Paediatrics Clinical Guide - Bradford VTS

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Updated Guidelines 2026:

NICE NG143 fever guidelines updated with revised traffic light system. Kawasaki disease recognition enhanced (NG143 2019 amendment). Bronchiolitis oxygen saturation thresholds updated (NG9 August 2021). New BTS/NICE/SIGN collaborative asthma guidelines (NG245 November 2024) with earlier MART therapy recommendations.

👶

Paediatrics Clinical Guide

Comprehensive clinical knowledge for GP trainees - Bradford VTS Style

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Tea-Friendly Learning

Digestible chunks perfect for your coffee break

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For GP Trainees Short on Time

Quick reference guides and essential knowledge

🚩

Red Flag Focused

Critical signs and when to worry highlighted

Date Updated: March 2026 | Guidelines: NICE NG143 (2026), BTS/NICE/SIGN NG245 (November 2024)

📋 Executive Summary

🎯 Learning Points

ABC + RED BURT systematic assessment approach
NICE traffic light system for fever in under 5s
Emergency drug dosages and protocols
Red flags for serious illness
Safety netting and when to refer
Normal child development and growth assessment
Neonatal screening and NIPE examination
Childhood immunisation schedules

📊 Quick Facts

Children = 20% of UK population
30% are frequent attenders (≥4 visits/year)
Average GP sees 400-600 children per 6 months
Most serious illness occurs <5 years
Parents' instinct usually correct - listen!
90% of meningococcal disease occurs <5 years
Febrile convulsions affect 3% of children

🧭 Quick Navigation

👁️Sick Child 👶Normal Child 🚦Traffic Light 🚨Emergencies 🦠Infections 🫁Chronic Conditions 🧠Development 🍼Neonatal 🛡️Safeguarding 💉Immunisation 🩺Procedures 😴Sleep

📥 Resources & Downloads

Essential resources and quick reference materials

path: PAEDIATRICS

Web Resources:

🔗RCPCH Growth Charts 🔗BNF for Children 🔗Black Country 0-18 🔗Paeds for Primary Care 🔗Spotting the Sick Child Online 🔗NHS Baby Reviews

🧠 Brainy Bites: Essential Paediatric Wisdom

The pearls of wisdom that will make you a paediatric pro

✅ Golden Rules

•Listen to parents: They know their child best - their instinct is usually correct
•Kids can dip and recover: That's normal. What's NOT normal is dipping and not coming back up
•Feeding & fluids: Ask about wet nappies - red flag if none >12hrs
•Resistant to examination? Alert, active children resist examination - if not, red flag
•Communication: Talk to the child as well as the parent - age-appropriate communication builds trust
⚠️
Children Change Quickly! Critical Point: Paediatrics is dangerous because children can be fine one moment and deteriorate rapidly the next (and vice versa).

Always Remember:
- •Provide clear, explicit safety-netting advice
- •Write instructions down if information is complex
- •Trust your instinct
- •Seek another opinion if unsure
- •Consider parental expectations and concerns

🧩 Memory Aids

ABC + RED BURT (Sick Child Assessment):

ABC: Alertness, Breathing, Colour | RED BURT: Responsiveness, Eye contact, Drinking, Breathing, Urine, Rash, Temperature

SOCRATES (Pain Assessment):

Site, Onset, Character, Radiation, Associations, Time course, Exacerbating factors, Severity

4 T's (Cyanotic Heart Disease):

Tetralogy of Fallot, Transposition, Tricuspid atresia, Truncus arteriosus

NIPE Examination:

Eyes, Heart, Hips, Testes (males) - Newborn & Infant Physical Examination

🎯 Clinical Decision Making Framework

Red, Amber, Green approach to paediatric clinical decisions

Key Insight from Dr Edward Snelson (Consultant Paediatrician): Most childhood illnesses are too dynamic for a snapshot to be completely valid. It's not just about the current traffic light - it's about how the lights are changing and what you're going to do with that information.

