Care Excellence (NICE), children who show symptoms of pneumonia but are not admitted to the hospital should not undergo a chest X-ray as a routine procedure. Instead, the first line of treatment for such cases is amoxicillin, which is safe to use in children without any drug allergies. It is important to follow these guidelines to ensure the best possible care for children with pneumonia symptoms.

Torsion: A Serious Condition with Limited Treatment Window

A short history of severe pain without any other symptoms should be considered as torsion. It is crucial to note that even if other symptoms are present, torsion should not be overlooked as there is only a limited time frame for treatment. A horizontal-lying testis is a typical indication of torsion, although it may not always be visible. Early diagnosis and treatment are crucial in managing torsion and preventing any long-term damage.

Infantile colic is characterized by repeated episodes of excessive and inconsolable crying in an otherwise healthy and thriving infant. This condition typically begins in the first few weeks of life and resolves by around 3-4 months of age. The crying often occurs in the late afternoon or evening and may be accompanied by the infant drawing its knees up to its abdomen or arching its back. Colic affects both breastfed and bottle-fed infants and occurs equally in both sexes. However, it can lead to complications such as parental stress, anxiety, and depression, sleep deprivation, family tension, and attachment difficulties between parent and infant. It may also result in premature cessation of breastfeeding or weaning onto solid foods, as well as an increased risk of child maltreatment.

Understanding Infantile Colic

Infantile colic is a common condition that affects infants under three months old. It is characterized by excessive crying and pulling up of the legs, usually worse in the evening. This condition affects up to 20% of infants, and its cause is unknown.

Despite its prevalence, the use of simeticone and lactase drops is not recommended by NICE Clinical Knowledge Summaries. These drops are commonly used to alleviate the symptoms of infantile colic, but their effectiveness is not supported by evidence. Therefore, it is important to seek medical advice before using any medication to treat infantile colic.

Breastfeeding and its Effects on Infant Health: A Comprehensive Overview

Breastfeeding has numerous benefits for infant health, including protection against sudden infant death syndrome (SIDS), many infections, childhood obesity, and future type 1 and 2 diabetes. While exclusive breastfeeding has the strongest protective effect against SIDS, any amount of breastfeeding can confer some protection. However, there is no evidence that exclusive breastfeeding protects against atopic eczema.

Breastfeeding may also affect neonatal jaundice. Breastfeeding jaundice, which occurs before the mother’s milk supply is fully developed, can make physiological jaundice appear worse. Breastmilk jaundice, on the other hand, is different and typically peaks between days 5 and 15 before becoming normal after week 3. It may persist up to age 3 months, and its cause is unclear.

Breastfeeding may also have implications for maternal bacterial infections, including tuberculosis. If the mother develops tuberculosis, temporarily stopping breastfeeding may be appropriate, but anti-tuberculosis drugs are safe for use with breastfeeding. Breastmilk is also low in vitamin D, so breastfed infants may need to receive vitamin D drops from 1 month of age if their mother has not taken supplements during pregnancy. This is particularly important for mothers at high risk of vitamin D deficiency.

Overall, breastfeeding has numerous benefits for infant health, but it is important to be aware of its potential implications for certain conditions.

Managing Gastroenteritis in Children: Importance of Oral Rehydration Salt Solution

Gastroenteritis is a common condition in children, which can lead to dehydration if not managed properly. While most children do not show signs of dehydration, those at increased risk should be given oral rehydration salt solution as supplemental fluid. According to the National Institute for Health and Care Excellence (NICE), children at increased risk include infants younger than one year, those who have passed more than five loose stools or vomited more than twice in the previous 24 hours, and those with signs of malnutrition.

It is important to note that feeding with formula or breast milk should continue if the child can tolerate it. Solid food should not be given, and fruit juices or carbonated drinks should be avoided due to their high osmolarity. While extra fluid intake should generally be encouraged, it may not be enough for children with multiple risk factors for dehydration. Therefore, oral rehydration salt solution should be given as recommended by healthcare professionals.

Distinguishing between Inguinal Hernia and Other Groin Conditions in Children

Inguinal hernias are a common condition affecting 1-3% of young children, with incarcerated or strangulated hernias accounting for 10-20% of cases. These hernias present as a swelling in the external or internal inguinal ring or scrotum, which may or may not be painful. In contrast, testicular torsion typically affects teenage boys and presents with testicular pain, tenderness, and swelling. Orchitis, caused by mumps, also presents with testicular pain and swelling but doesn’t involve swelling in the groin. Hydroceles, which contain fluid and transilluminate, are not typically tender and do not involve bowel in the scrotum. Undescended or retractile testicles may cause apparent groin swelling but do not involve tenderness. When evaluating a child with apparent groin swelling, it is important to palpate both testicles and consider the presence of tenderness, transillumination, and upper border of the swelling to distinguish between these conditions.

The automated otoacoustic emission test is utilized for screening hearing problems in newborns. This test involves inserting a small soft-tipped earpiece in the outer part of a baby’s ear to send clicking sounds down the ear. A healthy cochlea is indicated by the presence of a soft echo.

The auditory brainstem response test is an incorrect answer. It may be conducted by an audiologist if a baby is not found to have satisfactory hearing during newborn screening with the automated otoacoustic emission test. This test involves placing small sensors on the baby, playing sounds of different frequencies into their ears, and recording the response using a computer.

Play audiometry is also an incorrect answer. It is suitable for children between two and five years old and not for newborns as the child is required to perform a simple task when they hear a sound.

Pure tone audiometry is another incorrect answer. It is used in older children (school age) and adults and is not suitable for use in newborns as the patient must respond when they hear a noise by pressing a button.

Hearing Tests for Children

Hearing tests are important for children to ensure that they are developing normally. There are several tests that may be performed on children of different ages. For newborns, an otoacoustic emission test is typically done as part of the Newborn Hearing Screening Programme. This test involves playing a computer-generated click through a small earpiece and checking for the presence of a soft echo, which indicates a healthy cochlea. If the results of this test are abnormal, an Auditory Brainstem Response test may be done.

For infants between 6-9 months, a Distraction test may be performed by a health visitor with the help of two trained staff members. For children between 18 months to 2.5 years, a Recognition of familiar objects test may be used, which involves using familiar objects like a teddy or cup and asking the child simple questions like where is the teddy? For children over 2.5 years, Performance testing and Speech discrimination tests using similar-sounding objects like the Kendall Toy test or McCormick Toy Test may be used. Pure tone audiometry is typically done at school entry in most areas of the UK for children over 3 years old.

In addition to these tests, there is also a questionnaire for parents in the Personal Child Health Records called Can your baby hear you? This questionnaire can help identify any potential hearing issues in children. Overall, hearing tests are an important part of ensuring that children are developing normally and can help identify any issues early on.

Understanding Cystic Fibrosis

Cystic fibrosis is a genetic disorder that causes thickened secretions in the lungs and pancreas. It is an autosomal recessive condition that occurs due to a defect in the cystic fibrosis transmembrane conductance regulator gene (CFTR), which regulates a chloride channel. In the UK, 80% of CF cases are caused by delta F508 on chromosome 7, and the carrier rate is approximately 1 in 25.

CF patients are at risk of colonization by certain organisms, including Staphylococcus aureus, Pseudomonas aeruginosa, Burkholderia cepacia (previously known as Pseudomonas cepacia), and Aspergillus. These organisms can cause infections and exacerbate symptoms in CF patients. It is important for healthcare providers to monitor and manage these infections to prevent further complications.

Overall, understanding cystic fibrosis and its associated risks can help healthcare providers provide better care for patients with this condition.

If a child between the ages of 6 and 11 is experiencing an anaphylactic reaction, they should be given a dose of 300 micrograms (0.3ml) of adrenaline. This dose can be repeated every 5 minutes if necessary. Based on the patient’s age of 8 years old, it is recommended to administer the adrenaline at a dose of 300 micrograms IM immediately, as stated in the BNF. It is likely that the child is having an anaphylactic reaction to the nuts they were exposed to in the GP waiting room.

