Search

Coeliac disease (CD) is an autoimmune gluten-dependent condition with a prevalence of 1% in the population, if screened. However, approximately only a third of children with CD are diagnosed. When CD is suspected, serological screening with anti-tissue transglutaminase titres should be performed. Children with a positive result should be referred to a specialist in CD for confirmation of the diagnosis. The European Society for Paediatric Gastroenterology Hepatology and Nutrition revised their diagnostic guidance for CD in 2020 and this article discusses the current diagnostic pathways. Lifelong strict adherence to a gluten-free diet is necessary to prevent complications. Nurses and specialist paediatric dietitians have an important role in recognising and diagnosing CD early, as well as offering ongoing dietary and clinical support.

Recent interim guidance from the British Society of Gastroenterology, aligned to historical paediatric practice, advises a no-biopsy protocol (NBP) for adults with high anti-tissue transglutaminase (tTG-IgA) titres and other clinical factors. A 7-year retrospective review identified 433 patients with positive tTG-IgA. Of these 433, 98 (23%) fulfilled the high titre criteria for an NBP which may have reduced endoscopic burden on the service. A high titre versus low titre translated in a 95% versus 75% histological confirmation of coeliac disease (p

Background Coeliac disease (CD) is a systemic immune-mediated disorder caused by the ingestion of gluten and related prolamines in genetically predisposed individuals. The 2012 ESPGHAN guidelines suggested a no-biopsy pathway (NBP) for symptomatic children with IgA-based Tissue Transglutaminase (TGA-IgA) -10x Upper Limit of Normal (ULN). Biopsy confirmation remained mandatory for all other cases. Objectives This retrospective case note study was aimed at evaluating the extent of adherence to the ESPGHAN 2012 guidelines for diagnosing CD in our unit. Methods 179 cases with positive TGA-IgA were identified from the laboratory database between January'2013 to December' 2020. 17/179 (9%) patients were not referred to secondary care after the finding of positive TTG in primary care. Data was collected on the diagnostic pathways followed, and adherence was compared with the existing ESPGHAN 2012 guidelines. Results 129 cases assessed for CD were included and 124 children diagnosed with CD. 68/129 (53%) were diagnosed via the NBP. 57/68 were diagnosed via NBP until December 2019 and 24/57 (42%) children did not meet triple criteria as per 2012 ESPGHAN guidelines. HLA-DQ2/DQ8 testing wasn't done for 16/57 NBP cases and other 3/57 had a negative EMA result. In 2020, 13 patients were diagnosed via NBP, 11 in adherence to the 2020 ESPGHAN guidelines, other 2 [TGA-IgA

Cases of children presenting with limb or joint pain are relatively common and are due mainly to benign conditions. Early diagnosis will help reduce unnecessary invasive investigations so, although a relatively rare condition, benign acute childhood myositis (BACM), which presents with acute lower limb pain and an isolated rise in creatine kinase, should be considered. BACM is characterised by an infiltration of viruses into calf muscle fibres, which may cause a subsequent inflammatory response leading to calf-muscle pain. Symptomatic and supportive management, along with explanation and reassurance, is all that is required in managing this condition. This article discusses the management of a 10-year-old boy with a classical presentation of BACM, alongside differentials and management for clinician consideration.

Neonatal sepsis results from acute bacterial or viral infection occurring in the first 28 days of life. It causes significant morbidity and mortality, although the outcome can be improved by early recognition and prompt treatment by health professionals. This article describes the most common causes of sepsis, and explains why neonates are particularly vulnerable to infection. It highlights the non-specific way in which an infant with a serious infection may present, indicating the crucial features to elicit during history taking and examination, and emphasising the ‘red-flag’ signs and symptoms that should increase suspicion of a serious illness. The authors have adapted National Institute for Health and Care Excellence guidelines to produce an evidence-based approach to the management of an infant with suspected sepsis, and describe the roles of nurses in ensuring effective treatment and best outcomes for these babies.

