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Background: Escherichia coli is the predominant urinary pathogen in children. Irish and international studies have demonstrated increasing antimicrobial resistance (AMR) to antibiotics such as co-amoxiclav., Aims: We aimed to (1) examine the AMR patterns of paediatric urinary E. coli isolates, from both hospital and community sources, over a 10-year period; (2) assess the effectiveness of Children's Health Ireland (CHI) antimicrobial guidance given local susceptibility data; and (3) review the clinical management of an admitted patient sub-set over a 6-year period., Methods: Pure growth of urinary E. coli from patients aged ≤ 14 from 2012 to 2021 were analysed for AMR. Differences in susceptibility rates were assessed. A retrospective chart review conducted on inpatients aged ≥ 2 months to ≤ 14 years, 2016-2021., Results: E. coli accounted for 70.8% of likely significant positive pure growth cultures (9314 isolates). Susceptibility to co-amoxiclav significantly increased over time, from 66.7% to 80.4% (2016-2021, p < 0.001). Nitrofurantoin and cefalexin had significantly higher susceptibility rates than trimethoprim (< 70% annually). 85.1% of isolates were susceptible to the combination of co-amoxiclav and gentamicin, recommended for those > 2months and systemically unwell. The additional gain in empiric susceptibility provided by gentamicin above that provided by co-amoxiclav alone has fallen from 16.4% to 6.7% (2016-2021). The 222 clinical cases reviewed showed improved antimicrobial guideline compliance over time., Conclusions: This study provides important regional AMR data. Co-amoxiclav susceptibility increased significantly over time, contrasting with previous studies. This was temporally associated with stewardship measures reducing co-amoxiclav prescribing. Decreasing utility of gentamicin supports recent CHI guideline updates reducing gentamicin use., (© 2024. The Author(s), under exclusive licence to Royal Academy of Medicine in Ireland.)

A female infant presented to an Irish hospital with a 4-day history of fever, irritability and reduced oral intake. Initial inflammatory markers were significantly elevated, an erythematous tympanic membrane was noted on examination and an initial diagnosis of acute otitis media was made. By the third hospital day, the infant was noted to be irritable when being lifted up; pseudoparalysis of the right upper limb was observed. A radiograph of the right shoulder was normal; MRI identified acute scapular osteomyelitis with subperiosteal abscess formation. The child underwent 3 washout procedures and received 6 weeks of antibiotic therapy, with full clinical recovery at 3 months. This case highlights the importance of remaining flexible in the context of an evolving presentation and recognising hallmarks of musculoskeletal infection, fever, localised pain and pseudoparalysis. Additionally, we review the literature to highlight clues in diagnosis, treatment and outcome for paediatric acute scapular osteomyelitis., Competing Interests: Competing interests: None declared., (© BMJ Publishing Group Limited 2024. No commercial re-use. See rights and permissions. Published by BMJ.)

Competing Interests: None declared

Direct Provision in Ireland provides basic needs of food and shelter to asylum seekers while their refugee status is processed. There are a number of issues associated with living conditions in these centres including overcrowding, nutrition and play facilities (1,2). This article outlines the protocol of contact tracing and management of latent tuberculosis infection in the paediatric setting after a confirmed adult case of tuberculosis within a Direct Provision centre in Ireland. This is a retrospective case series of 82 children living in the centre. Twenty-two children were deemed at risk of infection, all asymptomatic. Sixteen children (20%) were treated for possible latent tuberculosis infection with isoniazid for 6-9 months; compliance was good with no side effects reported. This article highlights the risk to vulnerable populations, especially children, when residing in Direct Provision facilities. Initial migrant screening on entry is essential, in addition to improving living conditions and time spent by families in this living environment., (© 2021. The Author(s), under exclusive licence to Royal Academy of Medicine in Ireland.)

A 7-year-old boy presented with a 24-hour history of severe burning pain affecting both hands that had started within minutes of playing outdoors. His mother reported that he had been running his hands under cold water and shaking his hands and head to try and relieve the pain. On examination, there was swelling of his hands, eyelids and cheeks. His parents mentioned that his hands and face had 'swollen in the sun' every summer from the age of 2 years.A 3-year-old girl presented with a 2-day history of left upper limb swelling following a day of prolonged sun exposure. Examination revealed non-pitting oedema extending from her left shoulder to hand with no associated tenderness, erythema or rash. Her mother reported six previous episodes of irritability following sun exposure during which she would cry and flap her hands 'for hours'.Oral steroids and antihistamines were prescribed in both cases with little effect. Findings of routine baseline investigations were normal in both cases. A radiograph of the upper limb in the second patient disclosed nothing abnormal., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2021. No commercial re-use. See rights and permissions. Published by BMJ.)

