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ObjectiveChildren are relatively protected from COVID-19, due to a range of potential mechanisms. We investigated if contact with children also affords adults a degree of protection from COVID-19.DesignCohort study based on linked administrative data.SettingScotland.Study populationAll National Health Service Scotland healthcare workers and their household contacts as of March 2020.Main exposureNumber of young children (0–11 years) living in the participant’s household.Main outcomesCOVID-19 requiring hospitalisation, and any COVID-19 (any positive test for SARS-CoV-2) in adults aged ≥18 years between 1 March and 12 October 2020.Results241 266, 41 198, 23 783 and 3850 adults shared a household with 0, 1, 2 and 3 or more young children, respectively. Over the study period, the risk of COVID-19 requiring hospitalisation was reduced progressively with increasing numbers of household children—fully adjusted HR (aHR) 0.93 per child (95% CI 0.79 to 1.10). The risk of any COVID-19 was similarly reduced, with the association being statistically significant (aHR per child 0.93; 95% CI 0.88 to 0.98). After schools reopened to all children in August 2020, no association was seen between exposure to young children and risk of any COVID-19 (aHR per child 1.03; 95% CI 0.92 to 1.14).ConclusionBetween March and October 2020, living with young children was associated with an attenuated risk of any COVID-19 and COVID-19 requiring hospitalisation among adults living in healthcare worker households. There was no evidence that living with young children increased adults’ risk of COVID-19, including during the period after schools reopened.

BackgroundAssessment of the seriousness, expectedness and causality are necessary for any adverse event (AE) in a clinical trial. In addition, assessing AE severity helps determine the importance of the AE in the clinical setting. Standardisation of AE severity criteria could make safety information more reliable and comparable across trials. Although standardised AE severity scales have been developed in other research fields, they are not suitable for use in neonates. The development of an AE severity scale to facilitate the conduct and interpretation of neonatal clinical trials is therefore urgently needed.MethodsA stepwise consensus process was undertaken within the International Neonatal Consortium (INC) with input from all relevant stakeholders. The consensus process included several rounds of surveys (based on a Delphi approach), face-to-face meetings and a pilot validation.ResultsNeonatal AE severity was classified by five grades (mild, moderate, severe, life threatening or death). AE severity in neonates was defined by the effect of the AE on age appropriate behaviour, basal physiological functions and care changes in response to the AE. Pilot validation of the generic criteria revealed κ=0.23 and guided further refinement. This generic scale was applied to 35 typical and common neonatal AEs resulting in the INC neonatal AE severity scale (NAESS) V.1.0, which is now publicly available.DiscussionThe INC NAESS is an ongoing effort that will be continuously updated. Future perspectives include further validation and the development of a training module for users.

ObjectivesPain is a very common symptom of juvenile idiopathic arthritis (JIA). Disease activity alone cannot explain symptoms of pain in all children, suggesting other factors may be relevant. The objectives of this study were to describe the different patterns of pain experienced over time in children with JIA and to identify predictors of which children are likely to experience ongoing pain.MethodsThis study used longitudinal-data from patients (aged 1–16 years) with new-onset JIA. Baseline and up to 5-year follow-up pain data from the Childhood Arthritis Prospective Study (CAPS) were used. A two-step approach was adopted. First, pain trajectories were modelled using a discrete mixture model. Second, multinomial logistic regression was used to determine the association between variables and trajectories.ResultsData from 851 individuals were included (4 years, median follow-up). A three-group trajectory model was identified: consistently low pain (n=453), improved pain (n=254) and consistently high pain (n=144). Children with improved pain or consistently high pain differed on average at baseline from consistently low pain. Older age at onset, poor function/disability and longer disease duration at baseline were associated with consistently high pain compared with consistently low pain. Early increases in pain and poor function/disability were also associated with consistently high pain compared with consistently low pain.ConclusionsThis study has identified routinely collected clinical factors, which may indicate those individuals with JIA at risk of poor pain outcomes earlier in disease. Identifying those at highest risk of poor pain outcomes at disease onset may enable targeted pain management strategies to be implemented early in disease thus reducing the risk of poor pain outcomes.

