The most prevalent cause of meningococcal disease in children in the UK is currently Meningitis B. In 2015, the Meningitis B vaccination was added to the NHS routine childhood immunisation schedule. It is administered at 2, 4, and 12 months of age, in conjunction with other immunisations in the schedule. If given at a different time, doses must be spaced at least 2 months apart. For children over one year old, only two doses are necessary.

Meningitis B Vaccine Now Part of Routine NHS Immunisation

Children in the UK have been vaccinated against meningococcus serotypes A and C for many years, leaving meningococcal B as the most common cause of bacterial meningitis in the country. However, a new vaccine called Bexsero has been developed to combat this strain. Initially, the Joint Committee on Vaccination and Immunisation (JCVI) rejected the use of Bexsero due to a cost-benefit analysis. However, the decision was eventually reversed, and the vaccine has been added to the routine NHS immunisation schedule.

The vaccine is administered in three doses at 2 months, 4 months, and 12-13 months. Additionally, Bexsero will be available on the NHS for individuals at high risk of meningococcal disease, such as those with asplenia, splenic dysfunction, or complement disorder. This new vaccine is a significant step in protecting children and vulnerable individuals from meningitis B.

The neonate is displaying signs of heart failure, which may be caused by structural heart disease. Symptoms of heart failure in neonates include difficulty feeding, breathing problems, and an enlarged liver. Asthma is not typically diagnosed in this age group, and acute liver failure is rare and usually presents with growth issues and blood clotting problems. Viral wheezing is uncommon in neonates, and the poor feeding and weight loss suggest heart failure as the likely cause.

How Congenital Heart Disease Presents

Congenital heart disease can manifest in various ways. One of the earliest signs may be detected during the antenatal period when imaging of the heart is performed as part of the 18-20 week fetal anomaly scan. A murmur may also be detected during the routine newborn examination. Cyanosis, a bluish discoloration of the skin and mucous membranes, may also be present. In some cases, heart failure may occur, which can be characterized by poor feeding, shortness of breath, sweating, and hepatomegaly. It is important to be aware of these presentations in order to promptly diagnose and manage congenital heart disease.

For an unwell child with suspected meningitis who is over 3 months old, the recommended initial empirical therapy is IV 3rd generation cephalosporin, such as ceftriaxone. IV cefuroxime, a 2nd generation cephalosporin, is not recommended for this purpose. IV cefotaxime + amoxicillin is recommended for babies at risk of jaundice, but as the child in this case is 4 months old, this is not necessary. IV co-amoxiclav and piperacillin do not provide adequate coverage for meningitis and are not suitable for central nervous system infections.

Investigation and Management of Meningitis in Children

Meningitis is a serious condition that can affect children. When investigating meningitis, it is important to note any contraindications to lumbar puncture, such as signs of raised intracranial pressure, focal neurological signs, papilloedema, significant bulging of the fontanelle, disseminated intravascular coagulation, or signs of cerebral herniation. For patients with meningococcal septicaemia, a lumbar puncture is contraindicated, and blood cultures and PCR for meningococcus should be obtained instead.

The management of meningitis in children involves administering antibiotics, such as IV amoxicillin (or ampicillin) and IV cefotaxime for children under three months, and IV cefotaxime (or ceftriaxone) for children over three months. Steroids should be considered if the lumbar puncture reveals certain findings, such as purulent cerebrospinal fluid, a high white blood cell count, or bacteria on Gram stain. Fluids should be administered to treat shock, and cerebral monitoring should be conducted, including mechanical ventilation if necessary.

It is also important to notify public health authorities and administer antibiotic prophylaxis to contacts. Ciprofloxacin is now preferred over rifampicin for this purpose. Overall, prompt and appropriate management of meningitis in children is crucial for ensuring the best possible outcomes.

This child’s symptoms, including oliguria, peripheral edema, petechial bruising, and pallor, suggest the possibility of hemolytic uremic syndrome (HUS). HUS is often associated with diarrheal illnesses and is characterized by normocytic anemia, thrombocytopenia, and acute kidney injury. The most common cause of HUS is Shiga-toxin producing Escherichia coli, which can be contracted from undercooked meat, such as a chicken burger from a carnival. While Campylobacter jejuni is a common cause of acute diarrhea, it is not typically associated with HUS. Clostridium perfringens can cause acute diarrhea and vomiting but is not associated with HUS. Salmonella species can also cause diarrheal illnesses, but they are not a common cause of HUS. In this case, Escherichia coli is the most likely causative organism.