GGREEN Patients

Easy to manage - Clear decision-making

• Simple viral URTI
• Watchful waiting
• Appropriate safety-netting
• Reassurance to parents

RRED Patients

Easy to manage - Clear action needed

• Meningitis features
• Give benzylpenicillin
• 999 ambulance
• Immediate admission

AAMBER Patients

Complex decisions - Requires careful thought

• Not quite green, not quite red
• Consider trajectory of illness
• Multiple management options
• Where complexity lies

Key Decision-Making Factors:

• Parental confidence: Can they seek appropriate reassessment?
• Safeguarding concerns: Any child protection issues?
• Physiological parameters: Need to document improvement (especially heart rate)?
• Second opinion: Would another clinician's assessment add value?
• Safety netting: Empower parents to make dynamic, continuous assessments

Remember: Children change quickly! Paediatrics is dangerous because children can be fine one moment and deteriorate rapidly the next (and vice versa). Always provide clear, explicit safety-netting advice. Write it down if the information is complex.

🍼 Infant Feeding Guidelines

Essential feeding patterns and volumes for healthy infant development

Key Principle: As babies get older, they settle into more predictable feeding routines and go longer stretches at night without needing feeds.

Age	Volume per Feed	Frequency	Notes
First few days	1.5-3 oz (45-90ml)	Every 2-3 hours	Small, frequent feeds
About 2 months	4-5 oz (120-150ml)	Every 3-4 hours	Establishing routine
About 4 months	4-6 oz (120-180ml)	At each feeding	More predictable pattern
About 6 months	6-8 oz (180-230ml)	4-5 times per day	Weaning may begin

✅ Signs of Adequate Feeding:

• Regular wet nappies (at least 6 per day after day 5)
• Steady weight gain
• Content between feeds
• Alert and active when awake
• Good skin colour and tone

🚩 Red Flags - Feeding Concerns:

• No wet nappy for >12 hours
• Poor feeding or refusing feeds
• Excessive weight loss (>10% birth weight)
• Lethargic or difficult to rouse
• Persistent vomiting
• Signs of dehydration

Important History Questions:

• "How is feeding going?" - Open question first
• "How much are they taking?" - Specific volumes
• "How often are they feeding?" - Frequency pattern
• "When did they last have a wet nappy?" - Hydration status
• "Any vomiting or bringing up feeds?" - Retention
• "How are they between feeds?" - Contentment

"You don't need to be a paediatrician to provide excellent paediatric care. You just need to know when to worry, when to treat, and when to refer. Most children get better with time, TLC, and appropriate safety netting. Trust your clinical judgment, listen to parents, and don't be afraid to seek advice when needed."

— Bradford VTS Clinical Guide

👶 The Normal Child

Development, immunisation, and clinical procedures reference

👶 The Normal Child

Understanding normal development, growth, and behaviour

Key Principle:

Normal development has wide variation. Focus on overall pattern and trajectory rather than isolated delays. Parental concern is always significant.

🧠 Child Development & Growth Assessment

Normal development, growth monitoring, and when to worry

Developmental Milestones

Age	Gross Motor	Fine Motor & Vision	Speech & Hearing	Social & Personal
6 weeks	Holds head up briefly when prone	Follows face/bright object	Coos and gurgles	Social smile
3 months	Good head control when held	Holds rattle briefly when placed in hand	Babbles, laughs	Laughs and squeals with pleasure
6 months	Sits with support, rolls	Transfers objects hand to hand	Double syllables (mama, dada - no meaning)	Stranger awareness begins
9 months	Sits without support, crawls	Pincer grip developing	Says mama/dada with meaning	Waves bye-bye, plays peek-a-boo
12 months	Walks with support (cruising)	Neat pincer grip	First words (2-3 words)	Points to share interest
18 months	Walks independently, runs	Tower of 3 blocks, scribbles	10-20 words, understands simple commands	Symbolic play (feeds doll)
2 years	Runs well, kicks ball, jumps	Tower of 6 blocks, circular scribble	50+ words, 2-word phrases	Parallel play, temper tantrums
3 years	Pedals tricycle, stands on one foot	Copies circle, uses scissors	Sentences, asks questions	Group play, toilet trained