ObjectivesDespite improved nutrition and intensive treatment, subjects with cystic fibrosis have difficulty in maintaining anabolism during intercurrent infections, which can result in reduced body mass index and impaired skeletal growth. Insulin-like growth factor-I (IGF-I) and its binding protein IGFBP3 are sensitive to changes in nutritional status. The aim of this study was to determine the relation between circulating concentrations of these peptides, body mass index, and clinical status in cystic fibrosis.MethodsSerum concentrations of IGF-I and IGFBP3 were measured in 197 subjects (108 males, 89 females; mean age 9.69 years, range 0.41-17.9 years) and these data were analysed with respect to body mass index, pubertal stage, and clinical status as assessed by Shwachman score and forced expiratory volume in one second (FEV₁).ResultsThe mean height SD score of the children studied was -0.2 (SD 1.14) and the body mass index SD score -0.26 (1.4). The body mass index SD score declined with increasing age (r=-0.18) and paralleled changes in IGF-I concentrations, which also declined. The IGF-I SD score (calculated from control data) correlated with age (r=-0.53). The abnormalities were most obvious during late puberty, when IGF-I and IGFBP3 concentrations were significantly reduced compared with those in control subjects matched for pubertal stage. The IGF-I SD score correlated with height SD score (r=0.14) and the decline in IGF-I concentrations with the fall in body mass index SD score (r=0.42). IGF-I SD scores also correlated with the Shwachman score (r=0.33) and FEV₁(r=0.17).ConclusionsThe close relation between declining IGF-I and IGFBP3 concentrations and body mass index in patients with cystic fibrosis may simply reflect poor nutritional status and insulin hyposecretion. Nevertheless, IGF-I deficiency could also contribute towards the catabolism observed in these patients, and IGF-I SD scores correlated with other measures of clinical status such as the Shwachman score and FEV₁.

Subjective and objective sleep disturbance was studied in children with nocturnal asthma. Relations between such disturbance and daytime psychological function were also explored, including possible changes in learning and behaviour associated with improvements in nocturnal asthma and sleep. Assessments included home polysomnography, parental questionnaires concerning sleep disturbance, behaviour, and mood and cognitive testing. Compared with matched controls, children with asthma had significantly more disturbed sleep, tended to have more psychological problems, and they performed less well on some tests of memory and concentration. In general, improvement of nocturnal asthma symptoms by changes in treatment was followed by improvement in sleep and psychological function in subsequent weeks. The effects of asthma on sleep and the possible psychological consequences are important aspects of overall care.

AimThe aim of this audit was to establish whether immunosuppression was being prescribed correctly and whether target levels were being reached during the first six weeks post-transplant.1 2MethodThe standards were discussed and agreed, due to an absence of standardised local or national written protocols, with the lead paediatric cardiothoracic transplant consultant and a specialist transplant liaison nurse. The paediatric transplant database provided a list of patients between October 2016 and July 2018, from which paediatric cardiac transplant patients were included in this audit. All data were collected retrospectively, for the first six weeks post-transplant, from patient’s electronic records.ResultsTwenty-three patients were included in the audit; fifteen males and eight females and the mean age was 6 years old. The standards for the timing and dosing of the first ciclosporin dose were met for 87% and 78% of patients respectively. Six patients (26%) had a ciclosporin level within the target range by day 4 post-transplant, for the remaining seventeen patients the average was day 9 post-transplant. The mean levels remained within this range or slightly above after day 9. Azathioprine or mycophenolate was started within 7 days of transplant in 6 patients (23%). Four patients (17%) had documented episodes of rejection; in one patient all other standards were met and in the other three only one additional standard was not met. Nineteen patients (83%) did not have a documented episode of rejection.ConclusionsPost-transplant management is individualised based on multiple factors such as clinical conditions e.g. renal/liver impairment and whether other agents such as ATG or steroids are being used.1The lack of documentation around the treatment decisions made it difficult to explain deviations from standards in this audit. Ciclosporin standards were not met completely but were most likely unfeasible due to a narrow target range and the time between first dose and level monitoring. There did not appear to be a clear association between standards not being met and episodes of rejection. It would be beneficial to repeat this as a larger, prospective audit using revised standards.ReferencesCostanzo MR, Costanzo MR, Dipchand A, et al. The international society of heart and lung transplantation guidelines for the care of heart transplant recipients. J Heart Lung Transplant2010;29:914–56.Sandimmun Concentrate for Solution for Infusion 50 mg/ml - Summary of Product Characteristics (SmPC) - (eMC) [Internet]. [cited 2018 Sep 2]. Available from: https://www.medicines.org.uk/emc/product/1036

