Swelling, usually acute, non-pitting. May be erythema too. Typically affects face, especially lips, tongue, eyes, but can be limbs, even internal!
Usually related to urticaria (wheals). As with urticaria, can be allergy – clue is consistent trigger, pattern of recurrent episodes – but can have other causes.
Angioedema without urticaria – consider hereditary or drugs, especially NSAIDs and ACE inhibitors.
Pumps particularly good for recurrent hypoglycaemia, suboptimal control, under 5s, better QOL.
Good for sport.
Parents report loss of control!
Continuous blood glucose monitoring – 6 days, twice daily calibration bloods. Not Prescribable. Some link to pumps, others diagnostic only. Newest pumps can auto-adjust rate but only downwards. Esp normal pre-prandial bloods but Suspected hyperglycaemic between meals.
Ketones cause insulin resistance so higher doses acceptable. Blood ketone over 3 must come to hospital, but no fixed need for IV therapy.
Tight glucose from diagnosis seems to give best results in long term – “metabolic memory”? Prolonged honeymoon phase? Better education?
ADAPT study starting, prevention.
Only 15g snack allowed if on pen eg half apple! Else low carb eg cheese, pepperoni. Pumps allowed snacks of any size, tend to calm down after first couple of weeks!
Digestion v variable. High fat, high carb? Glycemic index ie fibre. Chewing!
Pump can bolus with individual courses! Slow bolus for cinema or buffet meal eg over 30 mins.
Non-waterproof pumps disconnected for bath etc, shower cap applies to cannula site, leave pump running to avoid air space.
Beware 2 problems, with additive or compensatory effects e.g. foot and hip!
Metatarsus adductus is common. Outer edge of foot is curved, and vertical line through heel misses 2nd/3rd toe space. Rigid forms need serial casting, else 90% improve without treatment by 6-9 months of age.
Internal tibial torsion can be seen by keeping patellae parallel (sitting, or kneeling), and seeing angle of foot. No treatment required unless severe (tibial rotational osteotomy).
Femoral ante version is more common in girls and often familial. W posture sitting, patella points in, eggbeater pattern running. 80% resolve spontaneously, else osteotomy (but high rate of complications).
Out toeing normal in first 24 months. Usually external tibial torsion; occ femoral retroversion. External tibial torsion associated with patellofemoral instability. Beware Perthes and SUFE in school age children, esp unilateral.
Pes Planus – Flexible or rigid? Arch reforms on tiptoeing? Rigid suggests congenital vertical talus (rocker bottom heel) or JIA, either way, usually painful. Beware CP or muscular dystrophy or connective tissue disorder. Asymptomatic is considered benign. Insoles may be useful for pain and shoe deformation, do not correct flat foot!
(Bow/knock) Gap between knees (intercondylar distance) should be <6cm, gap between ankles (intermalleolar) should be <8cm. Beware rickets, renal osteodysplasia, tumours, skeletal dysplasias. Note association between high impact sport and genu varum – cause or selection? Increased risk of injury/OA in later life… Differential includes Blounts disease (also associated with obesity).
Knock knees exacerbated by external tibial torsion, ligamentous laxity, obesity. Less typical pattern of rickets but seen.
[Yeo, BMJ 2015;351:h3394 – videos too]
Cytotoxic vs vasogenic (resistant to steroids) vs interstitial (obstruction eg meningitis – not steroids, ?osmotic) vs osmotic (CSF, ECF low osmo) vs hypertensive.
In DKA, there is a 25% mortality from cerebral oedema, 34% long term neurodisability.
Presents with headache, irritability, agitation (which can be difficult when child is unwell with something else). Then altered consciousness, posturing, focal neurology (check eye movements, pupils). Classically Cushing’s triad: hypertension, bradycardia, irregular breathing pattern.
Clinical diagnosis really. CT can show (better than MRI!).
Hypertonic saline (2.7 or 3%, 2.5-5ml/kg over 10-15 mins) or mannitol (20%, 0.5-1g/kg over 15 mins), some people prefer hypertonic saline but whatever is closest to hand! Frusemide adjunctive.
Consider Aciclovir if diagnosis unclear (in case herpes encephalitis – CT not great, LP can be non specific).
Brain protection = 30deg head up, midline position. Avoid hypotension. Avoid hypocapnia (intubate and ventilate if in doubt).
Hyponatraemia common – typically due to SIADH but treat any underlying cause, esp hypovolaemia.
Respiratory rate = 40 under 1 yr, 30 between 2 – 5, and 20 over 12
Systolic Blood pressure = 70 – 90 under 1 year, 80-100 between 2 and 5, 90 – 110 between 5 and 12, and 100-120 over 12. [Arch Dis Child. 2007 Apr;92(4):298-303.]
In other words, range of 20 @ every age, increasing by 10 in each group, with a Max of 100 @ 2-5, and a minimum of 100 @ 12+.
300 ml/m2/d – else:
Increase if in hot climate or fever by around 50%.
