Recognizing Early Signs of Autism in Children

Autistic spectrum disorders are often diagnosed after the age of three years, but parents may have concerns about their child’s development by 18 months. While a specialist diagnosis is required, general practitioners should be aware of warning signs. These include lack of social interactions, impaired communication, repetitive behavior, restricted interests, and difficulty regulating emotions. However, some behaviors that may seem concerning are actually normal parts of child development, such as copying gestures and exhibiting defiant behavior. It is important to note that language delay is a feature of autism, but only linking two words together in speech is a normal milestone that usually occurs between 20 and 24 months. When observing a child, it is crucial to look for a combination of these signs and seek professional evaluation if there are concerns.

If a child under the age of 3 months has a fever exceeding 38ºC, they should be considered at high risk for serious illness according to the NICE traffic light system. This is classified as a red alert. NICE CKS provides additional information, stating that research from six studies indicates that the risk of serious illness is more than 10 times greater in this age group compared to older children.

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

Polio Vaccination and Neurological Conditions

The Department of Health’s ‘Green Book’ provides guidelines for polio vaccination and neurological conditions. According to the book, stable pre-existing neurological conditions such as spina bifida and congenital brain abnormalities do not prevent polio vaccination. However, if a child has an unstable or deteriorating neurological condition, vaccination should be deferred, and the child should be referred to a specialist for further assessment and advice. This includes children with uncontrolled epilepsy.

It is important to note that a family history of seizures or epilepsy doesn’t prevent immunization. However, if there is a personal or family history of febrile seizures, there is an increased risk of these occurring after any fever, including post-immunization. In such cases, immunization should proceed as recommended, with advice on the prevention and management of fever beforehand.

Common Scrotal Conditions in Children

Testicular torsion, epididymo-orchitis, hydrocele, testicular tumour, and varicocele are common scrotal conditions in children. Testicular torsion is a common condition that occurs between the ages of 7 and 12 years. It presents with an acutely swollen scrotum with a painful testicle. Lifting the testis up over the symphysis increases pain, and the testis is usually retracted upwards with an absent cremasteric reflex. Immediate reduction is necessary to increase the chances of testicular salvage. Epididymo-orchitis presents with pain, swelling, and inflammation of the epididymis, commonly due to sexually transmitted infections. Hydrocele is painless swelling, and the scrotum transilluminates when a torch is held against it. Testicular tumour produces scrotal enlargement, only infrequently accompanied by pain. Varicocele is usually asymptomatic and presents with infertility investigations. An obvious varicocele is often described as feeling like a bag of worms.

Pertussis: Diagnosis and Symptoms

Pertussis, commonly known as whooping cough, is most contagious during the first 7-14 days of the illness, which is called the catarrhal phase. During this phase, there is an increase in lymphocytes in the blood. Diagnosis of pertussis can be made by taking blood for pertussis serology or by isolating the organism from nasal secretions. It is important to note that an inspiratory whoop may not always be present, but complete apnoeic episodes can occur.

The vaccine for rotavirus is administered orally and is live attenuated. It is given to infants at two and three months of age, along with other oral vaccines like polio and typhoid. Two doses are necessary, and it is not typically given to children at three years of age. This vaccine is not injected and is not an inactivated toxin vaccine, which includes vaccines for tetanus, diphtheria, and pertussis.

The Rotavirus Vaccine: A Vital Tool in Preventing Childhood Mortality

Rotavirus is a significant public health concern, causing high rates of morbidity and hospitalization in developed countries and childhood mortality in developing nations. To combat this, a vaccine was introduced into the NHS immunization program in 2013. The vaccine is an oral, live attenuated vaccine that requires two doses, the first at two months and the second at three months. It is important to note that the first dose should not be given after 14 weeks and six days, and the second dose cannot be given after 23 weeks and six days due to the theoretical risk of intussusception.

The vaccine is highly effective, with an estimated efficacy rate of 85-90%, and is predicted to reduce hospitalization rates by 70%. Additionally, the vaccine provides long-term protection against rotavirus. The introduction of the rotavirus vaccine is a vital tool in preventing childhood mortality and reducing the burden of rotavirus-related illness.

To confirm the suspected IgE mediated allergy diagnosis, an atopy patch test is utilized.

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.