BackgroundIn the absence of consensus, the present meta-analysis was performed to determine an optimal dosing regimen of vancomycin for neonates.MethodsA ‘meta-model’ using NONMEM with 4894 concentrations from 1631 neonates was built and Monte Carlo simulations were performed to design an optimal intermittent infusion, aiming at reaching a target AUC0-24 of 400 mg*h/L at steady state in at least 80% of neonates.ResultsA two-compartment model best fitted the data. Current weight, post-menstrual age (PMA) and serum creatinine were the significant covariates for clearance (CL). After model validation, simulations showed that a loading dose (25 mg/kg) and a maintenance dose (15 mg/kg twice daily if < 35 weeks PMA and 15 mg/kg three times daily if ≥ 35 weeks PMA) achieved the AUC0-24 target earlier than a standard ‘Blue Book’ dosage regimen in more than 89% of the treated patients.ConclusionsThe results of a population meta-analysis of vancomycin data have been used to develop a new dosing regimen for neonatal use and assist in the design of the model-based, multinational European trial, NeoVanc.Disclosure(s)Nothing to disclose

BackgroundA paediatric global ratings scale for endoscopy(PGRS) is currently being piloted and this will provide a quality and safety framework for service improvement in Paediatric endoscopy units. An important aspect of this is patient involvement and an annual survey on the patient’s experience.AimA patient/parent feedback survey was used to evaluate the endoscopy experience for our patients and family, as part of an annual endoscopy audit plan.MethodA questionnaire that has previously been approved by our clinical governance team in 2013 was used. Questionnaires were distributed to patients and parents over a 3 week period (24/10/16–11/11/16).Results28 questionnaires were returned, including an even spread between age groups. The results are illustrated in Table 1.Abstract G190(P) Table 1Results of patient/parent questionnairePreparation before procedureYes (%)No (%)Not recorded (%)Was the procedure explained during consent?10000Did you feel you had opportunity to ask questions?10000Were you given information leaflets about the procedure?75187In those who had colonoscopies, were you explained the10000importance of bowel preparation?Were you informed of waiting time in advance?71254Did you have an opportunity to discuss options with the82117Anaesthetist?Overall preparation rated as 'excellent' or 'good'79147Experience post procedureDid the patient experience post-operative pain?296110Did the patient experience post-operative bleeding?48610Were the endoscopy findings discussed and explained?711117Were follow up arrangements given at discharge?71425Was advice given about complications after discharge?46747Overall experienceOverall patient comfort rated as 'excellent' or 'good'75 718Overall experience rated as 'excellent' or 'good'75 718ConclusionOverall, patients and families have had a good experience of endoscopy at our Unit, which is in line with previous studies. Areas for improvement include a need for specific endoscopy information and post procedure advice leaflets, and adolescent care.

Posaconazole is a broad spectrum triazole antifungal with activity against a range of invasive fungal pathogens including Candida and Aspergillus species.1Due to its range of activity it has been shown, by randomised controlled trials, to be superior to fluconazole and itraconazole for prevention of fungal infection in neutropenic patients,2as well as being cost saving.1Fungal prophylaxis with posaconazole has become the drug of choice within a paediatric cancer unit due to its broad spectrum of activity however there are significant differences in bioavailability of the suspension and tablet preparations and there is limited data relating to its use in the paediatric population.ObjectiveTo determine if the paediatric cancer unit is undertaking effective dosing and appropriate therapeutic drug monitoring (TDM) of posaconazole in paediatric haematology and oncology patients.MethodsA retrospective analysis of clinical data from 38 paediatric patients treated with posaconazole was undertaken. Patients received either 18–24-mg/kg/day posaconazole suspension in divided doses (maximum 800-mg/day,3or 6–8-mg/kg/day posaconazole tablets (maximum 300-mg/day). Compliance with this guidance, initial and subsequent levels, efficacy and tolerability were analysed.SettingThe study was undertaken within the XXXX cancer unit; data for patients treated with posaconazole between January 2016 and August 2017 was reviewed.Key findingsThere was good compliance with the dosing advice for liquid and tablet posaconazole with 82% of patients dosed correctly. Due to this, the initial trough level of ≥0.7 mg/L was achieved in 82% of patients within 14 days of treatment initiation; there were no significant differences between formulations. Trough levels were monitored on a monthly basis for 71% of patients but dose adjustments were necessary in 34% of patients. Posaconazole had a good tolerability profile during the study with most side effects resolving on continuation of treatment however one patient had to discontinue the drug due to widespread rash. No patients developed a fungal infection whilst on posaconazole.ConclusionSafe and effective dosing and monitoring of posaconazole suspension and tablet formulations has been undertaken at the XXXX. Trough levels attained the desired target concentration of ≥0.7 mg/L in the majority of patients but dose adjustments were required with both formulations emphasising the need for regular TDM. Posaconazole was well tolerated and clinically effective in preventing fungal infection indicating its appropriateness in this patient group. From this review, a guideline for initiation and appropriate TDM of posaconazole can be developed.ReferencesDranitsaris G, Khoury H. Posaconazole versus fluconazole or itraconazole for prevention of invasive fungal infections in patients undergoing intensive cytotoxic therapy for acute myeloid leukemia or myelodysplasia: a cost effectiveness analysis. Supportive Care in Cancer. 2011; 19(11): 1807–1813.Cornely O, Maertens J, Winston D, et al. Posaconazole vs. Fluconazole or Itraconazole in Patients with Neutropenia. New England Journal of Medicine. 2007; 356(4): 348–359.Bernardo V, Cross S, Crews K, et al. Posaconazole Therapeutic Drug Monitoring in Paediatric Patients and Young Adults with Cancer. The Annals of Pharmacotherapy. 2013; 47: 976–983.

