The pertussis vaccination, typically administered as part of the DTaP or Tdap vaccines, is crucial in preventing whooping cough, which can be particularly severe in infants and children. However, there are specific situations where the pertussis vaccine may not be recommended.

• Child with Spina Bifida:
  • Recommendation: Pertussis vaccination is recommended.
  • Explanation: Children with spina bifida do not have contraindications for the pertussis vaccine. In fact, they should receive all standard childhood immunizations, including the DTaP vaccine, unless there are other specific contraindications not related to spina bifida.
• Breastfeeding Mother:
  • Recommendation: Pertussis vaccination is recommended.
  • Explanation: Breastfeeding mothers are encouraged to receive the Tdap vaccine, especially postpartum if they did not receive it during pregnancy. This helps to protect both the mother and the infant by reducing the risk of transmission.
• Children with progressive neurological disorders such as uncontrolled epilepsy:
  • Recommendation: Pertussis vaccination is contraindicated.
  • Explanation: Children with progressive neurological disorders such as uncontrolled epilepsy or progressive encephalopathy should not receive the pertussis component of the vaccine until the condition is stabilised. This is due to the risk of vaccine-related exacerbations of the neurological condition.
• HIV Infected Individual:
  • Recommendation: Pertussis vaccination is recommended.
  • Explanation: HIV-infected individuals, including children, should receive the pertussis vaccine according to the standard immunization schedule, unless they are severely immunocompromised. The DTaP vaccine is an inactivated vaccine, making it safe for use in immunocompromised individuals.
• Pregnant Woman:
  • Recommendation: Pertussis vaccination is recommended.
  • Explanation: Pregnant women are specifically recommended to receive the Tdap vaccine during each pregnancy, ideally between 27 and 36 weeks of gestation. This practice helps provide passive immunity to the newborn and reduces the risk of pertussis transmission.

Osteomyelitis in Children

Osteomyelitis is a common infection in children that affects the metaphysis of long bones, particularly the proximal tibia and distal femur. The condition presents with a painful, pseudoparetic limb associated with an acute febrile illness. Swelling, extreme tenderness, and warmth to the touch can be observed at the site of the infection, with visible erythema. Movement of the affected limb causes marked pain. In infants, the onset can be more insidious.

This 6-year-old child has a typical presentation of osteomyelitis, with no history of injury and the presence of fever and recent onset pointing towards an acute infective aetiology. Tibial fracture would be unlikely in this age group. The normal clinical examination of the knee, hip, and ankle joints rules out septic arthritis. Although juvenile idiopathic arthritis (or Juvenile chronic arthritis) can cause an acute febrile illness, it typically causes arthritis and a characteristic salmon-pink rash, which is not reported in this case.

Understanding Threadworm Infestation: Symptoms and Differential Diagnosis

Threadworm infestation is a common parasitic infection in the United Kingdom, particularly among children. The threadworm, a small white worm that tapers at both ends, can cause itching around the anus and vulva due to the mucous accompanying the eggs it lays at night. Scratching can lead to skin infection and re-infection with the worms. While pre-pubertal girls with certain symptoms should also be investigated for threadworm, other conditions such as hookworm infestation, eczema, psychological pruritus, and tapeworm infestation should be ruled out through differential diagnosis. Understanding the symptoms and differential diagnosis of threadworm infestation can help healthcare providers provide appropriate treatment and care for affected individuals.

Understanding Eczema in Children

Eczema is a common skin condition that affects around 15-20% of children and is becoming more prevalent. It usually appears before the age of 2 and clears up in around 50% of children by the age of 5 and in 75% of children by the age of 10. The condition is characterized by an itchy, red rash that can worsen with repeated scratching. In infants, the face and trunk are often affected, while in younger children, eczema typically occurs on the extensor surfaces. In older children, a more typical distribution is seen, with flexor surfaces affected and the creases of the face and neck.

To manage eczema in children, it is important to avoid irritants and use simple emollients. Large quantities of emollients should be prescribed, roughly in a ratio of 10:1 with topical steroids. If a topical steroid is also being used, the emollient should be applied first, followed by waiting at least 30 minutes before applying the topical steroid. Creams soak into the skin faster than ointments, and emollients can become contaminated with bacteria, so fingers should not be inserted into pots. Many brands have pump dispensers to prevent contamination.