🚩 Red Flags for Developmental Delay:

Motor Development:

• Not sitting by 12 months
• Not walking by 18 months
• Loss of previously acquired skills
• Persistent primitive reflexes
• Significant asymmetry

Speech & Language:

• No babbling by 12 months
• No words by 18 months
• No 2-word phrases by 2 years
• Speech not understood by strangers by 3 years
• Regression in language skills

📈 Growth Assessment:

Normal Growth Patterns:

• Birth weight: Regained by 10-14 days
• 0-3 months: 150-200g/week
• 3-6 months: 100-150g/week
• 6-12 months: 70-90g/week
• 1-2 years: 2-3kg/year
• 2-puberty: 2kg/year

Faltering Growth:

Definition: Sustained drop of 2 centile spaces over 2 weighing intervals on WHO growth chart

🔍 Neonatal Screening

Newborn Blood Spot (Guthrie):

• Day 5-8 of life
• PKU (phenylketonuria)
• Congenital hypothyroidism
• Cystic fibrosis
• Sickle cell disease
• MCADD (metabolic disorder)

Hearing Screening:

• Within first few weeks
• Automated otoacoustic emissions (AOAE)
• Automated auditory brainstem response (AABR)
• Refer if not clear response

NIPE Examination:

• Within 72 hours of birth
• Eyes (cataracts, red reflex)
• Heart (murmurs, pulses)
• Hips (developmental dysplasia)
• Testes (undescended)

🧠 Emotional & Psychological Development

Age	Normal Behaviour	Common Concerns	When to Worry
0-6 months	Crying peaks at 6 weeks, settles by 3-4 months	Colic, sleep patterns	No social smile by 8 weeks
6-12 months	Stranger anxiety, separation anxiety	Sleep regression, feeding issues	No babbling by 12 months
1-2 years	Tantrums, negativism, parallel play	Toilet training, behaviour	No words by 18 months
2-5 years	Imaginative play, questions, fears	Behaviour, sleep issues	No pretend play by 3 years

💉 UK Immunisation Schedule 2026

Current UK childhood immunisation programme

Primary Schedule:

Age	Vaccines	Diseases Protected Against
8 weeks	6-in-1 (DTaP/IPV/Hib/HepB) Pneumococcal (PCV13) Rotavirus MenB	Diphtheria, tetanus, pertussis, polio, Hib, hepatitis B, pneumococcal disease, rotavirus, meningococcal B
12 weeks	6-in-1 (2nd dose) Rotavirus (2nd dose)	As above
16 weeks	6-in-1 (3rd dose) Pneumococcal (2nd dose) MenB (2nd dose)	As above
1 year	Hib/MenC MMR Pneumococcal (3rd dose) MenB (3rd dose)	Hib, meningococcal C, measles, mumps, rubella, pneumococcal, meningococcal B
2-10 years	Influenza (annual)	Seasonal influenza
3 years 4 months	4-in-1 (DTaP/IPV) MMR (2nd dose)	Diphtheria, tetanus, pertussis, polio, measles, mumps, rubella
12-13 years (girls)	HPV (2 doses)	Human papillomavirus
14 years	3-in-1 (Td/IPV) MenACWY	Tetanus, diphtheria, polio, meningococcal ACWY

Administration & Safety

Administration:

• Check identity and consent
• Anterolateral thigh (<1 year)
• Deltoid muscle (>1 year)
• Different sites for multiple vaccines
• Record batch numbers
• Observe for 15 minutes

Contraindications:

• Severe immunodeficiency
• Previous severe reaction
• Acute febrile illness
• Pregnancy (live vaccines)
• Recent immunoglobulin (MMR)

