If a baby’s femoral pulses are absent or weak during their 6-8 week check, it is crucial to discuss this immediately with a paediatrics specialist. Similarly, if a child shows signs of a critical or major congenital heart abnormality during this check, urgent attention from a specialist is necessary. Advising the mother that these findings are normal would be incorrect, as they are abnormal and require prompt attention. Referring the child to the emergency department is also not the best course of action, as they may not have the necessary expertise to deal with this issue. Referring routinely to paediatrics or making an appointment in two weeks would also be inappropriate, as the child needs urgent attention from the appropriate specialist.

Types of Congenital Heart Disease

Congenital heart disease refers to heart defects that are present at birth. There are two main types of congenital heart disease: acyanotic and cyanotic. Acyanotic heart defects are more common and include ventricular septal defects (VSD), atrial septal defects (ASD), patent ductus arteriosus (PDA), coarctation of the aorta, and aortic valve stenosis. VSDs are the most common acyanotic heart defect, accounting for 30% of cases. ASDs are less common but tend to be diagnosed in adults as they present later.

Cyanotic heart defects are less common but more serious. They include tetralogy of Fallot, transposition of the great arteries (TGA), and tricuspid atresia. Fallot’s is more common than TGA, but TGA is the more common lesion at birth as patients with Fallot’s generally present at around 1-2 months. The presence of cyanosis in pulmonary valve stenosis depends on the severity and any other coexistent defects. Understanding the different types of congenital heart disease is important for proper diagnosis and treatment.

Down’s Syndrome: Epidemiology and Genetics

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

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

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

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.

Foreign Body Aspiration, Peanut Allergy, and Spontaneous Pneumothorax: Symptoms and Signs

Unilateral wheeze in a child should always prompt the search for an inhaled foreign body, especially if symptoms started acutely in an otherwise healthy child. Large foreign bodies can cause complete airway obstruction and are rapidly fatal, while smaller ones, like peanuts, usually lodge in the right main bronchus and cause hyperinflation of the unaffected side, reduced air entry on the affected side, and a unilateral monophonic wheeze. Symptoms of foreign body aspiration may not always include the classic triad of coughing, wheezing, and decreased breathing sounds, and patients with chronic symptoms may have been misdiagnosed as having asthma or bronchitis. Peanut allergy symptoms can include itching, urticaria, facial swelling, bronchospasm, vomiting, diarrhea, abdominal pain, and collapse with anaphylactic shock. Spontaneous pneumothorax presents with sudden onset of pain and dyspnea, hyper-resonance, and reduced breath sounds on the affected side. It is important to recognize the symptoms and signs of these conditions to ensure prompt and appropriate treatment.

For children between the ages of 5 and 16 with asthma that is not being effectively managed with a combination of a short-acting beta agonist (SABA), low-dose inhaled corticosteroids (ICS), and a leukotriene receptor antagonist, it is recommended to add a long-acting beta agonist (LABA) to the treatment plan and discontinue the use of the leukotriene receptor antagonist.

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.

It is recommended that children diagnosed with scarlet fever should not attend nursery or school until they have been on antibiotics for at least 24 hours.

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.

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.

Understanding the Pneumococcal Vaccine

The pneumococcal vaccine is an important immunization that helps protect against pneumococcal disease, which can cause serious illnesses such as pneumonia, meningitis, and blood infections. However, it’s important to note that there are two types of pneumococcal vaccines – the pneumococcal conjugate vaccine (PCV) and the pneumococcal polysaccharide vaccine (PPV).

The PCV vaccine is given to children under the age of 2, with the first dose administered at 12 weeks old and a booster at 1 year. On the other hand, the PPV vaccine is given to individuals over the age of 2, with otherwise healthy individuals receiving it at 65 years of age. It’s important to know which vaccine to administer as the immune response to each vaccine is different.

In addition to the recommended age groups, individuals with certain medical conditions such as chronic respiratory or heart disease, diabetes, and immunosuppression are also eligible for the pneumococcal vaccine. Surgeries will carry both vaccines in stock, so it’s crucial to be aware of the appropriate vaccine to administer based on age and medical history. By understanding the pneumococcal vaccine and its administration, we can help protect ourselves and others from serious illnesses.