Understanding Haemolytic Uraemic Syndrome

Haemolytic uraemic syndrome (HUS) is a condition that primarily affects young children and is characterized by a triad of symptoms, including acute kidney injury, microangiopathic haemolytic anaemia, and thrombocytopenia. The majority of cases are secondary and caused by Shiga toxin-producing Escherichia coli (STEC) 0157:H7, also known as ‘verotoxigenic’ or ‘enterohaemorrhagic’. Other causes of HUS include pneumococcal infection, HIV, systemic lupus erythematosus, drugs, and cancer. Primary HUS, also known as ‘atypical’, is caused by complement dysregulation.

To diagnose HUS, doctors may perform a full blood count to check for microangiopathic hemolytic anaemia and thrombocytopenia. A fragmented blood film may also be done to look for schistocytes and helmet cells. Additionally, a stool culture may be performed to check for evidence of STEC infection, and PCR for Shiga toxins may be done.

Treatment for HUS is supportive and may include fluids, blood transfusion, and dialysis if required. Antibiotics are not recommended, despite the preceding diarrhoeal illness in many patients. Plasma exchange may be considered for severe cases of HUS not associated with diarrhoea, while eculizumab, a C5 inhibitor monoclonal antibody, has shown greater efficiency than plasma exchange alone in the treatment of adult atypical HUS.

Overall, understanding the causes, symptoms, and management of HUS is crucial for healthcare professionals to provide appropriate care for patients with this condition.

Understanding Infantile Seborrhoeic Dermatitis (Cradle Cap)

Infantile seborrhoeic dermatitis, commonly known as cradle cap, is a condition that typically affects infants between the second week of life and the sixth month. It presents as a yellow scaly/flaky rash on the scalp, but can also affect other areas such as the ears, neck, face, and napkin area. While the condition is not harmful, it can be unsightly and uncomfortable for the infant.

Management of cradle cap involves simple measures such as regular washing of the scalp with baby shampoo, softening of scales with baby oil or soaking the crusts overnight with white petroleum jelly, then shampooing in the morning. If these measures are not effective, topical imidazole cream can be used.

It is important to note that cradle cap is not a fungal infection, eczema, erythema toxicum neonatorum (ETN), or scalp psoriasis. These conditions have different presentations and require different management strategies. Understanding the differences between these conditions can help parents and caregivers provide appropriate care for their infants.

The child is experiencing life-threatening acute asthma, which is a medical emergency. This is defined as having any of the following features: SpO2 below 92%, peak expiratory flow below 33% of the best or predicted, silent chest, cyanosis, poor respiratory effort, hypotension, exhaustion, or confusion. Therefore, 999 should be called immediately. This is not moderate or mild acute asthma, nor is it acute severe asthma, as the child is showing signs of cyanosis. Acute severe asthma is defined as having any of the following: SpO2 between 33-50% of the best or predicted, inability to complete sentences in one breath or too breathless to talk or feed, heart rate above 125 beats/min (for ages over 5) or above 140 beats/min (for ages 1-5), or respiratory rate above 30 breaths/min (for ages over 5) or above 40 breaths/min (for ages 1-5).

The recommended initial treatment for paediatric migraines is ibuprofen. Sumatriptan nasal spray is only approved for use in children over the age of 12, and oral sumatriptan is not approved for those under 18. Codeine and oramorph are not recommended for treating migraines in children. Indomethacin is also not typically used for paediatric migraines.

Understanding Headaches in Children

Headaches are a common occurrence in children, with up to 50% of 7-year-olds and 80% of 15-year-olds experiencing at least one headache. Migraine without aura is the most common cause of primary headache in children, with a strong female preponderance after puberty. The International Headache Society has produced criteria for diagnosing pediatric migraine without aura, which includes headache attacks lasting 4-72 hours, with at least two of four specific features and accompanying symptoms such as nausea and vomiting.

When it comes to acute management, ibuprofen is considered more effective than paracetamol for pediatric migraine. Triptans may be used in children over 12 years old, but follow-up is required, and only sumatriptan nasal spray is licensed for use in young people. However, oral triptans are not currently licensed for those under 18 years old, and side effects may include tingling, heat, and pressure sensations.