In severe cases, wet wrapping may be used, which involves applying large amounts of emollient (and sometimes topical steroids) under wet bandages. Oral ciclosporin may also be used in severe cases. By understanding the features and management of eczema in children, parents and caregivers can help alleviate symptoms and improve the child’s quality of life.

Changes in Regulation of Over-the-Counter Cough and Cold Remedies for Children

In 2009, the Medicines and Healthcare products Regulatory Agency (MHRA) and Commission on Human Medicines (CHM) made a significant change in the regulation of over-the-counter (OTC) cough and cold remedies for children. The change affected medicines containing various ingredients, including cough suppressants, expectorants, nasal decongestants, and antihistamines. These ingredients, such as dextromethorphan, guaifenesin, ephedrine, and chlorphenamine, were found to be potentially harmful to children under the age of 6 years. As a result, products with these ingredients should be avoided in young children. For children aged 6-12 years, products containing these ingredients will only be available after consultation with a pharmacist. This change in regulation aims to ensure the safety of children when using OTC cough and cold remedies.

Understanding Meningococcal Septicaemia

Meningococcal septicaemia is a serious condition that can cause high morbidity and mortality if not treated early. It is the leading infectious cause of death in early childhood, making it crucial to have a high index of suspicion. According to the 2010 NICE guidelines, meningococcal disease can present as meningitis, septicaemia, or a combination of both.

NICE divides the symptoms of meningococcal septicaemia into three categories: common nonspecific symptoms/signs, less common nonspecific symptoms/signs, and more specific symptoms/signs. Common nonspecific symptoms/signs include fever, vomiting, and lethargy, while less common nonspecific symptoms/signs include chills and shivering. More specific symptoms/signs include a non-blanching rash, altered mental state, capillary refill time more than 2 seconds, unusual skin colour, shock, hypotension, leg pain, and cold hands/feet.

If meningococcal septicaemia is suspected, it is important to give intramuscular or intravenous benzylpenicillin unless there is a history of anaphylaxis. However, if giving benzylpenicillin will delay hospital transfer, it should not be given. NICE recommends phoning 999 in case of suspected meningococcal septicaemia.

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

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

The cure rate for acute lymphoblastic leukemia is high, with most patients achieving complete remission. Symptoms typically start off gradually but can quickly become severe, causing the child to feel extremely unwell. Common symptoms include fatigue, shortness of breath, weakness, fever, swollen lymph nodes, possible enlargement of organs, and a rash characterized by purple spots.

Understanding Acute Lymphoblastic Leukaemia

Acute lymphoblastic leukaemia (ALL) is a type of cancer that commonly affects children, accounting for 80% of childhood leukaemias. It is most prevalent in children aged 2-5 years, with boys being slightly more affected than girls. Symptoms of ALL can be divided into those caused by bone marrow failure, such as anaemia, neutropaenia, and thrombocytopenia, and other features like bone pain, splenomegaly, hepatomegaly, fever, and testicular swelling.

There are three types of ALL: common ALL, T-cell ALL, and B-cell ALL. Common ALL is the most common type, accounting for 75% of cases, and is characterized by the presence of CD10 and pre-B phenotype. T-cell ALL accounts for 20% of cases, while B-cell ALL accounts for only 5%.

Certain factors can affect the prognosis of ALL, including age, white blood cell count at diagnosis, T or B cell surface markers, race, and sex. Children under 2 years or over 10 years of age, those with a WBC count over 20 * 109/l at diagnosis, and those with T or B cell surface markers, non-Caucasian, and male sex have a poorer prognosis.

Understanding the different types and prognostic factors of ALL can help in the early detection and management of this cancer. It is important to seek medical attention if any of the symptoms mentioned above are present.

Febrile Seizures: Risk Factors, Recurrence, Immunizations, and Management

Febrile seizures are common in young children and can be a cause of concern for parents. Here are some important points to keep in mind:

Risk Factors: The likelihood of epilepsy increases if the child has a complex febrile seizure (prolonged seizure, multiple seizures or seizure with focal features), if there is a neurological abnormality, if there is a family history of epilepsy and if the duration of fever was less than one hour before the seizure. Without these features, there is only a small increase in risk compared with the general population.