Introduction The genetic association of Coeliac Disease (CD) and Type 1 Diabetes Mellitus (T1DM) is well known. Although NICE does not include annual screening for CD in the T1DM guidance,1 children with T1DM are routinely screened for CD in England. The incidence of children with CD on gluten free diet (GFD) developing T1DM appears to be small.2 The value of screening for T1DM in CD patients is thus not known. Methods A 4-year retrospective review was conducted of a case series of children with known CD attending outpatient clinic across 4 centres. Patients were diagnosed as per ESPGHAN guidelines. In these centres HbA1c is tested as part of the CD annual review to detect impairment of glucose metabolism (> 41 mmol/mol). Abnormal HbA1c was documented in patients with CD. Results 345 children with CD who had HbA1c screening were identified. Children with T1DM diagnosed prior to developing CD were excluded from analysis. Six of the 345 patients (1.7%) were identified with an abnormal HbA1c. Only 2/6 were confirmed as having T1DM (1 within 4 months of diagnosis); 2/6 had subsequent glucose tolerance tests that were normal, 1 patient had Turner’s syndrome and was taking growth hormone, which has an impact on glucose metabolism, and 1 patient is undergoing further investigations for Type 2 Diabetes Mellitus (high BMI). Discussion The findings confirm the conclusion of previous studies that showed that a new diagnosis of T1DM in known CD children is uncommon. The annual screening for T1DM in children with CD who have developed impaired glucose tolerance is questionable. There is no standard screening test for T1DM, and HbA1c as a screening test for T1DM is also not routinely used. The exact mechanism for expressing coexisting autoantigens that generate both autoimmune conditions is poorly understood, and it is not clear whether the GFD in CD plays a role. Reference National Institute of Health and Care Excellence (NICE) (2020) ‘Management of children and young people with type 1 diabetes’. Available at: https://cks.nice.org.uk/topics/diabetes-type-1/management/management-children-young-people/ Ludvigsson JF, et al. ‘Celiac disease and the risk of subsequent type 1 diabetes’. Diabetes Care29:2483–2488, 2006

Background The coeliac disease (CD) guidelines were updated by ESPGHAN in 2020 confirming that children (0–16yrs) with TGA-IgA titres ≥10x upper limit of normal (≥10xULN) and positive EMA result can safely be diagnosed with CD via the no-biopsy pathway (NBP). This practice is well adopted in the UK and has led to prompt diagnosis, reduction of the burden on endoscopy services and significant cost saving to the NHS. The COVID-19 pandemic has led to unprecedented challenges for the health service especially endoscopy services. We rarely observed non-diagnostic histopathology TGA-IgA ≥5x ULN in our unit which receives referrals from whole of Southwest England. Aims To explore the relationship of TGA-IgA ≥5x ULN with histological diagnosis of CD in children referred to a single large tertiary centre. Methods Prospectively recorded data for children diagnosed with CD following endoscopy over 14-year period (September 2006 to August 2020) was analysed. The data included age, sex, reason for screening, indication for endoscopy, TGA-IgA levels at endoscopy, and histological findings. Where quantitative TGA-IgA was unavailable or not recorded were excluded from the analysis. Statistical analysis was performed using χ2 analysis and p Results 947 children had endoscopy, but 871 had complete data and were included in final analysis. 772/871 received a histological confirmation of CD by Marsh-Oberhuber histological grading (MO-HG) 2 to 3c. 441 had TGA-IgA ≥5x and 439 (99.5%) had a positive histological diagnosis. The likelihood of a positive biopsy with TGA-IgA ≥5x titre (439/441) compared to TGA-IgA 10 ULN. The mean and median ages of the patients with confirmed CD (n=772) was 8.68 years and 9.1 years respectively (range 0–17 years), with a male to female ratio ≈ 1:2. Figure 1 shows the outcome of the 947 children who had endoscopy. Conclusion This study showed that 99.5% of children with TGA-IgA ≥5xULN had clear histological confirmation of CD with p

Fever is a natural and almost universal mammalian response to infection. There exists a fear amongst general public and healthcare providers regarding fever being harmful leading to its overzealous management with antipyretics. Although the National Institute for Health and Care Excellence (NICE) guidelines suggest the use of single antipyretic agent for management of fever, combination therapy with paracetamol, and ibuprofen is common in paediatric practice in the United Kingdom. These antipyretics at times can cause significant adverse events even when administered at regular therapeutic doses. We describe a young boy who presented with significant hypothermia (34.1°C) and was initially treated as cold sepsis. Once the boy got warmed up and as blood results became subsequently available, it became clearer that the hypothermia was secondary to therapeutic doses of antipyretics. In conclusion, we hope to improve awareness regarding this condition in clinical practice and educate health care professionals and caregivers with recommended NICE guidelines.