Prophylaxis for pediatric migraine is limited, with no clear consensus guidelines. Pizotifen and propranolol are recommended as first-line preventatives, while valproate, topiramate, and amitriptyline are considered second-line preventatives. Tension-type headache is the second most common cause of headache in children, with diagnostic criteria including at least 10 previous headache episodes lasting from 30 minutes to 7 days, with specific pain characteristics and the absence of nausea or vomiting.

In summary, headaches in children are common, and migraine without aura is the most common primary headache. Acute management includes ibuprofen and triptans, while prophylaxis is limited. Tension-type headache is also a common cause of headache in children. It is important to seek medical advice if headaches are frequent or severe, or if there are any concerning symptoms such as neurological deficits or changes in behavior.

If the patient’s respiratory distress worsened or their feeding was impacted, they would be admitted. It is important to note that amoxicillin is not effective in treating bronchiolitis, but may be used for uncomplicated community-acquired pneumonia or acute otitis media. Dexamethasone is commonly used for croup, but this diagnosis is unlikely as the patient does not have a barking cough, hoarse voice, or inspiratory stridor. Inhaled racemic adrenaline is also used for croup. Nebulised salbutamol is not necessary for this patient as they are stable and require only supportive management.

Bronchiolitis is a condition where the bronchioles become inflamed, and it is most commonly caused by respiratory syncytial virus (RSV). This virus is responsible for 75-80% of cases, with other causes including mycoplasma and adenoviruses. Bronchiolitis is most prevalent in infants under one year old, with 90% of cases occurring in those aged 1-9 months. The condition is more serious in premature babies, those with congenital heart disease or cystic fibrosis. Symptoms include coryzal symptoms, dry cough, increasing breathlessness, and wheezing. Hospital admission is often necessary due to feeding difficulties associated with increasing dyspnoea.

Immediate referral is recommended if the child has apnoea, looks seriously unwell, has severe respiratory distress, central cyanosis, or persistent oxygen saturation of less than 92% when breathing air. Clinicians should consider referral if the child has a respiratory rate of over 60 breaths/minute, difficulty with breastfeeding or inadequate oral fluid intake, or clinical dehydration. Immunofluorescence of nasopharyngeal secretions may show RSV, and management is largely supportive. Humidified oxygen is given via a head box if oxygen saturations are persistently low, and nasogastric feeding may be necessary if children cannot take enough fluid/feed by mouth. Suction may also be used for excessive upper airway secretions. NICE released guidelines on bronchiolitis in 2015 for more information.

Managing Asthma in Children: NICE Guidelines

Asthma management in children has been updated by NICE in 2017, following the 2016 BTS guidelines. The new guidelines for children aged 5-16 are similar to those for adults, with a stepwise approach for treatment. For newly-diagnosed asthma, short-acting beta agonist (SABA) is recommended. If symptoms persist, a combination of SABA and paediatric low-dose inhaled corticosteroid (ICS) is used. Leukotriene receptor antagonist (LTRA) is added if symptoms still persist, followed by long-acting beta agonist (LABA) if necessary. Maintenance and reliever therapy (MART) is used as a combination of ICS and LABA for daily maintenance therapy and symptom relief. For children under 5 years old, clinical judgement plays a greater role in diagnosis. The stepwise approach is similar to that for older children, with an 8-week trial of paediatric moderate-dose ICS before adding LTRA. If symptoms persist, referral to a paediatric asthma specialist is recommended.

It should be noted that NICE does not recommend changing treatment for well-controlled asthma patients simply to adhere to the latest guidelines. The definitions of low, moderate, and high-dose ICS have also changed, with different definitions for adults and children. For children, <= 200 micrograms budesonide or equivalent is considered a paediatric low dose, 200-400 micrograms is a moderate dose, and > 400 micrograms is a high dose. Overall, the new NICE guidelines provide a clear and concise approach to managing asthma in children.

Understanding Tetralogy of Fallot

Tetralogy of Fallot (TOF) is a congenital heart disease that results from the anterior malalignment of the aorticopulmonary septum. It is the most common cause of cyanotic congenital heart disease, and it typically presents at around 1-2 months, although it may not be detected until the baby is 6 months old. The condition is characterized by four features, including ventricular septal defect (VSD), right ventricular hypertrophy, right ventricular outflow tract obstruction, and overriding aorta. The severity of the right ventricular outflow tract obstruction determines the degree of cyanosis and clinical severity.

