Feeding Difficulty and Physiological Jaundice

Feeding difficulty is a common problem among infants, but it is not associated with physiological jaundice. Physiological jaundice is a benign condition that is short-lived and does not generally cause any symptoms. This means that it is not related to feeding difficulties that infants may experience.

It is important for parents to be aware of the signs of feeding difficulty in their infants, such as difficulty latching, poor weight gain, and excessive crying during feeding. These symptoms may indicate an underlying medical condition that requires prompt attention. On the other hand, physiological jaundice is a normal occurrence in many newborns and typically resolves on its own without any treatment.

In summary, while feeding difficulty is a common problem among infants, it is not associated with physiological jaundice. Parents should be aware of the signs of feeding difficulty and seek medical attention if necessary, but they can rest assured that physiological jaundice is a benign condition that does not generally cause any symptoms.

The first step in managing duct dependent congenital heart disease is to maintain the ductus arteriosus using prostaglandins. In newborns less than 24-hours-old, the most common cause of cyanosis is transposition of the great arteries (TGA). Administering prostaglandins is the initial emergency management for TGA, as it keeps the ductus arteriosus open, allowing oxygenated and deoxygenated blood to mix and ensuring tissues receive oxygen until definitive management can be performed. Echocardiograms are performed alongside prostaglandin administration. Ibuprofen is not used to keep the ductus arteriosus open, but rather to close it in newborns. Indomethacin, a type of NSAID, is used to close the ductus arteriosus in newborns. Intubation and ventilation are not the initial management for TGA, but may be used in extreme cases or for transport to a tertiary center. Definitive management for TGA involves performing surgery on the infant before they are 4-weeks-old, but prostaglandin E1 must be administered prior to surgical intervention to keep the ductus arteriosus patent.

Understanding Transposition of the Great Arteries

Transposition of the great arteries (TGA) is a type of congenital heart disease that results in a lack of oxygenated blood flow to the body. This condition occurs when the aorticopulmonary septum fails to spiral during septation, causing the aorta to leave the right ventricle and the pulmonary trunk to leave the left ventricle. Children born to diabetic mothers are at a higher risk of developing TGA.

The clinical features of TGA include cyanosis, tachypnea, a loud single S2 heart sound, and a prominent right ventricular impulse. Chest x-rays may show an egg-on-side appearance.

To manage TGA, it is important to maintain the ductus arteriosus with prostaglandins. Surgical correction is the definitive treatment for this condition. Understanding the basic anatomical changes and clinical features of TGA can help with early diagnosis and appropriate management.

High Impact Injuries to the Left Flank

High impact injuries to the left flank can result in damage to the spleen or kidney, as well as the ribs and soft tissue. If the patient experiences fractured ribs and hypotension, it is important to suspect a spleen rupture. Fluid resuscitation can be used to determine if the patient responds positively, and a CT scan can be arranged to confirm the diagnosis. Based on the injury grade and physical parameters, a decision can be made to either manage the injury conservatively or operate.

Observation should be conducted in a High Dependency Unit (HDU) setting initially to ensure that any deterioration in haemodynamic parameters can be addressed promptly. CT scans are also useful in trauma cases to rule out other injuries, such as hollow visceral injuries that would require a laparotomy. Renal trauma typically does not cause hypotension unless other organs are also injured, and aortic dissection would require more force.

To reduce the risk of getting infections, the 23-year-old woman with cystic fibrosis should minimize contact with other patients with the same condition. It is not recommended to introduce a low-calorie diet, but rather to have a high-calorie diet. Exercise and chest physiotherapy are also recommended. While a salbutamol inhaler can provide relief for breathlessness, it will not reduce the risk of infections. Enzyme supplements are useful in treating cystic fibrosis, but they do not reduce the risk of infection.

Managing Cystic Fibrosis: A Multidisciplinary Approach

Cystic fibrosis (CF) is a chronic condition that requires a multidisciplinary approach to management. Regular chest physiotherapy and postural drainage, as well as deep breathing exercises, are essential to maintain lung function and prevent complications. Parents are usually taught how to perform these techniques. A high-calorie diet, including high-fat intake, is recommended to meet the increased energy needs of patients with CF. Vitamin supplementation and pancreatic enzyme supplements taken with meals are also important.

Patients with CF should try to minimize contact with each other to prevent cross-infection with Burkholderia cepacia complex and Pseudomonas aeruginosa. Chronic infection with Burkholderia cepacia is an important CF-specific contraindication to lung transplantation. In cases where lung transplantation is necessary, careful consideration is required to ensure the best possible outcome.