Recurrence: Recurrent febrile seizures occur in about 30% of cases. Risk factors for later recurrences of febrile seizures include onset before 18 months, a seizure with a lower temperature close to 38°C, a shorter duration of fever (less than one hour) before the seizure and a family history of febrile seizures.

Immunizations: Childhood immunizations should continue even if the febrile seizure followed an immunization. Immunization doesn’t increase the risk of further seizures.

Management: Antipyretic drugs may be given to reduce fever but there is no evidence they reduce the number of febrile seizures. Anticonvulsant drugs should not be routinely prescribed. There is no evidence that intellect is affected, even for children with complex febrile seizures.

Breastfeeding and Maternal Health: Considerations and Recommendations

Breastfeeding is a crucial aspect of maternal and infant health, providing numerous benefits for both parties. However, certain health conditions may impact the safety and efficacy of breastfeeding. Here are some considerations and recommendations for breastfeeding mothers:

Human immunodeficiency virus (HIV) infection: HIV can be transmitted through breast milk, so it is recommended that HIV-positive mothers exclusively formula-feed their infants from birth.

Hepatitis B: The benefits of breastfeeding outweigh the risk of infection for infants born to mothers with hepatitis B. Infants should receive hepatitis B-specific immunoglobulin and be vaccinated from birth.

Hepatitis C: Breastfeeding is safe for infants born to mothers with hepatitis C, as there is no evidence of mother-to-infant transmission. However, if the mother’s nipples are cracked and bleeding, it is recommended to abstain from breastfeeding until they are healed.

Mastitis: Mastitis is a common condition that causes breast pain, swelling, and redness. It is usually caused by Staphylococcus aureus entering through a cracked nipple. Antibiotics may be necessary, but it is recommended to continue breastfeeding or pumping to improve milk flow.

Vitamin D deficiency: Vitamin D deficiency is prevalent in the UK, and breastfeeding mothers and infants are at risk of developing rickets. It is recommended that both take a daily supplement of vitamin D to prevent this condition.

PCV in addition to the 6-1 vaccine (which includes protection against diphtheria, tetanus, whooping cough, polio, Hib, and hepatitis B).

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.

Vaccination Contraindications

Vaccinations are generally safe and effective in preventing infectious diseases. However, certain conditions may raise concerns about the safety of immunisation. It is important to note that febrile convulsions, congenital heart disease, epilepsy in a sibling or first degree relative, and cystic fibrosis are not contraindications to vaccination.

Nevertheless, appropriate measures should be taken to prevent fever from occurring at the time of immunisation. Any concurrent febrile illness, on the other hand, contraindicates vaccination. It is crucial to consult with a healthcare provider to determine the best course of action for individuals with underlying medical conditions before receiving any vaccines. By doing so, we can ensure that everyone receives the necessary protection against preventable diseases.

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.

Changes to UK Immunisation Schedule in 2020

In January 2020, the UK immunisation schedule was updated with a few minor changes. It is important to stay up-to-date with these changes as they may be tested in exams. One change to note is that both boys and girls should receive the HPV immunisation at the age of 12 to 13. This is an important step in protecting against certain types of cancer caused by the human papillomavirus. It is recommended that parents and healthcare providers ensure that children receive this immunisation at the appropriate age.

NICE Guidance on Depression in Children and Young People

NICE has released guidance on how to manage depression in children and young people. For those presenting with mild depression, a ‘watchful waiting’ approach should be taken, with a further assessment arranged two weeks later. If the depression persists after up to four weeks of watchful waiting, psychological therapies such as individual non-directive supportive therapy, group cognitive behavioural therapy, or guided self-help can be offered for a limited period of around two to three months. Antidepressant medication should not be used at this stage. If the mild depression remains unresponsive to psychological therapies after two to three months, referral to tier 2-3 CAMHS can be made for further assessment and management. This guidance aims to provide a structured approach to managing depression in children and young people, ensuring that appropriate interventions are offered at the right time.

The recommended treatment for pregnant women with pinworm infection involves a combination of physical removal of eggs and hygiene methods. This may include washing the perianal area in the morning and at regular intervals throughout the day. Therefore, relying solely on strict personal hygiene measures for two weeks would not be the preferred option for this patient. Mebendazole is not recommended during the first trimester of pregnancy, but may be considered in the later stages if necessary.