Chest X-ray (CXR) is one of the most common radiological investigations undertaken in practice with children. CXRs are requested for a number of suspected diagnoses, including pneumonia, pneumothorax and foreign body aspiration or ingestion. They may also be requested as part of a skeletal survey or to confirm the position of central and umbilical lines, as well as nasogastric tubes. Nurses play a vital role in ensuring that X-rays are performed in a safe and timely manner, and to ensure children are supported and positioned appropriately to obtain the best quality images. It is useful for nurses working with children to understand the underlying mechanism and rationale for requesting X-rays because this helps them to communicate the relevance of the procedure to other team members. This article provides an overview of the fundamental principles of obtaining a CXR and interpreting the images.

Reflex anoxic seizures (RAS) present with a transient loss of consciousness and are triggered by an unexpected stimuli. These are paroxysmal, short-lived episodes of pronounced bradycardia or transient asystole; the episodes are self-limiting, lasting between 15 seconds and 1 minute. RAS are an important differential diagnosis of transient loss of consciousness but they are commonly misdiagnosed as epileptic events. An accurate and focused history is key to the diagnosis. They are mostly managed by performing an ECG to rule out other causes of arrhythmia, with subsequent explanation of the condition and reassurance given to parents. Nurses play an important role in eliciting the history and providing support to parents following the diagnosis. This article addresses the epidemiology and pathophysiology of RAS, with suggestions for management. An illustrative case study is included to highlight some of the challenges that health professionals working in different clinical set-ups are likely to come across while managing a child with RAS.

Neonatal infection has been recognised as the third most common cause of neonatal death globally.1 In the UK, a retrospective analysis that spanned over 30 neonatal units from 2005 to 2014 found the incidence of neonatal infection was 6.1 per 1000 live births and 48.8 per 1000 neonatal admissions.2 The incidence of early-onset neonatal sepsis (EONS) in the UK was 0.7 per 1000 live births.2 The National Institute for Health and Care Excellence (NICE) published the first guideline (CG149) intended for management of early-onset sepsis in 2012; this has been updated (NG195) in 2021.3 The guideline refers to the use of Kaiser Permanente Sepsis Risk Calculator (KPSRC), which applies a multivariable modelling approach to predict individualised risk of EONS.4 The KPSRC has been used widely across the world; published reports indicate a significant reduction in antibiotic use without missing true cases of EONS.4–6 The current guideline (NG195) provides new recommendations for intrapartum antibiotics and details the risk factors for infection. It refers to the assessment of risk using the KPSRC, lists the clinical indicators of possible infection and recommends management of late-onset neonatal sepsis (LONS). This guideline should be used in conjunction with existing NICE guidelines on meningitis (bacterial) and meningococcal septicaemia in under 16s (CG102), urinary tract infection (CG54), sepsis (NG51), fever in under 5s (NG143) and specialist neonatal respiratory care for babies born preterm (NG124) (see box 1). Box 1 ### Resources

Nutrition in the postnatal period is essential to achieve optimal growth and maintain biochemical normality. Feeding growth-restricted premature neonates remains a big challenge for pediatricians and neonatologists. The choice of milk is one of the biggest challenges. Breast milk is recommended, although feeding with preterm formulas can ensure a more consistent delivery of optimal levels of nutrients. The timing of introduction of feeds and the rate of advancement of those feeds in preterm infants are both topics of significant controversy. Early feeding is advantageous because it improves the functional adaptation of the gastrointestinal tract and reduces the duration of total parenteral nutrition. A faster rate of advancement will also reduce the duration of need for parenteral nutrition. Despite this, enteral feeding is often delayed and is often slowly increased in high-risk infants because of a possible increased risk of necrotizing enterocolitis (NEC). Growth-restricted neonates are at increased risk of developing NEC due to a combination of antenatal and postnatal disturbances in gut perfusion. If enteral feeding is introduced earlier and advanced more quickly, this may lead to increased risk of NEC, but slower feeds extend the duration of parenteral nutrition and its risks and may have adverse consequences for survival, growth, and development. Premature infants pose a significant nutritional challenge. Overall, we would suggest the preferential use of human breast milk, early minimal enteral feeds, and standardized feeding protocols with cautious advancements of feeds to facilitate gastrointestinal adaptation and reduce the risk of NEC, however further research is needed.