Lumacaftor/Ivacaftor (Orkambi) is a medication used to treat cystic fibrosis patients who are homozygous for the delta F508 mutation. Lumacaftor increases the number of CFTR proteins that are transported to the cell surface, while ivacaftor is a potentiator of CFTR that is already at the cell surface. This increases the probability that the defective channel will be open and allow chloride ions to pass through the channel pore.

It is important to note that the standard recommendation for CF patients has changed from high-calorie, low-fat diets to high-calorie diets to reduce the amount of steatorrhea. With a multidisciplinary approach to management, patients with CF can lead fulfilling lives and manage their condition effectively.

Capacity to make decisions is dependent on both time and the individual’s ability to make decisions. If the patient did not have the capacity to make a decision in the past, but currently has the capacity to do so, their consent is the only one required. It is advisable to involve parents in the decision-making process for pediatric patients, especially in cases involving contraception. However, if the patient is not convinced, the treatment can still proceed as long as they have the capacity to make the decision. If there are doubts, it is good practice to involve another healthcare team member, but if the patient is deemed capable of making the decision, their capacitous consent is sufficient according to the GMC. There is no requirement for a time gap between consultations to allow for decision-making.

Guidelines for Obtaining Consent in Children

The General Medical Council has provided guidelines for obtaining consent in children. According to these guidelines, young people who are 16 years or older can be treated as adults and are presumed to have the capacity to make decisions. However, for children under the age of 16, their ability to understand what is involved determines whether they have the capacity to decide. If a competent child refuses treatment, a person with parental responsibility or the court may authorize investigation or treatment that is in the child’s best interests.

When it comes to providing contraceptives to patients under 16 years of age, the Fraser Guidelines must be followed. These guidelines state that the young person must understand the professional’s advice, cannot be persuaded to inform their parents, is likely to begin or continue having sexual intercourse with or without contraceptive treatment, and will suffer physical or mental health consequences without contraceptive treatment. Additionally, the young person’s best interests require them to receive contraceptive advice or treatment with or without parental consent.

Some doctors use the term Fraser competency when referring to contraception and Gillick competency when referring to general issues of consent in children. However, rumors that Victoria Gillick removed her permission to use her name or applied copyright have been debunked. It is important to note that in Scotland, those with parental responsibility cannot authorize procedures that a competent child has refused.

Although immediate CT is not necessary, patients should be admitted and closely monitored with a low threshold.

Criteria for Immediate CT Scan of Head in Paediatric Head Injury Cases

Head injuries in children can be serious and require immediate medical attention. In some cases, a CT scan of the head may be necessary to assess the extent of the injury. The following criteria are used to determine when an immediate CT scan is required:

– Loss of consciousness lasting more than 5 minutes (witnessed)
– Amnesia (antegrade or retrograde) lasting more than 5 minutes
– Abnormal drowsiness
– Three or more discrete episodes of vomiting
– Clinical suspicion of non-accidental injury
– Post-traumatic seizure but no history of epilepsy
– GCS less than 14, or for a baby under 1 year GCS (paediatric) less than 15, on assessment in the emergency department
– Suspicion of open or depressed skull injury or tense fontanelle
– Any sign of basal skull fracture (haemotympanum, panda’ eyes, cerebrospinal fluid leakage from the ear or nose, Battle’s sign)
– Focal neurological deficit
– If under 1 year, presence of bruise, swelling or laceration of more than 5 cm on the head
– Dangerous mechanism of injury (high-speed road traffic accident either as pedestrian, cyclist or vehicle occupant, fall from a height of greater than 3 m, high-speed injury from a projectile or an object)

It is important for healthcare professionals to be aware of these criteria and to promptly order a CT scan when necessary to ensure the best possible outcome for the child.

The presented history indicates a possible case of meconium ileus, where the thickened meconium caused a blockage in the small intestine due to cystic fibrosis. The neonate is likely to have a swollen abdomen and may not pass meconium. Vomiting may contain bile, which is different from pyloric stenosis that does not have bile. Additionally, there is no indication of intussusception or pyloric stenosis mass.

Cystic Fibrosis: Symptoms and Characteristics

Cystic fibrosis is a genetic disorder that affects various organs in the body, particularly the lungs and digestive system. The symptoms of cystic fibrosis can vary from person to person, but there are some common features that are often present. In the neonatal period, around 20% of infants with cystic fibrosis may experience meconium ileus, which is a blockage in the intestine caused by thick, sticky mucous. Prolonged jaundice may also occur, but less commonly. Recurrent chest infections are a common symptom, affecting around 40% of patients. Malabsorption is another common feature, with around 30% of patients experiencing steatorrhoea (excessive fat in the stool) and failure to thrive. Liver disease may also occur in around 10% of patients.