Anaphylaxis is a severe and potentially life-threatening allergic reaction that affects the entire body. It can be caused by various triggers, including food, drugs, and insect venom. The symptoms of anaphylaxis typically develop suddenly and progress rapidly, affecting the airway, breathing, and circulation. Swelling of the throat and tongue, hoarse voice, and stridor are common airway problems, while respiratory wheeze and dyspnea are common breathing problems. Hypotension and tachycardia are common circulation problems. Skin and mucosal changes, such as generalized pruritus and widespread erythematous or urticarial rash, are also present in around 80-90% of patients.

The most important drug in the management of anaphylaxis is intramuscular adrenaline, which should be administered as soon as possible. The recommended doses of adrenaline vary depending on the patient’s age, with the highest dose being 500 micrograms for adults and children over 12 years old. Adrenaline can be repeated every 5 minutes if necessary. If the patient’s respiratory and/or cardiovascular problems persist despite two doses of IM adrenaline, IV fluids should be given for shock, and expert help should be sought for consideration of an IV adrenaline infusion.

Following stabilisation, non-sedating oral antihistamines may be given to patients with persisting skin symptoms. Patients with a new diagnosis of anaphylaxis should be referred to a specialist allergy clinic, and an adrenaline injector should be given as an interim measure before the specialist allergy assessment. Patients should be prescribed two adrenaline auto-injectors, and training should be provided on how to use them. A risk-stratified approach to discharge should be taken, as biphasic reactions can occur in up to 20% of patients. The Resus Council UK recommends a fast-track discharge for patients who have had a good response to a single dose of adrenaline and have been given an adrenaline auto-injector and trained how to use it. Patients who require two doses of IM adrenaline or have had a previous biphasic reaction should be observed for a minimum of 6 hours after symptom resolution, while those who have had a severe reaction requiring more than two doses of IM adrenaline or have severe asthma should be observed for a minimum of 12 hours after symptom resolution. Patients who present late at night or in areas where access to emergency care may be difficult should also be observed for a minimum of 12

Giardiasis: A Chronic Diarrhoeal Disease

Giardiasis is a chronic diarrhoeal disease caused by the flagellate protozoan parasite, Giardia lamblia. This parasite attaches to the small bowel but doesn’t invade it. The disease is prevalent in tropical regions and is contracted by ingesting cysts present in contaminated water or food.

To diagnose giardiasis, stool microscopy is used to detect the cysts. Treatment for giardiasis involves the use of oral metronidazole or tinidazole. These medications are effective in eliminating the parasite and relieving symptoms.

In conclusion, giardiasis is a chronic diarrhoeal disease that can be contracted by ingesting contaminated water or food. Early diagnosis and treatment are essential to prevent complications and reduce the spread of the disease.

A teacher who specializes in coordinating special educational needs is known as a SENCO.

Special educational needs (SEN) refer to children who have a greater difficulty in learning compared to their peers or have a disability that hinders their access to educational facilities. When a child is struggling, a review called ‘School Action’ is conducted by the school and parents to determine what can be done. If outside help is required, such as from an educational psychologist or speech therapist, the review is called ‘School Action Plus’. However, if these actions are not sufficient, a formal statement of educational needs may be necessary.

To assess children who may require help, a special educational needs coordinator (SENCO) is a teacher who specializes in this area. The statement of SEN should be made and reviewed annually to ensure that the child’s needs are being met. The Education Act 1993 aimed to provide early intervention to children with SEN.

To treat umbilical granulomas, salt or silver nitrate cautery can be applied. These granulomas are a common occurrence in babies and appear as a painless lump in the umbilicus, often accompanied by discharge. The umbilical stump typically falls off within ten days of birth, but granulomas can form as the area heals. To speed up the healing process, table salt can be applied for thirty minutes, followed by rinsing the area. This treatment should be repeated twice daily for five days and usually results in resolution within three weeks. If salt treatment is ineffective, silver nitrate cautery can be used, but it’s important to protect the surrounding skin with petroleum jelly.

Paediatric Umbilical Disorders

Embryology plays a significant role in the development of umbilical disorders in children. The umbilicus has two umbilical arteries and one umbilical vein during development. After birth, the cord separates, and the umbilical ring closes. Umbilical hernia is a common disorder in neonates, with up to 20% of infants affected. It is more prevalent in premature infants and usually resolves spontaneously within three years. Strangulation is rare. Paraumbilical hernia is another disorder caused by defects in the linea alba near the umbilicus. It is less likely to resolve spontaneously than an umbilical hernia. Omphalitis is a severe condition caused by an infection of the umbilicus, usually by Staphylococcus aureus. It can spread rapidly through the umbilical vessels, leading to portal pyaemia and portal vein thrombosis. Treatment involves a combination of topical and systemic antibiotics. Umbilical granuloma is characterised by cherry red lesions surrounding the umbilicus, which may bleed on contact and discharge seropurulent fluid. Chemical cautery with silver nitrate is an effective treatment. Persistent urachus is characterised by urinary discharge from the umbilicus and is caused by the persistence of the urachus, which attaches to the bladder. It is associated with other urogenital abnormalities. Persistent vitello-intestinal duct presents as an umbilical discharge that discharges small bowel content. It is best imaged using a contrast study to delineate the anatomy and is managed by laparotomy and surgical closure.

Febrile Convulsions: A Common Occurrence in Young Children

Febrile convulsions are a relatively common occurrence in young children, with a prevalence of 5% between the ages of 6 months and 5 years. Clinical experience has shown that most of these convulsions occur before the age of three. The convulsions are typically tonic-clonic in nature, and most children (75%) will only experience one seizure. A strong family history of febrile seizures is the most important factor in predicting whether a child will develop further seizures.

Fortunately, epilepsy develops in only approximately 2% of children who experience febrile convulsions. After the first seizure, no treatment is required other than symptomatic care. It is important for parents and caregivers to be aware of the signs and symptoms of febrile convulsions and to seek medical attention if they occur. With proper management and care, most children will recover fully from febrile convulsions without any long-term effects.

Undescended Testes in Infants

Undescended testes, also known as cryptorchidism, is a condition where one or both testes fail to descend into the scrotum. It is more common in unilateral cases, occurring four times more often than bilateral cases. At birth, the prevalence of undescended testes is 3.7%, which decreases to 1.0% by three months of age.

It is important to review infants with unilateral undescended testes at three months of age and refer them before six months of age if the condition persists. While most cases will resolve on their own, surgical intervention may be necessary to prevent complications such as impaired fertility, testicular cancer, and testicular torsion. It is not appropriate to reassure and discharge infants with undescended testes, as some cases will require intervention.

In cases where a disorder of sexual development is suspected, referral for endocrine and genetic testing may be useful. It is crucial to address undescended testes early to prevent potential complications and ensure proper treatment.

Treatment Options for Croup: Choosing the Right Approach

Croup is a common respiratory illness in children that can cause coughing, difficulty breathing, and other symptoms. When it comes to treating croup, there are several options available, but not all of them are appropriate for every child. Here’s a breakdown of some common treatment options and when they might be used:

Oral Dexamethasone: For mild-to-moderate croup, a single oral dose of dexamethasone is often the best choice. This medication can help reduce inflammation in the airways and alleviate symptoms. If the child is too unwell to take oral medication, inhaled budesonide may be used instead.

Nebulised Epinephrine: For children with moderate-to-severe distress, nebulised epinephrine can be effective in reducing swelling in the trachea. However, this treatment only lasts for a few hours, so close monitoring is necessary.

Inhaling Humidified Air: While inhaling humidified air may help reduce a child’s anxiety, there is little evidence to suggest that it provides any significant symptomatic relief.

IM Hydrocortisone: IM hydrocortisone is not typically used to treat croup. However, IM dexamethasone may be used as an alternative to oral dexamethasone.

Nebulised Salbutamol: Salbutamol is not an appropriate treatment for croup, as it is typically used to treat asthma.

In summary, the best treatment for croup will depend on the severity of the child’s symptoms and their overall health. If you suspect that your child has croup, it’s important to seek medical attention promptly to ensure that they receive the appropriate care.