Chickenpox is an extremely contagious infectious disease caused by varicella zoster virus (VZV). It is a common childhood illness characterised by an itchy vesicular rash and fever, which usually resolves spontaneously without medical intervention. Serious, and rarely fatal, complications can occur, including pneumonia, central nervous system infection, overwhelming secondary bacterial infections, especially with Group A streptococcus, and necrotising fasciitis. Therefore it is crucial that emergency department (ED) nurses can recognise the signs and symptoms that indicate deterioration. This article reviews best practice management of children with chickenpox, gives up-to-date guidance on the safe use of antipyretics, the avoidance of ibuprofen and discusses immunisation against VZV. It also includes implications for nursing practice and a case study that illustrates some of the challenges that ED nurses may encounter.

Respiratory tract infections (RTIs), including community-acquired pneumonia (CAP), bronchiolitis, viral-induced wheeze and croup, account for more primary care consultations than any other illness group and are the most likely reason for a parent or carer to contact a health professional. The majority of RTIs in fully immunised children are usually self-limiting. However, in a small percentage of children RTIs may become life threatening and it is crucial that all front-line health professionals are able to recognise and identify these children who are at risk of deterioration. To ensure this, fast recognition of symptoms is important, with care taken to exclude any ‘red flag’ features that may prompt a referral to secondary care. Nurses are well placed to reassure and support families, and to provide education regarding the facts about fever, the appropriate use of a single antipyretic medication, how to avoid dehydration in children with RTIs, and the beneficial role of immunisation in preventing infection. It is also important to explain in cases of CAP where antibiotics are necessary about how soon to expect a response, any side effects from antibiotics, and to provide ‘safety net advice’ on when to consider reassessment for the child. An illustrative case study is included to highlight some of the challenges that are likely to be encountered in clinical practice.

Summary Background Bronchiolitis is the most common reason for hospitalization in young children. In addition to respiratory syncytial virus (RSV), other viruses have been increasingly implicated. Guidance on testing has also changed. Aims To compare clinicopathological outcomes in young children admitted with bronchiolitis due to RSV in comparison with rhinovirus (RV), and identify associated risk/epidemiological factors. Methods Children aged less than two years admitted to hospital with a clinical diagnosis of bronchiolitis with positive results for either RSV or RV were included in this study. Polymerase-chain-reaction-negative cases using an extended respiratory virus panel served as a control group. Retrospective data were collected on sex, risk factors, respiratory support, intravenous fluids and antibiotics. Outcomes such as length of stay (LOS) and need for transfer to the high-dependency unit/paediatric intensive care unit were included. Findings Two hundred and twenty-seven out of 437 nasopharyngeal aspirate samples were positive for either RSV (N = 162) or RV (N = 65). The median age of cases was three months and 75% had at least one risk factor. Risk factors were higher in the RV group (P = 0.004). RV accounted for the majority of cases outside the RSV season (P

Foreign body ingestion and foreign body aspiration commonly affect young children between 6 months and 6 years. A large number of these events remain unwitnessed and asymptomatic while the swallowed foreign body traverses the gastrointestinal tract and is passed in the stool. Recent literature has shown an increase in morbidity associated with button battery and (neomydium) magnet ingestions in children, particularly over the last decade. Early identification and management in a time critical manner is required in cases where button batteries get lodged in the oesophagus or multiple magnets are swallowed. Deaths, although rare, have been reported with these dangerous foreign body ingestions in children where diagnoses were delayed. Nurses through their direct contact with children in different clinical settings play a vital role in managing foreign body ingestions.

Children who present with transient loss of consciousness (T-LOC) are often first seen in emergency departments (EDs). Reflex anoxic seizure (RAS), vasovagal syncope and prolonged respiratory apnoea are benign, syncopal events that can be generally managed by explanation and reassurance. RAS is a short, paroxysmal, self-reverting episode of asystole that is triggered by pain, fear or anxiety and is caused by increased vagal response. It is an important differential diagnosis in pre-school age children who present with T-LOC, but is often underdiagnosed and can sometimes be misdiagnosed as epilepsy. Nurses working in EDs are among the first healthcare professionals to see children in acute settings and should therefore be aware of RAS, the presenting features and management options. This article discusses the epidemiology, pathophysiology and management of RAS, includes an illustrative case study and discusses the role of ED nurses.