Differentiating between types of muscular dystrophy

Muscular dystrophies are a group of inherited disorders that cause progressive muscle wasting and weakness. There are several types of muscular dystrophy, each with its own unique characteristics. It is important to differentiate between these types in order to provide appropriate treatment and management.

Becker muscular dystrophy is a less severe form of the disorder, with a later onset and longer life expectancy. It mainly affects the proximal muscles of the limbs and is inherited in an X-linked-recessive pattern.

Duchenne muscular dystrophy, on the other hand, is a more severe form that presents in early childhood and leads to wheelchair dependence and early death. It is also inherited in an X-linked-recessive pattern and affects the proximal muscles of the limbs, as well as the heart and intellect.

Facioscapulohumeral dystrophy is an autosomal dominant or recessive disorder that affects the face and shoulder muscles in early adulthood, but doesn’t affect life expectancy.

Limb-girdle muscular dystrophy is an autosomal dominant or recessive disorder that presents in the teenage years with weakness in the pelvic girdle and shoulders, but doesn’t affect life expectancy or intellect.

Myasthenia gravis is an acquired, autoimmune disorder that causes fluctuating muscle weakness, particularly in the extraocular, bulbar, or proximal limb muscles. It typically occurs in adulthood.

Understanding the differences between these types of muscular dystrophy can aid in diagnosis and management of the disorder.

Chickenpox is a viral infection caused by the varicella zoster virus. It is highly contagious and can be spread through respiratory droplets. The virus can also reactivate later in life and cause shingles. Chickenpox is most infectious from four days before the rash appears until five days after. The incubation period is typically 10-21 days. Symptoms include fever and an itchy rash that starts on the head and trunk before spreading. The rash goes through stages of macular, papular, and vesicular. Management is supportive, with measures such as keeping cool and using calamine lotion. Immunocompromised patients and newborns with peripartum exposure should receive varicella zoster immunoglobulin. Complications can include secondary bacterial infection of the lesions, pneumonia, encephalitis, and rare complications such as disseminated haemorrhagic Chickenpox.

One common complication of Chickenpox is secondary bacterial infection of the lesions, which can be increased by the use of NSAIDs. This can manifest as a single infected lesion or small area of cellulitis. In rare cases, invasive group A streptococcal soft tissue infections may occur, resulting in necrotizing fasciitis. Other rare complications of Chickenpox include pneumonia, encephalitis (which may involve the cerebellum), disseminated haemorrhagic Chickenpox, and very rarely, arthritis, nephritis, and pancreatitis. It is important to note that school exclusion may be necessary, as Chickenpox is highly infectious and can be caught from someone with shingles. It is advised to avoid contact with others until all lesions have crusted over.

Accidents become the leading cause of death in children after they turn one year old.

Sudden infant death syndrome (SIDS) is the leading cause of death in infants during their first year of life, with the highest incidence occurring at three months of age. There are several major risk factors associated with SIDS, including placing the baby to sleep on their stomach, parental smoking, prematurity, bed sharing, and hyperthermia or head covering. These risk factors are additive, meaning that the more risk factors present, the higher the likelihood of SIDS. Other risk factors include male sex, multiple births, lower social classes, and maternal drug use. SIDS incidence also tends to increase during the winter months. However, there are protective factors that can reduce the risk of SIDS, such as breastfeeding, room sharing (but not bed sharing), and the use of pacifiers. In the event of a SIDS case, it is important to screen siblings for potential sepsis and inborn errors of metabolism.

Measles Exclusion Guidelines for Schools and Workplaces

Measles is a highly infectious disease that spreads through airborne or droplet transmission. To prevent the spread of the disease, individuals who have contracted measles should be excluded from school or work for four days after the onset of the rash. This exclusion period is outlined in the infection control guidelines published by Public Health England for schools and other childcare settings.

It is important to note that individuals are infectious from the beginning of the prodromal period, when the first symptoms appear, until four days after the onset of the rash. Therefore, it is crucial to follow the exclusion guidelines to prevent the spread of measles in schools and workplaces. By doing so, we can protect the health and well-being of everyone in the community.

Understanding Vitamin D Deficiency

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

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

The recurrence rate of Down’s syndrome is typically 1 in 100.

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.