Adverse Events:

• Local reactions common
• Fever, irritability
• Anaphylaxis rare (1:1,000,000)
• Report serious events to MHRA
• Have resuscitation equipment ready

🩺 Paediatric Procedures

Common procedures and measurements in children

Growth Measurements:

• Weight: electronic scales, naked if possible
• Length: <2 years lying, >2 years standing
• Head circumference: largest occipitofrontal
• Plot on appropriate growth charts
• Consider corrected age if premature
• Look for crossing centiles

Venepuncture in Children:

• Use topical anaesthetic (EMLA, Ametop)
• Distraction techniques
• Appropriate restraint/positioning
• Consider butterfly needles
• Antecubital fossa, dorsum of hand
• Reward after procedure

Urine Collection:

• Clean catch (preferred)
• Urine collection pads
• Catheter sample (if urgent)
• Suprapubic aspiration (specialist)
• Avoid bag samples for culture
• Process within 4 hours

🩺 Clinical Stuff

The nitty-gritty clinical knowledge you need

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The 10-Second Doorway Assessment

Before touching the child, quickly observe four things:

Interaction with Environment

Ask yourself:

• Is the child alert and looking around?

• Do they track movement or recognise parent?

• Are they playing or engaging?

⚠️ Red flags: staring blankly, not interacting, difficult to rouse

Activity and Tone

Normal child:

• Sitting upright, moving limbs

• Reaching for toys

• Good muscle tone

⚠️ Red flags: floppy, lying still, limp when picked up, not moving much

Work of Breathing

Look for:

• Tachypnoea

• Subcostal/intercostal recession

• Nasal flaring, grunting

• Head bobbing (infants)

⚠️ Any of these → potential respiratory distress

Colour and Circulation

Look at:

• Skin colour

• Lips

• Hands and feet

⚠️ Red flags: pale, mottled, cyanosed, ashen appearance

💡 Key Point: These four observations can be made from across the room in seconds and give you immediate insight into the child's condition before any physical examination.

✅

Structured Approach: ABC + RED BURT

A simple two-step structured approach for spotting the sick child in primary care:

ABC Doorway Check (5 seconds)

Before examining the child, quickly observe:

Alertness

Level of consciousness and tone

⚠️ Drowsy, floppy, difficult to rouse

Breathing

Work of breathing

⚠️ Recession, nasal flaring, grunting, tachypnoea

Colour

Skin perfusion and oxygenation

⚠️ Pale, mottled, cyanosed

RED BURT Check

Structured assessment covering key clinical domains:

Responsiveness/Behaviour

Playful vs miserable? Interested in toys, surroundings, stethoscope? Floppy or disengaged children are concerning.

Eye Contact

Engaged vs vacant stare. Good eye contact is reassuring.

Drinking

Drinking normally? Not drinking for ~8-12 hours is concerning (especially infants).

Breathing

Signs of respiratory distress such as recession or nasal flaring.

Urine Output

Wet nappies/passing urine? Dry nappies for ~12 hours or markedly reduced urine is concerning.

Rash

Especially non-blanching rash - check with glass test.

Temperature

Fever or hypothermia - both can be concerning.

💎 Clinical Pearls & Essential Rules

Rule of Febrile Thirds

For predicting future febrile convulsions in a child who has had one:

1/3 Will NOT have any more with future febrile illnesses
1/3 Will experience ONE more febrile convulsion
1/3 Will have REPEATED bouts with future illnesses

Avoid Availability Bias

Definition: The tendency to rely on information that comes readily to mind when making decisions.

In Paediatrics: Yes, most kids with cough have viral infections and recover nicely. BUT don't let this cloud your judgment - you're there to assess how they've been and how they are.

Children Change Quickly!

Critical Point: Paediatrics is dangerous because children can be fine one moment and deteriorate rapidly the next (and vice versa).