Other features of TOF include cyanosis, which may cause episodic hypercyanotic ‘tet’ spells due to near occlusion of the right ventricular outflow tract. These spells are characterized by tachypnea and severe cyanosis that may occasionally result in loss of consciousness. They typically occur when an infant is upset, in pain, or has a fever, and they cause a right-to-left shunt. Additionally, TOF may cause an ejection systolic murmur due to pulmonary stenosis, and a right-sided aortic arch is seen in 25% of patients. Chest x-ray shows a ‘boot-shaped’ heart, while ECG shows right ventricular hypertrophy.

The management of TOF often involves surgical repair, which is usually undertaken in two parts. Cyanotic episodes may be helped by beta-blockers to reduce infundibular spasm. However, it is important to note that at birth, transposition of the great arteries is the more common lesion as patients with TOF generally present at around 1-2 months. Understanding the features and management of TOF is crucial for healthcare professionals to provide appropriate care and treatment for affected infants.

Understanding Dehydration in Children: Symptoms and Management

Dehydration is a common concern in children, especially when they are suffering from illnesses like gastroenteritis. It is important to recognize the different levels of dehydration and manage them accordingly.

Clinical dehydration is characterized by symptoms such as restlessness and decreased urine output. Signs of clinical dehydration include irritability, sunken eyes, dry mucous membranes, tachycardia, and normal capillary refill time (CRT).

Children with no clinically detectable dehydration do not show any signs or symptoms of dehydration and can be managed with oral fluids until the illness subsides.

Clinical shock is a severe form of dehydration that requires immediate medical attention. Symptoms of clinical shock include a decreased level of consciousness, pale or mottled skin, cold extremities, tachycardia, tachypnea, hypotension, weak peripheral pulses, and a prolonged CRT. Children with clinical shock require admission and rehydration with intravenous fluids and electrolyte supplementation.

A euvolemic child, on the other hand, has a normal general appearance, normal eyes, a moist tongue, and present tears. They have a normal CRT and are not tachycardic.

It is important to recognize the signs and symptoms of dehydration in children and manage it accordingly to prevent further complications. Fluid overload is also a concern, but in cases of gastroenteritis-induced dehydration, rehydration is necessary.

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 occurs when there is an extra copy of chromosome 21. The risk of having a child with Down’s syndrome increases with maternal age. At 20 years old, the risk is 1 in 1,500, but by 45 years old, the risk increases to 1 in 50 or greater. To remember this, one can start with a risk of 1/1,000 at 30 years old and divide the denominator by 3 for every extra 5 years of age.

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. The risk of recurrence is 1 in 100 if the mother is under 35 years old. Robertsonian translocation occurs when part of chromosome 21 attaches to another chromosome, usually chromosome 14. This accounts for 5% of cases and has a higher risk of recurrence if the mother or father is a carrier. Mosaicism accounts for 1% of cases and occurs when there are two genetically different populations of cells in the body.

In summary, Down’s syndrome is a genetic disorder that is more common with increasing maternal age. The risk of recurrence depends on the type of Down’s syndrome and whether the parents are carriers. It is important for individuals to understand the genetics and epidemiology of Down’s syndrome to make informed decisions about family planning.

If a girl develops secondary sexual characteristics before the age of 8 and a boy before the age of 9, it is considered precocious puberty. However, if a girl is developing within the normal time frame, such as breast development, there is no need for the mother to worry or seek medical attention. Checking sex hormones or referring to a pediatric specialist is unnecessary as the child is developing normally and the breast development will continue as part of the natural pubertal process.

Understanding Precocious Puberty

Precocious puberty is a condition where secondary sexual characteristics develop earlier than expected, before the age of 8 in females and 9 in males. It is more common in females and can be classified into two types: gonadotrophin dependent and gonadotrophin independent. The former is caused by premature activation of the hypothalamic-pituitary-gonadal axis, resulting in raised levels of FSH and LH. The latter is caused by excess sex hormones, with low levels of FSH and LH. In males, precocious puberty is uncommon and usually has an organic cause, such as gonadotrophin release from an intracranial lesion, gonadal tumour, or adrenal cause. In females, it is usually idiopathic or familial and follows the normal sequence of puberty. Organic causes are rare and associated with rapid onset, neurological symptoms and signs, and dissonance, such as in McCune Albright syndrome. Understanding precocious puberty is important for early detection and management of the condition.