BackgroundLower respiratory tract infections (LRTI) are a major cause of morbidity and mortality in patients with neurological impairment. Prophylactic antibiotics and eradication of colonisers are approaches employed in the prevention of recurrent LRTI.AimsTo determine the evidence base for this practice in children with neurological impairment.MethodsAn electronic database search identified studies reporting on outcomes of efficacy for antimicrobial interventions and microbial findings relevant to LRTI in our population of interest. Results were synthesised into a narrative review.ResultsOur search revealed a small case-series suggesting nebulized tobramycin may be effective in reducing the frequency of pneumonias and associated hospitalisations. We identified 5 papers focusing on microbial findings – there was significant variability in the frequency of bacterial isolation, and in the species identified. These studies were heterogeneous and subject to individual biases which limits the wider applicability of results.ConclusionsThe direct evidence for antimicrobial interventions as a prophylactic strategy against LRTI in patients with neurological impairment is lacking and warrants further research. In addition, we still lack a clear understanding of the microbiota contributing to respiratory pathology, which could inform therapeutic targets.

AimRecruiting sufficient numbers of nurses can provide a challenge for hospitals. Pharmacists have been identified as being able to support nurses by taking on medicines management tasks alongside traditional nursing responsibilities such as medicines administration and discharge planning.1At Barts Health NHS Trust there was increased pressure on nursing staff particularly on one of the complex medical wards during the winter pressure months. Paediatric pharmacists were identified as being able to support nurse:Safe nursing time by taking on some of nursing responsibilitiesActive discharge planning and coordinationReduce discharge prescription waiting timesImprove education and training for nurses, doctors and patients in relation to medicines management.MethodA pilot project on one paediatric medical ward was started in February 2016. The pharmacist is supernumerary to standard ward pharmacy service, reporting to the ward manager and lead pharmacist. Working hours are 9 am–5 pm Monday to Friday.Intensive training was provided over 2.5 weeks with subsequent sign off for administration of oral medication, 2nd checking for intravenous (IV) medication and IV giving.Drug listing for discharge prescription (TTA) was introduced, which involves a discussion with the doctor for medicines on discharge, transcribing these onto the TTA and using ward based dispensing where possible. Results were collected pre and post implementation.ResultsMedication administration activity:Nurse time – 60 hours/month (medication administration and 2nd checking) saved.Discharge information:Proportion of TTAs dispensed at ward level increased from 19% to 78% post implementation, avoiding delays in dispensary.Average time writing TTA to being ready for discharge reduced from 280 min to 91 min.Drug listing reduced discharge time further to 52 min.Missed and delayed doses:Random sample of 5 patients audited over 48 hour period, shown to reduce missed doses from 14% to 0%.Comments from staff:‘Because of skill mix and use of agency staff, assisting in preparing and giving IVABs has been a major help as on many days only 1 IV giver.’‘Junior staff value and support WFP and have felt has been useful to them.’‘Junior and agency staff feels better supported in understanding medicines usage’.‘Lot of complex patients with many drugs, the pharmacist has helped reducing delay in administration times’.‘TTAs for patients identified as going home have been validated sooner’.‘She helped us to reduce the number of incidents with expiry dates of medicines’.ConclusionThe role of the medicines facilitation pharmacist has been very well received by the nursing staff and the pharmacist is now an integral part of the ward team. The pharmacist was able to save a significant amount of nursing time and reduced risks of delayed and missed doses significantly and is able to provide continuous input into all aspects of medicines management. The average discharge time has reduced to substantially due to improved discharge planning, drug listing and ward based dispensing.ReferenceRobinson S. Hospital hires pharmacists for wards amid nurse shortage. Pharmaceutical Journal 23/30 May 2015;294(7863/4). [online] doi:10.1211/PJ.2015.20068544

