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ObjectiveTo report the performance of clinical practice guidelines (CPG) in the diagnosis of serious/invasive bacterial infections (SBI/IBI) in infants presenting with a fever to emergency care in the UK and Ireland. Two CPGs were from the National Institutes for Health and Care Excellence (NICE guidelines NG51 and NG143) and one was from the British Society for Antimicrobial Chemotherapy (BSAC).DesignRetrospective multicentre cohort study.PatientsFebrile infants aged 90 days or less attending between the 31 August 2018 to 1 September 2019.Main outcome measuresThe sensitivity, specificity and predictive values of CPGs in identifying SBI and IBI.SettingSix paediatric Emergency Departments in the UK/Ireland.Results555 participants were included in the analysis. The median age was 53 days (IQR 32 to 70), 447 (81%) underwent blood testing and 421 (76%) received parenteral antibiotics. There were five participants with bacterial meningitis (1%), seven with bacteraemia (1%) and 66 (12%) with urinary tract infections. The NICE NG51 CPG was the most sensitive: 1.00 (95% CI 0.95 to 1.00). This was significantly more sensitive than NICE NG143: 0.91 (95% CI 0.82 to 0.96, p=0.0233) and BSAC: 0.82 (95% 0.72 to 0.90, p=0.0005). NICE NG51 was the least specific 0.0 (95% CI 0.0 to 0.01), and this was significantly lower than the NICE NG143: 0.09 (95% CI 0.07 to 0.12, pConclusionNone of the studied CPGs demonstrated ideal performance characteristics. CPGs should be improved to guide initial clinical decision making.Trial registration numberNCT04196192.

The limping child is a common presentation to paediatric services. In most instances the cause is benign with few, if any, investigations required. There is, however, always that concern that the limping child may have an underlying limb-threatening or life-threatening disease. This poses a challenge to clinicians, who must find that balance between correctly identifying disease early and avoiding the risks and harms of overinvestigation. In this article we discuss the diagnostic approach to the limping child and present a structure for assessment, investigation and risk management.

As technology evolves and cultural attitudes towards diagnosis change, there is an increasing move towards newer, faster and more accurate diagnostic testing. As new tests are developed, clinicians are increasingly required to appraise data from diagnostic test accuracy (DTA) studies.The accuracy of a test is fluid and changes depending on the population, setting, timing and position within the diagnostic pathway. This article attempts to provide a short guide to understanding diagnostic test accuracy and a simple approach to appraising DTA studies.

It’s 21:00 and you receive a stand-by call from the local ambulance service. Peter, a 9-year-old boy, was riding an electric scooter and has collided with a car. He has reduced consciousness, signs of shock and is hypoxic. How will you prepare your team? What are the possible injuries? Who will perform the primary survey? Injury is the leading cause of morbidity and mortality in the paediatric population accounting for approximately half of all attendances to paediatric emergency departments in the UK and Ireland. Major trauma can be distressing for patients, parents and physicians. Managing major trauma is challenging and it is vital to have a clear and organised approach. In this 15-minute guide we describe a structured approach to the primary survey that includes how to prepare before the child’s arrival, the suggested roles of team members and the key components of the primary survey. We discuss life-threatening injuries, the life-saving bundle and the principles of resuscitation, and the role of imaging in the initial assessment of the injured child.

A 3-month-old baby is brought to the paediatric emergency department by their parents because of a fever. You decide to check their inflammatory markers. Their C-reactive protein (CRP) level comes back as 20 mg/L. Does this affect whether or not you start antibiotic therapy? Does it influence your decision to admit or discharge the patient? CRP is a commonly used biochemical test and yet its use is constantly debated and challenged. We look at the current evidence and suggest the best way to use this test in clinical practice.

‘It is midnight and you are called to see a thirteen-year-old boy who has been brought to the paediatric emergency department with a 24-hour history of swelling and redness of his left eye. He has had a ‘runny nose’ for a couple of days. He is systemically well. His upper and lower lids are red and swollen such that his eye is not open fully, though you elicit normal eye movements when you open his eye. Pupils are equal and reactive with no afferent pupillary defect. Visual acuity and colour vision are normal on examination.’ In this article, we consider the approach to preseptal and orbital cellulitis in children including the initial assessment and management options.

Its 2am and you are called to review a “well looking child” in the emergency department who has presented with a new non-blanching rash. He has been hot at home with some coryzal symptoms. Mum is worried, she thinks the rash has spread in the last hour! What are you going to do? In this article, we discuss the aetiology and initial assessment of non-blanching rashes in children.

Mast cell tryptase (tryptase) is an enzyme produced almost exclusively by mast cells that is easy to measure using a widely available test. In this article we discuss the physiology of the mast cell and how that relates to IgE-mediated anaphylaxis and mastocytosis. We also describe the technical aspects of testing tryptase and the reported normal ranges in health. Finally we explore the diagnostic performance of serum mast cell tryptase measurements, when used to confirm anaphylaxis, estimate future anaphylaxis risk and in diagnosing/monitoring leukaemia.