Referring Child Abuse Cases: A Doctor’s Responsibility

As a doctor, it is your responsibility to protect children and young people from abuse. In cases where there is ongoing risk of serious abuse, it is important to refer the child in a timely manner, even if it goes against their wishes. This is because the safety of the child should always be the top priority.

According to the General Medical Council (UK), doctors have a duty to protect children and young people from harm. Referring cases of abuse is a crucial step in ensuring their safety. It is important to act quickly and make the necessary referrals to safeguard the child’s well-being. Even if the child expresses reluctance or resistance to the referral, it is important to prioritize their safety and take appropriate action. By doing so, doctors can fulfill their responsibility to protect vulnerable children and young people from harm.

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

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

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

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

Dosage Calculation for Furosemide Oral Solution

To calculate the correct dosage for furosemide oral solution, the patient’s weight and prescribed dose must be taken into account. For example, if the patient weighs 16 kg and the prescribed dose is 0.5 mg/kg BD, then the total daily dose would be 8 mg BD (16 kg x 0.5 mg/kg).

The furosemide oral solution comes in a concentration of 20 mg in 5 ml, which means there is 4 mg in 1 ml. To determine the correct dosage, we can use the conversion factor of 8 mg = 2 ml. Therefore, the patient should take 2 ml of the furosemide oral solution twice a day. Proper dosage calculation is crucial to ensure the patient receives the correct amount of medication for their condition.

The majority of croup cases are caused by parainfluenza virus.

Hand foot and mouth disease is mainly caused by enterovirus.

The common cold is primarily caused by rhinovirus.

Slapped cheek disease is mainly caused by Parvovirus B19.

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.

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.

Understanding Child Tax Credits

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

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

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

It is not recommended to prescribe oral choline salicylate gels to teething children as it may increase the risk of Reye’s syndrome. However, in this case, reassurance is appropriate as the child’s symptoms are mild and self-limiting. Simple measures such as allowing the child to bite on a cool, clean object and administering paracetamol/ibuprofen suspension for those aged three months and older can be helpful. It is not recommended to use topical anaesthetics or herbal teething powders as they may have adverse effects.

Teething: Symptoms, Diagnosis, and Treatment Options

Teething is the process of primary tooth eruption in infants, which typically begins around 6 months of age and is usually complete by 30 months of age. It is characterized by a subacute onset of symptoms, including gingival irritation, parent-reported irritability, and excessive drooling. These symptoms occur in approximately 70% of all children and are equally prevalent in boys and girls, although girls tend to develop their teeth sooner than boys.

During examination, teeth can typically be felt below the surface of the gums prior to breaking through, and gingival erythema will be noted around the site of early tooth eruption. Treatment options include chewable teething rings and simple analgesia with paracetamol or ibuprofen. However, topical analgesics or numbing agents are not recommended, and oral choline salicylate gels should not be prescribed due to the risk of Reye’s syndrome.

It is important to note that teething doesn’t cause systemic symptoms such as fevers or diarrhea, and these symptoms should be treated as warning signs of other systemic illness. Additionally, teething necklaces made from amber beads on a cord are a common naturopathic treatment for teething symptoms but represent a significant strangulation and choking hazard. Therefore, it is crucial to avoid their use.

In conclusion, teething is a clinical diagnosis that can be managed with simple interventions. However, it is essential to be aware of potential hazards and to seek medical attention if systemic symptoms are present.

Pertussis Immunisation for Infants and Pregnant Women

Young infants are most vulnerable to serious complications from pertussis, which is why children receive multiple doses of the vaccine starting at two months of age. The vaccine is given as part of the 6-in-1 vaccine and again before starting school. However, pregnant women are now also being immunised against pertussis in the later stages of pregnancy. This is to enable them to transfer a high level of antibodies across the placenta to their unborn child, providing protection against pertussis until the first dose of immunisation. By vaccinating pregnant women, we can help protect the most vulnerable members of our population from this potentially deadly disease.

