Pyloric stenosis is characterized by recurring episodes of projectile vomiting and the presence of a mass in the upper abdomen, often described as an olive. This patient exhibits clinical features that align with pyloric stenosis and possesses several common risk factors, including being a male, being the firstborn son, being bottle-fed, and being delivered via C-section. It is important to note that intestinal atresia is typically diagnosed either during pregnancy or shortly after birth.

Further Reading:

Pyloric stenosis is a condition that primarily affects infants, characterized by the thickening of the muscles in the pylorus, leading to obstruction of the gastric outlet. It typically presents between the 3rd and 12th weeks of life, with recurrent projectile vomiting being the main symptom. The condition is more common in males, with a positive family history and being first-born being additional risk factors. Bottle-fed children and those delivered by c-section are also more likely to develop pyloric stenosis.

Clinical features of pyloric stenosis include projectile vomiting, usually occurring about 30 minutes after a feed, as well as constipation and dehydration. A palpable mass in the upper abdomen, often described as like an olive, may also be present. The persistent vomiting can lead to electrolyte disturbances, such as hypochloremia, alkalosis, and mild hypokalemia.

Ultrasound is the preferred diagnostic tool for confirming pyloric stenosis. It can reveal specific criteria, including a pyloric muscle thickness greater than 3 mm, a pylorus longitudinal length greater than 15-17 mm, a pyloric volume greater than 1.5 cm3, and a pyloric transverse diameter greater than 13 mm.

The definitive treatment for pyloric stenosis is pyloromyotomy, a surgical procedure that involves making an incision in the thickened pyloric muscle to relieve the obstruction. Before surgery, it is important to correct any hypovolemia and electrolyte disturbances with intravenous fluids. Overall, pyloric stenosis is a relatively common condition in infants, but with prompt diagnosis and appropriate management, it can be effectively treated.

Bronchiolitis is primarily caused by the respiratory syncytial virus (RSV), while whooping cough is caused by pertussis.

Further Reading:

Croup, also known as laryngotracheobronchitis, is a respiratory infection that primarily affects infants and toddlers. It is characterized by a barking cough and can cause stridor (a high-pitched sound during breathing) and respiratory distress due to swelling of the larynx and excessive secretions. The majority of cases are caused by parainfluenza viruses 1 and 3. Croup is most common in children between 6 months and 3 years of age and tends to occur more frequently in the autumn.

The clinical features of croup include a barking cough that is worse at night, preceded by symptoms of an upper respiratory tract infection such as cough, runny nose, and congestion. Stridor, respiratory distress, and fever may also be present. The severity of croup can be graded using the NICE system, which categorizes it as mild, moderate, severe, or impending respiratory failure based on the presence of symptoms such as cough, stridor, sternal/intercostal recession, agitation, lethargy, and decreased level of consciousness. The Westley croup score is another commonly used tool to assess the severity of croup based on the presence of stridor, retractions, air entry, oxygen saturation levels, and level of consciousness.

In cases of severe croup with significant airway obstruction and impending respiratory failure, symptoms may include a minimal barking cough, harder-to-hear stridor, chest wall recession, fatigue, pallor or cyanosis, decreased level of consciousness, and tachycardia. A respiratory rate over 70 breaths per minute is also indicative of severe respiratory distress.

Children with moderate or severe croup, as well as those with certain risk factors such as chronic lung disease, congenital heart disease, neuromuscular disorders, immunodeficiency, age under 3 months, inadequate fluid intake, concerns about care at home, or high fever or a toxic appearance, should be admitted to the hospital. The mainstay of treatment for croup is corticosteroids, which are typically given orally. If the child is too unwell to take oral medication, inhaled budesonide or intramuscular dexamethasone may be used as alternatives. Severe cases may require high-flow oxygen and nebulized adrenaline.

When considering the differential diagnosis for acute stridor and breathing difficulty, non-infective causes such as inhaled foreign bodies

Acute epiglottitis is a condition characterized by inflammation of the epiglottis. It can be life-threatening as it can completely block the airway, especially if not diagnosed promptly. In the past, the most common cause was Haemophilus influenzae type b (Hib), but with the widespread use of the Hib vaccine, it has become rare in children and is now more commonly seen in adults caused by Streptococcus spp like Streptococcus pyogenes and Streptococcus pneumonia. Other bacterial causes include Staphylococcus aureus, Pseudomonas spp, Moraxella catarrhalis, and Mycobacterium tuberculosis.

The typical symptoms of acute epiglottitis include fever, sore throat (initially resembling a viral sore throat), painful swallowing, difficulty swallowing secretions (seen as drooling in children), muffled voice (referred to as ‘hot potato’ voice), rapid heartbeat, tenderness in the front of the neck over the hyoid bone, cervical lymph node enlargement, and rapid deterioration in children.