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.

If a child is under 3 months old and has a temperature above 38ºC, it is considered a ‘red’ characteristic in the updated NICE guidelines, necessitating immediate referral to a pediatrician.

The NICE Feverish illness in children guidelines were introduced in 2007 and updated in 2013 to provide a ‘traffic light’ system for assessing the risk of febrile illness in children under 5 years old. The guidelines recommend recording the child’s temperature, heart rate, respiratory rate, and capillary refill time, as well as looking for signs of dehydration. Measuring temperature should be done with an electronic thermometer in the axilla for children under 4 weeks or with an electronic/chemical dot thermometer in the axilla or an infra-red tympanic thermometer. The risk stratification table categorizes children as green (low risk), amber (intermediate risk), or red (high risk) based on their symptoms. Management recommendations vary depending on the risk level, with green children managed at home, amber children provided with a safety net or referred to a specialist, and red children urgently referred to a specialist. The guidelines also advise against prescribing oral antibiotics without an apparent source of fever and note that a chest x-ray is not necessary if a child with suspected pneumonia is not being referred to the hospital.

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.

Symptoms of Systemic Juvenile Idiopathic Arthritis

Systemic Juvenile Idiopathic Arthritis (JIA) is characterized by joint symptoms, high fevers that quickly return to normal, and a salmon pink rash. Other symptoms include lymph node enlargement, hepatomegaly, splenomegaly, and serositis (pericarditis, pleuritis, peritonitis).

Oligoarticular JIA may also cause joint symptoms, but it doesn’t explain the fever or rash. Osgood-Schlatter disease typically presents with knee pain, but it doesn’t account for the other symptoms reported in this scenario. Osteochondritis Dissecans may cause aching and swollen joints that worsen with activity, but it doesn’t explain the fevers or pink rash. Septic arthritis is less likely in this case since there is no specific joint that is red and swollen, and the child doesn’t appear to be generally unwell.

Treatment Options for Enuresis: From Simple Measures to Medications

Enuresis, or bedwetting, is a common problem among children. While most children outgrow it, some may need treatment. The first step is to try simple measures such as restricting fluid intake and encouraging regular toilet use. If bedwetting persists, an enuresis alarm may be considered as first-line treatment. Desmopressin, a medication that reduces urine production, can be used for rapid control or in combination with an alarm. However, it should be used second line after an alarm has been tried. Desmopressin with an anticholinergic medication like oxybutynin is another option, but specialist assessment is recommended. Imipramine, a tricyclic antidepressant, may be considered as a last resort after all other treatments have failed and with caution due to potential side effects. Overall, treatment options for enuresis should be tailored to the individual child and their specific needs.

Slipped Upper Epiphysis: Diagnosis and Treatment

Slipped upper epiphyses are more common in overweight boys aged 10-15 and are associated with obesity and hypothyroidism. Patients often present with pain, which may be referred to the knee, and it is important to examine the hips thoroughly. On examination, abduction and internal rotation may both be reduced, and the affected leg may be shortened. The key findings supporting the diagnosis are the presence of risk factors and gait abnormalities.

Slipped epiphyses can be classified as acute, chronic, or acute on chronic, and as unstable or stable. In the case of unstable slipped epiphysis, urgent surgical repair is necessary to prevent avascular necrosis. Stable slipped epiphysis is usually treated with in situ screw fixation, and prophylactic fixation of the contralateral hip may also be considered.

In the primary care setting, emergency admission under orthopaedics is necessary for patients with acute and unstable slipped epiphysis. For chronic and stable cases, x-ray is the first line investigation, and U&Es, serum TFTs, and serum growth hormone may also be considered.

In summary, early diagnosis and appropriate treatment are crucial in managing slipped upper epiphysis.

Understanding Coeliac Disease Testing: Differentiating Between IgA tTGAs, IgA Gliadin Antibodies, IgA EMAs, HLA Genetic Testing, and IgG tTGAs

Coeliac disease is a condition that affects the small intestine and is caused by an intolerance to gluten. While small-bowel biopsy is the most reliable way to diagnose coeliac disease, IgA tissue transglutaminase antibodies (tTGAs) are the preferred initial investigation. This test is highly specific and sensitive for untreated coeliac disease, but should not be performed on children younger than two years as it may give a false negative result.

It is important to note that around 0.4% of the population has selective IgA deficiency, which can lead to a false-negative result. In such cases, the laboratory should measure IgA levels. Some laboratories may do this routinely when measuring tTGAs.

IgA gliadin antibodies are not commonly used to diagnose coeliac disease. Instead, IgA EMAs are autoantibodies against tissue transglutaminase type 2 (tTGA2) and are highly specific and sensitive for untreated coeliac disease. However, IgA EMAs should be measured if IgA tTG is only weakly positive.

HLA genetic testing is not recommended for diagnosing coeliac disease in primary care. Coeliac disease is strongly associated with the genes HLA-DQ2 and HLA-DQ8, but testing for these genes is not necessary for diagnosis.

Finally, IgG tTGAs should only be considered in people who are IgA deficient to avoid the risk of a false-negative IgA tTGA result.

In summary, understanding the differences between these tests is crucial in accurately diagnosing coeliac disease and providing appropriate treatment.

Breath Holding Attacks and Reflex Anoxic Seizures in Toddlers

Breath holding attacks and reflex anoxic seizures are two types of episodes that can occur in toddlers. Breath holding attacks are triggered by upset and can start as early as six months of age, with a peak incidence at two years and typically stopping by five years of age. During a breath holding attack, the child cries, holds their breath, and becomes cyanosed, which can sometimes lead to loss of consciousness and stiffening. However, rapid recovery is common, and no treatment is required.

On the other hand, reflex anoxic seizures are triggered by pain or discomfort, such as minor head trauma, cold food, or fright. After the trigger, the child becomes pale and falls to the floor, which can induce a seizure due to hypoxia resulting from cardiac asystole from vagal inhibition. These episodes are characterized by the pallor typically seen in reflex anoxic seizures.

It is important to note that breath holding attacks can be confused with other options, especially when the child stiffens or progresses to a seizure. However, understanding the differences between these two types of episodes can help parents and caregivers provide appropriate care and reassurance to the child.

Noisy breathing in infants is often caused by a benign condition called laryngomalacia. This condition is characterized by the softening of the larynx cartilage, which leads to its collapse during inhalation. Although it can present at birth, it typically worsens during the first few weeks of life and resolves on its own before the child turns two years old. On the other hand, symptoms of foreign body obstruction occur suddenly. Cystic fibrosis, which is associated with poor growth and meconium ileus, can be detected through a neonatal heel prick test.

Stridor in Children: Causes and Symptoms

Stridor is a high-pitched, wheezing sound that occurs during breathing and is commonly seen in children. There are several causes of stridor in children, including croup, acute epiglottitis, inhaled foreign body, and laryngomalacia. Croup is a viral infection that affects the upper respiratory tract and is characterized by stridor, barking cough, fever, and coryzal symptoms. Acute epiglottitis is a rare but serious infection caused by Haemophilus influenza type B, which can lead to airway obstruction. Inhaled foreign body can cause sudden onset of coughing, choking, vomiting, and stridor, depending on the site of impaction. Laryngomalacia is a congenital abnormality of the larynx that typically presents in infants at 4 weeks of age with stridor.

It is important to recognize the symptoms of stridor in children and seek prompt medical attention, especially if the child appears unwell or toxic. Treatment may include medications, such as corticosteroids or nebulized epinephrine, to reduce inflammation and improve breathing. In severe cases, hospitalization and airway management may be necessary. Parents and caregivers should also take steps to prevent the spread of viral infections, such as washing hands frequently and avoiding close contact with sick individuals.

Although nurseries and schools may provide contradictory advice, the guidelines from the Health Protection Agency are unambiguous in stating that children do not require exclusion. Providing parents with a copy of these guidelines to present to their childcare provider can be beneficial in certain situations.