To prevent nappy rash, it is recommended to leave the nappies off for as long as possible and use water or fragrance-free and alcohol-free baby wipes for cleaning. After cleaning, it is important to dry the area gently without rubbing vigorously. Bathing the child daily is also recommended, but excessive bathing (more than twice a day) should be avoided as it may dry out the skin. It is advised not to use soap, bubble bath, or lotions. Additionally, using nappies with high absorbency, such as disposable gel matrix nappies, and changing the child as soon as possible after wetting or soiling can also help prevent nappy rash.

Understanding Napkin Rashes and How to Manage Them

Napkin rashes, also known as nappy rashes, are common skin irritations that affect babies and young children. The most common cause of napkin rash is irritant dermatitis, which is caused by the irritant effect of urinary ammonia and faeces. This type of rash typically spares the creases. Other causes of napkin rash include candida dermatitis, seborrhoeic dermatitis, psoriasis, and atopic eczema.

To manage napkin rash, it is recommended to use disposable nappies instead of towel nappies and to expose the napkin area to air when possible. Applying a barrier cream, such as Zinc and castor oil, can also help. In severe cases, a mild steroid cream like 1% hydrocortisone may be necessary. If the rash is suspected to be candidal nappy rash, a topical imidazole should be used instead of a barrier cream until the candida has settled.

It is important to note that napkin rash can be uncomfortable for babies and young children, so it is essential to manage it promptly. By following these general management points, parents and caregivers can help prevent and manage napkin rashes effectively.

Understanding Measles

Measles is a highly contagious disease that is characterized by a rash with maculopapular lesions. The onset of the disease is marked by a prodromal phase, which includes symptoms such as fever, malaise, loss of appetite, cough, rhinorrhea, and conjunctivitis. This phase typically lasts for one to four days before the rash appears.

The rash usually starts on the head and then spreads to the trunk and extremities over a few days. The fever usually subsides once the rash appears. The rash itself lasts for at least three days and then fades in the order of appearance. In some cases, it can leave behind a brownish discoloration and may become confluent over the buttocks.

It is important to note that measles is a serious disease that can lead to complications such as pneumonia, encephalitis, and even death. Vaccination is the best way to prevent measles and its complications.

Recommended Vaccinations for Adolescents

A booster vaccination for tetanus and diphtheria is required for adolescents between the ages of 14 and 16. It is recommended that these boosters be administered every 10 years thereafter. In some countries, a second dose of the MMR vaccine is given at age 12. The BCG vaccine is not routinely given, but is offered to individuals who are at risk. It is important for adolescents to stay up-to-date on their vaccinations to protect themselves and those around them from preventable diseases.

The milestones of development are categorized into gross motor skills, fine motor skills, vision, speech and hearing, and social behavior and play. For children who are -years old, they should be able to run, climb stairs, construct a tower using 6 cubes, replicate a vertical line, use 2-word phrases, eat with a spoon, dress themselves with a hat and shoes, and engage in play activities with other children.

Fine Motor and Vision Developmental Milestones

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

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

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

New advice on vitamin D supplements

The latest advice from Public Health England (PHE) recommends that adults and children over the age of one should consider taking a daily supplement containing 10mcg of vitamin D, especially during autumn and winter. Those who are at a higher risk of vitamin D deficiency, such as people who have little or no exposure to the sun, those who cover their skin when outside, and people with dark skin from African, African-Caribbean, and South Asian backgrounds, are advised to take a supplement all year round. This advice is based on a review by the Scientific Advisory Committee on Nutrition (SACN), which identified these groups as being at risk of vitamin D deficiency.

The Most Common Form of Child Abuse

Neglect is the most prevalent form of child abuse, as opposed to direct emotional, physical, or sexual abuse. Neglect occurs when a caregiver fails to provide the necessary care and attention that a child needs to thrive. This can include not providing adequate food, shelter, clothing, medical care, or supervision. Neglect can also manifest in emotional neglect, where a child is not given the love, support, and attention they need to develop emotionally. It is important to recognize neglect as a form of abuse and take action to protect children from its harmful effects.