As usual, any system that has reasonable sensitivity has rubbish specificity (negative predictive value). Retrospective analysis of 9000 UK A&E attendees <15yrs –
[Verbakel, Pediatric Emergency Care 2014; 30: 373–80]
Same author applied rules to different data sets across UK, Netherlands and Belgium, found that all had lower performance than in their original derivation studies, but also wide variation across datasets eg NICE CG160 specificity ranged from 1-28.7%! Hard to understand differences. [BMC Medicine 2013; 11: 10]
Lacour scoring system (“Laboratory-Score”) based on CRP, PCT and urinalysis. Has sensitivity of 94%, spec of 81%. Would reduce incidence of antibiotic use from 65 to 40% but good enough? [Lacour, PIDJ 2008 PMID 18536624]
See NICE CG224 (refers then to CG111 (pyelonephritis) and CG109 (lower tract UTI)): Under 3 months get IV treatment. Else 3 days oral treatment if lower tract, 7-10 days oral for upper tract. IV for vomiting, unable to take oral or severe illness (but also says underlying known anomalies should influence choice) 2-4 days IV then oral for total of 10 days (!). No preference between cefuroxime, ceftriaxone and gentamicin. Upper tract defined as fever else loin pain/tenderness
Cochrane review concluded that 2-4 day course of oral antibiotic is as effective as a 7-14 day course in the treatment of lower-tract UTIs in children. PMID 12535494 The majority of febrile infants with UTI have nuclear scan evidence of pyelonephritis, suggesting that infants should not receive short course treatment.
Also concluded that for pyelonephritis oral antibiotics are as effective as the combination of parenteral followed by oral antibiotics. Based on:
Crucial that oral antibiotics are not vomited, of course.
Gauthier et al treated infants and toddlers with febrile UTIs as outpatients using a single daily dose of intravenous gentamicin until the children were afebrile for at least 24 hours, after which oral amoxicillin (!) was given until the urinary culture report was available. Successful in three quarters. Current Opinion in Pediatrics. 18(2):134-8, 2006
1/3 of UTI E coli resistant to trimethoprim, 2/3 if underlying renal abnormality. 61% of women with UTIs and resistant organisms do not reconsult! So should we use community surveillance to guide prescribing rather than individual culture and sensitivity?
UTI prophylaxis did not reduce recurrent infection (n=611). But lower rate (12%) reported than might be expected. Higher resistance rates are seen in recurrent infections, which could be anticipated (JAMA 2007;298;179)
Same definitions of upper, lower and atypical. 
If USS abnormal, refer for consideration of further imaging.
But:
Studies do not address whether placebo or nothing is worse than prophylaxis (Cochrane: suggests about 36% reduction in infection, but all 3 studies biased, and most other work has prophylaxis vs surgery). Eg Sweden, only screen if additional risk factor, and v low prevalence of scars. Garin study (Paeds 2006) non placebo controlled, found no protection from recurrent infection with antibiotic prophylaxis (the rate for those with reflux was close to significance but seemed to be cystitis rather than pyelo) – plus the bugs were resistant. The rate of scarring was actually higher in the prophylaxis group…
[(Roberts, Kenneth) PIDJ 23(12); 2004:1163-1164 ]
Atypical defined as seriously ill, poor urine flow, abdominal/bladder mass, raised creatinine, septicaemia, failure to respond to appropriate antibiotics within 48 hrs, non-E. coli infection
Recurrent defined as 3 lower tract UTIs, else 1 upper tract plus any other
If another UTI occurs before the DMSA is done, don’t defer DMSA in case scarring already established.
Prophylactic antibiotics for MCUG (1 day before to 1 day after).
See NICE 224 (2022).
Classic symptoms – dysuria, frequency, new wetting, dark or cloudy or smelly urine. Frank haematuria, loin pain. Fever, shivering (rigors), history of UTI.
Clean catch ideally, pad (commercial, not cotton wool balls or gauze) if clean catch unsuccessful. Else catheter. Suprapubic aspiration is an option but needs ultrasound to confirm bladder full.
See Sofia method of urine collection.
Under 3 months – send for culture and microscopy. Urgent?
Microscopy interpretation is simply on basis of pyuria pos/neg, bacteria pos/neg.
Over 3/12, dipstick is standard. A positive dipstick urinalysis for BOTH leucocyte esterase (LE) and nitrite is specific, negative both is a good negative predictor. If dipstick positive for just one, not reliable either way. Metanalysis, Huicho Luis, PIDJ 2002;21:1-11. Previous metanalysis by Gorelick and Shaw (Peds 1999) concluded nitrite/LE tests superior to microscopy!
If nitrites and leucocytes positive, assume infection. Culture only if high risk for serious infection or recurrent UTI.
Nitrites only positive, treat but send culture.
Leucocytes only positive, send culture, treat if classic UTI symptoms or under 3yrs, else await result before treating.
Culture if high risk of serious illness, upper tract signs, poor response to treatment, recurrent UTI.
Most studies show that clean catch is equivalent to suprapubic aspiration (SPA); limited data on pad, nappy or bag specimens.
Uricol (Euron, Newcastle) urine pads. Check at 10 min intervals (discard after 30mins). Cost 18p each. Agrees with clean catch for gluc/ket/blood/nitrite (within 1 block ) but in study only 2 cases with leucocytes so ?reliable.
Health Technology Assessment (Winchester, England). 10(36):iii-iv, xi-xiii, 1-154, 2006 Oct.