There are over 300 new cases of imported paediatric malaria in the UK each year and this has been increasing over the last 20 years. Malaria in children is particularly difficult to diagnose because the initial presenting features are subtler than in adults and do not display the classical presenting features. However, they are also more likely to deteriorate rapidly and to develop severe malaria. The 'gold standard' for ruling out the diagnosis of malaria if clinically suspected is three negative thin and thick blood films, which require serial phlebotomy and the availability of trained technicians. There are now a range of other tests, including rapid diagnostic tests and PCR, as well as clinical features that make the diagnosis more or less likely. We explore the different tests available and whether these might replace the three negative blood films currently needed. We also look at whether we are able to use clinical features to aid the tests used for a diagnosis of imported malaria.

Meningitis is a critical diagnosis not to miss in children presenting with fever. Since the early 20th century, classical clinical signs have been used to aid the diagnosis of meningitis. These classical signs are nuchal rigidity, Kernig’s sign and Brudzinski’s sign. Each of these relies on the principle that stretching the inflamed meningeal membranes causes clinically detectable irritation. Several primary studies have quantified the diagnostic performance of clinical examination in detecting meningitis in children. The results of these studies vary significantly due to methodological differences, clinical heterogeneity and interobserver variability. However, their findings demonstrate that positive meningitic signs increase the likelihood of a diagnosis of meningitis, and the absence of meningitic signs reduces this probability. These signs have greatest utility when combined with other features in the history and examination to contribute to a comprehensive clinical assessment.

Background Despite successful vaccination programmes meningococcal disease (MD) remains the leading infectious cause of septicaemia and death in children in the UK and Ireland. 1,2 The early diagnosis of MD significantly improves outcomes with reduced morbidity and mortality. 1,2 The early stages of MD are often indistinguishable from a simple viral illness making an early positive diagnosis of MD difficult. 1 Hibergene have developed a commercially available bedside Loop-mediated isothermal AMPlification PCR (LAMP-MD) test that is a highly sensitive 0.89 (95%CI 0.72–0.96) and specific 1.0 (95%CI 0.97–1.0) for identifying children with invasive MD (4) (figure 1). Aims The aims of this RCEM funded study were: Assess the ease of use and suitability for the ED Determine the time taken to perform the test Independently verify LAMP-MD performance against TaqMan quantitative PCR. Method The LAMP-MD was assessed for practicality and ease of use within the ED including an assessment of training needs, footprint and health and safety requirements. For verification of the Hibergene LAMP-MD analyser and assay we used dry nasopharyngeal swabs sent for viral screening. Additional verification was undertaken using N. meningitidis genomic DNA spiked over a range of concentrations. This included serotypes A, B, C, W, X and Y and a dilution series to determine the limit of detection. All samples were then analysed using real time TaqMan qPCR. Results The LAMP-MD analyser was easy to use and could be accommodated in the ED The mean time for detection of Meningococcal DNA was 14.01 min Detection of meningococcal serogroups A, B, C, W, X and Z was confirmed The detection limit for dry nasopharyngeal swabs was below 2 genomic copies per µl No non-specific amplification was observed in 17 randomly selected negative clinical swabs The LAMP-MD assay was 100% sensitive and specific relative to real-time TaqMAN PCR. Conclusion LAMP-MD is a practical, rapid point of care test that can reliably detect all Meningococcal serotypes in less than 15 min. Funding has been secured to perform a PERUKI supported study to investigate the potential for LAMP-MD in the diagnosis of meningococcal disease in children. References Meningitis Research Foundation. Meningococcal Meningitis and Septicaemia Guidance Notes 2014. O Maoldomhnaigh, et al. Invasive meningococcal disease in children in Ireland . PMID: 27566800. NICE. Management of petechial rash . Bourke TW, et al. Diagnostic accuracy of loop-mediated isothermal amplification as a near-patient test for meningococcal disease in children . PMID: 25728843.

Introduction Approximately 3 in 10 children aged 2–15 years in the UK are overweight or obese.1 NICE guidance states that “Health professionals should tell the parents of children…about local lifestyle weight management programmes.” The purpose of this project is to better understand how overweight and obese children can be identified and managed following presentation to the paediatric emergency department in Northern Ireland. Aims Audit existing practice Compile a list of available weight management programmes Work with parents to improve the service Work with health professionals to improve the service Methods Existing practice was audited retrospectively by reviewing 100 case notes selected randomly over 12 months. Weight and demographic data were recorded, as was any intervention. Barriers to care in the department were explored through the use of focus groups. A review of existing lifestyle and weight management programs was conducted by: Contacting public health Northern Ireland, Searching district council websites Questioning clinicians Parent involvement was encouraged through a questionnaire. This collected data on; attitudes towards obesity, how best to discuss the topic and on what services parents want access to. Results No patients had weight issues discussed. There are no endorsed or well recognised obesity services for children in Northern Ireland Health professionals felt uncomfortable discussing obesity and those that did discuss the issue felt the lack of available lifestyle and weight management services undermined any discussion they had. 51 questionnaires were returned by parents. 98% felt that obesity was an important health issue with 84% stating that overweight or obese children should be identified in the emergency department. Our parents told us that 77% of them would want to be referred on to a dietetic or weight loss service. Conclusion Parents are worried about obesity and the vast majority would like to be told (even if it is in the emergency department). Health professionals however, find it difficult discussing weight issues when they know there are no community services to refer to. There is an urgent need for community obesity services for children in Northern Ireland.