The Health Protection Agency has provided guidance on when children should be excluded from school due to infectious conditions. Some conditions, such as conjunctivitis, fifth disease, roseola, infectious mononucleosis, head lice, threadworms, and hand, foot and mouth, do not require exclusion. Scarlet fever requires exclusion for 24 hours after commencing antibiotics, while whooping cough requires exclusion for 2 days after commencing antibiotics or 21 days from onset of symptoms if no antibiotics are taken. Measles requires exclusion for 4 days from onset of rash, rubella for 5 days from onset of rash, and Chickenpox until all lesions are crusted over. Mumps requires exclusion for 5 days from onset of swollen glands, while diarrhoea and vomiting require exclusion until symptoms have settled for 48 hours. Impetigo requires exclusion until lesions are crusted and healed, or for 48 hours after commencing antibiotic treatment, and scabies requires exclusion until treated. influenza requires exclusion until the child has recovered for 48 hours.

Regarding Chickenpox, Public Health England recommends that children should be excluded until all lesions are crusted over, while Clinical Knowledge Summaries suggest that infectivity continues until all lesions are dry and have crusted over, usually about 5 days after the onset of the rash. It is important to follow official guidance and consult with healthcare professionals if unsure about exclusion periods for infectious conditions.

Common Causes of Vomiting in Infants: Symptoms and Descriptions

Projectile vomiting is a common symptom in infants, but it can be caused by various conditions. One of the most common causes is infantile hypertrophic pyloric stenosis, which is characterized by forceful vomiting after feeding. This condition is caused by the narrowing of the pyloric canal due to the hypertrophy and hyperplasia of the smooth muscle of the antrum of the stomach and pylorus. It usually occurs in infants aged 2-8 weeks and can be treated by pyloromyotomy.

Gastro-oesophageal reflux is another cause of vomiting in infants, which is characterized by non-forceful regurgitation of milk due to the functional immaturity of the lower oesophageal sphincter. This condition is most common in the first weeks of life and usually resolves by 12-18 months.

Duodenal atresia is a condition that causes hydramnios during pregnancy and intestinal obstruction in the newborn. About 30% of cases have Down syndrome and 30% have cardiovascular abnormalities.

Gastroenteritis is an acute illness that can cause vomiting and loose stools. However, the vomiting is not usually projectile, and the baby would not appear hungry straight after vomiting. These are typical symptoms of pyloric stenosis in this age group.

Lactose intolerance is a condition that develops in people with low lactase levels. Symptoms include bloating, nausea, abdominal pain, diarrhea, and flatulence. Although babies and children can be affected, primary lactose intolerance most commonly appears between 20 and 40 years.

Understanding the Causes of Vomiting in Infants

Managing Gastroenteritis in Children

Gastroenteritis is a common childhood illness that requires effective management to determine whether the child can be treated at home or needs referral to a hospital. It is important to note that not all children develop lactose intolerance after gastroenteritis, so switching to lactose-free formula is not recommended. Antibiotics are also usually unnecessary, as gastroenteritis is typically viral. The decision to manage the illness at home depends on the child’s hydration status and the parents’ ability to maintain that hydration.

Hydration status is assessed clinically based on various factors such as alertness, pulse rate, capillary refill time, mucous membranes, skin turgor, and urine output. In primary care, taking blood to check for signs of dehydration is not routinely recommended. Referral to paediatrics should not be the default option for children under 12 months of age; the decision to treat at home or refer should be based on the clinical assessment. If the child is not clinically dehydrated and there are no atypical features, it would be reasonable to monitor them at home with advice on how to maintain hydration and when to seek review if their condition worsens.

Understanding Meningococcal Septicaemia

Meningococcal septicaemia is a serious condition that can cause high morbidity and mortality if not treated early. It is the leading infectious cause of death in early childhood, making it crucial to have a high index of suspicion. According to the 2010 NICE guidelines, meningococcal disease can present as meningitis, septicaemia, or a combination of both.

NICE divides the symptoms of meningococcal septicaemia into three categories: common nonspecific symptoms/signs, less common nonspecific symptoms/signs, and more specific symptoms/signs. Common nonspecific symptoms/signs include fever, vomiting, and lethargy, while less common nonspecific symptoms/signs include chills and shivering. More specific symptoms/signs include a non-blanching rash, altered mental state, capillary refill time more than 2 seconds, unusual skin colour, shock, hypotension, leg pain, and cold hands/feet.

If meningococcal septicaemia is suspected, it is important to give intramuscular or intravenous benzylpenicillin unless there is a history of anaphylaxis. However, if giving benzylpenicillin will delay hospital transfer, it should not be given. NICE recommends phoning 999 in case of suspected meningococcal septicaemia.

Flat feet (pes planus) and ‘knock knees’ (genu valgum) are common in children of this age and typically resolve on their own between the ages of 4-8 years. Therefore, reassurance should be given to the mother and orthopaedic or podiatry assessment is not necessarily required. However, if the parents are highly anxious, a paediatrician can be consulted for further reassurance. Additionally, physiotherapy is not necessary as there is no significant musculoskeletal abnormality to correct.

Common Variations in Lower Limb Development in Children

Parents may become concerned when they notice what appears to be abnormalities in their child’s lower limbs. This often leads to a visit to the primary care physician and a referral to a specialist. However, many of these variations are actually normal and will resolve on their own as the child grows.

One common variation is flat feet, where the medial arch is absent when the child is standing. This is typically seen in children of all ages and usually resolves between the ages of 4-8 years. Orthotics are not recommended, and parental reassurance is appropriate.

Another variation is in-toeing, which can be caused by metatarsus adductus, internal tibial torsion, or femoral anteversion. In most cases, these will resolve on their own, but severe or persistent cases may require intervention such as serial casting or surgical intervention. Out-toeing is also common in early infancy and usually resolves by the age of 2 years.

Bow legs, or genu varum, are typically seen in the first or second year of life and are characterized by an increased intercondylar distance. This variation usually resolves by the age of 4-5 years. Knock knees, or genu valgum, are seen in the third or fourth year of life and are characterized by an increased intermalleolar distance. This variation also typically resolves on its own.

In summary, many variations in lower limb development in children are normal and will resolve on their own. However, if there is concern or persistent symptoms, intervention may be appropriate.

Syndromes and their Association with Cancer

There are certain syndromes that have been linked to an increased risk of developing certain types of cancer. Down’s syndrome, for example, has been associated with leukaemia, while neurofibromatosis, which is inherited in an autosomal dominant fashion, has been linked to CNS tumours. Other rare syndromes have also been linked to certain cancers.

It is important for primary healthcare professionals to be aware of these associations and to be vigilant for any unexplained symptoms in children or young people with these syndromes. Early detection and treatment can greatly improve outcomes for these patients. Therefore, it is crucial for healthcare professionals to stay informed and up-to-date on the latest research and recommendations regarding these syndromes and their potential links to cancer.

As expected, the child’s respiratory rate is less than 30 breaths per minute and heart rate is less than 125 beats per minute. The appropriate treatment for this asthma attack is oral prednisolone and salbutamol via a spacer, with one puff every 30-60 seconds up to a maximum of 10 puffs. It is important to administer steroid therapy to all children experiencing an asthma attack. High flow oxygen and salbutamol nebuliser are not necessary as the child’s SP02 is already at 97%.

The management of acute asthma attacks in children depends on the severity of the attack. Children with severe or life-threatening asthma should be immediately transferred to the hospital. For children with mild to moderate acute asthma, bronchodilator therapy and steroid therapy should be given. The dosage of prednisolone depends on the age of the child. It is important to monitor SpO2, PEF, heart rate, respiratory rate, use of accessory neck muscles, and other clinical features to determine the severity of the attack.

It is common for individuals to experience a fever of over 38 degrees after receiving the Meningitis B vaccine. To prevent this from occurring, it is recommended that infants receive three doses of paracetamol, with the first dose administered immediately after vaccination. If necessary, parents should continue to administer paracetamol every 4-6 hours for up to 48 hours after vaccination. It is believed that the use of paracetamol doesn’t affect the effectiveness of the vaccine.

