NICE Guidelines for Children Under Five with Suspected Asthma

For children under the age of five with suspected asthma, NICE recommends an eight week trial of a moderate dose of inhaled corticosteroid (ICS) if there are symptoms that clearly indicate the need for maintenance therapy. These symptoms include occurring three times a week or more, causing waking at night, or being uncontrolled with a short-acting beta-agonist (SABA) alone.

After the eight week trial, the ICS treatment should be stopped and the child’s symptoms monitored. If the symptoms did not resolve during the trial period, an alternative diagnosis should be considered. If the symptoms resolved but reoccurred within four weeks of stopping the ICS treatment, the ICS should be restarted at a low dose as first-line maintenance therapy. If the symptoms resolved but reoccurred beyond four weeks after stopping the ICS treatment, another eight week trial of a moderate dose of ICS should be repeated.

It is important to follow these guidelines to ensure proper management of asthma in young children.

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.

Children with hand, foot and mouth disease do not need to be excluded from childcare or school. Supportive management and simple pain relief are sufficient, and antibiotics are not necessary as the condition is caused by a virus. There is no evidence to support the use of antivirals or chlorhexidine mouthwash. Although the illness is contagious and often occurs in outbreaks at nurseries and schools, NICE guidelines suggest that children should only be kept off if they are too ill to attend.

Hand, Foot and Mouth Disease: A Contagious Condition in Children

Hand, foot and mouth disease is a viral infection that commonly affects children. It is caused by intestinal viruses from the Picornaviridae family, particularly coxsackie A16 and enterovirus 71. This condition is highly contagious and often occurs in outbreaks in nurseries.

The clinical features of hand, foot and mouth disease include mild systemic upset such as sore throat and fever, followed by the appearance of oral ulcers and vesicles on the palms and soles of the feet.

Symptomatic treatment is the only management option available, which includes general advice on hydration and analgesia. It is important to note that there is no link between this disease and cattle, and children do not need to be excluded from school. However, the Health Protection Agency recommends that children who are unwell should stay home until they feel better. If there is a large outbreak, it is advisable to contact the agency for assistance.

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.

Newborns who are found to have bilateral undescended testes during their initial examination should be urgently reviewed by a senior paediatrician within 24 hours, as per the current guidelines from Public Health England. This is crucial as bilateral undescended testes may indicate underlying endocrine disorders or ambiguous genitalia, and early intervention can help prevent complications such as infertility, torsion, and testicular cancer.

It is not appropriate to monitor bilateral undescended testes in primary care, unlike unilateral undescended testes which may be monitored. Waiting for 4 months, 12 months, or 24 months is too long and can increase the risk of complications.

Arranging an ultrasound and waiting for the results is also not appropriate as it can take too much time. Urgent referral to a paediatrician is necessary to ensure timely diagnosis and management.

Undescended testis is a condition that affects approximately 2-3% of male infants born at term, but is more common in premature babies. Bilateral undescended testes occur in about 25% of cases. This condition can lead to complications such as infertility, torsion, testicular cancer, and psychological issues.

To manage unilateral undescended testis, it is recommended to consider referral from around 3 months of age, with the baby ideally seeing a urological surgeon before 6 months of age. Orchidopexy, a surgical procedure, is typically performed at around 1 year of age, although surgical practices may vary.

For bilateral undescended testes, it is important to have the child reviewed by a senior paediatrician within 24 hours as they may require urgent endocrine or genetic investigation.

Soya milk is not a suitable alternative as a significant proportion of infants who have an allergy to cow’s milk protein are also unable to tolerate it.

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.

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.

Neonatal sepsis is a serious bacterial or viral infection in the blood that affects babies within the first 28 days of life. It is categorized into early-onset (EOS) and late-onset (LOS) sepsis, with each category having distinct causes and presentations. The most common causes of neonatal sepsis are group B streptococcus (GBS) and Escherichia coli. Premature and low birth weight babies are at higher risk, as well as those born to mothers with GBS colonization or infection during pregnancy. Symptoms can range from subtle signs of illness to clear septic shock, and may include respiratory distress, jaundice, seizures, and poor feeding. Diagnosis is usually established through blood culture, and treatment involves early identification and use of intravenous antibiotics. Other important management factors include maintaining adequate oxygenation and fluid/electrolyte status, and preventing or managing hypoglycemia and metabolic acidosis.

Understanding ADHD: Symptoms and Diagnostic Criteria

Attention-deficit/hyperactivity disorder (ADHD) is a neurodevelopmental disorder that affects both children and adults. One of the diagnostic criteria for ADHD is impulsivity, which can manifest as difficulty waiting turns, interrupting others, or blurting out answers prematurely. However, restricted, repetitive behaviors are not a symptom of ADHD but rather a diagnostic criterion for autism spectrum disorder. Similarly, aggression towards people and animals is not a symptom of ADHD but is included in the diagnostic criteria for conduct disorder. Argumentative or defiant behavior is also not a symptom of ADHD but is a diagnostic criterion for oppositional defiant disorder. It is important to note that high educational attainment is not a diagnostic criterion for ADHD, as individuals with ADHD may struggle in school due to inattention and difficulty concentrating. Understanding the symptoms and diagnostic criteria for ADHD can aid in early identification and appropriate treatment.

Giardia Lamblia: Causes, Symptoms, and Treatment

Giardia lamblia is a parasite that can cause malabsorption and non-bloody diarrhea. The condition can be acquired locally, and stool microscopy may not always detect it. However, the good news is that it can be treated with metronidazole. Once treated, malabsorption typically resolves. If you experience symptoms of giardia lamblia, it is important to seek medical attention promptly to receive an accurate diagnosis and appropriate treatment.