The use of cephalosporins during breastfeeding is deemed to be safe.

Breastfeeding has some contraindications that are important to know, especially when it comes to drugs. Antibiotics like penicillins, cephalosporins, and trimethoprim are safe for breastfeeding mothers, as are endocrine drugs like glucocorticoids (in low doses) and levothyroxine. Epilepsy drugs like sodium valproate and carbamazepine, asthma drugs like salbutamol and theophyllines, and hypertension drugs like beta-blockers and hydralazine are also safe. Anticoagulants like warfarin and heparin, as well as digoxin, are also safe. However, some drugs should be avoided, such as antibiotics like ciprofloxacin, tetracycline, chloramphenicol, and sulphonamides, psychiatric drugs like lithium and benzodiazepines, aspirin, carbimazole, methotrexate, sulfonylureas, cytotoxic drugs, and amiodarone. Other contraindications include galactosaemia and viral infections, although the latter is controversial in the developing world due to the increased risk of infant mortality and morbidity associated with bottle feeding.

Management of Dehydration in Children with Gastroenteritis

Gastroenteritis is a common illness in children that can lead to dehydration if not managed properly. Oral rehydration solution (ORS) is the first-line treatment for children at increased risk of dehydration, including those who have vomited more than twice in the last 24 hours or have other risk factors such as age less than one year, low birth weight, or signs of malnutrition. However, if a child is clinically dehydrated and not responding to ORS, intravenous (IV) fluids may be necessary.

It is important to encourage fluid intake in children with gastroenteritis, but carbonated drinks and fruit juices should be avoided as they can worsen diarrhea. If a child is unable to drink, an NG tube may be considered, but ORS should be attempted first. A bolus of IV fluids is only indicated in cases of suspected or confirmed shock.

Overall, prompt recognition and management of dehydration in children with gastroenteritis can prevent serious complications and improve outcomes.

Developmental dysplasia of the hip (DDH) is more likely to occur in newborns who were in a breech presentation during pregnancy, as well as those with a family history of hip problems in early life. To screen for DDH, ultrasound is performed at 6 weeks of age for infants with these risk factors. Additionally, infants who test positive for the Barlow or Ortolani test are also sent for a hip ultrasound to check for DDH.

Developmental dysplasia of the hip (DDH) is a condition that affects 1-3% of newborns and is more common in females, firstborn children, and those with a positive family history or breech presentation. It used to be called congenital dislocation of the hip (CDH). DDH is more often found in the left hip and can be bilateral in 20% of cases. Screening for DDH is recommended for infants with certain risk factors, and all infants are screened using the Barlow and Ortolani tests at the newborn and six-week baby check. Clinical examination includes testing for leg length symmetry, restricted hip abduction, and knee level when hips and knees are flexed. Ultrasound is used to confirm the diagnosis if clinically suspected, but x-ray is the first line investigation for infants over 4.5 months. Management includes the use of a Pavlik harness for children under 4-5 months and surgery for older children with unstable hips.

Cystic fibrosis is a genetic disorder that affects the lungs and is inherited in an autosomal recessive manner. In the United Kingdom, newborns are screened for cystic fibrosis on the sixth day of life using a dried blood spot collected on a Guthrie card.

Understanding Cystic Fibrosis and the Organisms that Affect Patients

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

CF patients are susceptible to colonization by certain organisms, including Staphylococcus aureus, Pseudomonas aeruginosa, Burkholderia 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 improve patient outcomes. By understanding the genetic basis of CF and the organisms that affect patients, healthcare providers can provide better care for those with this condition.

Congenital heart disease can be categorized into two types: acyanotic and cyanotic. Acyanotic heart diseases are more common and include ventricular septal defects (VSD), atrial septal defect (ASD), patent ductus arteriosus (PDA), coarctation of the aorta, and aortic valve stenosis. VSD is the most common acyanotic heart disease, accounting for 30% of cases. ASDs are less common than VSDs, but they are more frequently diagnosed in adult patients as they tend to present later. On the other hand, cyanotic heart diseases are less common and 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.