Expressivity is a term used in genetics to describe how much a genotype is expressed in an individual’s phenotype. This can vary greatly, even among individuals with the same gene. Neurofibromatosis type 1 is an example of a condition with high phenotypic variability due to expressivity. Penetrance is a similar concept, but it looks at the statistical variability of a genotype in a population. Incomplete penetrance occurs when the genotype is present but the phenotype is not observed, which can explain why some monogenic disorders do not follow predictable inheritance patterns. Hemingway’s cats in Florida showed high penetrance but variable expression of polydactyly, where the gene always caused extra toes but the number varied. Aneuploidy is when there is an abnormal number of chromosomes in a cell, such as in Down syndrome. Anticipation refers to the increasing severity of an inherited disorder in subsequent generations, as seen in Huntington’s disease.

Understanding Penetrance and Expressivity in Genetic Disorders

Penetrance and expressivity are two important concepts in genetics that help explain why individuals with the same gene mutation may exhibit different degrees of observable characteristics. Penetrance refers to the proportion of individuals in a population who carry a disease-causing allele and express the related disease phenotype. In contrast, expressivity describes the extent to which a genotype shows its phenotypic expression in an individual.

There are several factors that can influence penetrance and expressivity, including modifier genes, environmental factors, and allelic variation. For example, some genetic disorders, such as retinoblastoma and Huntington’s disease, exhibit incomplete penetrance, meaning that not all individuals with the disease-causing allele will develop the condition. On the other hand, achondroplasia shows complete penetrance, meaning that all individuals with the disease-causing allele will develop the condition.

Expressivity, on the other hand, describes the severity of the phenotype. Some genetic disorders, such as neurofibromatosis, exhibit a high level of expressivity, meaning that the phenotype is more severe in affected individuals. Understanding penetrance and expressivity is important in genetic counseling and can help predict the likelihood and severity of a genetic disorder in individuals and their families.

Importance of Timely and Accurate Note-Taking in Medical Practice

Making notes immediately after a consultation with a patient is crucial in medical practice. It is equally important to make further contemporaneous notes whenever you see the patient again. This ensures that all relevant information is recorded accurately and in a timely manner.

It is easy to forget or omit making notes about telephone consultations, which can lead to repeat prescribing of the wrong drug in the future. Therefore, it is essential to record all encounters with patients, including telephone consultations, in the clinical record.

Cases involving child protection are particularly important, and it is good practice to record the contents of the consultation immediately, even if the eventual diagnosis is uncertain. This ensures that all relevant information is documented and can be used to inform future decisions.

In summary, timely and accurate note-taking is essential in medical practice to ensure that all relevant information is recorded and can be used to inform future decisions.

Understanding Sleep Disorders in Children

Sleep disorders in children can be distressing for both the child and their parents. It is important to identify the specific type of sleep disorder in order to provide appropriate treatment. Here are some common sleep disorders in children:

Night Terrors: These are different from nightmares and can affect children between the ages of 4 and 12 years. Symptoms include sudden arousal from non-REM sleep, fear-related behavior, confusion upon waking, and amnesia regarding the event.

Sleepwalking: Similar to night terrors, sleepwalking involves getting up and moving around while asleep. It is important to ensure the child’s safety during these episodes.

Nocturnal Epilepsy: Seizures occur only during sleep in this type of epilepsy. It may be difficult to diagnose, but symptoms include involuntary movements during sleep and changes upon awakening.

Nightmares: These are vivid and frightening dreams that most children experience occasionally. Comforting the child can help them get back to sleep.

Panic Attacks: Unlike other sleep disorders, panic attacks occur while the child is awake and can be very distressing.

Post-Traumatic Stress Disorder: Bad dreams about a traumatic event and sleep disturbance are features of PTSD and can be similar to nightmares.

Understanding these sleep disorders can help parents and healthcare providers provide appropriate care and support for children experiencing sleep disturbances.

If a patient presents with symptoms consistent with whooping cough within 21 days of onset, the recommended first-line treatment is a macrolide antibiotic such as clarithromycin or azithromycin. Starting treatment within this timeframe can reduce the risk of spread. It is not recommended to delay treatment or offer a booster vaccination as initial management. Doxycycline is not the first-line antibiotic for whooping cough.

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 answer is mother’s brother, as X-linked recessive conditions are exclusive to males and do not transmit from male to male.