It is important to note that while many patients are diagnosed with cystic fibrosis during newborn screening or early childhood, around 5% of patients are not diagnosed until after the age of 18. Other features of cystic fibrosis may include short stature, diabetes mellitus, delayed puberty, rectal prolapse (due to bulky stools), nasal polyps, male infertility, and female subfertility. Overall, the symptoms and characteristics of cystic fibrosis can vary widely, but early diagnosis and treatment can help manage the condition and improve quality of life.

To diagnose SUFE, X-rays are the preferred imaging method. It is important to image both hips, even if there are no symptoms, to rule out involvement of the other hip. MRI is not typically used as a first-line investigation, but may be considered if there is still suspicion of SUFE despite normal X-rays. While CT is sensitive for SUFE, it is not typically used as a first-line investigation in children due to the radiation exposure.

Slipped Capital Femoral Epiphysis: A Rare Hip Condition in Children

Slipped capital femoral epiphysis, also known as slipped upper femoral epiphysis, is a rare hip condition that primarily affects children between the ages of 10 and 15. It is more commonly seen in obese boys. This condition is characterized by the displacement of the femoral head epiphysis postero-inferiorly, which may present acutely following trauma or with chronic, persistent symptoms.

The most common symptoms of slipped capital femoral epiphysis include hip, groin, medial thigh, or knee pain and loss of internal rotation of the leg in flexion. In some cases, a bilateral slip may occur. Diagnostic imaging, such as AP and lateral (typically frog-leg) views, can confirm the diagnosis.

The management of slipped capital femoral epiphysis typically involves internal fixation, which involves placing a single cannulated screw in the center of the epiphysis. However, if left untreated, this condition can lead to complications such as osteoarthritis, avascular necrosis of the femoral head, chondrolysis, and leg length discrepancy.

In summary, slipped capital femoral epiphysis is a rare hip condition that primarily affects children, especially obese boys. It is characterized by the displacement of the femoral head epiphysis postero-inferiorly and can present with various symptoms. Early diagnosis and management are crucial to prevent complications.

Primary amenorrhoea can be caused by conditions such as Turner syndrome, where the absence of ovaries and uterus leads to underdeveloped inguinal hernias containing immature testes. Aromatase can cause breast bud development and sparse pubic hair, while the lack of menstruation is due to the absence of reproductive organs. Anorexia nervosa is not indicated in this case, as it typically presents with a low body mass index, distorted body image, and extreme dietary or exercise habits. Polycystic ovarian syndrome (PCOS) is a possible cause of secondary amenorrhoea, often seen in patients with a high BMI, irregular menses, hyperandrogenism, and multiple ovarian follicles. If the patient had PCOS, other signs of hyperandrogenism, such as hirsutism or acne, would be expected. Pregnancy is another cause of secondary amenorrhoea.

Disorders of sex hormones can have various effects on the body, as shown in the table below. Primary hypogonadism, also known as Klinefelter’s syndrome, is characterized by high levels of LH and low levels of testosterone. Patients with this disorder often have small, firm testes, lack secondary sexual characteristics, and are infertile. They may also experience gynaecomastia and have an increased risk of breast cancer. Diagnosis is made through chromosomal analysis.

Hypogonadotrophic hypogonadism, or Kallmann syndrome, is another cause of delayed puberty. It is typically inherited as an X-linked recessive trait and is caused by the failure of GnRH-secreting neurons to migrate to the hypothalamus. Patients with Kallmann syndrome may have hypogonadism, cryptorchidism, and anosmia. Sex hormone levels are low, and LH and FSH levels are inappropriately low or normal. Cleft lip/palate and visual/hearing defects may also be present.

Androgen insensitivity syndrome is an X-linked recessive condition that causes end-organ resistance to testosterone, resulting in genotypically male children (46XY) having a female phenotype. Complete androgen insensitivity syndrome is the new term for testicular feminisation syndrome. Patients with this disorder may experience primary amenorrhoea, undescended testes causing groin swellings, and breast development due to the conversion of testosterone to oestradiol. Diagnosis is made through a buccal smear or chromosomal analysis to reveal a 46XY genotype. Management includes counseling to raise the child as female, bilateral orchidectomy due to an increased risk of testicular cancer from undescended testes, and oestrogen therapy.

The BCG vaccine for TB should be provided to infants who have a family history of TB or come from regions/countries with a high risk of TB (as defined by WHO as having more than 40 cases per 100,000). This recommendation applies to babies up to one year old.

Immunisation is the process of administering vaccines to protect individuals from infectious diseases. The Department of Health has provided guidance on the safe administration of vaccines in its publication ‘Immunisation against infectious disease’ in 2006. The guidance outlines general contraindications to immunisation, such as confirmed anaphylactic reactions to previous doses of a vaccine containing the same antigens or another component contained in the relevant vaccine. Vaccines should also be delayed in cases of febrile illness or intercurrent infection. Live vaccines should not be administered to pregnant women or individuals with immunosuppression.