Diabetes mellitus (type 1) is an autoimmune condition leading to absolute insulin deficiency resulting in hyperglycaemia and its associated manifestations. It is the most common type of diabetes seen in children, characterised by the 4Ts (toilet, thinner, thirsty, tired). The signs and symptoms can sometimes be non-specific and a delay or missed diagnosis may be catastrophic to the health of the child. Children with an established diagnosis of diabetes often present to the health service with issues such as hypoglycaemia, hyperglycaemia, or diabetic ketoacidosis. The condition requires life-long monitoring and strict control of blood glucose levels with insulin replacement therapy, with the aim of achieving an HbA1c level of 48 mmol/mol. There are often physical and psychosocial issues that arise from the diagnosis leading to poor control. Nurses working in different clinical settings play a vital role in raising suspicions of diabetes leading to timely diagnosis and rapid initiation of treatment. They are best placed to provide essential support in helping children and their families to come to terms with the diagnosis, as well as manage this chronic condition by addressing the common issues that arise in the ongoing management, with a particular emphasis on managing the various day-to-day challenges. Two case studies are included to highlight some of the challenges that nurses may encounter while managing children with diabetes.

Rationale and key points Measuring and monitoring growth in infants and young children under two years old is an important part of their clinical assessment in hospital and the community. This article outlines the procedure for measuring growth in infants and children under two years old, and discusses the main factors to consider when undertaking this assessment. » The procedures and some of the data used to monitor the growth of infants and children under two years old differs from those used in older children. » Obtaining growth information for an infant or child involves measuring and recording their length, weight and head circumference. The process of obtaining this information is not necessarily straightforward and errors may occur while measuring and plotting or interpreting data. » Correct use of growth measuring equipment and growth charts is essential to obtain accurate results. Nurses should be able to plot weight, length and head circumference data for infants and children under two years old, and to correctly interpret this data to identify malnutrition and faltering growth. Reflective activity 'How to' articles can help you update your practice and ensure it remains evidence-based. Apply this article to your practice. Reflect on and write a short account of: 1. How you think this article will change your practice when you assess growth in infants and children under two years old. 2. What practical experience you require to consolidate your learning, having read this article. 3. Any learning needs that you have identified that would increase your clinical effectiveness and professional development.

Foreign body ingestion and foreign body aspiration commonly affect children. The most vulnerable age is between six months and four years, when children tend to explore new objects with their mouths. Many of these events remain asymptomatic, with the swallowed object passing through the gastrointestinal tract without causing harm. However, the frequency of serious complications as a result of the ingestion of hazardous objects has increased in recent years, in particular button batteries and magnets. To increase the likelihood of identifying foreign body ingestion and aspiration, healthcare professionals should maintain a high index of suspicion, be aware of the variation in presentations and include it as a differential diagnosis in children presenting with non-specific symptoms, such as fever, cough, drooling, dysphagia and abdominal pain. Management of most foreign body ingestions is conservative, using a 'watch-and-wait' approach. Children should be triaged as an emergency if they have signs or symptoms of airway obstruction or a history that indicates dangerous foreign body ingestion. Early recognition and management leads to improved outcomes for patients. Nurses have a vital role in providing education and practical advice to parents, which reduces the occurrence of these events. Stronger legislation is required to ensure manufacturers emphasise the potential dangers of certain products and design child-safe devices.

Systemic lupus erythematosus (SLE) is an autoimmune multisystem disease. Childhood-onset SLE is extremely rare and comprises only 10% to 20% of all cases. In this case report, we present a 9-year-old boy from northeastern India who presented with fever, cough, vague abdominal pain, lethargy and swelling of face and legs. Initial impression was one of sepsis with central nervous system (CNS) involvement and was treated accordingly. Detailed clinical examination with subsequent laboratory and imaging studies clinched the diagnosis of SLE. The patient showed rapid resolution of symptoms with immunoglobulins, cyclophosphamide and steroid therapy. A brief discussion on childhood neuropsychiatric lupus syndrome and SLE with CNS infections is included here.

Coeliac disease (CD) is an immune-mediated systemic disorder caused by the ingestion of gluten. In children, it may present with intestinal or extra-intestinal manifestations such as diarrhoea, weight loss, iron deficiency anaemia or faltering growth. Diagnosis is confirmed by small bowel biopsies showing histological changes consistent with enteropathy. In 2012, the European Society for Paediatric Gastroenterology, Hepatology and Nutrition revised the CD guidelines and suggested that, in a selective group of symptomatic children, CD can be diagnosed without the need for small-bowel biopsies. Management of CD is through strict adherence to a life-long gluten-free diet (GFD). CD is of great public health significance as its prevalence in developing countries has been found to be similar to that in developed countries. Early recognition and treatment improves prognosis. Patients and families require long term support to enable effective adherence to a GFD lifestyle. This alone can be challenging, but through support of health professionals and dietitians, can improve patient outcomes. In resource-limited settings medical professionals need to be creative in formulating cheaper and locally sourced gluten free options in close cooperation with the dietitians thereby ensuring availability of gluten free food items at affordable prices. In this paper, we gave an overview of the subject followed by authors’ view to emphasize the need for improved awareness in resource-limited settings.