To diagnose acute epiglottitis, the gold standard investigation is fibre-optic laryngoscopy, which allows direct visualization of the epiglottis. However, laryngoscopy should only be performed in settings prepared for intubation or tracheostomy in case upper airway obstruction occurs. If laryngoscopy is not possible, a lateral neck X-ray may be helpful, as it can show the characteristic ‘thumbprint sign’.

Management of acute epiglottitis usually involves conservative measures such as intravenous or oral antibiotics. However, in some cases, intubation may be necessary.

The most suitable approach for investigation in this case would be to send a blood test for Epstein-Barr virus (EBV) viral serology. Glandular fever, also known as infectious mononucleosis, is commonly caused by the Epstein-Barr virus. The symptoms described by the patient, including a sore throat, fever, and feeling unwell, are consistent with this condition. To confirm the diagnosis, a blood test for EBV viral serology can be performed. This test detects antibodies produced by the body in response to the virus. It is important to note that the Monospot test, which is another blood test for infectious mononucleosis, may not be as accurate in younger children. Therefore, the most appropriate option would be to send a blood test for EBV viral serology in 2-3 days time. This will allow for the detection of specific antibodies and provide a more accurate diagnosis.

Further Reading:

Glandular fever, also known as infectious mononucleosis or mono, is a clinical syndrome characterized by symptoms such as sore throat, fever, and swollen lymph nodes. It is primarily caused by the Epstein-Barr virus (EBV), with other viruses and infections accounting for the remaining cases. Glandular fever is transmitted through infected saliva and primarily affects adolescents and young adults. The incubation period is 4-8 weeks.

The majority of EBV infections are asymptomatic, with over 95% of adults worldwide having evidence of prior infection. Clinical features of glandular fever include fever, sore throat, exudative tonsillitis, lymphadenopathy, and prodromal symptoms such as fatigue and headache. Splenomegaly (enlarged spleen) and hepatomegaly (enlarged liver) may also be present, and a non-pruritic macular rash can sometimes occur.

Glandular fever can lead to complications such as splenic rupture, which increases the risk of rupture in the spleen. Approximately 50% of splenic ruptures associated with glandular fever are spontaneous, while the other 50% follow trauma. Diagnosis of glandular fever involves various investigations, including viral serology for EBV, monospot test, and liver function tests. Additional serology tests may be conducted if EBV testing is negative.

Management of glandular fever involves supportive care and symptomatic relief with simple analgesia. Antiviral medication has not been shown to be beneficial. It is important to identify patients at risk of serious complications, such as airway obstruction, splenic rupture, and dehydration, and provide appropriate management. Patients can be advised to return to normal activities as soon as possible, avoiding heavy lifting and contact sports for the first month to reduce the risk of splenic rupture.

Rare but serious complications associated with glandular fever include hepatitis, upper airway obstruction, cardiac complications, renal complications, neurological complications, haematological complications, chronic fatigue, and an increased risk of lymphoproliferative cancers and multiple sclerosis.

A person’s level of consciousness is determined by their alertness. In this case, the score for alertness is 0, indicating that the person is not alert. Based on the scoring system, a total score of 4 suggests a moderate case of croup. Moderate croup is typically diagnosed when the scores range from 3 to 5.

Further Reading:

Croup, also known as laryngotracheobronchitis, is a respiratory infection that primarily affects infants and toddlers. It is characterized by a barking cough and can cause stridor (a high-pitched sound during breathing) and respiratory distress due to swelling of the larynx and excessive secretions. The majority of cases are caused by parainfluenza viruses 1 and 3. Croup is most common in children between 6 months and 3 years of age and tends to occur more frequently in the autumn.

The clinical features of croup include a barking cough that is worse at night, preceded by symptoms of an upper respiratory tract infection such as cough, runny nose, and congestion. Stridor, respiratory distress, and fever may also be present. The severity of croup can be graded using the NICE system, which categorizes it as mild, moderate, severe, or impending respiratory failure based on the presence of symptoms such as cough, stridor, sternal/intercostal recession, agitation, lethargy, and decreased level of consciousness. The Westley croup score is another commonly used tool to assess the severity of croup based on the presence of stridor, retractions, air entry, oxygen saturation levels, and level of consciousness.

In cases of severe croup with significant airway obstruction and impending respiratory failure, symptoms may include a minimal barking cough, harder-to-hear stridor, chest wall recession, fatigue, pallor or cyanosis, decreased level of consciousness, and tachycardia. A respiratory rate over 70 breaths per minute is also indicative of severe respiratory distress.