Threadworms: A Common Infestation Among Children in the UK

Infestation with threadworms, also known as pinworms, is a prevalent condition among children in the UK. The infestation occurs when individuals swallow eggs present in their environment. Although around 90% of cases are asymptomatic, some possible features 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 recommended management for threadworm infestation is a combination of anthelmintic with hygiene measures for all members of the household. Mebendazole is used as a first-line treatment for children over six months old, with a single dose given unless the infestation persists. By following these guidelines, individuals can effectively manage and prevent the spread of threadworms.

The Dangers of Swallowing Button Batteries: Why Immediate Action is Necessary

Button batteries are small, but they can cause serious harm if swallowed. These batteries contain metals and concentrated solutions of caustic electrolytes, which can damage the oesophageal wall if left stuck for even just two hours. Therefore, it is essential to arrange immediate admission for investigation and possible endoscopy if a child has swallowed a button battery.

Prescribing laxatives and taking no further action is not appropriate for a high-risk foreign body like a button battery. Similarly, asking the mother to collect all stools and return in 48 hours if the battery doesn’t pass is not recommended. Instead, it may be appropriate to observe asymptomatic children for the passage of the battery in the stool, but only if certain conditions are met.

Reassuring the mother that no action is necessary is also not appropriate, as symptoms may still develop even if the child is asymptomatic. Referring for an abdominal X-ray on the next day is also not recommended, as urgent chest and abdominal X-rays will be carried out in the hospital.

In conclusion, immediate action is necessary when a child swallows a button battery. Delaying treatment can lead to serious harm, and it is important to seek medical attention as soon as possible.

Meningococcal Septicaemia and Other Skin Conditions

Meningococcal septicaemia is a serious condition that can cause a non-blanching purpuric eruption all over the body. This symptom is a key indicator of the disease and should be taken seriously. Other skin conditions, such as giant urticaria, measles rash, and haemophilia, do not typically present with this type of rash.

Giant urticaria is characterised by recurrent attacks of oedema that appear suddenly in various areas of the body. The measles rash, on the other hand, appears as a macular eruption on the face and neck that spreads over three days. Haemophilia is not associated with any generalised rash.

HSP, another skin condition, may present in a subacute manner and is not typically associated with a high fever in an acutely unwell child. It may occur following an upper respiratory tract infection.

Coughing is a common symptom that can be caused by various factors. Asthma, recurrent infections, and prolonged infections are very common causes of coughing. Cigarette smoking, habit or psychogenic cough, and idiopathic reasons are also common causes. Uncommon causes include aspiration, gastro-oesophageal reflux, incoordinate swallowing, intrabronchial foreign body, suppurative lung disease, and mediastinal or pulmonary tumors. Very rare causes include suppurative lung disease. Other less common causes of coughing include cystic fibrosis, post-infective conditions, tuberculosis, ciliary abnormalities, congenital abnormalities of the respiratory tract, and immunodeficiency.

Pediatric Craniofacial Abnormalities: Causes and Characteristics

Craniofacial abnormalities in infants and children can arise from a variety of causes, ranging from positional factors to genetic syndromes. Here are some common types of abnormalities and their characteristics:

Positional Plagiocephaly: This occurs when a baby’s head becomes flattened on one side due to sleeping in the same position or pressure in the uterus. It can cause asymmetry in the head shape, such as misaligned ears and a parallelogram-like appearance.

Facial Nerve Palsy: While rare, facial palsy in infants can occur due to congenital factors or birth trauma. It may also develop during childhood, such as with Bell’s palsy.

Congenital Torticollis: This is a muscular condition in which one or more neck muscles are extremely tight, causing the head to tilt and the chin to point in the opposite direction. It can lead to the development of plagiocephaly.

Craniosynostosis: This occurs when one or more fibro sutures in the skull prematurely fuse, changing the growth pattern and resulting in an abnormal head shape and facial features. Surgery is often necessary.

Frontal Bossing: This is an unusually prominent forehead, sometimes associated with heavy brow ridges. It can be caused by conditions such as thalassaemia major and sickle cell anaemia, as well as rare syndromes like Russell-Silver dwarfism and Hurler syndrome.