Specific vaccines may have their own contraindications, such as deferring DTP vaccination in children with an evolving or unstable neurological condition. However, there are no contraindications to immunisation for individuals with asthma or eczema, a history of seizures (unless associated with fever), or a family history of autism. Additionally, previous natural infections with pertussis, measles, mumps, or rubella do not preclude immunisation. Other factors such as neurological conditions like Down’s or cerebral palsy, low birth weight or prematurity, and patients on replacement steroids (e.g. CAH) also do not contraindicate immunisation.

It is recommended to refer a child with hypospadias to a specialist for possible surgery around the age of 12 months. This timing is considered optimal, taking into account various factors such as developmental milestones, tolerance of surgery and anesthesia, and the size of the penis. It is important to refer the child to a specialist at the time of diagnosis. Referring a child for surgery within the first month of life or within four hours is not necessary, as this is not an urgent or life-threatening issue. Hypospadias always requires a specialist referral, even if it is mild, and it is the specialist’s responsibility, along with the parents, to decide whether surgery is necessary. It is crucial to advise parents not to circumcise their child with hypospadias, as the prepuce may be used during corrective surgery.

Understanding Hypospadias: A Congenital Abnormality of the Penis

Hypospadias is a condition that affects approximately 3 out of 1,000 male infants. It is a congenital abnormality of the penis that is usually identified during the newborn baby check. However, if missed, parents may notice an abnormal urine stream. This condition is characterized by a ventral urethral meatus, a hooded prepuce, and chordee in more severe forms. The urethral meatus may open more proximally in the more severe variants, but 75% of the openings are distally located. There appears to be a significant genetic element, with further male children having a risk of around 5-15%.

Hypospadias most commonly occurs as an isolated disorder, but it can also be associated with other conditions such as cryptorchidism (present in 10%) and inguinal hernia. Once hypospadias has been identified, infants should be referred to specialist services. Corrective surgery is typically performed when the child is around 12 months of age. It is essential that the child is not circumcised prior to the surgery as the foreskin may be used in the corrective procedure. In boys with very distal disease, no treatment may be needed. Understanding hypospadias is important for parents and healthcare providers to ensure proper management and treatment of this condition.

If the testicle remains undescended after 3 months, it is recommended to refer the child to a paediatric surgeon for review before they reach 6 months of age, as per the NICE guidelines for undescended testes.

Undescended Testis: Causes, Complications, and Management

Undescended testis is a condition that affects around 2-3% of male infants born at term, but it is more common in preterm 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, NICE CKS recommends considering 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 crucial to have the child reviewed by a senior paediatrician within 24 hours as they may require urgent endocrine or genetic investigation. Proper management of undescended testis is essential to prevent complications and ensure the child’s overall health and well-being.

Pediatric Wheezing: Causes and Characteristics

Pediatric wheezing can be caused by various conditions, each with its own unique characteristics. Unilateral wheeze in a child under three years old is often associated with inhalation of a foreign body, which can partially or completely obstruct the airway. Bronchiolitis, typically caused by respiratory syncytial virus, initially presents as an upper respiratory tract infection and progresses to a lower respiratory tract infection with bilateral wheeze, cough, and difficulty breathing. Pneumonia may also cause wheezing, but is typically accompanied by systemic symptoms such as fever and crepitations on auscultation. Asthma, a common cause of pediatric wheezing, is characterized by bilateral expiratory wheezing due to premature bronchiole collapse. Croup, caused by a parainfluenza virus, presents with a barking cough, stridor, and respiratory distress, and is treated with dexamethasone.

Developmental milestones for speech and hearing are important indicators of a child’s growth and development. These milestones can help parents and caregivers track a child’s progress and identify any potential issues early on. At three months, a baby should be able to quieten to their parents’ voice and turn towards sound. They may also start to squeal. By six months, they should be able to produce double syllables like adah and erleh. At nine months, they may say mama and dada and understand the word no. By 12 months, they should know and respond to their own name and understand simple commands like give it to mummy.

Between 12 and 15 months, a child may know about 2-6 words and understand more complex commands. By two years old, they should be able to combine two words and point to parts of their body. Their vocabulary should be around 200 words by 2 1/2 years old. At three years old, they should be able to talk in short sentences and ask what and who questions. They may also be able to identify colors and count to 10. By four years old, they may start asking why, when, and how questions. These milestones are important to keep in mind as a child grows and develops their speech and hearing abilities.

According to the NICE traffic light system, reduced skin turgor is a red flag symptom in children. This system is used to identify the risk of serious illness in children. Decreased activity is considered an amber symptom, while age <6 months is not a red flag symptom. Age 3-6 months with a temperature of >=39ºC is an amber flag symptom, and age <3 months with a temperature of >=38°C is a red flag symptom. A respiratory rate of >60 breaths/minute is also a red flag symptom. Finally, a heart rate of >160 beats/minute in children under 12 months is an amber flag symptom.