Children with moderate or severe croup, as well as those with certain risk factors such as chronic lung disease, congenital heart disease, neuromuscular disorders, immunodeficiency, age under 3 months, inadequate fluid intake, concerns about care at home, or high fever or a toxic appearance, should be admitted to the hospital. The mainstay of treatment for croup is corticosteroids, which are typically given orally. If the child is too unwell to take oral medication, inhaled budesonide or intramuscular dexamethasone may be used as alternatives. Severe cases may require high-flow oxygen and nebulized adrenaline.

When considering the differential diagnosis for acute stridor and breathing difficulty, non-infective causes such as inhaled foreign bodies

Signs that a child with gastroenteritis may be at risk of progressing to shock include altered responsiveness (such as being irritable or lethargic), sunken eyes, a fast heart rate, rapid breathing, and reduced skin elasticity. In infants aged 3 months or younger, a temperature above 38ºC is also a red flag.

Further Reading:

Gastroenteritis is a common condition in children, particularly those under the age of 5. It is characterized by the sudden onset of diarrhea, with or without vomiting. The most common cause of gastroenteritis in infants and young children is rotavirus, although other viruses, bacteria, and parasites can also be responsible. Prior to the introduction of the rotavirus vaccine in 2013, rotavirus was the leading cause of gastroenteritis in children under 5 in the UK. However, the vaccine has led to a significant decrease in cases, with a drop of over 70% in subsequent years.

Norovirus is the most common cause of gastroenteritis in adults, but it also accounts for a significant number of cases in children. In England & Wales, there are approximately 8,000 cases of norovirus each year, with 15-20% of these cases occurring in children under 9.

When assessing a child with gastroenteritis, it is important to consider whether there may be another more serious underlying cause for their symptoms. Dehydration assessment is also crucial, as some children may require intravenous fluids. The NICE traffic light system can be used to identify the risk of serious illness in children under 5.

In terms of investigations, stool microbiological testing may be indicated in certain cases, such as when the patient has been abroad, if diarrhea lasts for more than 7 days, or if there is uncertainty over the diagnosis. U&Es may be necessary if intravenous fluid therapy is required or if there are symptoms and/or signs suggestive of hypernatremia. Blood cultures may be indicated if sepsis is suspected or if antibiotic therapy is planned.

Fluid management is a key aspect of treating children with gastroenteritis. In children without clinical dehydration, normal oral fluid intake should be encouraged, and oral rehydration solution (ORS) supplements may be considered. For children with dehydration, ORS solution is the preferred method of rehydration, unless intravenous fluid therapy is necessary. Intravenous fluids may be required for children with shock or those who are unable to tolerate ORS solution.

Antibiotics are generally not required for gastroenteritis in children, as most cases are viral or self-limiting. However, there are some exceptions, such as suspected or confirmed sepsis, Extraintestinal spread of bacterial infection, or specific infections like Clostridium difficile-associated pseudomembranous enterocolitis or giardiasis.

The doses of commonly used drugs in paediatric cardiac arrest are summarized in the following table:

Drug: Adrenaline (epinephrine) IV/IO
Dose: 10 mcg/kg

Drug: Adrenaline (epinephrine) ET bolus
Dose: 100 mcg/kg

Drug: Amiodarone IV infusion
Dose: 5 mg/kg over 3 minutes (maximum 300 mg)

Drug: Calcium gluconate 10%
Dose: 0.3-0.5 ml/kg

Drug: Lidocaine IV/IO
Dose: 1 mg/kg (maximum 100 mg)

Drug: Magnesium sulphate IV
Dose: 25-50 mg/kg

Drug: Sodium bicarbonate IV
Dose: 1 ml/kg 8.4%

Croup, also known as laryngotracheobronchitis, is a respiratory infection that primarily affects infants and toddlers. It is characterized by a barking cough and can cause stridor (a high-pitched sound during breathing) and respiratory distress due to swelling of the larynx and excessive secretions. The majority of cases are caused by parainfluenza viruses 1 and 3. Croup is most common in children between 6 months and 3 years of age and tends to occur more frequently in the autumn.

The clinical features of croup include a barking cough that is worse at night, preceded by symptoms of an upper respiratory tract infection such as cough, runny nose, and congestion. Stridor, respiratory distress, and fever may also be present. The severity of croup can be graded using the NICE system, which categorizes it as mild, moderate, severe, or impending respiratory failure based on the presence of symptoms such as cough, stridor, sternal/intercostal recession, agitation, lethargy, and decreased level of consciousness. The Westley croup score is another commonly used tool to assess the severity of croup based on the presence of stridor, retractions, air entry, oxygen saturation levels, and level of consciousness.

In cases of severe croup with significant airway obstruction and impending respiratory failure, symptoms may include a minimal barking cough, harder-to-hear stridor, chest wall recession, fatigue, pallor or cyanosis, decreased level of consciousness, and tachycardia. A respiratory rate over 70 breaths per minute is also indicative of severe respiratory distress.