X-linked recessive inheritance affects only males, except in cases of Turner’s syndrome where females are affected due to having only one X chromosome. This type of inheritance is transmitted by carrier females, and male-to-male transmission is not observed. Affected males can only have unaffected sons and carrier daughters.

If a female carrier has children, each male child has a 50% chance of being affected, while each female child has a 50% chance of being a carrier. It is rare for an affected father to have children with a heterozygous female carrier, but in some Afro-Caribbean communities, G6PD deficiency is relatively common, and homozygous females with clinical manifestations of the enzyme defect can be seen.

The UK immunisation schedule recommends certain vaccines at different ages. At birth, the BCG vaccine is given if the baby is at risk of tuberculosis. At 2, 3, and 4 months, the ‘6-1 vaccine’ (diphtheria, tetanus, whooping cough, polio, Hib and hepatitis B) and oral rotavirus vaccine are given, along with Men B and PCV at specific intervals. At 12-13 months, the Hib/Men C, MMR, PCV, and Men B vaccines are given. At 3-4 years, the ‘4-in-1 Preschool booster’ (diphtheria, tetanus, whooping cough and polio) and MMR vaccines are given. At 12-13 years, the HPV vaccination is given, and at 13-18 years, the ‘3-in-1 teenage booster’ (tetanus, diphtheria and polio) and Men ACWY vaccines are given. Additionally, the flu vaccine is recommended annually for children aged 2-8 years.

It is important to note that the meningitis ACWY vaccine has replaced meningitis C for 13-18 year-olds due to an increased incidence of meningitis W disease in recent years. The ACWY vaccine is also offered to new students up to the age of 25 years at university. GP practices will automatically send letters inviting 17-and 18-year-olds in school year 13 to have the Men ACWY vaccine, while students going to university or college for the first time should contact their GP to have the vaccine before the start of the academic year.

The Men C vaccine used to be given at 3 months but has now been discontinued as there are almost no cases of Men C disease in babies or young children in the UK. All children will continue to be offered the Hib/Men C vaccine at one year of age, and the Men ACWY vaccine at 14 years of age to provide protection across all age groups.

Management of Constipation in a 12-Month-Old Child

This 12-month-old child has presented with constipation. Referral for specialist assessment or further investigation is not necessary at this stage, as there are no red flags in the history or examination. Treatment should be initiated in primary care.

A rectal examination is not necessary for the primary care assessment. A thorough history and examination, as discussed in the stem, is sufficient to make an accurate diagnosis and identify the presence of any impaction.

The first-line treatment for constipation is laxative treatment. A good first-line agent is macrogol polyethylene glycol 3350 with electrolytes (Movicol® Paediatric Plain). If there is a lack of effect, a stimulant laxative such as senna can be added to the treatment. In addition to laxative use, the patient and carers should be advised on lifestyle factors such as diet, including adequate fluid intake.

Behavioural interventions, such as scheduled toileting, encouragement, and reward systems, may be appropriate depending on the age of the patient. Advice on exercise in older children may also be helpful. However, dietary interventions should not be used alone as a first-line treatment. Early use of a laxative is indicated and is the most appropriate option.

Pediatric Eye Examinations: Tests and Their Significance

Pediatric eye examinations are crucial for detecting eye diseases and disorders in children. Here are some common tests and their significance:

Red Reflex Test: This test involves shining a light source from an ophthalmoscope about 50 cm away from the child’s eyes. A bright and equal red reflex should be seen from each pupil. An abnormal red reflex could indicate serious eye diseases such as cataract or retinoblastoma.

Cover Test: This test is used to detect squint. The child focuses on a near object while a cover is placed briefly over one eye and then removed. The squinting eye will deviate inwards or outwards.

Corneal Light Reflex Test: This test involves the reflection of a light source off the cornea. In people with normal fixation, its position will be symmetrical in each eye. It is used in an examination for squint.

Eye Movements: Eye movement testing is used to assess ocular motor function, particularly cranial nerve palsies.

Visual Acuity: In babies, the ability to follow objects is a guide to visual acuity. In a child with retinoblastoma, visual acuity in the affected eye(s) may be reduced. However, there are other reasons for reduced vision.