The NICE Feverish illness in children guidelines were introduced in 2007 and updated in 2013. These guidelines use a ‘traffic light’ system to assess the risk of children under 5 years old presenting with a fever. It is important to note that these guidelines only apply until a clinical diagnosis of the underlying condition has been made. When assessing a febrile child, their temperature, heart rate, respiratory rate, and capillary refill time should be recorded. Signs of dehydration should also be looked for. Measuring temperature should be done with an electronic thermometer in the axilla if the child is under 4 weeks old or with an electronic/chemical dot thermometer in the axilla or an infrared tympanic thermometer.

The risk stratification table includes green for low risk, amber for intermediate risk, and red for high risk. The table includes categories such as color, activity, respiratory, circulation and hydration, and other symptoms. If a child is categorized as green, they can be managed at home with appropriate care advice. If they are categorized as amber, parents should be provided with a safety net or referred to a pediatric specialist for further assessment. If a child is categorized as red, they should be urgently referred to a pediatric specialist. It is important to note that oral antibiotics should not be prescribed to children with fever without an apparent source, and a chest x-ray does not need to be routinely performed if a pneumonia is suspected but the child is not going to be referred to the hospital.

If a child is experiencing hip pain or a limp and has a fever, it is important to refer them for same-day assessment, even if the suspected diagnosis is transient synovitis.

The correct course of action in this case is to advise the patient to attend the emergency department. Although the patient appears to be well, the presence of a fever raises concerns about septic arthritis, which can cause long-term complications. Further investigations cannot be performed in a general practice setting, making it necessary to seek urgent medical attention.

Advising the patient to attend a local minor injury unit is not appropriate, as the staff there would most likely transfer the patient to an emergency department, causing unnecessary delays. Similarly, arranging an urgent orthopaedic outpatient appointment is not appropriate in this acute situation.

Prescribing aspirin and providing a safety net is not a suitable option, as aspirin should never be given to children due to the risk of Reye’s syndrome. It is also unwise to exclude septic arthritis without further supporting evidence.

Finally, growing pains are an unlikely diagnosis in this case, as they are typically bilateral and do not interfere with daily activities.

Transient synovitis, also known as irritable hip, is a common cause of hip pain in children aged 3-8 years. It typically occurs following a recent viral infection and presents with symptoms such as groin or hip pain, limping or refusal to weight bear, and occasionally a low-grade fever. However, a high fever may indicate other serious conditions such as septic arthritis, which requires urgent specialist assessment. To exclude such diagnoses, NICE Clinical Knowledge Summaries recommend monitoring children in primary care with a presumptive diagnosis of transient synovitis, provided they are aged 3-9 years, well, afebrile, mobile but limping, and have had symptoms for less than 72 hours. Treatment for transient synovitis involves rest and analgesia, as the condition is self-limiting.

Mechanisms of Congenital Heart Defects

Congenital heart defects can arise from various mechanisms during fetal development. Understanding these mechanisms can aid in the diagnosis and treatment of these conditions.

Anterosuperior displacement of the infundibular septum is responsible for the characteristic boot-shaped heart seen in tetralogy of Fallot. This condition is characterized by pulmonary stenosis, right ventricular hypertrophy, ventricular septal defect, and an overriding aorta.

Transposition of the great vessels occurs when the aorticopulmonary septum fails to spiral during development. Persistent truncus arteriosus results from the failure of the aorticopulmonary septum to divide.

Infundibular stenosis is caused by underdevelopment of the conus arteriosus of the right ventricle. Sinus venosus atrial septal defects arise from incomplete absorption of the sinus venosus into the right atrium.

By understanding the mechanisms behind these congenital heart defects, healthcare professionals can provide better care for affected individuals.

When dealing with suspected or confirmed bacterial meningitis in children under 3 months old, it is not recommended to use corticosteroids. Instead, the most appropriate treatment option would be a combination of IV cefotaxime and IV amoxicillin. IV cefotaxime is effective in covering for pneumococcal and haemophilus influenzae, but since children under 3 months are at risk of listeria monocytogenes as a cause of bacterial meningitis, amoxicillin is necessary to provide adequate coverage. It is important to note that IV dexamethasone is typically given to patients with bacterial meningitis to reduce the risk of neurological complications, but this is not recommended for children under 3 months old.

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.

Regardless of severity, a single dose of oral dexamethasone (0.15 mg/kg) should be taken immediately for mild croup, which is characterized by a barking cough and the absence of stridor or systemic symptoms.

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.