In 2012, the European Society for Paediatric Gastroenterology, Hepatology and Nutrition (ESPGHAN) revised diagnostic guidance for paediatric coeliac disease (CD).1 It recommended a no-biopsy pathway (NBP) for symptomatic children if so-called ‘triple test’ criteria are satisfied1: The British Society of Paediatric Gastroenterology, Hepatology and Nutrition adopted the guidelines in 2013. ESPGHAN suggested that CD can only be diagnosed by paediatric gastroenterologists or consultant paediatricians with special interest (SPIN) in gastroenterology.1 Many secondary care centres (SCC) in the UK have no SPIN consultant, therefore CD diagnosis is often made by (non-SPIN) general paediatricians. The NBP was implemented in Southwest England (SWE) in May 2013.2 An electronic register is maintained in …

Enteroviral meningitis in infants and children commonly leads to hospital admission. Diagnosing viral meningitis can be difficult clinically. We examined the usefulness of enteroviral polymerase chain reaction (PCR) testing using cerebrospinal fluid (CSF) samples on clinical practice by comparing positive enteroviral CSF PCR cases (n = 39/136) to negative controls using both clinical outcomes and laboratory parameters. A positive result correlated with a reduced admission to high dependency unit, reduced the duration of antibiotics and a shorter length of stay (P .05). Adjusted CSF white cell count 5/μL correlated with positive PCR (P .05) but would have missed 32% of cases of enteroviral meningitis. Following these findings, an algorithm for the management of suspected viral meningitis has been introduced.

Feverish illness is one of the leading causes for a child to be seen by healthcare professionals, and is a major cause for hospital admissions. In 2007, the National Institute for Health and Care Excellence (NICE) published the original guidance on feverish illness in children (CG47). This was developed to aid healthcare professionals in their decision-making process while managing children aged

Diabetes mellitus is a common condition in children, characterised by chronic hyperglycaemia resulting from an absolute insulin deficiency. It can present in various ways, and hospital admission may result from complications related to previously diagnosed diabetes, or from a new diagnosis. To raise awareness of the condition, Diabetes UK has launched the 4Ts campaign, which highlights the four most common symptoms of diabetes. This article discusses the different clinical presentations, diagnosis and management of children with diabetes, and includes two case studies to illustrate some of the challenges faced by emergency department nurses.

Irritable bowel syndrome (IBS) is the most common cause of non-organic recurrent abdominal pain in children. IBS is a clinical diagnosis, which is based on the Rome IV criteria for functional gastrointestinal disorders in children, as well as the patient's history. The diagnosis of IBS is established following the exclusion of organic causes of recurrent abdominal pain. Staggered investigations should be avoided because they might increase the child's and family's anxiety in the absence of an organic diagnosis. In most cases, providing a positive diagnosis of IBS and explaining the current understanding of the functional pathophysiology of the condition and management strategies gives reassurance to the child and their family. Management is based on dietary, pharmacological and biopsychosocial interventions. IBS can be a debilitating condition, with effects on activities of daily living, education and social interactions. Nurses working in various clinical settings will encounter children with IBS and have an important role in the management of children with this condition.

Head injury is the most common cause of injury-related death and permanent disability in children. Minor head trauma is common in childhood and does not require any medical treatment. Although deficits can occur even after mild to moderate head injury, they are markedly greater and become clinically evident following severe head injury. It is important that emergency department clinicians are aware of the signs and symptoms that indicate severe traumatic brain injury and triage for urgent intervention in those children who present with these signs and symptoms. Clinicians also need to know when children can be sent home with reassurance and information, and when they require admission or transfer to a neurosurgical unit. This article examines the literature on head injuries in children, describes assessment, management and treatment, and provides a simple management algorithm.

Children with a petechial rash commonly present to emergency departments. The rash can be associated with serious illnesses, such as invasive meningococcal disease (IMD), but is usually associated with less severe conditions. This article discusses the common and important causes of petechial rash, including IMD, viral illnesses, trauma, Henoch-Schonlein purpura and idiopathic thrombocytopenic purpura. It also analyses the National Institute for Health and Care Excellence (NICE) ( 2014 ) pathway for management of petechial rash in children and examines treatment of the various causes. The article includes two relevant case studies and discusses the role of emergency nurses.