Meningitis B Vaccine Now Part of Routine NHS Immunisation

Children in the UK have been receiving immunisation against meningococcus serotypes A and C for many years. However, this led to meningococcal B becoming the most common cause of bacterial meningitis in the country. To address this, a vaccine against meningococcal B called Bexsero was developed and introduced to the UK market.

Initially, the Joint Committee on Vaccination and Immunisation (JCVI) rejected the use of Bexsero after conducting a cost-benefit analysis. However, this decision was eventually reversed, and meningitis B has now been added to the routine NHS immunisation. Children will receive three doses of the vaccine at 2 months, 4 months, and 12-13 months.

Moreover, Bexsero will also be available on the NHS for patients at high risk of meningococcal disease, such as those with asplenia, splenic dysfunction, or complement disorder. With the inclusion of meningitis B vaccine in the routine NHS immunisation, the UK hopes to reduce the incidence of bacterial meningitis and protect more children and high-risk patients from the disease.

In case of suspected bacterial meningococcal septicaemia, benzylpenicillin should be administered to the patient without delaying their transfer to the hospital, unless there is a history of anaphylaxis. Ceftriaxone is the preferred treatment in secondary care, while cefotaxime can be used as an alternative if calcium-containing infusions are being given. Ampicillin can also be used in secondary care along with ceftriaxone. If the organism isolated is Listeria monocytogenes, gentamicin should be added to the treatment regimen.

Understanding Meningococcal Septicaemia

Meningococcal septicaemia is a serious condition that can cause high morbidity and mortality if not treated early. It is the leading infectious cause of death in early childhood, making it crucial to have a high index of suspicion. According to the 2010 NICE guidelines, meningococcal disease can present as meningitis, septicaemia, or a combination of both.

NICE divides the symptoms of meningococcal septicaemia into three categories: common nonspecific symptoms/signs, less common nonspecific symptoms/signs, and more specific symptoms/signs. Common nonspecific symptoms/signs include fever, vomiting, and lethargy, while less common nonspecific symptoms/signs include chills and shivering. More specific symptoms/signs include a non-blanching rash, altered mental state, capillary refill time more than 2 seconds, unusual skin colour, shock, hypotension, leg pain, and cold hands/feet.

If meningococcal septicaemia is suspected, it is important to give intramuscular or intravenous benzylpenicillin unless there is a history of anaphylaxis. However, if giving benzylpenicillin will delay hospital transfer, it should not be given. NICE recommends phoning 999 in case of suspected meningococcal septicaemia.

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.

Disease Notification and Surveillance

The notification of diseases has a long history, dating back to the great epidemics of the past. With improvements in hygiene and vaccination, infectious diseases have become less common, and many GP disease notification returns are inconsistent. However, it is still a legal obligation to report diseases. It is also essential that hospitals are informed of potential infectious diseases when patients are referred. The government uses various data sources for disease surveillance and increasingly relies on electronic data returns. Mumps remains a risk to unimmunised populations.

Mumps: Epidemiology, Surveillance, and Control

Mumps is a viral infection that can cause swelling of the salivary glands, fever, and headache. It is still a risk to unimmunised populations. To control the spread of mumps, it is essential to have effective epidemiology, surveillance, and control measures in place. This includes reporting cases to health authorities, monitoring outbreaks, and promoting vaccination. With the help of electronic data returns and other surveillance methods, it is possible to track the spread of mumps and take appropriate action to prevent further transmission. By working together, we can reduce the impact of mumps and other infectious diseases on our communities.

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.

While positional management of gastro-oesophageal reflux may seem logical, it is important to note that infants should always sleep on their backs to minimize the risk of cot death. Although there are no concerning symptoms, it is advisable to provide treatment for the child’s distress. It is not recommended to increase the volume of feeds as this may exacerbate reflux. Instead, smaller and more frequent feeds could be considered. Diluting the feeds will not improve symptoms and may actually increase the volume in the stomach.

Gastro-oesophageal reflux is a common cause of vomiting in infants, with around 40% of babies experiencing some degree of regurgitation. However, certain risk factors such as preterm delivery and neurological disorders can increase the likelihood of developing this condition. Symptoms typically appear before 8 weeks of age and include vomiting or regurgitation, milky vomits after feeds, and excessive crying during feeding. Diagnosis is usually made based on clinical observation.

Management of gastro-oesophageal reflux in infants involves advising parents on proper feeding positions, ensuring the infant is not overfed, and considering a trial of thickened formula or alginate therapy. However, proton pump inhibitors (PPIs) are not recommended as a first-line treatment for isolated symptoms of regurgitation. PPIs may be considered if the infant experiences unexplained feeding difficulties, distressed behavior, or faltering growth. Metoclopramide, a prokinetic agent, should only be used with specialist advice.

Complications of gastro-oesophageal reflux can include distress, failure to thrive, aspiration, frequent otitis media, and dental erosion in older children. If medical treatment is ineffective and severe complications arise, fundoplication may be considered. It is important for healthcare professionals to be aware of the risk factors, symptoms, and management options for gastro-oesophageal reflux in infants.

Autism spectrum disorder (ASD) is a neurodevelopmental condition that affects social interaction, communication, and behavior. It can be diagnosed in early childhood or later in life and is more common in boys than girls. Around 50% of children with ASD also have an intellectual disability. Symptoms can range from subtle difficulties in understanding and social function to severe disabilities. While there is no cure for ASD, early diagnosis and intensive educational and behavioral management can improve outcomes. Treatment involves a comprehensive approach that includes non-pharmacological therapies such as applied behavioral analysis, structured teaching methods, and family counseling. Pharmacological interventions may also be used to reduce symptoms like repetitive behavior, anxiety, and aggression. The goal of treatment is to increase functional independence and quality of life while decreasing disability and comorbidity.

Meningococcal Septicaemia and Other Skin Conditions

Meningococcal septicaemia is a serious condition that can cause a non-blanching purpuric eruption all over the body. This symptom is a key indicator of the disease and should be taken seriously. Other skin conditions, such as giant urticaria, measles rash, and haemophilia, do not typically present with this type of rash.

Giant urticaria is characterised by recurrent attacks of oedema that appear suddenly in various areas of the body. The measles rash, on the other hand, appears as a macular eruption on the face and neck that spreads over three days. Haemophilia is not associated with any generalised rash.

HSP, another skin condition, may present in a subacute manner and is not typically associated with a high fever in an acutely unwell child. It may occur following an upper respiratory tract infection.

The recommended treatment for pregnant women with pinworm infection involves a combination of physical removal of eggs and hygiene methods. This may include washing the perianal area in the morning and at regular intervals throughout the day. Therefore, relying solely on strict personal hygiene measures for two weeks would not be the preferred option for this patient. Mebendazole is not recommended during the first trimester of pregnancy, but may be considered in the later stages if necessary.

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.

Referral Pathways for Children with Developmental Delays

When a child presents with developmental delays, it is important to consider appropriate referral pathways to ensure they receive the necessary assessments and interventions. Here are some examples of referral pathways for children with specific concerns:

Refer to Audiology: If a child is presenting with speech delay and suspected hearing loss, they should be referred to Audiology for assessment.

Refer to Paediatrics: For children with delays in one area of development or more general concerns, a full developmental assessment with a Paediatrician may be necessary. However, for isolated concerns regarding hearing and speech, an audiology assessment can be a useful initial investigation.

Refer to Physiotherapy: Children presenting with delays in gross motor development may benefit from a referral to Physiotherapy.

Refer to Social Services: While there may be no safeguarding concerns identified, it is important to remain vigilant about safeguarding concerns in children presenting with developmental delays.

Refer to the Health Visitor: The Health Visitor can provide support to parents and caregivers, but if there are concerns regarding hearing and speech delays, a referral to Audiology should be made for assessment.

For the treatment of asthma in children, the recommended dose of prednisolone is 1-2 mg/kg once daily for a period of 3-5 days.