When evaluating infants under 3 months with a fever, the following tests should be conducted: a complete blood count, blood culture, C-reactive protein test, urine analysis to check for urinary tract infections, and a chest X-ray if respiratory symptoms are present. Additionally, a stool culture should be performed if the infant is experiencing diarrhea.

The NICE Feverish illness in children guidelines were introduced in 2007 and updated in 2013. These guidelines use a ‘traffic light’ system to assess the risk of children under 5 years old presenting with a fever. It is important to note that these guidelines only apply until a clinical diagnosis of the underlying condition has been made. When assessing a febrile child, their temperature, heart rate, respiratory rate, and capillary refill time should be recorded. Signs of dehydration should also be looked for. Measuring temperature should be done with an electronic thermometer in the axilla if the child is under 4 weeks old or with an electronic/chemical dot thermometer in the axilla or an infrared tympanic thermometer.

The risk stratification table includes green for low risk, amber for intermediate risk, and red for high risk. The table includes categories such as color, activity, respiratory, circulation and hydration, and other symptoms. If a child is categorized as green, they can be managed at home with appropriate care advice. If they are categorized as amber, parents should be provided with a safety net or referred to a pediatric specialist for further assessment. If a child is categorized as red, they should be urgently referred to a pediatric specialist. It is important to note that oral antibiotics should not be prescribed to children with fever without an apparent source, and a chest x-ray does not need to be routinely performed if a pneumonia is suspected but the child is not going to be referred to the hospital.

According to NICE guidelines, if a patient has developed a cough within the last 21 days and does not require hospitalization, macrolide antibiotics such as azithromycin or clarithromycin should be prescribed for children over 1 month old and non-pregnant adults. In this case, the patient does not meet the criteria for hospitalization due to their age, breathing difficulties, or complications. Along with antibiotics, patients should be advised to rest, stay hydrated, and use pain relievers like paracetamol or ibuprofen for symptom relief.

Whooping Cough: Causes, Symptoms, Diagnosis, and Management

Whooping cough, also known as pertussis, is a contagious disease caused by the bacterium Bordetella pertussis. It is commonly found in children, with around 1,000 cases reported annually in the UK. The disease is characterized by a persistent cough that can last up to 100 days, hence the name cough of 100 days.

Infants are particularly vulnerable to whooping cough, which is why routine immunization is recommended at 2, 3, 4 months, and 3-5 years. However, neither infection nor immunization provides lifelong protection, and adolescents and adults may still develop the disease.

Whooping cough has three phases: the catarrhal phase, the paroxysmal phase, and the convalescent phase. The catarrhal phase lasts around 1-2 weeks and presents symptoms similar to a viral upper respiratory tract infection. The paroxysmal phase is characterized by a severe cough that worsens at night and after feeding, and may be accompanied by vomiting and central cyanosis. The convalescent phase is when the cough subsides over weeks to months.

To diagnose whooping cough, a person must have an acute cough that has lasted for 14 days or more without another apparent cause, and have one or more of the following features: paroxysmal cough, inspiratory whoop, post-tussive vomiting, or undiagnosed apnoeic attacks in young infants. A nasal swab culture for Bordetella pertussis is used to confirm the diagnosis, although PCR and serology are increasingly used.

Infants under 6 months with suspected pertussis should be admitted, and in the UK, pertussis is a notifiable disease. An oral macrolide, such as clarithromycin, azithromycin, or erythromycin, is indicated if the onset of the cough is within the previous 21 days to eradicate the organism and reduce the spread. Household contacts should be offered antibiotic prophylaxis, although antibiotic therapy has not been shown to alter the course of the illness. School exclusion is recommended for 48 hours after commencing antibiotics or 21 days from onset of symptoms if no antibiotics are given.

Complications of whooping cough include subconjunctival haemorrhage, pneumonia, bronchiectasis, and

Understanding Alpha-Thalassaemia

Alpha-thalassaemia is a condition that arises from a deficiency of alpha chains in haemoglobin. This occurs due to the absence or reduced production of alpha-globulin genes located on chromosome 16. The severity of the condition depends on the number of alpha globulin alleles affected. If one or two alleles are affected, the blood picture would be hypochromic and microcytic, but the haemoglobin level would typically be normal. However, if three alleles are affected, it results in a hypochromic microcytic anaemia with splenomegaly, which is known as Hb H disease. In the case where all four alpha globulin alleles are affected, which is known as homozygote, it can lead to death in utero, also known as hydrops fetalis or Bart’s hydrops. Understanding the severity of alpha-thalassaemia is crucial in managing the condition and providing appropriate treatment.