Managing Attention-Deficit Hyperactivity Disorder (ADHD): Myths and Facts

Attention-Deficit Hyperactivity Disorder (ADHD) is a common neurodevelopmental disorder that affects children and adults. Managing ADHD can be challenging, and there are many myths and misconceptions about the condition and its treatment. Here are some common myths and facts about managing ADHD:

Myth: Referral to a parent-training program should wait for a formal diagnosis.
Fact: If the problems are having an adverse impact on development or family life, a General Practitioner should consider referral to a parent-training and/or education program even before a formal diagnosis. The parent program may include skills to manage problem behavior and communicate with the child and help to understand the child’s emotions and behavior.

Myth: Eliminating artificial coloring and additives from the diet is important.
Fact: NICE doesn’t recommend this unless there seems to be a link between deterioration in behavior and consumption of artificial additives.

Myth: A food diary to seek a relationship between specific foods and symptoms is unhelpful.
Fact: The National Institute for Health and Care Excellence (NICE) advises that if there seems to be a clear relationship between specific foods and symptoms, parents should keep a diary recording food and drinks taken and behavior. If the diary supports a relationship, then referral to a dietician should be offered.

Myth: Dietary fatty acid supplements (omega 3 and omega 6) are beneficial.
Fact: Many parents have experimented with these supplements, but according to NICE guidelines, these should not be routinely recommended.

Myth: Methylphenidate (Ritalin®) can be prescribed immediately.
Fact: In more severe attention-deficit hyperactivity disorder or where other measures have not been successful, medication is usually recommended. Drug treatment should not be started in primary care. Methylphenidate (Ritalin®) is the most commonly used drug.

In conclusion, managing ADHD requires a comprehensive approach that includes parent training, dietary changes, and medication when necessary. It is important to separate myths from facts to ensure that individuals with ADHD receive the best possible care.

The Importance of Routine Six-Week Baby Checks

Routine six-week baby checks are crucial in identifying potential health issues in newborns. While some conditions may be identified before or just after birth, others may not present symptoms until later in childhood. It is important to note that even a normal cardiac examination at six weeks doesn’t completely rule out congenital heart disease, as it may still manifest later on.

Congenital hypothyroidism is typically tested for soon after birth in the heel-prick Guthrie test, along with other conditions such as phenylketonuria and cystic fibrosis. Congenital cataracts are usually diagnosed at newborn examination by the identification of absence of the red reflex, and surgery should ideally be performed before two months of age to prevent irreversible amblyopia.

While a check for developmental dysplasia of the hip is usually carried out at or soon after birth, some late diagnoses still occur. Undescended testicles should also be detected at birth, with surgery indicated if they remain undescended at 12 months.

In summary, routine six-week baby checks are essential in identifying potential health issues in newborns, including congenital heart disease, congenital hypothyroidism, congenital cataracts, developmental dysplasia of the hip, and undescended testicles. It is important for parents and healthcare providers to remain vigilant in monitoring a child’s health and development.

Vision and Hearing Issues in Down’s Syndrome

Individuals with Down’s syndrome are at a higher risk of experiencing vision and hearing problems. When it comes to vision, they are more likely to have refractive errors, which can cause blurred vision. Strabismus, a condition where the eyes do not align properly, is also common in 20-40% of individuals with Down’s syndrome. Cataracts, which can cause cloudiness in the eye lens, are more prevalent in those with Down’s syndrome, both congenital and acquired. Recurrent blepharitis, an inflammation of the eyelids, and glaucoma, a condition that damages the optic nerve, are also potential issues.

In terms of hearing, otitis media and glue ear are very common in individuals with Down’s syndrome. These conditions can lead to hearing problems, which can affect speech and language development. It is important for individuals with Down’s syndrome to receive regular vision and hearing screenings to detect and address any issues early on.

Soya milk may not be a suitable alternative for infants with cow’s milk protein allergy as many of them are also intolerant to it. Amino acid-based formula is the recommended management for severe cases or when extensive hydrolysed formula milk is ineffective.