Background: Cashew nut (CN) allergy appears to be increasing. Reactions are variable and may include anaphylaxis., Aim: To describe the clinical features of CN allergy in a group of children attending an allergy clinic with suspected peanut allergy and confirmed sensitisation to CN., Methods: Patients were identified retrospectively by reviewing the Immunology Database at University Hospital Galway over a 5-year period, Oct. 2010 to Sept. 2015. Patients confirmed sensitised to CN (specific IgE > 0.35 kUa/L, ImmunoCAP Assay) were selected and contacted., Results: Over the 5-year period, 115 children were identified; 102/115 were individually contacted. Of the 102 children, 55 had a history of prior CN exposure with confirmed clinical reaction, 43 had no prior CN exposure, and 4 were sensitised and tolerating CN. For those with clinical CN allergy (N = 55), 30 (55%) were male and median age of onset was 2 years (lower quartile 1.5, upper quartile 4.8). Severity of reaction was graded as mild for 13 children, moderate in 13 additional children, and severe in 29 children. Median CN serum IgE level was 3.2 kUa/L (range 0.36 to > 100) in the clinical reaction group, 2.91 kUa/L (range 0.36 to > 100) in the sensitised group, and 3.4 kUa/L (range 0.94 to 5.21) in those tolerating CN. IgE values were not significantly different between those with mild, moderate, or severe reaction to CN (p = 0.346)., Conclusion: Children are ingesting CN at a young age with more than half of allergic reactions reportedly severe in nature. The specific CN IgE value was not helpful in predicting severity of reactions.

Kawasaki disease (KD) is the most common systemic vasculitis of childhood. The following presentation of a 4-year-old Irish boy referred to a secondary care paediatric service from the community with prolonged fever, oral mucous membrane changes and painless blistering lesions of the hands and feet in the presence of elevated inflammatory markers serves as an opportunity to discuss the diagnostic criteria and treatment for KD and incomplete KD, an often missed diagnosis with significant paediatric morbidity outside an academic paediatric centre., Competing Interests: Competing interests: None declared., (© BMJ Publishing Group Ltd (unless otherwise stated in the text of the article) 2017. All rights reserved. No commercial use is permitted unless otherwise expressly granted.)

The case commences with an innocuous right ankle injury (lateral malleolus), for which the patient, a 9-year-old boy, was placed in a temporary cast at his local hospital. Three days following this incident, the patient was diagnosed with new-onset type 1 diabetes mellitus. He was admitted to his local hospital with severe diabetic ketoacidosis appropriately treated and subsequently discharged c.1 week later clinically well. Approximately 1 week later, again he presented for a third time with a significant serosanguinous discharge from the site of the initial injury permeating through the temporary cast in place for c.2 weeks by that time. On removal of the cast, a severely invasive infection of bone and soft tissue was noted, and the patient was urgently transferred to our unit at the tertiary general hospital for further management. He underwent a series of orthopaedic and plastic surgery procedures with an eventual satisfactory outcome., Competing Interests: Competing interests: None declared., (© BMJ Publishing Group Ltd (unless otherwise stated in the text of the article) 2017. All rights reserved. No commercial use is permitted unless otherwise expressly granted.)

Codeine is widely prescribed in clinical practice with over the counter (OTC) preparations of codeine freely available for consumption typically as a component of remedies for the common cold/cough. We describe the first reported case of acute confusional state in a previously healthy 14-year-old girl ultimately attributed to inappropriate codeine use. The usage of codeine in the paediatric setting has been highlighted in recent years with many reported deaths--mostly due to respiratory depression. The risks associated with codeine usage may be particularly unnecessary with OTC cough suppressants as evidence of efficacy is absent. Finally, codeine dependence is a common problem among adults and has been reported locally and internationally among adolescents. The combination of lack of efficacy, risk of acute intoxication and dependence, suggests that the use of OTC codeine preparations may be unwarranted., (2015 BMJ Publishing Group Ltd.)

We present the interesting case of a 9-year-old boy with type 1 diabetes mellitus. He presented to the emergency department extremely unwell and the diagnosis of diabetic ketoacidosis was promptly performed. He was started on the local diabetic ketoacidosis (DKA) protocol, but his recovery remained slow. The possibility of an underlying pathology was later addressed and led to the diagnosis of primary adrenal insufficiency. This case highlights the difficulty in diagnosis of childhood Addison's disease due to its vague and non-specific symptoms and the importance of a high degree of clinical suspicion. This case also highlights the existence of autoimmune polyendocrine syndromes and the ongoing need to increase awareness and screening of these conditions., (2014 BMJ Publishing Group Ltd.)

Among unvaccinated populations, primary varicella zoster virus (VZV) infection results in a minor childhood illness for the majority of individuals. Mortality is rare, and fatalities associated with cardiac complications are exceptional. In a population where routine VZV vaccination is not practised, we report a death in a previously healthy child secondary to VZV myocarditis. A literature review of cardiac-related VZV mortality in childhood is included. This identified a further 13 cases where death was associated with or attributable to, direct involvement of the myocardium or conducting system with what is frequently considered a benign childhood illness.

Primary sternal osteomyelitis (PSO) is rare. In a 9-year-old boy with Staphylococcus aureus bacteremia, magnetic resonance imaging helped to promptly establish the diagnosis of PSO. Eleven previously reported cases are reviewed, emphasiz ing surgical drainage and antimicrobial therapy for optimal outcome. Magnetic resonance imaging may be superior to other imaging studies for the diagnosis of PSO.