Total Anomalous Pulmonary Venous Connection

Total anomalous pulmonary venous connection (TAPVC) is a condition that causes cyanosis in newborns. It is characterized by an abnormality in blood flow where all four pulmonary veins drain into systemic veins or the right atrium, with or without pulmonary venous obstruction. This results in the mixing of systemic and pulmonary venous blood in the right atrium.

In contrast, conditions such as patent ductus arteriosus (PDA), atrial septal defect (ASD), and ventricular septal defect (VSD) are left to right shunts. Tricuspid atresia is another condition that is typically associated with cyanosis, but mitral regurgitation is not.

It is important to understand the differences between these conditions and their effects on blood flow in order to properly diagnose and treat them. Further reading on TAPVC can be found on Medscape.

Mebendazole is the recommended first-line treatment for threadworm infestations. This particular case presents with typical symptoms of a threadworm infection, which is a common helminth in children. The infection is usually acquired through the ingestion of eggs found in the environment, often from touching soil and then putting hands in the mouth. While the infection is often asymptomatic, it can cause perianal itching, especially at night. Diagnosis is often made empirically, and treatment typically involves hygiene recommendations and mebendazole.

Diethylcarbamazine is an anti-helminthic medication used to treat filarial infections, such as those caused by Wuchereria bancrofti (which can lead to elephantiasis) and Toxocara canis (which can cause visceral larva migrans and retinal granulomas).

Ivermectin is another antiparasitic drug, but it is used to treat Strongyloides stercoralis infections, which can cause symptoms such as diarrhea, abdominal pain, and papulovesicular lesions where the skin has been penetrated by infective larvae.

Metronidazole, on the other hand, is an antibiotic used to treat a variety of bacterial infections, such as gingivitis, pelvic inflammatory disease, syphilis, and bacterial vaginosis. It is not effective in treating threadworms.

Threadworm Infestation in Children

Threadworm infestation, caused by Enterobius vermicularis or pinworms, is a common occurrence among children in the UK. The infestation happens when eggs present in the environment are ingested. In most cases, threadworm infestation is asymptomatic, but some possible symptoms include perianal itching, especially at night, and vulval symptoms in girls. Diagnosis can be made by applying Sellotape to the perianal area and sending it to the laboratory for microscopy to see the eggs. However, most patients are treated empirically, and this approach is supported in the CKS guidelines.

The CKS recommends a combination of anthelmintic with hygiene measures for all members of the household. Mebendazole is the first-line treatment for children over six months old, and a single dose is given unless the infestation persists. It is essential to treat all members of the household to prevent re-infection. Proper hygiene measures, such as washing hands regularly, keeping fingernails short, and washing clothes and bedding at high temperatures, can also help prevent the spread of threadworm infestation.

Autistic spectrum disorder and learning difficulties have been linked to fragile X syndrome, especially in males, which is a trinucleotide repeat disorder. However, recent guidance has shown that there is no connection between the MMR vaccine and autistic spectrum disorder, contrary to what the media may suggest. Additionally, a higher risk of autistic spectrum disorder has been associated with low birth weight, not high birth weight, and there is no evidence to support a link between childhood obesity and autistic spectrum disorder. It is important to note that males have a significantly higher risk of developing autistic spectrum disorder compared to females, with a male to female ratio of approximately 4:1.

Fragile X Syndrome: A Genetic Disorder

Fragile X syndrome is a genetic disorder caused by a trinucleotide repeat. It affects both males and females, but males are more severely affected. Common features in males include learning difficulties, large low set ears, long thin face, high arched palate, macroorchidism, hypotonia, and a higher likelihood of autism. Mitral valve prolapse is also a common feature. Females, who have one fragile chromosome and one normal X chromosome, may have a range of symptoms from normal to mild.

Diagnosis of Fragile X syndrome can be made antenatally by chorionic villus sampling or amniocentesis. The number of CGG repeats can be analyzed using restriction endonuclease digestion and Southern blot analysis. Early diagnosis and intervention can help manage the symptoms of Fragile X syndrome and improve the quality of life for those affected.

Puberty: Normal Changes in Males and Females

Puberty is a natural process that marks the transition from childhood to adulthood. In males, the first sign of puberty is testicular growth, which typically occurs around the age of 12. A testicular volume greater than 4 ml indicates the onset of puberty. The maximum height spurt for males occurs at the age of 14.

For females, the first sign of puberty is breast development, which typically occurs around the age of 11.5. The height spurt for females reaches its maximum early in puberty, at the age of 12, before menarche. Menarche, the onset of menstruation, typically occurs at the age of 13.

Following menarche, there is only a small increase of about 4% in height. It is important to note that normal changes in puberty may include gynaecomastia in boys, asymmetrical breast growth in girls, and diffuse enlargement of the thyroid gland. These changes are a natural part of the process and should not cause alarm. Understanding the normal changes that occur during puberty can help individuals navigate this important stage of development with confidence.