Differential diagnosis of vomiting and poor weight gain in infants

Vomiting and poor weight gain are common symptoms in infants, but they can be caused by different conditions that require specific management. One possible cause is pyloric stenosis, which results from an enlarged muscle at the outlet of the stomach, leading to projectile vomiting, dehydration, and failure to thrive. Another possible cause is gastro-oesophageal reflux disease (GORD), which may also involve vomiting, but not projectile, and may respond to conservative measures such as frequent feeds and upright positioning, or medication such as Gaviscon® or proton pump inhibitors. Cow’s milk protein allergy is another potential cause, which may present with a range of symptoms, including vomiting, but not projectile, and may require an exclusion diet for the mother if breastfeeding. Gastroenteritis is a common cause of vomiting and diarrhoea in infants, but it usually resolves within a few days and does not cause an abdominal mass. Finally, volvulus is a rare but serious condition that involves a twisted bowel, leading to acute obstruction and ischaemia, which requires urgent surgical intervention. Therefore, a careful history, examination, and investigations, such as ultrasound or blood tests, may help to differentiate these conditions and guide appropriate treatment.

The majority of croup cases are caused by parainfluenza virus, and it is recommended to avoid throat examination as it may lead to airway obstruction.

Understanding Croup: A Respiratory Infection in Infants and Toddlers

Croup is a type of upper respiratory tract infection that commonly affects infants and toddlers. It is characterized by a barking cough, fever, and coryzal symptoms, and is caused by a combination of laryngeal oedema and secretions. Parainfluenza viruses are the most common cause of croup. The condition typically peaks between 6 months and 3 years of age, and is more prevalent during the autumn season.

The severity of croup can be graded based on the presence of symptoms such as stridor, cough, and respiratory distress. Mild cases may only have occasional barking cough and no audible stridor at rest, while severe cases may have frequent barking cough, prominent inspiratory stridor at rest, and marked sternal wall retractions. Children with moderate or severe croup, those under 6 months of age, or those with known upper airway abnormalities should be admitted to the hospital.

Diagnosis of croup is usually made based on clinical presentation, but a chest x-ray may show subglottic narrowing, commonly referred to as the steeple sign. Treatment for croup typically involves a single dose of oral dexamethasone or prednisolone, regardless of severity. In emergency situations, high-flow oxygen and nebulized adrenaline may be necessary.

Understanding croup is important for parents and healthcare providers alike, as prompt recognition and treatment can help prevent complications and improve outcomes for affected children.

It is common for newborn girls to experience a mucoid white vaginal discharge, which typically resolves by the age of 3 months. Reassurance is the most suitable course of action, and there is no need to refer to paediatrics or suspect sexual abuse. Arranging a transvaginal ultrasound for these symptoms is not necessary.

Gynaecological Problems in Children

In children, gynaecological problems are not uncommon. However, it is important to note that vaginal examinations and vaginal swabs should not be performed. Instead, referral to a paediatric gynaecologist is appropriate for persistent problems. One of the most common gynaecological disorders in girls is vulvovaginitis. This condition can be caused by bacterial or fungal organisms and is often associated with poor hygiene, tight clothing, lack of labial fat pads protecting the vaginal orifice, and lack of protective acid secretion found in the reproductive years. In some cases, vulvovaginitis may be a result of sexual abuse, which can present as bloody discharge.

It is important to manage vulvovaginitis appropriately. Advising children about hygiene is crucial, and soothing creams may be useful. Topical antibiotics or antifungals may also be prescribed. In resistant cases, oestrogen cream may be recommended. It is important to note that most newborn girls have some mucoid white vaginal discharge, which usually disappears by three months of age.

The child’s symptoms suggest that they may have gastro-oesophageal reflux disease (GORD), which is characterized by regurgitation of milk after feeds and crying due to abdominal pain. This can lead to failure to gain weight or even weight loss. Infantile colic is less likely as it would not cause these symptoms. Intussusception, a condition where part of the bowel invaginates into another, causing colicky abdominal pain, vomiting, and passing of redcurrant stools, requires immediate hospitalization. Pyloric stenosis, which presents with projectile vomiting, dehydration, and faltering growth, is less likely as the child does not have projectile vomiting. Volvulus, a complete twisting of an intestinal loop, could present with bilious vomiting, signs of shock, peritonitis, and blood per rectum, and typically occurs in the first year of life.

Common Causes of Bowel Obstruction in Children

Bowel obstruction in children can be caused by various conditions, each with its own distinct features. Here are some of the most common causes:

1. Intussusception: This occurs when one segment of the bowel telescopes into another, leading to obstruction. It is most common in children aged 6-9 months and may be idiopathic or caused by a viral infection. Symptoms include bilious vomiting, distended abdomen, tinkling bowel sounds, and redcurrant jelly stools.