AimTo gain consensus from an expert paediatric and neonatal clinical pharmacist panel on criteria to be applied in the design of a triage tool for use in paediatric and neonatal settings.MethodsThe ‘Delphi Technique’1was used to identify pharmaceutical care issues, known as criteria, to aid in the prioritisation and targeting of pharmacists’ time to deliver pharmaceutical care to paediatric and neonatal patients. Criteria based ’statements’ based upon the literature2–4were developed and put into a questionnaire format which was distributed amongst members of the Scottish Neonatal and Paediatric Pharmacy Group (SNAPP). A five point Likert-scale and option for free hand text was used to record responses. Responses were analysed and used to modify subsequent rounds of the Delphi technique.Results18 criteria were identified for use in the triage tool and were largely characterised upon time of review. Criteria pertaining to daily review included patients prescribed high risk medicines, psychotropic medication, continuous infusions and those with severe, acute kidney injury. Criteria pertaining to 48-hourly review included patients with stable chronic renal failure and mild kidney injury. Criteria for 72-hourly review included stable patients with no acute issues.ConclusionA triage tool to aid pharmaceutical prioritisation in paediatric and neonatal patients has been developed and will be piloted for use in clinical practice.ReferencesMcMillian S, King M, Tully M. How to use the nominal group and Delphi techniques. Int J Clin Pharm 2016;38:655–622.Abbas S. The sensitivity of the paediatric triage tool in identifying care issues. Abstracts from 21st Annual Conference of Neonatal and Paediatric Pharmacists Group, NPPG, 2015.Cottrell R, Caldwell M, Jardine G. Developing and implementing a pharmacy risk screening tool. Hospital Pharmacy Europe (Magazine)2013;71.Stuart Z. The development and pilot evaluation of referral tool for pharmacy technicians to use within a paediatric medical acute receiving unit2014. MSc Project submitted to the University of Strathclyde.

BackgroundEstimation of calorie need in children with cerebral palsy is challenging; many have decreased energy requirements in line with increasing severity of gross motor impairment. However, those with dyskinesia may have higher calorie demand but there is limited evidence to quantify this. Gastrointestinal dysmotility is common in children with dystonia and dystonia is often exacerbated by gastrointestinal pain. A vicious cycle can result leading to severe dystonia, gastrointestinal failure and a poor nutritional state. We report a case of a child requiring total parental nutrition (TPN) that enabled estimation of calorie demand in poorly controlled dystonia.Case historyA 7 year old boy with 4 limb dystonic cerebral palsy (GMFCS V), secondary to extreme prematurity (23 weeks), presented with frequent episodes of status dystonicus and enteral feeding and medication intolerance associated with intercurrent illness and hip surgery. Weight gain had been limited for several years. Failure of conservative management, including jejunal feeding and sigmoid colectomy, led to a prolonged admission requiring TPN. As enteral baclofen was not tolerated, it was decided to insert an intrathecal baclofen (ITB) pump. Prior to this, dystonia management was very difficult needing high dose intravenous clonidine and diazepam. Following insertion, there was a dramatic improvement in dystonia control which had a profound effect on calorie demand. At the time of ITB insertion (week 8 of TPN, weight 23.55 kg) satisfactory weight gain had been achieved at 84 kcal/kg/day. Over the next 4 weeks, he gained 2.05 kg despite calorie reduction by 36% to 53 kcal/kg/day. This need continued until week 28 when it was decreased to 42 kcal/ kg/day (50% of initial requirement). After a further 9 months, he remains on 42 kcal/kg/day of home TPN. He has not yet reestablished enteral nutrition but dystonia remains well controlled with ITB (690 micrograms/day), PR diazepam 20 mg BD and enteral clonidine 25 micrograms at night.ConclusionCalorie requirements in children with severe dystonia are high; recognising this is important to ensure optimal nutrition. When dystonia is complicated by gut dysmotility, providing calories, in addition to achieving dystonia control, can be a challenge; in this case ITB was an effective treatment.