Understanding Head Lice: Causes, Symptoms, and Management

Head lice, also known as pediculosis capitis or ‘nits’, is a common condition in children caused by a parasitic insect called Pediculus capitis. These small insects live only on humans and feed on our blood. The eggs, which are grey or brown and about the size of a pinhead, are glued to the hair close to the scalp and hatch in 7 to 10 days. Nits, on the other hand, are the empty egg shells and are white and shiny. They are found further along the hair shaft as they grow out.

Head lice are spread by direct head-to-head contact and tend to be more common in children who play closely together. It is important to note that head lice cannot jump, fly, or swim. When newly infected, cases have no symptoms, but itching and scratching on the scalp occur 2 to 3 weeks after infection. There is no incubation period.

To diagnose head lice, fine-toothed combing of wet or dry hair is necessary. Treatment is only indicated if living lice are found. A choice of treatments should be offered, including malathion, wet combing, dimeticone, isopropyl myristate, and cyclomethicone. Household contacts of patients with head lice do not need to be treated unless they are also affected. It is important to note that school exclusion is not advised for children with head lice.

In conclusion, understanding the causes, symptoms, and management of head lice is crucial in preventing its spread. By taking the necessary precautions and seeking appropriate treatment, we can effectively manage this common condition.

Ankle Injuries in Children and the Ottawa Ankle Rules

The history of ankle injuries in children suggests a forced internal rotation at the ankle joint, which can cause a sprain of the lateral ligaments. This type of injury requires supportive strapping, analgesia, and graduated mobilization. However, ankle sprains are less common in children than adults because their ligaments are stronger than their growth plates. As a result, the growth plate tends to fracture before the ligament tears.

In some cases, Salter-Harris Type 1 fractures and ligament tears may not show up on radiographs. Therefore, it is important to consider the patient’s history, such as tenderness over the ligament rather than bone and whether the patient is weight-bearing.

The Ottawa ankle rules are helpful in assisting GPs in the management of ankle injuries in adults and determining the need for an x-ray. A recent study published in the BMJ showed that the Ottawa ankle rules are highly accurate at excluding ankle fractures after a sprain injury. By following these guidelines, healthcare professionals can provide appropriate care for ankle injuries in children and adults.

Functional abdominal pain is a common condition among children, affecting up to 25% of them. It is characterized by pain in the abdominal area that is not caused by any organic factors. Symptoms that may indicate a non-organic cause include pain near the belly button, absence of other gastrointestinal symptoms, no disturbance in sleep, normal physical examination, and the child’s overall well-being. In most cases, a thorough history, examination, and explanation are sufficient to manage the condition. However, if the symptoms persist, referral to a pediatrician and further investigations may be necessary to rule out organic causes. School refusal is a psychological disorder that causes severe anxiety in children when attending school or being separated from their parents. Abdominal pain may be a symptom, but it is not usually experienced on weekends. Abdominal migraine is characterized by sudden episodes of intense pain in the periumbilical area, lasting for at least an hour, accompanied by anorexia, nausea, vomiting, headache, photophobia, or pallor. Intussusception is a rare condition that occurs mostly in infants aged five to ten months, making it unlikely to be the diagnosis for this patient. Irritable bowel syndrome is also unlikely as the patient has no changes in bowel habits.

When dealing with a child suffering from mild, moderate, or severe croup, it is recommended to administer a one-off dose of 0.15mg/kg of dexamethasone or 1-2 mg/kg of prednisolone as an alternative. It is important to note that steam inhalation and decongestants should not be recommended, as they are not effective in treating the barking cough associated with croup. Antibiotics are also not necessary, as croup is caused by a virus, typically parainfluenza. Inhaled salbutamol is not mentioned in the guidance.

Parents should be informed that croup is self-limiting and symptoms usually resolve within 48 hours, although they may last up to a week. Paracetamol or ibuprofen can be used to control fever and pain, but over- or under-dressing a child with a fever should be avoided. Tepid sponging is not recommended, and antipyretic drugs should not be given solely to reduce body temperature. Adequate fluid intake should be ensured.

It is important to arrange a follow-up consultation within a few hours, either face-to-face or by telephone. Urgent medical advice should be sought if there is a progression from mild to moderate airways obstruction, if the child becomes toxic, or if the child becomes cyanosed, unusually sleepy, or struggles to breathe.