Fragile X Syndrome: A Genetic Disorder

Fragile X syndrome is a genetic disorder caused by a trinucleotide repeat. It affects both males and females, but males are more severely affected. Common features in males include learning difficulties, large low set ears, long thin face, high arched palate, macroorchidism, hypotonia, and a higher likelihood of autism. Mitral valve prolapse is also a common feature. Females, who have one fragile chromosome and one normal X chromosome, may have a range of symptoms from normal to mild.

Diagnosis of Fragile X syndrome can be made antenatally by chorionic villus sampling or amniocentesis. The number of CGG repeats can be analyzed using restriction endonuclease digestion and Southern blot analysis. Early diagnosis and intervention can help manage the symptoms of Fragile X syndrome and improve the quality of life for those affected.

If a foetus is diagnosed with exomphalos before birth, it is recommended to schedule and perform a caesarean section at term to reduce the risk of sac rupture, infection, and atresia. While a ward delivery provides access to theatres, specific surgical planning is necessary to minimize complications. Instrumental delivery in theatre does not decrease the risk of sac rupture. It is important to explain to the mother why hospital delivery is necessary and the risks associated with a home birth. Induction of labour at 37 weeks is not advisable as it increases the risk of complications during vaginal delivery.

Gastroschisis and exomphalos are both types of congenital visceral malformations. Gastroschisis refers to a defect in the anterior abdominal wall located just beside the umbilical cord. In contrast, exomphalos, also known as omphalocoele, involves the protrusion of abdominal contents through the anterior abdominal wall, which are covered by an amniotic sac formed by amniotic membrane and peritoneum.

When it comes to managing gastroschisis, vaginal delivery may be attempted, but newborns should be taken to the operating theatre as soon as possible after delivery, ideally within four hours. As for exomphalos, a caesarean section is recommended to reduce the risk of sac rupture. In cases where primary closure is difficult due to lack of space or high intra-abdominal pressure, a staged repair may be undertaken. This involves allowing the sac to granulate and epithelialise over several weeks or months, forming a shell. As the infant grows, the sac contents will eventually fit within the abdominal cavity, at which point the shell can be removed and the abdomen closed.

Overall, both gastroschisis and exomphalos require careful management to ensure the best possible outcome for the newborn. By understanding the differences between these two conditions and the appropriate steps to take, healthcare professionals can provide effective care and support to both the infant and their family.

The oxygen level is below 15 kPa, indicating a cyanotic heart defect. The most likely defect to present soon after birth is transposition of the great arteries, which is consistent with the examination findings. Pulmonary valve stenosis may also cause cyanosis if the lesion is large enough and is associated with Noonan syndrome. It produces a mid-systolic crescendo-decrescendo murmur. Tetralogy of Fallot is the most common cyanotic heart defect but typically presents between 1 and 6 months of age. It is characterized by a loud ejection systolic murmur that is most prominent at the left upper sternal edge and radiates to the axillae.

Understanding Transposition of the Great Arteries

Transposition of the great arteries (TGA) is a type of congenital heart disease that results in a lack of oxygenated blood flow to the body. This condition occurs when the aorticopulmonary septum fails to spiral during septation, causing the aorta to leave the right ventricle and the pulmonary trunk to leave the left ventricle. Children born to diabetic mothers are at a higher risk of developing TGA.

The clinical features of TGA include cyanosis, tachypnea, a loud single S2 heart sound, and a prominent right ventricular impulse. Chest x-rays may show an egg-on-side appearance.

To manage TGA, it is important to maintain the ductus arteriosus with prostaglandins. Surgical correction is the definitive treatment for this condition. Understanding the basic anatomical changes and clinical features of TGA can help with early diagnosis and appropriate management.

Treatment Approach for Suspected Asthma in Children Under Five Years Old

When a child under five years old is suspected to have asthma, the diagnosis can be challenging as they cannot perform objective lung function tests. Therefore, a low threshold for referral is recommended if treatment fails to control symptoms.

The first step in treatment is a trial of a moderate-dose inhaled corticosteroid (ICS) for eight weeks. If symptoms persist, adding a leukotriene receptor antagonist (LTRA) is recommended. However, if the asthma is still poorly controlled, referral to a paediatrician is advised.

It is not appropriate to change the short-acting beta agonist (SABA) inhaler, but increasing the dose of the ICS should only be done under specialist advice. If the child needs to use a SABA inhaler regularly, the ICS should be stopped for four weeks, and if symptoms recur, the inhaler should be restarted at a low dose.

In summary, a stepwise approach is recommended for treating suspected asthma in children under five years old, with a low threshold for referral to a specialist if treatment fails to control symptoms.

Treatment Approach for Suspected Asthma in Children Under Five Years Old