2. Congenital hypertrophic pyloric stenosis: This is a gastric outlet obstruction that typically presents at around 3 weeks of life. It is caused by hypertrophy of the pylorus and leads to non-bilious projectile vomiting and a palpable olive mass in the epigastric region. Treatment involves surgical excision.

3. Duodenal atresia: This is a type of bowel obstruction that only occurs in neonates. It results from failure of recanalization of the small bowel in early fetal life and presents with bilious vomiting, proximal stomach distension, and a double-bubble sign on X-ray. It is associated with Down’s syndrome.

4. Ileus: This is a condition in which the bowel becomes aperistaltic, leading to obstruction. It is common after abdominal surgery, electrolyte disturbances, or infection.

5. Meconium obstruction: This is a type of bowel obstruction that only occurs in newborns. It presents with failure to pass meconium, bilious vomiting, and abdominal distension. Diagnosis can be made prenatally or after birth with an abdominal X-ray showing dilated loops of the small intestine and a soap bubble appearance. Treatment involves radiographic contrast enema or surgery if enemas are unsuccessful.

In conclusion, bowel obstruction in children can have various causes, and prompt diagnosis and treatment are essential to prevent complications.

Differentiating Sickle Cell Disease Complications: A Guide

Sickle cell disease is a genetic disorder that affects the shape of red blood cells, leading to a range of complications. Here is a guide to differentiating between some of the most common complications:

Splenic Sequestration Crisis: This occurs when sickled red blood cells become trapped in the spleen, leading to abdominal pain, splenomegaly, and signs of anemia. It is most common in children aged 5 months to 2 years and may be associated with infection. Treatment involves fluid resuscitation and transfusion, with splenectomy advised for recurrent cases.

Haemolytic Crisis: Chronic haemolysis is a feature of sickle cell disease, but worsening haemolysis may accompany acute deteriorations. This leads to a reduction in haemoglobin and an increase in unconjugated bilirubin. However, isolated haemolysis would not lead to abdominal pain and splenomegaly.

Aplastic Crisis: This is a temporary cessation of red blood cell production, often associated with parvovirus B19 infection. Patients present with fatigue, pallor, shortness of breath, and low reticulocyte counts.

Girdle Syndrome: This rare complication is characterised by an established ileus, with vomiting, distended abdomen, and absent bowel sounds. It is often associated with bilateral basal lung consolidation, but this patient does not exhibit these features.

Painful Crisis: This is the most common reason for hospital admission in sickle cell disease patients. It is characterised by recurrent attacks of acute severe pain, triggered by sickling and vaso-occlusion. Splenomegaly is not a feature of painful crisis.

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 and is resistant to antipyretics. Other symptoms 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, rather than angiography.

Complications of Kawasaki disease can be serious, with coronary artery aneurysm being the most common. It is important to recognize the symptoms of Kawasaki disease early on and seek medical attention promptly to prevent potential complications.

If sitting without support is not achieved by 12 months, referral is necessary, although it should typically be achieved by 7-8 months.

Gross Motor Developmental Milestones

Gross motor skills refer to the ability to use large muscles in the body for activities such as crawling, walking, running, and jumping. These skills are essential for a child’s physical development and are achieved through a series of developmental milestones.
At 3 months, a baby should have little or no head lag when pulled to sit and should have good head control when lying on their abdomen. By 6 months, they should be able to lift and grasp their feet when lying on their back, pull themselves to a sitting position, and roll from front to back. At 9 months, they should be able to pull themselves to a standing position and crawl. By 12 months, they should be able to cruise and walk with one hand held. At 18 months, they should be able to walk unsupported and squat to pick up a toy. By 2 years, they should be able to run and walk up and down stairs holding onto a rail. At 3 years, they should be able to ride a tricycle using pedals and walk up stairs without holding onto a rail. By 4 years, they should be able to hop on one leg.

It is important to note that while the majority of children crawl on all fours before walking, some children may bottom-shuffle, which is a normal variant that runs in families. These milestones serve as a guide for parents and healthcare professionals to monitor a child’s physical development and identify any potential delays or concerns.