Understanding these craniofacial abnormalities can help parents and healthcare providers identify and address them early on for optimal treatment and outcomes.

Understanding Hydroceles and Hernias in Children

During fetal development, the testicle descends into the scrotum accompanied by a sac-like extension of peritoneum called the processus vaginalis (PV). If the PV fails to close, it can result in a communicating hydrocele, where only fluid can pass through, or a hernia, where other abdominal contents protrude.

To diagnose a hydrocele, transillumination of the scrotum can reveal fluid in the tunica vaginalis (TV). However, this test may not fully exclude a hernia, as bowel may also transilluminate. Hydroceles may appear to enlarge during the day and disappear at night due to gravity’s effect on filling.

Hernias may present with abdominal pain, constipation, or vomiting, and the lump may be more prominent when the child cries. Bowel sounds in the scrotum strongly suggest a hernia.

In infants, many hydroceles resolve spontaneously due to PV closure early after birth. Observation is often appropriate up to 12-18 months of age.

Slipped Upper Epiphysis: Diagnosis and Treatment

Slipped upper epiphyses are more common in overweight boys aged 10-15 and are associated with obesity and hypothyroidism. Patients often present with pain, which may be referred to the knee, and it is important to examine the hips thoroughly. On examination, abduction and internal rotation may both be reduced, and the affected leg may be shortened. The key findings supporting the diagnosis are the presence of risk factors and gait abnormalities.

Slipped epiphyses can be classified as acute, chronic, or acute on chronic, and as unstable or stable. In the case of unstable slipped epiphysis, urgent surgical repair is necessary to prevent avascular necrosis. Stable slipped epiphysis is usually treated with in situ screw fixation, and prophylactic fixation of the contralateral hip may also be considered.

In the primary care setting, emergency admission under orthopaedics is necessary for patients with acute and unstable slipped epiphysis. For chronic and stable cases, x-ray is the first line investigation, and U&Es, serum TFTs, and serum growth hormone may also be considered.

In summary, early diagnosis and appropriate treatment are crucial in managing slipped upper epiphysis.

Health Risks Associated with Premature Birth

Premature birth, defined as birth before 37 weeks of gestation, can lead to a range of health problems for the newborn. These include cerebral palsy, blindness, deafness, learning disabilities, motor function problems, and speech and language problems. Premature infants are also at an increased risk of having special educational needs. The risk of these health problems is higher for infants born at earlier gestational ages and with lower birthweights.

One specific visual problem that premature infants may experience is retinopathy of prematurity, a vascular disorder of the immature retina. Additionally, premature infants are at an increased risk of developing chronic kidney disease during adulthood, although the reason for this is not clear.

However, not all health problems are associated with premature birth. Cystic fibrosis, for example, is caused by an autosomal-recessive gene and is not more prevalent in premature infants. Similarly, congenital adrenal hyperplasia is caused by several autosomal-recessive genes and is not more prevalent in premature infants. Developmental dysplasia of the hip, while more common in infants with neuromuscular disorders, is not commonly associated with prematurity.

Urgent specialist assessment is needed for a child < 3 years with an acute limp, as septic arthritis is more common than transient synovitis in this age group. Routine paediatric referral, urgent x-ray, and urgent hip ultrasound scan are not appropriate. Causes of Limping in Children Vary by Age When a child is limping, the cause can vary depending on their age. For younger children, transient synovitis is a common cause. This condition has an acute onset and is often accompanied by viral infections, but the child is usually well or has a mild fever. It is more common in boys aged 2-12 years. On the other hand, septic arthritis/osteomyelitis is a more serious condition that causes a high fever and an unwell child. Juvenile idiopathic arthritis can also cause a limp, which may be painless. Trauma is usually the cause of a limp in children, and the history of the injury can often diagnose the issue. Development dysplasia of the hip is usually detected in neonates and is six times more common in girls. Perthes disease is more common in children aged 4-8 years and is caused by avascular necrosis of the femoral head. Finally, slipped upper femoral epiphysis is a condition that occurs in children aged 10-15 years and is caused by the displacement of the femoral head epiphysis postero-inferiorly. Understanding the potential causes of a limp in children can help parents and healthcare providers identify and treat the issue promptly.

If a child is under 3 months old and has a temperature above 38ºC, it is considered a ‘red’ characteristic in the updated NICE guidelines, necessitating immediate referral to a pediatrician.