Children with red swollen eyes frequently present to emergency departments. Some patients will have orbital cellulitis, a condition that requires immediate diagnosis and treatment. Orbital cellulitis can be confused with the less severe, but more frequently encountered, periorbital cellulitis, which requires less aggressive management. Delayed recognition of the signs and symptoms of orbital cellulitis can lead to serious complications such as blindness, meningitis and cerebral abscess. This article describes the clinical features, epidemiology and outcomes of the condition, and discusses management and treatment. It also includes a case study.

Coeliac disease is an autoimmune condition caused by the ingestion of gluten-containing foods and affects about 1% of children and young people in the UK. Classic symptoms include diarrhoea, bloating, weight loss and abdominal pain. However, extra-intestinal manifestations, such as iron deficiency anaemia, faltering growth, delayed puberty and mouth ulcers, are increasingly being recognised. Some children have an increased risk of developing coeliac disease, such as a strong family history, certain genetic conditions and type 1 diabetes, therefore there is a need for increased awareness and early diagnosis before symptoms occur. If coeliac disease is suspected, a child should have serological screening with anti-tissue transglutaminase titres. Diagnosis is traditionally confirmed by a small bowel biopsy while the child remains on a 'normal' diet that does not exclude gluten. More recently, for a selective group of children, modification of the European Society for Paediatric Gastroenterology, Hepatology and Nutrition guidelines has enabled non-biopsy (serological) diagnosis of coeliac disease. Children's nurses have an important role in recognising and diagnosing coeliac disease earlier as well as offering ongoing dietary support. Enabling children to maintain a gluten-free diet is essential for general wellbeing and preventing long-term complications.

Febrile convulsions (FCs) are characterised by convulsions associated with fever in children aged between 6 months and 6 years. FCs are relatively common and affect 3–4% of children in western countries. This is the most common seizure disorder seen in children. The cause of febrile illness in FC is usually benign and most frequently due to acute viral infection. Convulsions secondary to an intracranial infection (e.g. meningitis, encephalitis) or from acute electrolyte imbalance should not be labelled as FCs. The diagnosis is based mainly on clinical history, and further investigations are generally unnecessary; management is largely symptomatic. Prolonged FC may need anticonvulsant medication to stop the seizure. Referral to paediatric neurologists may be considered in cases of complex or recurrent FC or in children where there is a pre-existing neurological disorder. One third of children with a first FC will develop a further FC during subsequent febrile illness; the likelihood increases in presence of other risk factors. This article outlines the presentation, management, investigations and prognosis for FC, and highlights how nurses in different clinical settings can provide education, support and counselling to help families return to normality after the event. An illustrative case study is also included to highlight the challenges faced by health professionals while managing children with this condition.

A newborn male infant was admitted to the neonatal unit with suspected early onset neonatal sepsis for monitoring and intravenous antibiotics. Despite his initial normal clinical and laboratory parameters, cerebrospinal fluid cultures done on day 4 of life confirmed Streptococcus oralis meningitis. His mother became unwell shortly after labour, and grew Streptococcus oralis in her blood cultures. Both were successfully treated with antibiotics and made a full recovery. Streptococcus oralis has been associated with meningitis in patients receiving spinal anaesthesia or following dental work, but is an uncommon cause of neonatal meningitis and maternal sepsis. We describe the first case in the literature where a mother-baby pair developed invasive non-pyogenic streptococcal disease with the same organism. There is a need for robust guidelines on antibiotic therapy in these cases.

Commentary on: Mukhopadhyay S, Taylor JA, Von Kohorn I, et al . Variation in sepsis evaluation across a national network of nurseries. Pediatr 2017;139:e20162845. Neonatal sepsis is a leading cause of morbidity and mortality. However, there are substantial differences in the practice of risk assessment of neonates with suspected EOS. Attempts have been made to streamline the management pathways in the USA, UK and elsewhere through publication of the national guidelines.1 2 A rational approach is needed to …

Coeliac disease is an immune-mediated systemic disorder caused by ingestion of gluten. The condition presents classically with gastrointestinal signs including diarrhoea, bloating, weight loss and abdominal pain, but presentations can include extra-intestinal symptoms such as iron-deficiency anaemia, faltering growth, delayed puberty and mouth ulcers. Some children are at higher risk of developing coeliac disease, for example those with a strong family history, certain genetic disorders and other autoimmune conditions. If coeliac disease is suspected, serological screening with anti-tissue transglutaminase titres should be performed and the diagnosis may be confirmed by small bowel biopsy while the child remains on a normal (gluten-containing) diet. Modified European guidelines recommend that symptomatic children with anti-tissue transglutaminase titres more than ten times the upper limit of normal, and positive human leucocyte antigen (HLA)-DQ2 or HLA-DQ8 status, do not require small bowel biopsy for diagnosis of coeliac disease. Management of the disease involves strict adherence to a lifelong gluten-free diet, which should lead to resolution of symptoms and prevention of long-term complications. Healthcare professionals should be aware of the varied presentations of coeliac disease to ensure timely screening and early initiation of a gluten-free diet.