BackgroundA paediatric global ratings scale for endoscopy(PGRS) is currently being piloted nationally, and this will provide a quality and safety framework for service improvement in Paediatric endoscopy units. An annual endoscopy audit plan is essential to help units identify that they are meeting the required measures and identifying areas of improvement.AimTo develop an annual endoscopy audit plan to facilitate quality improvement in the endoscopy service in a tertiary centre.Subjects and MethodsA retrospective audit of all procedures done by the Paediatric gastroenterology team during 1/10/16–15/ 10/16 was done. We used measures from the P-GRS to develop standards for the audit plan. Letters of correspondence, consent, operation notes, anaesthetic charts, nursing documentation and biopsy reports were reviewed. Patient feedback questionnaires were also included.Results46 patients(age range 8 months to 17 years) had endoscopies during the study period. 78%(36) of these had elective procedures. Out of the 22%(10) who had non-elective procedures, 18%(8) were urgent and 4%(2) were emergency procedures. 100% of procedures had a clearly documented indication, and had completed consent forms, all of which were 2-stage. The procedure completion rate was 100%, and bowel preparation was adequate in 98%. One patient developed post-operative oxygen requirement; otherwise there were no other post-procedure complications. There were no deaths within 30 days of the procedure. Patient feedback questionnaires showed 78% of respondents rated their overall endoscopy experience as ‘excellent’ or ‘good’. One patient had an endoscopic assessment for Upper GI bleeding during the audit period. This patient was risk assessed and had an endoscopic assessment appropriately.Summary and conclusionThe audit showed that our Unit is performing well against a number of the quality and safety measures in the P-GRS. Areas that require improvement include developing procedure-specific after care patient information leaflets, better documentation on patients‘ anaesthetic needs, and procuring an endoscopy reporting system(ERS). This also highlighted the need for close collaboration with other stakeholders such as anaesthetics and theatre admissions staff to share findings and implement change.

BackgroundLoss of the primary dentition is a physiological process. However, changes in pattern of tooth loss may herald systemic disease. Dental trauma and non-accidental injury should also be considered. A number of cases of premature exfoliation with subsequent investigation and diagnosis are presented.Case presentationsA four year old girl presented with painful, bleeding gingivae and oral ulceration. Haematological investigations revealed a raised B12 and neutrophil count of 0.16 and a diagnosis of cyclic neutropenia was confirmed. A complicating factor was dental caries which required dental extractions under general anaesthesia. Although this case didn’t present with premature exfoliation there was significant recession and mobility of the primary teeth which if left untreated could lead to exfoliation.A 2 year old female patient presented with a history of pyrexial illness, swollen gingivae and difficulty eating. On examination severely hyperplastic, atrophic erythematous gingivitis affecting the upper and lower anterior gingiva was noted. The severity of the presentation prompted a review of her recent hospitalisation investigations. A discharge summary obtained from her GP showed a neutrophil count of 0.07 × 109/L. An urgent referral to Paediatric Haematology was required for same day hospital admission. A bone marrow aspirate showed the presence of antigranulocyte antibodies in her serum leading to a diagnosis of primary autoimmune neutropenia.Siblings presented with premature exfoliation of anterior primary teeth with generalised bone loss and mobility in the remaining dentition. Blood tests revealed low vitamin D levels which were remedied with vitamin supplementation. They also showed decreased alkaline phosphatase levels and increased CRP levels. Both were diagnosed with odonto-hypophosphatasia.A 3 year old presented with premature loss of upper left central primary incisor. History revealed the child was upset, with oral bleeding and the tooth was found on a coffee table. The contralateral incisor showed signs of trauma. Clinical diagnosis is trauma however the tooth was sent to histopathology to rule out any other cause.ConclusionPremature loss of primary teeth should alert clinicians to the possibility of dental trauma, safeguarding issues or systemic involvement. Therefore, prompt referral to a Consultant in Paediatric Dentistry is indicated.