Scarlet Fever: Symptoms, Causes, and Treatment

Scarlet fever is a bacterial infection caused by toxin-producing strains of the group A streptococcal bacterium (Streptococcus pyogenes). It is a notifiable disease to Public Health England. The symptoms include a sore throat, fever, and a rash with a red strawberry tongue, cervical lymphadenopathy, fine papular rash, tonsillitis, tiredness, headache, nausea, and vomiting.

The condition is treated with fluids, an antipyretic, and phenoxymethylpenicillin. Other causes such as Influenza pneumoniae, Escherichia coli, Haemophilus influenzae, and Parvovirus B19 are not related to scarlet fever. It is important to seek medical attention if you suspect you or your child has scarlet fever.

Incomplete immunisation may be a concern for patients belonging to travelling communities with regards to acute epiglottitis caused by Haemophilus influenzae type B.

Acute epiglottitis is a rare but serious infection caused by Haemophilus influenzae type B. It is important to recognize and treat it promptly as it can lead to airway obstruction. Although it was once considered a disease of childhood, it is now more common in adults in the UK due to the immunization program. The incidence of epiglottitis has decreased since the introduction of the Hib vaccine. Symptoms include a rapid onset, high temperature, stridor, drooling of saliva, and a tripod position where the patient leans forward and extends their neck to breathe easier. Diagnosis is made by direct visualization, but x-rays may be done to rule out a foreign body.

Immediate senior involvement is necessary, including those who can provide emergency airway support such as anaesthetics or ENT. Endotracheal intubation may be necessary to protect the airway. It is important not to examine the throat if epiglottitis is suspected due to the risk of acute airway obstruction. The diagnosis is made by direct visualization, but only senior staff who are able to intubate if necessary should perform this. Treatment includes oxygen and intravenous antibiotics.

If a child shows a preference for one hand before the age of 12 months, it may be a sign of cerebral palsy and should be addressed promptly. The appropriate course of action is to refer the child to a child development service for a comprehensive evaluation by a multidisciplinary team. Children with cerebral palsy typically receive specialized care from birth, but in some cases, the condition may be suspected in a primary care setting. According to NICE guidelines, delayed motor milestones such as not sitting by 8 months (adjusted for gestational age), not walking by 18 months (adjusted for gestational age), early asymmetry of hand function, and persistent toe-walking may indicate cerebral palsy. In this case, as the child is exhibiting hand preference before the age of 1 year and has a risk factor for cerebral palsy (low birth weight), an urgent referral is necessary. Other options are not appropriate and may delay diagnosis and treatment.

Common Developmental Problems and Possible Causes

Developmental problems can manifest in various ways, including referral points such as not smiling at 10 weeks, inability to sit unsupported at 12 months, and failure to walk at 18 months. Fine motor skill problems may also arise, such as abnormal hand preference before 12 months, which could indicate cerebral palsy. Gross motor problems are often caused by a variant of normal, cerebral palsy, or neuromuscular disorders like Duchenne muscular dystrophy. Speech and language problems should always be checked for hearing issues, as they can also be caused by environmental deprivation or general development delay.

It is important to recognize these developmental problems early on and seek appropriate interventions to address them. By doing so, children can receive the necessary support to reach their full potential and overcome any challenges they may face. With proper care and attention, many children with developmental problems can go on to lead happy and fulfilling lives.

The answer, which is typically 7-8 months, differs slightly from the 6 months stated in the MRCPCH Development Guide.

Gross Motor Developmental Milestones

Gross motor skills refer to the ability to use large muscles in the body for activities such as crawling, walking, running, and jumping. These skills are essential for a child’s physical development and are achieved through a series of developmental milestones.
At 3 months, a baby should have little or no head lag when pulled to sit and should have good head control when lying on their abdomen. By 6 months, they should be able to lift and grasp their feet when lying on their back, pull themselves to a sitting position, and roll from front to back. At 9 months, they should be able to pull themselves to a standing position and crawl. By 12 months, they should be able to cruise and walk with one hand held. At 18 months, they should be able to walk unsupported and squat to pick up a toy. By 2 years, they should be able to run and walk up and down stairs holding onto a rail. At 3 years, they should be able to ride a tricycle using pedals and walk up stairs without holding onto a rail. By 4 years, they should be able to hop on one leg.

It is important to note that while the majority of children crawl on all fours before walking, some children may bottom-shuffle, which is a normal variant that runs in families. These milestones serve as a guide for parents and healthcare professionals to monitor a child’s physical development and identify any potential delays or concerns.