The management of acute asthma attacks in children depends on the severity of the attack. Children with severe or life-threatening asthma should be immediately transferred to the hospital. For children with mild to moderate acute asthma, bronchodilator therapy and steroid therapy should be given. The dosage of prednisolone depends on the age of the child. It is important to monitor SpO2, PEF, heart rate, respiratory rate, use of accessory neck muscles, and other clinical features to determine the severity of the attack.

Children with hand foot and mouth infection can attend school or nursery as long as they are well enough to do so, and do not need to be excluded. This is because the infection is typically mild and self-limiting. However, if the child has a fever, they should be kept at home. It is important to note that exclusion periods for other illnesses, such as Chickenpox, rubella, measles, scarlet fever, and impetigo, differ from those for hand foot and mouth. For more information on exclusion periods, refer to the Public Health Agency website.

The Health Protection Agency has provided guidance on when children should be excluded from school due to infectious conditions. Some conditions, such as conjunctivitis, fifth disease, roseola, infectious mononucleosis, head lice, threadworms, and hand, foot and mouth, do not require exclusion. Scarlet fever requires exclusion for 24 hours after commencing antibiotics, while whooping cough requires exclusion for 2 days after commencing antibiotics or 21 days from onset of symptoms if no antibiotics are taken. Measles requires exclusion for 4 days from onset of rash, rubella for 5 days from onset of rash, and Chickenpox until all lesions are crusted over. Mumps requires exclusion for 5 days from onset of swollen glands, while diarrhoea and vomiting require exclusion until symptoms have settled for 48 hours. Impetigo requires exclusion until lesions are crusted and healed, or for 48 hours after commencing antibiotic treatment, and scabies requires exclusion until treated. influenza requires exclusion until the child has recovered for 48 hours.

Regarding Chickenpox, Public Health England recommends that children should be excluded until all lesions are crusted over, while Clinical Knowledge Summaries suggest that infectivity continues until all lesions are dry and have crusted over, usually about 5 days after the onset of the rash. It is important to follow official guidance and consult with healthcare professionals if unsure about exclusion periods for infectious conditions.

The management of acute asthma attacks in children depends on the severity of the attack. Children with severe or life-threatening asthma should be immediately transferred to the hospital. For children with mild to moderate acute asthma, bronchodilator therapy and steroid therapy should be given. The dosage of prednisolone depends on the age of the child. It is important to monitor SpO2, PEF, heart rate, respiratory rate, use of accessory neck muscles, and other clinical features to determine the severity of the attack.

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%.

Tetanus Vaccination and Management of Wounds

The tetanus vaccine is a purified toxin that is given as part of a combined vaccine. In the UK, it is given as part of the routine immunisation schedule at 2, 3, and 4 months, 3-5 years, and 13-18 years, providing a total of 5 doses. This is considered to provide long-term protection against tetanus.

When managing wounds, the first step is to classify them as clean, tetanus-prone, or high-risk tetanus-prone. Clean wounds are less than 6 hours old and non-penetrating with negligible tissue damage. Tetanus-prone wounds include puncture-type injuries acquired in a contaminated environment, wounds containing foreign bodies, and compound fractures. High-risk tetanus-prone wounds include wounds or burns with systemic sepsis, certain animal bites and scratches, heavy contamination with material likely to contain tetanus spores, wounds or burns that show extensive devitalised tissue, and wounds or burns that require surgical intervention.

If the patient has had a full course of tetanus vaccines with the last dose less than 10 years ago, no vaccine or tetanus immunoglobulin is required regardless of the wound severity. If the patient has had a full course of tetanus vaccines with the last dose more than 10 years ago, a reinforcing dose of vaccine is required for tetanus-prone wounds, and a reinforcing dose of vaccine plus tetanus immunoglobulin is required for high-risk wounds. If the vaccination history is incomplete or unknown, a reinforcing dose of vaccine is required regardless of the wound severity, and a reinforcing dose of vaccine plus tetanus immunoglobulin is required for tetanus-prone and high-risk wounds.

Gastro-oesophageal reflux is a common cause of vomiting in infants, with around 40% of babies experiencing some degree of regurgitation. However, certain risk factors such as preterm delivery and neurological disorders can increase the likelihood of developing this condition. Symptoms typically appear before 8 weeks of age and include vomiting or regurgitation, milky vomits after feeds, and excessive crying during feeding. Diagnosis is usually made based on clinical observation.

Management of gastro-oesophageal reflux in infants involves advising parents on proper feeding positions, ensuring the infant is not overfed, and considering a trial of thickened formula or alginate therapy. However, proton pump inhibitors (PPIs) are not recommended as a first-line treatment for isolated symptoms of regurgitation. PPIs may be considered if the infant experiences unexplained feeding difficulties, distressed behavior, or faltering growth. Metoclopramide, a prokinetic agent, should only be used with specialist advice.

Complications of gastro-oesophageal reflux can include distress, failure to thrive, aspiration, frequent otitis media, and dental erosion in older children. If medical treatment is ineffective and severe complications arise, fundoplication may be considered. It is important for healthcare professionals to be aware of the risk factors, symptoms, and management options for gastro-oesophageal reflux in infants.

The use of aspirin as a pain reliever is not recommended for children because it can increase the risk of Reye’s syndrome. This condition is characterized by symptoms such as fever, rash, and vomiting, which can quickly progress to encephalopathy and even lead to death.

However, aspirin is approved for use in treating Kawasaki disease and as an antiplatelet medication to prevent blood clots after surgery.

Reye’s syndrome is a serious condition that affects children and causes progressive brain damage. It is often accompanied by the accumulation of fat in the liver, kidneys, and pancreas. The exact cause of Reye’s syndrome is not fully understood, but it is believed to be associated with the use of aspirin and viral infections. The condition is most common in children around 2 years of age and is characterized by confusion, seizures, and coma. Treatment for Reye’s syndrome is primarily supportive, and while the prognosis has improved in recent years, there is still a mortality rate of 15-25%.

Paediatric vital signs refer to the normal range of heart rate and respiratory rate for children of different ages. These vital signs are important indicators of a child’s overall health and can help healthcare professionals identify any potential issues. The table below outlines the age-appropriate ranges for heart rate and respiratory rate. Children under the age of one typically have a higher heart rate and respiratory rate, while older children have lower rates. It is important for healthcare professionals to monitor these vital signs regularly to ensure that children are healthy and developing properly.

Age Heart rate Respiratory rate
< 1 110 - 160 30 - 40
1 – 2 100 – 150 25 – 35
2 – 5 90 – 140 25 – 30
5 – 12 80 – 120 20 – 25
> 12 60 – 100 15 – 20

• Measles vaccination should not be given to a child with cystic fibrosis:
  • False:
    • Explanation: Children with cystic fibrosis should receive all routine vaccinations, including the measles, mumps, and rubella (MMR) vaccine. Cystic fibrosis does not contraindicate live vaccines like MMR unless the child is severely immunocompromised. In fact, it is crucial to protect these children from preventable infections due to their underlying lung disease.
• Children with a history of febrile convulsions should not be given polio vaccine:
  • False:
    • Explanation: A history of febrile convulsions is not a contraindication for receiving the polio vaccine. The polio vaccine is not associated with an increased risk of febrile seizures. The oral polio vaccine (OPV) has been replaced in many places by the inactivated polio vaccine (IPV), which is safer and does not cause the rare side effects associated with the live virus.
• A live attenuated vaccine should not be given to a child with asthma:
  • False:
    • Explanation: Asthma, in itself, is not a contraindication for live attenuated vaccines, such as MMR or the live attenuated influenza vaccine (LAIV). However, if the asthma is severe or poorly controlled, especially if the child is on high-dose systemic corticosteroids, consultation with a healthcare provider is advisable before administering live vaccines.
• Children with congenital heart disease should not be immunised against pertussis:
  • False:
    • Explanation: Children with congenital heart disease should receive all routine vaccinations, including the DTaP vaccine, which protects against pertussis. These children are at higher risk for severe complications from pertussis (whooping cough), making vaccination even more important.
• Postponement of 6 in 1 vaccination is advised in the presence of fever:
  • True:
    • Explanation: It is generally recommended to postpone vaccination if a child has a moderate or severe acute illness with or without fever. This is to ensure that any potential side effects of the vaccine are not confused with the symptoms of the illness and to prevent further stress on the child’s immune system. Mild illnesses, however, typically do not warrant delaying vaccination.