Breastfeeding is encouraged if the mother eliminates cows milk proteins from her diet, but it may not be practical if she cannot produce enough milk for the child. For infants with mild to moderate cows milk protein allergy who are formula-fed, extensive hydrolysed milk formula is the first-line management.

Gastro-oesophageal reflux (GORD) may be managed with omeprazole or ranitidine, but only after a 1-2 week trial of alginate therapy. However, if the infant presents with persistent diarrhoea, cow’s milk protein allergy is a more likely diagnosis than GORD.

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

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

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

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

Understanding Functional Incontinence in Children

Functional incontinence in children is often associated with a history of constipation or painful defecation. This may have been caused by an anal fissure, which can lead to ongoing issues with bowel movements. Children with functional incontinence may exhibit retentive posturing and withholding behavior, but any behavioral difficulties associated with soiling are likely a result of the incontinence rather than its cause.

Symptoms of functional incontinence include frequent low-volume solid stools, which can be so large that they block the toilet. Children may also be aware of soiling but deny the urge to defecate associated with their episodes. In some cases, they may be unable to differentiate between passing gas and passing feces. On examination, stools may be palpable in the abdomen or rectum.

Non-retentive fecal incontinence is a less common form of functional incontinence, typically seen in children over 4 years old with no evidence of constipation. In this form, stools are more likely to be passed in inappropriate places. There may be an associated oppositional defiant disorder or conduct disorder.

Overall, understanding the symptoms and causes of functional incontinence in children can help parents and healthcare providers address the issue and provide appropriate treatment.

Diagnosis and Management of UTIs in Children

This child doesn’t exhibit any immediately life-threatening symptoms, but a UTI is the most likely diagnosis based on their clinical history. Early detection and treatment of UTIs can prevent the development of renal scarring and end-stage renal failure. Dipstick tests for leukocyte esterase and nitrite can be used to diagnose UTIs in children aged 2 years and older. However, a urine sample should be sent for microscopy and culture to confirm the diagnosis.

The following table outlines urine-testing strategies for children aged 3 years and older:

Leukocyte+ Nitrite+ – Antibiotic treatment should be started, and a urine sample should be sent for culture if the child has a high or intermediate risk of serious illness or a history of previous UTIs.

Leukocyte- Nitrite+ – Antibiotic treatment should be started if the urine test was carried out on a fresh sample of urine. A urine sample should be sent for culture, and management will depend on the results.

Leukocyte+ Nitrite- – A urine sample should be sent for microscopy and culture. Antibiotic treatment should not be started unless there is clear clinical evidence of a UTI.

Leukocyte- Nitrite- – Antibiotics should not be started, and a urine sample should not be sent for culture. Other potential causes of illness should be explored.

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.

Management of Asthma in Children Under Five Years Old: Adding a Leukotriene Receptor Antagonist to the Current Regimen

The British Guidelines on the Management of Asthma and The Institute for Health and Care Excellence (NICE) recommend prescribing an inhaled corticosteroid for prophylaxis of asthma in children under five years old when they require a beta-2 agonist more than twice a week, experience symptoms that disturb sleep at least once a week, or have suffered an exacerbation in the last two years requiring a systemic corticosteroid. However, long-term use of high doses of inhaled corticosteroids can cause adrenal suppression, and growth impairment may occur. Therefore, it is important to monitor height and weight.

If a child’s asthma remains poorly controlled despite receiving the recommended very low dose of beclomethasone (100 µg twice a day), a leukotriene receptor antagonist (e.g. montelukast) should be added before considering an increase in corticosteroid dosage. Both NICE and SIGN guidelines agree on this approach.

It is important to note that a long acting beta-agonist is not the preferred add-on treatment for children under five years old, as recommended for children aged five years and older. Referral to a respiratory paediatrician is also not necessary in this case, as NICE recommends referral for investigation and further management by an asthma expert only if control is not achieved with a low dose of inhaled corticosteroid and a leukotriene receptor antagonist as maintenance therapy.

In summary, adding a leukotriene receptor antagonist to the current beclomethasone regimen is the appropriate next step in managing asthma in children under five years old.