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.

A child under 1 typically has a normal respiratory rate of 30-40 breaths per minute. The AKT may test knowledge of normal ranges, and sometimes the best course of action is to do nothing.

If a mother expresses concern about her child’s respiratory rate being higher than an older child’s, but the child’s rate is within the normal range for their age group (such as 34 breaths per minute), referral or medication would not be necessary and would be a misuse of resources.

During a physical examination of a child, certain vital signs are checked to ensure that they fall within normal ranges. These ranges vary depending on the age of the child. For example, a heart rate of 110-160 beats per minute is considered normal for a child under the age of one, while a heart rate of 80-100 beats per minute is normal for a child over the age of 12. Similarly, systolic blood pressure, which measures the pressure in the arteries when the heart beats, and respiratory rate, which measures the number of breaths per minute, also have different normal ranges depending on the child’s age. It is important for healthcare professionals to be aware of these normal ranges in order to identify any potential health concerns in children.

If a child develops measles, they should not attend school for four days after the rash appears. Measles is a highly contagious viral disease that can be severe, especially for those with weakened immune systems, young infants, and pregnant women. The best way to prevent measles is through vaccination, but there have been recent outbreaks in unvaccinated individuals in London. While the UK has achieved elimination of measles, there are still small clusters of cases. Symptoms of measles include a runny nose, cough, fever, and rash. Cases are infectious for four days before and after the rash appears, so it’s important to keep them out of school during this time. Public health officials should be notified if there is a suspected case of measles to control outbreaks through testing, contact tracing, and immunization.

The Health Protection Agency has provided guidance on when children should be excluded from school due to infectious conditions. Some conditions, such as conjunctivitis, fifth disease, roseola, infectious mononucleosis, head lice, threadworms, and hand, foot and mouth, do not require exclusion. Scarlet fever requires exclusion for 24 hours after commencing antibiotics, while whooping cough requires exclusion for 2 days after commencing antibiotics or 21 days from onset of symptoms if no antibiotics are taken. Measles requires exclusion for 4 days from onset of rash, rubella for 5 days from onset of rash, and Chickenpox until all lesions are crusted over. Mumps requires exclusion for 5 days from onset of swollen glands, while diarrhoea and vomiting require exclusion until symptoms have settled for 48 hours. Impetigo requires exclusion until lesions are crusted and healed, or for 48 hours after commencing antibiotic treatment, and scabies requires exclusion until treated. influenza requires exclusion until the child has recovered for 48 hours.

Regarding Chickenpox, Public Health England recommends that children should be excluded until all lesions are crusted over, while Clinical Knowledge Summaries suggest that infectivity continues until all lesions are dry and have crusted over, usually about 5 days after the onset of the rash. It is important to follow official guidance and consult with healthcare professionals if unsure about exclusion periods for infectious conditions.

It is recommended to consider prescribing calcium supplements and vitamin D for breastfeeding mothers whose babies have or are suspected to have CMPI. This is to prevent deficiency while they exclude dairy from their diet, which puts them at risk of deficiency. Soya milk is not advised for infants due to its phyto-oestrogen content, and lactase enzyme products are not relevant as lactose intolerance is a different condition. Lactulose is also not indicated based on the given history.

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.

Paediatric vital signs refer to the normal range of heart rate and respiratory rate for children of different ages. These vital signs are important indicators of a child’s overall health and can help healthcare professionals identify any potential issues. The table below outlines the age-appropriate ranges for heart rate and respiratory rate. Children under the age of one typically have a higher heart rate and respiratory rate, while older children have lower rates. It is important for healthcare professionals to monitor these vital signs regularly to ensure that children are healthy and developing properly.

Age Heart rate Respiratory rate
< 1 110 - 160 30 - 40
1 – 2 100 – 150 25 – 35
2 – 5 90 – 140 25 – 30
5 – 12 80 – 120 20 – 25
> 12 60 – 100 15 – 20

Babies with cow’s milk protein allergy may also have an intolerance to soya milk. The primary milk alternatives used for such babies are extensively hydrolysed formula and alpha amino acid formula. Oat and almond milk are not advised for babies with this allergy, although there is no evidence of any adverse reactions to them.

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

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

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

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