Atypical Urinary Tract Infection in Children

According to NICE guidelines, an atypical urinary tract infection (UTI) in children is characterized by certain features such as a seriously ill child, poor urine flow, abdominal or bladder mass, raised creatinine, septicaemia, failure to respond to a suitable antibiotic within 48 hours, or infection with non-Escherichia coli organisms.

If a child experiences renal angle pain during the acute infection, an ultrasound should be performed. However, surgical intervention is generally avoided if possible. It is recommended that the child be referred to a paediatric urologist for further evaluation and management. Early detection and appropriate treatment of atypical UTIs can prevent complications and improve outcomes in children.

Differential Diagnosis of Abdominal Pain in Children: Intussusception as the Most Likely Diagnosis

Intussusception is a common cause of intestinal obstruction in young children. It occurs when a section of bowel invaginates into the section next to it, leading to the sloughing off of ischaemic bowel mucosa and the characteristic redcurrant jelly stool. In most cases, the cause of intussusception is unclear, but in some cases, a pathological lead-point may be present. Meckel’s diverticulum is the most common lead-point, but an enlarged Peyer patch caused by a viral infection may also be a factor.

Other potential causes of abdominal pain in children include intestinal duplication, appendicitis, and Henoch-Schönlein purpura (HSP). Intestinal duplication is a rare congenital malformation that may present as a solid or cystic tumor, intussusception, perforation, or bleeding. Appendicitis is most common in older children and typically presents with central abdominal pain that localizes to the right iliac fossa. HSP may cause abdominal pain, nausea, vomiting, and bloody diarrhea, but it is typically accompanied by a purpuric rash, which is absent in this scenario.

Overall, given the age of the patient and the presence of a tender mass in the upper abdomen and emptiness in the right lower quadrant, intussusception is the most likely diagnosis. A lead-point may be present, making non-operative reduction unlikely.

Common Rashes and Their Characteristics

Roseola infantum is a viral infection caused by herpesvirus 6. It is known to cause a rash with lymphadenopathy. The rash is macular in nature and is usually seen in infants and young children.

Erythema multiforme is a skin condition that causes target lesions with blistering. It is often caused by an allergic reaction to medication or an infection.

Idiopathic thrombocytopenia is a condition that causes a petechial rash. This rash is caused by a low platelet count and can be seen in individuals of all ages.

Henoch-Schönlein purpura is a condition that causes a purpuric rash on the buttocks and lower limbs. It is often seen in children and is caused by inflammation of the blood vessels.

Meningococcal septicaemia is a serious bacterial infection that can cause a non-blanching purpuric rash. This rash is a medical emergency and requires immediate treatment.

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

Child Health Surveillance in the UK

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

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

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

Understanding Koplik Spots in Measles Diagnosis

Koplik spots are a crucial clinical sign of measles infection, named after the American Paediatrician, Henry Koplik, who first described them in 1896. These spots appear as red spots with a bluish-white central dot on erythematous buccal mucosa, often described as looking like grains of salt on a wet background. They typically appear 1-2 days before the rash and may persist for a further 1-2 days afterwards.

It is essential for healthcare professionals to recognize Koplik spots as a pathognomonic feature of measles infection. However, fewer doctors may know how to identify them. Other clinical signs, such as herald patches, sub occipital lymph nodes, oral ulceration, and violaceous papules on the wrist, are not specific to measles and may lead to misdiagnosis.

In addition to accurate diagnosis, infection control measures should be considered in the GP surgery/OOH setting. For example, scheduling appointments for suspected measles patients at the end of surgery to avoid sharing a waiting room with vulnerable individuals. It is also crucial for healthcare workers and carers to ensure they are immune or have received 2 × MMR vaccines themselves to prevent the spread of measles.

Causes of Stridor: An Overview

Stridor is a high-pitched, wheezing sound that occurs during breathing and is often a sign of an underlying respiratory problem. One common cause of stridor is laryngomalacia, a congenital condition that results in flaccidity of supraglottic structures. This condition may not present until the child is a few months old.

It is important to note that stridor doesn’t occur in bronchiolitis, asthma, or reflux. In the UK, viral croup is the most common cause of stridor in general practice, while epiglottitis is a much rarer cause that can produce severe stridor with distress and cyanosis very quickly. Structural abnormalities such as micrognathia and trachea-oesophageal fistula can also cause stridor.

It is worth noting that stridor doesn’t occur with pertussis but used to be seen with diphtheria. Other causes of stridor include smoke inhalation, angio-oedema, and foreign body. Understanding the various causes of stridor is crucial for prompt diagnosis and treatment.

If symptoms appear after formula is introduced, it strongly indicates the presence of cow’s milk protein intolerance.

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

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

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

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

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.

It is rare for patients of this age to exhibit the inspiratory ‘whoop’.

A vaccination programme for pregnant women was introduced in 2012 to combat an outbreak of whooping cough that resulted in the death of 14 newborn children. The vaccine is over 90% effective in preventing newborns from developing whooping cough. The programme was extended in 2014 due to uncertainty about future outbreaks. Pregnant women between 16-32 weeks are offered the vaccine.

The risk of Down’s syndrome is 1 in 1,000 at the age of 30, and this risk decreases by a factor of 3 for every 5 years.

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.