If a baby is found to have an abnormal hearing test at birth, they will be offered an auditory brainstem response test as a follow-up. This test involves placing electrodes on the scalp to measure auditory evoked potentials after sounds are played, and can indicate reduced hearing ability if there is no response.

It is not appropriate to use a distraction test on a newborn, as they are not yet developed enough for this type of testing. This test is typically used for toddlers aged 6-9 months, and requires two staff members to assess the loudness required for the baby to react to sounds produced out of their field of view.

Newborn otoacoustic emission testing is the initial screening assessment for hearing loss, but further investigations are needed to confirm the diagnosis. This test involves generating a click sound through an earpiece and measuring for the presence of a soft echo that indicates a healthy cochlea.

Pure tone audiometry is not an appropriate second-line hearing investigation for newborns, as it requires the input of the participant when they hear specific sounds and is typically used in school-aged children.

Hearing Tests for Children

Hearing tests are important for children to ensure that they are developing normally. There are several tests that may be performed on children of different ages. For newborns, an otoacoustic emission test is typically done as part of the Newborn Hearing Screening Programme. This test involves playing a computer-generated click through a small earpiece and checking for the presence of a soft echo, which indicates a healthy cochlea. If the results of this test are abnormal, an Auditory Brainstem Response test may be done.

For infants between 6-9 months, a Distraction test may be performed by a health visitor with the help of two trained staff members. For children between 18 months to 2.5 years, a Recognition of familiar objects test may be used, which involves using familiar objects like a teddy or cup and asking the child simple questions like where is the teddy? For children over 2.5 years, Performance testing and Speech discrimination tests using similar-sounding objects like the Kendall Toy test or McCormick Toy Test may be used. Pure tone audiometry is typically done at school entry in most areas of the UK for children over 3 years old.

In addition to these tests, there is also a questionnaire for parents in the Personal Child Health Records called Can your baby hear you? This questionnaire can help identify any potential hearing issues in children. Overall, hearing tests are an important part of ensuring that children are developing normally and can help identify any issues early on.

Pierre-Robin syndrome is diagnosed in a baby who has micrognathia and a cleft palate. The baby is positioned in a prone position to alleviate upper airway obstruction. There is no familial history of similar conditions.

Childhood syndromes are a group of medical conditions that affect children and are characterized by a set of common features. Patau syndrome, also known as trisomy 13, is a syndrome that presents with microcephaly, small eyes, cleft lip/palate, polydactyly, and scalp lesions. Edward’s syndrome, or trisomy 18, is characterized by micrognathia, low-set ears, rocker bottom feet, and overlapping of fingers. Fragile X syndrome is a condition that causes learning difficulties, macrocephaly, a long face, large ears, and macro-orchidism. Noonan syndrome presents with a webbed neck, pectus excavatum, short stature, and pulmonary stenosis. Pierre-Robin syndrome is characterized by micrognathia, posterior displacement of the tongue, and cleft palate. Prader-Willi syndrome presents with hypotonia, hypogonadism, and obesity. William’s syndrome is characterized by short stature, learning difficulties, a friendly and extroverted personality, and transient neonatal hypercalcaemia. Finally, Cri du chat syndrome, also known as chromosome 5p deletion syndrome, presents with a characteristic cry due to larynx and neurological problems, feeding difficulties and poor weight gain, learning difficulties, microcephaly, micrognathism, and hypertelorism. It is important to note that Pierre-Robin syndrome has many similarities with Treacher-Collins syndrome, but the latter is autosomal dominant and usually has a family history of similar problems.

Maternal Rubella Infection in Pregnancy

Maternal rubella infection during pregnancy can lead to fetal loss or congenital rubella syndrome (CRS). CRS is characterized by various abnormalities such as cataracts, deafness, cardiac defects, microcephaly, retardation of intrauterine growth, and inflammatory lesions in the brain, liver, lungs, and bone marrow.

If the infection occurs within the first eight to ten weeks of pregnancy, up to 90% of surviving infants may experience damage, often with multiple defects. However, the risk of damage decreases to about 10-20% if the infection occurs between 11 and 16 weeks of gestation. Infections after 16 weeks of pregnancy are rare and typically only result in deafness, with no other fetal damage reported up to 20 weeks of pregnancy.

Overall, maternal rubella infection during pregnancy can have severe consequences for the developing fetus, highlighting the importance of vaccination and prevention measures.

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.

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.

Management of Bronchiolitis in Infants

Bronchiolitis is an acute infectious disease of the lower respiratory tract that commonly affects infants aged between two and six months. It is caused by respiratory syncytial virus (RSV) and peaks during the winter months. Supportive measures such as fluid input, feeding, and temperature control are the mainstay of treatment. Antibiotics are not indicated as bronchiolitis is usually caused by a virus. Hospital admission is only necessary in severe cases or if there are significant comorbidities. Salbutamol via a spacer is not indicated in bronchiolitis. Careful safety netting is important to teach parents to spot deterioration and seek medical attention if necessary. Most infants with bronchiolitis have a mild, self-limiting illness that lasts for seven to ten days.

Understanding Cot Death or Sudden Infant Death Syndrome

Cot death or sudden infant death syndrome (SIDS) is a tragic occurrence that affects approximately 50 out of 100,000 live births. It is a condition that is associated with several risk factors, including parental smoking, teenage pregnancy, inadequate prenatal care, laying the infant to sleep on their stomach, excess bedding, and low birth weight. Co-sleeping is also regarded as a risk factor for SIDS.

Contrary to popular belief, baby monitors do not reduce the incidence of cot death. However, Breastfeeding has been associated with a reduced incidence of SIDS. It is important for parents and caregivers to be aware of these risk factors and take necessary precautions to reduce the risk of SIDS. This includes placing the infant to sleep on their back, avoiding excess bedding, and ensuring a smoke-free environment. By understanding the risk factors and taking necessary precautions, we can work towards reducing the incidence of cot death and ensuring the safety of our infants.

Parents should be informed that if their child experiences a febrile convulsion lasting longer than 5 minutes, they should immediately call for an ambulance. While some children may have recurrent febrile convulsions, simple ones typically last up to 15 minutes and result in complete recovery within an hour. In these cases, parents can manage their child at home with clear guidance on when to seek medical help and the use of medications like buccal midazolam or rectal diazepam. However, any febrile convulsion lasting longer than 5 minutes requires immediate medical attention, and if a second convulsion occurs within 30 minutes of the first, parents should also call for an ambulance.

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%.

Understanding Eczema in Children

Eczema is a common skin condition that affects around 15-20% of children and is becoming more prevalent. It usually appears before the age of 2 and clears up in around 50% of children by the age of 5 and in 75% of children by the age of 10. The condition is characterized by an itchy, red rash that can worsen with repeated scratching. In infants, the face and trunk are often affected, while in younger children, eczema typically occurs on the extensor surfaces. In older children, a more typical distribution is seen, with flexor surfaces affected and the creases of the face and neck.

To manage eczema in children, it is important to avoid irritants and use simple emollients. Large quantities of emollients should be prescribed, roughly in a ratio of 10:1 with topical steroids. If a topical steroid is also being used, the emollient should be applied first, followed by waiting at least 30 minutes before applying the topical steroid. Creams soak into the skin faster than ointments, and emollients can become contaminated with bacteria, so fingers should not be inserted into pots. Many brands have pump dispensers to prevent contamination.

In severe cases, wet wrapping may be used, which involves applying large amounts of emollient (and sometimes topical steroids) under wet bandages. Oral ciclosporin may also be used in severe cases. By understanding the features and management of eczema in children, parents and caregivers can help alleviate symptoms and improve the child’s quality of life.