Children with moderate or severe croup, as well as those with certain risk factors such as chronic lung disease, congenital heart disease, neuromuscular disorders, immunodeficiency, age under 3 months, inadequate fluid intake, concerns about care at home, or high fever or a toxic appearance, should be admitted to the hospital. The mainstay of treatment for croup is corticosteroids, which are typically given orally. If the child is too unwell to take oral medication, inhaled budesonide or intramuscular dexamethasone may be used as alternatives. Severe cases may require high-flow oxygen and nebulized adrenaline.

When considering the differential diagnosis for acute stridor and breathing difficulty, non-infective causes such as inhaled foreign bodies

In pediatric patients who have sustained burns in a house fire, the presence of burns greater than 15% of the total body surface area should trigger the initiation of immediate fluid resuscitation.

Further Reading:

Burn injuries can be classified based on their type (degree, partial thickness or full thickness), extent as a percentage of total body surface area (TBSA), and severity (minor, moderate, major/severe). Severe burns are defined as a >10% TBSA in a child and >15% TBSA in an adult.

When assessing a burn, it is important to consider airway injury, carbon monoxide poisoning, type of burn, extent of burn, special considerations, and fluid status. Special considerations may include head and neck burns, circumferential burns, thorax burns, electrical burns, hand burns, and burns to the genitalia.

Airway management is a priority in burn injuries. Inhalation of hot particles can cause damage to the respiratory epithelium and lead to airway compromise. Signs of inhalation injury include visible burns or erythema to the face, soot around the nostrils and mouth, burnt/singed nasal hairs, hoarse voice, wheeze or stridor, swollen tissues in the mouth or nostrils, and tachypnea and tachycardia. Supplemental oxygen should be provided, and endotracheal intubation may be necessary if there is airway obstruction or impending obstruction.

The initial management of a patient with burn injuries involves conserving body heat, covering burns with clean or sterile coverings, establishing IV access, providing pain relief, initiating fluid resuscitation, measuring urinary output with a catheter, maintaining nil by mouth status, closely monitoring vital signs and urine output, monitoring the airway, preparing for surgery if necessary, and administering medications.

Burns can be classified based on the depth of injury, ranging from simple erythema to full thickness burns that penetrate into subcutaneous tissue. The extent of a burn can be estimated using methods such as the rule of nines or the Lund and Browder chart, which takes into account age-specific body proportions.

Fluid management is crucial in burn injuries due to significant fluid losses. Evaporative fluid loss from burnt skin and increased permeability of blood vessels can lead to reduced intravascular volume and tissue perfusion. Fluid resuscitation should be aggressive in severe burns, while burns <15% in adults and <10% in children may not require immediate fluid resuscitation. The Parkland formula can be used to calculate the intravenous fluid requirements for someone with a significant burn injury.

The term Apparent Life-Threatening Event (ALTE) has traditionally been used to describe a specific type of event. However, in 2016, the American Academy of Paediatrics (AAP) recommended replacing this term with a new one called Brief Resolved Unexplained Event (BRUE).

An ALTE is defined as an episode that is frightening to the observer and is characterized by a combination of symptoms such as apnoea (central or occasionally obstructive), color change (usually cyanotic or pallid but occasionally erythematous or plethoric), significant change in muscle tone (usually marked limpness), choking, or gagging. In some cases, the observer may even fear that the infant has died.

On the other hand, BRUE has stricter criteria and is only applicable to episodes that occur in infants under 12 months old. A BRUE is considered brief, typically lasting 2-30 seconds but no longer than 1 minute. It must also have resolved, meaning the infant has returned to their baseline state. Additionally, it should not be explained by any identifiable medical condition and must be characterized by at least one of the following: cyanosis or pallor, absent, decreased, or irregular breathing, marked change in muscle tone (hyper- or hypotonia), or altered level of responsiveness.

To diagnose a BRUE, a full history and physical examination of the infant must be conducted, and if no explanation for the event is found, it can be classified as a BRUE. Once a BRUE is diagnosed, it can be risk-stratified to guide further management.

A BRUE is considered low risk if the infant has fully recovered, there are no concerning history or physical examination findings, and the following criteria are met: the infant is over 60 days old, born after 32 weeks gestation with a corrected gestational age over 45 weeks, no CPR was performed by a trained healthcare professional, and this was the first event that lasted less than 1 minute.

Low-risk infants can be safely discharged with early outpatient follow-up within 24 hours. However, it is important to involve the parents/caregivers in the decision-making process. They should be informed that a low-risk BRUE is unlikely to indicate a severe underlying disorder and that the event is unlikely to happen again.

Before discharge, it may be advisable to perform an ECG, observe the infant for a brief period, and conduct a pertussis swab