Apart from causing the majority of episodes of gastroenteritis in children, rotaviruses can also cause systemic illnesses such as encephalitis, hepatitis, and acute haemorrhagic edema. Infectious rotavirus particles have been demonstrated in the blood and CSF and more associations are to be expected. This case series present a new association of encephalopathic state and vasculitic rash in 3 children who were found to have rotavirus on stool testing. Rotavirus can mimic serious bacterial infections including meningococcaemia and meningitis and any child presenting with vasculitic rash, encephalopathy and gastroenteritis should have a stool sample examined for rotavirus. Awareness of this association will help paediatricians provide a definitive diagnosis for some children presenting with signs of meningococcal sepsis who test positive for rotavirus.

The causes of febrile convulsions are usually benign. Such convulsions are common in children and their long-term consequences are rare. However, other causes of seizures, such as intracranial infections, must be excluded before diagnosis, especially in infants and younger children. Diagnosis is based mainly on history taking, and further investigations into the condition are not generally needed in fully immunised children presenting with simple febrile convulsions. Treatment involves symptom control and treating the cause of the fever. Nevertheless, febrile convulsions in children can be distressing for parents, who should be supported and kept informed by experienced emergency department (ED) nurses. This article discusses the aetiology, clinical presentation, diagnosis and management of children with febrile convulsion, and best practice for care in EDs. It also includes a reflective case study to highlight the challenges faced by healthcare professionals who manage children who present with febrile convulsion.

Accidental hanging is rare in childhood but is often fatal. Window blind cords pose a particular and unique risk to young children in the UK, accounting for one to two deaths annually. These accidents are frequently associated with non-adherence to the safety instructions provided by the manufacturers. Early discovery of the child and initiation of effective cardiopulmonary resuscitation at the site of the incident are likely to improve the outcome. Prolonged suspension, children who are pulseless at first contact by the emergency paramedic responder, and patients with prolonged periods of remaining in asystole before return of spontaneous circulation after starting cardiopulmonary resuscitation are unlikely to have intact neurological survival. Management in the hospital includes early airway protection by intubation, maintenance of normal oxygen saturation, normothermia, active control of clinical and sub-clinical seizures, and strict electrolyte and glucose regulation. Child safeguarding concerns should be considered when children have asphyxial injuries, and other signs of child physical abuse should be actively looked for. There is a need for stronger legislation in the UK to prevent some of these accidents, especially those relating to window blind cords.

To document the frequency at diagnosis and evolution over time of inflammatory bowel disease-unclassified in children. Analysis of case records (2004–2011) of patients diagnosed with inflammatory bowel disease-unclassified following uppergastrointestinal endoscopy, ileocolonoscopy and small bowel imaging. Any subsequent diagnostic reclassification by 2016 was recorded. 344 children diagnosed as inflammatory bowel disease: 58% Crohn’s disease, 34.5% ulcerative colitis, and 7.5% (n=26) inflammatory bowel disease-unclassified. 25/26 inflammatory bowel disease-unclassified patients were followed for 4.5–11.5 years. 17 of these patients needed endoscopic reevaluation leading to changed diagnosis in ten (Crohn’s disease 7, ulcerative colitis 3). 7.5% (25/344) of inflammatory bowel disease children had inflammatory bowel disease-unclassified at diagnosis; 10 (40%) evolved into Crohn’s disease or ulcerative colitis.

Eating disorders form a group of mental health conditions characterised by abnormal eating habits and are associated with high mortality rates. This article provides nurses working in various settings with evidence-based strategies to identify, manage and refer children and young people with eating disorders. It explores what eating disorders are, and their association with physical and psychiatric co-morbidities. Eating disorders have a significant effect on children and young people's health and development, and nurses have a vital role in managing them. This article presents a case study that illustrates some of the challenges nurses may experience when managing children and young people with eating disorders.