Misdiagnosis of a Heart Murmur: Understanding the Differences between Rheumatic Fever, Lyme Disease, HSP, Juvenile Idiopathic Arthritis, and Scarlet Fever

A heart murmur can be a concerning symptom, but it is important to correctly diagnose the underlying condition. Rheumatic fever, Lyme disease, Henoch–Schönlein purpura (HSP), juvenile idiopathic arthritis, and scarlet fever can all present with a heart murmur, but each has distinct features that can help differentiate them.

Rheumatic fever requires the presence of recent streptococcal infection and the fulfilment of Jones criteria, which include major criteria such as carditis, arthritis, Sydenham’s chorea, subcutaneous nodules, and erythema marginatum, as well as minor criteria such as fever, arthralgia, raised ESR or CRP, and prolonged PR interval on an electrocardiogram.

Lyme disease presents with erythema migrans, arthralgia, and other symptoms depending on the stage of the disease, but a heart murmur is not a typical feature.

HSP is characterised by purpura, arthritis, abdominal pain, gastrointestinal bleeding, orchitis, and nephritis.

Juvenile idiopathic arthritis is chronic arthritis occurring before the age of 16 years that lasts for at least six weeks in the absence of any other cause, and may involve few or many joints, with additional features in some subsets, but it should not present with a heart murmur.

Scarlet fever is characterised by a widespread red rash, fever, tachycardia, myalgia, and circumoral pallor, rather than joint pain.

In summary, a heart murmur can be a symptom of various conditions, but a thorough evaluation of other symptoms and criteria is necessary to make an accurate diagnosis and provide appropriate treatment.

Puberty: Normal Changes in Males and Females

Puberty is a natural process that marks the transition from childhood to adolescence. In males, the first sign of puberty is testicular growth, which typically occurs around the age of 12. Testicular volume greater than 4 ml indicates the onset of puberty. The maximum height spurt for boys occurs at the age of 14. On the other hand, in females, the first sign of puberty is breast development, which usually occurs around the age of 11.5. The height spurt for girls reaches its maximum early in puberty, at the age of 12, before menarche. Menarche, or the first menstrual period, typically occurs at the age of 13, with a range of 11-15 years. Following menarche, there is only a slight increase of about 4% in height.

During puberty, it is normal for boys to experience gynaecomastia, or the development of breast tissue. Girls may also experience asymmetrical breast growth. Additionally, diffuse enlargement of the thyroid gland may be seen in both males and females. These changes are all part of the normal process of puberty and should not be a cause for concern.

There is no proof that administering antipyretics to a child with a fever can prevent febrile convulsions.

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%.

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.

If a child with bronchiolitis displays any high risk signs, it is important to admit them for support with feeding to prevent dehydration. The NICE CKS provides a comprehensive list of these signs, which include a respiratory rate exceeding 60 per minute, intermittent apnoea, grunting, moderate or severe chest in-drawing, cyanosis, pale, ashen, mottled or blue skin color, lack of response to social cues, inability to be roused or stay awake, and appearing ill. Reduced skin turgor is also a sign of dehydration to watch out for.

Understanding Bronchiolitis

Bronchiolitis is a condition that is characterized by inflammation of the bronchioles. It is a serious lower respiratory tract infection that is most common in children under the age of one year. The pathogen responsible for 75-80% of cases is respiratory syncytial virus (RSV), while other causes include mycoplasma and adenoviruses. Bronchiolitis is more serious in children with bronchopulmonary dysplasia, congenital heart disease, or cystic fibrosis.

The symptoms of bronchiolitis include coryzal symptoms, dry cough, increasing breathlessness, and wheezing. Fine inspiratory crackles may also be present. Children with bronchiolitis may experience feeding difficulties associated with increasing dyspnoea, which is often the reason for hospital admission.

Immediate referral to hospital is recommended if the child has apnoea, looks seriously unwell to a healthcare professional, has severe respiratory distress, central cyanosis, or persistent oxygen saturation of less than 92% when breathing air. Clinicians should consider referring to hospital if the child has a respiratory rate of over 60 breaths/minute, difficulty with breastfeeding or inadequate oral fluid intake, or clinical dehydration.

The investigation for bronchiolitis involves immunofluorescence of nasopharyngeal secretions, which may show RSV. Management of bronchiolitis is largely supportive, with humidified oxygen given via a head box if oxygen saturations are persistently < 92%. Nasogastric feeding may be needed if children cannot take enough fluid/feed by mouth, and suction is sometimes used for excessive upper airway secretions.

A reflex anoxic seizure, also known as white reflex asystolic attacks, is not an epileptic seizure but is often misdiagnosed as one. It occurs due to increased vagal tone, resulting in transient reflex asystole. These seizures can occur from birth but are common between six months to two years of age and are triggered by shock, anxiety, or minor injury. Symptoms include pallor, loss of consciousness, stiffening, eye deviation, and vagal asystole, which may progress to a seizure. However, there is a rapid spontaneous recovery, and no treatment is required. Unlike epileptic seizures, patients having a reflex anoxic seizure do not usually bite their tongue.

No need for school exclusion with roseola infantum as it is a self-limiting condition.

Understanding Roseola Infantum

Roseola infantum, also known as exanthem subitum or sixth disease, is a common illness that affects infants and is caused by the human herpesvirus 6 (HHV6). The incubation period for this disease is between 5 to 15 days, and it typically affects children between the ages of 6 months to 2 years.

The symptoms of roseola infantum include a high fever that lasts for a few days, followed by a maculopapular rash. Other symptoms that may be present include Nagayama spots, which are papular enanthems on the uvula and soft palate, as well as cough and diarrhea. In some cases, febrile convulsions may occur in around 10-15% of cases.

While roseola infantum can lead to other complications such as aseptic meningitis and hepatitis, school exclusion is not necessary.

If general advice has not been effective in treating nocturnal enuresis in a child, an enuresis alarm is typically the first-line option recommended by NICE guidelines. However, it may be worth exploring alternative reward systems to ensure the child is motivated to make the necessary effort. It is assumed that the mother can appropriately motivate their child, so this may not be a route taken by the clinic. If the enuresis alarm doesn’t work, pharmacological interventions such as desmopressin, oxybutynin, and unlicensed tolterodine may be considered.

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.

Management of Unilateral Undescended Testicle in Infants

In cases of unilateral undescended testicle in infants, it is important to determine whether it is unilateral or bilateral as the management would differ. If it is unilateral, the infant should be re-examined at 6-8 weeks. If the testicle is still absent, another examination should be done at 4-5 months of age. If the testicle remains undescended at this stage, the child should be referred to a specialist. However, if both testicles are present in the scrotum at 4-5 months review, no further action is required.

It is important to note that undescended testes pose a risk of developing future malignancy, especially if they present later in life. Therefore, boys and young men with a history of undescended testis should be advised to perform regular testicular self-examination during and after puberty to detect any potential testicular cancer.

Common Elbow Injuries in Children and Adults

Radial head subluxation is a frequent injury in children under the age of 6 years. The rounded end of the radial head is still made of cartilage and can easily slip out of the encircling annular ligament when the arm is pulled. There is usually no history of trauma, but there may be a history of axial traction by a pull on the hand or wrist. Tenderness at the head of the radius may be present. Imaging is only necessary when a fracture is suspected. Manipulation can be done in the GP surgery by immobilizing the elbow with one hand and with the other hand applying axial compression while supinating the forearm and flexing the elbow. Alternatively, it can be done while pronating the forearm. A click indicates success.

Supracondylar fracture of the humerus is most commonly seen in children and usually results from a fall on to an outstretched arm. The patient usually has elbow swelling and pain.

Lateral epicondylitis (tennis elbow) is a chronic condition that peaks between 40 and 50 years of age. It is thought to be an overload tendon injury.

Radial neck fracture occurs due to trauma such as a fall onto the outstretched arm. The median age is 9–10 years. There is pain, swelling, and tenderness over the lateral side of the elbow.

In cases of suspected non-accidental injury, the explanation should be consistent with the injury, and in the absence of other features, non-accidental injury is unlikely.