Parents should be informed that cough medicines, decongestants, and short-acting beta-agonists are not effective in treating croup, as it is usually caused by a viral illness and antibiotics are not necessary.

Croup is a respiratory infection that affects young children, typically those between 6 months and 3 years old. It is most common in the autumn and is caused by parainfluenza viruses. The main symptom is stridor, which is caused by swelling and secretions in the larynx. Other symptoms include a barking cough, fever, and cold-like symptoms. The severity of croup can be graded based on the child’s symptoms, with mild cases having occasional coughing and no audible stridor at rest, and severe cases having frequent coughing, prominent stridor, and significant distress or lethargy. Children with moderate or severe croup should be admitted to the hospital, especially if they are under 6 months old or have other airway abnormalities. Diagnosis is usually made based on clinical symptoms, but a chest x-ray can show subglottic narrowing. Treatment typically involves a single dose of oral dexamethasone or prednisolone, and emergency treatment may include high-flow oxygen or nebulized adrenaline.

If an infant with GORD is experiencing troublesome symptoms even after a 1-2 week trial of alginate therapy, the recommended course of action is to prescribe a 4-week trial of a proton pump inhibitor. This is in line with NICE guidelines.

Opting for a 2-week trial of omeprazole is not advisable as it may not be sufficient to alleviate the symptoms.

Continuing with alginate suspension alone is not appropriate as the symptoms have worsened since starting the treatment.

Ranitidine is no longer recommended due to the presence of small amounts of the carcinogen N-nitrosodimethylamine (NMDA) in formulations from multiple manufacturers. Nitrosamines, which are carcinogens commonly found in smoked fish, are linked to high rates of oesophageal and gastric cancer in East Asian countries.

If metoclopramide, a prokinetic agent, is used, it should be done so with caution and under the supervision of a specialist.

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

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

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

Recurrent Abdominal Pain in Children: Possible Causes and Diagnosis

Recurrent abdominal pain is a common complaint among children, but it is often difficult to identify the underlying cause. In many cases, no organic pathology can be found, but a significant number of cases are organic and require careful examination and investigation. Recurrent abdominal pain is defined as pain that occurs for at least three episodes within three months and is severe enough to affect a child’s activities.

The most probable causes of recurrent abdominal pain in children are irritable bowel syndrome, abdominal migraine/periodic syndrome, constipation, mesenteric adenitis, and urinary tract infections. However, other possible causes should also be considered.

Despite the lack of organic pathology in most cases, psychological factors are not always the cause. A study found no significant differences in emotional and behavioral scores between patients with organic pathology and those without. Therefore, a thorough examination and investigation are necessary to identify the underlying cause of recurrent abdominal pain in children.

Urinary Tract Infection in Children: Symptoms, Diagnosis, and Treatment

Urinary tract infections (UTIs) are more common in boys until 3 months of age, after which the incidence is substantially higher in girls. At least 8% of girls and 2% of boys will have a UTI in childhood. The presentation of UTIs in childhood depends on age. Infants may experience poor feeding, vomiting, and irritability, while younger children may have abdominal pain, fever, and dysuria. Older children may experience dysuria, frequency, and haematuria. Features that may suggest an upper UTI include a temperature of over 38ºC and loin pain or tenderness.

According to NICE guidelines, a urine sample should be checked in a child if there are any symptoms or signs suggestive of a UTI, with unexplained fever of 38°C or higher (test urine after 24 hours at the latest), or with an alternative site of infection but who remain unwell (consider urine test after 24 hours at the latest). A clean catch is the preferable method for urine collection. If not possible, urine collection pads should be used. Invasive methods such as suprapubic aspiration should only be used if non-invasive methods are not possible.

Infants less than 3 months old should be referred immediately to a paediatrician. Children aged more than 3 months old with an upper UTI should be considered for admission to the hospital. If not admitted, oral antibiotics such as cephalosporin or co-amoxiclav should be given for 7-10 days. Children aged more than 3 months old with a lower UTI should be treated with oral antibiotics for 3 days according to local guidelines, usually trimethoprim, nitrofurantoin, cephalosporin, or amoxicillin. Parents should be asked to bring the children back if they remain unwell after 24-48 hours. Antibiotic prophylaxis is not given after the first UTI but should be considered with recurrent UTIs.

Treatment Options for Enuresis: From Simple Measures to Medications

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

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