Always Remember: Provide clear, explicit safety-netting advice. Write instructions down if information is complex.

GP Workload Statistics

• Children make up ~20% of UK population
• Clinical workload increased 9% (2007-2014) in <5 years
• ~25% of patients <18 years visit GP annually
• Average GP sees 400-600 children per 6 months
• 30% of children are frequent attenders (≥4 visits/year)

📋 History & Examination

Key Principles:

• Build rapport with both child and parent
• Age-appropriate communication
• Observe before touching
• Use distraction techniques
• Listen to parental concerns

History Taking Tips:

Opening Questions:

• "What's been worrying you?"
• "How has [child's name] been?"
• "Tell me about the problem"

Red Flag Questions:

• "Any difficulty breathing?"
• "Any rash that doesn't fade?"
• "Any fits or funny turns?"
• "Eating and drinking normally?"

🚦 NICE Traffic Light System

For fever in children under 5 years (NICE NG143 - Updated 2026)

GGREEN - Low Risk

• Normal colour of skin, lips and tongue
• Responds normally to social cues
• Content/smiles
• Stays awake or awakens quickly
• Strong normal cry/not crying
• Normal skin and eyes
• Moist mucous membranes

Management: Home care with safety netting

AAMBER - Intermediate Risk

• Pallor of skin, lips or tongue
• Not responding normally to social cues
• Wakes only with prolonged stimulation
• Decreased activity
• Nasal flaring
• Tachypnoea (>50 breaths/min age 6-12 months, >40 breaths/min age >12 months)
• Oxygen saturation ≤95% in air
• Crackles in the chest
• Tachycardia (>160 beats/min age 6-12 months, >150 beats/min age 12-24 months, >140 beats/min age 2-5 years)
• CRT ≥3 seconds
• Dry mucous membranes
• Poor feeding in infants
• Reduced urine output
• Rigors
• Age 3-6 months, temperature ≥39°C
• Fever for ≥5 days
• Swelling of a limb or joint
• Non-weight bearing/not using an extremity
• A new lump >2cm

Management: Provide safety net or refer for paediatric assessment

RRED - High Risk

• Pale/mottled/ashen/blue skin, lips or tongue
• No response to social cues
• Appears ill to a healthcare professional
• Does not wake or if roused does not stay awake
• Weak, high-pitched or continuous cry
• Grunting
• Tachypnoea (>60 breaths/min)
• Moderate or severe chest indrawing
• Reduced skin turgor
• Age <3 months, temperature ≥38°C
• Non-blanching rash
• Bulging fontanelle
• Neck stiffness
• Status epilepticus
• Focal neurological signs
• Focal seizures
• Bile-stained vomiting

Management: Urgent referral to paediatric specialist

🚨 Paediatric Emergencies

Meningitis & Septicaemia▼

Clinical Features:

• Non-blanching rash (late sign)
• Fever and rigors
• Headache, photophobia
• Neck stiffness (may be absent in infants)
• Altered consciousness
• Vomiting
• Irritability, high-pitched cry
• Bulging fontanelle (infants)
• Cold hands and feet
• Rapid breathing

Emergency Management:

1. Benzylpenicillin IM/IV immediately (don't delay for investigations)
2. Call 999 ambulance
3. Inform receiving hospital
4. Support airway, breathing, circulation
5. Document time of antibiotic administration

Benzylpenicillin Doses:

Age	Dose	Route
<1 month	300mg	IM/IV
1-11 months	600mg	IM/IV
1-9 years	1.2g	IM/IV
≥10 years	1.2g	IM/IV

Anaphylaxis▼

Recognition:

• Sudden onset of symptoms
• Airway: swelling of throat and tongue
• Breathing: wheeze, stridor, cyanosis
• Circulation: tachycardia, hypotension, collapse
• Disability: confusion, agitation
• Exposure: urticaria, angioedema

Emergency Management:

1. Remove trigger if possible
2. Call for help (999)
3. Adrenaline IM (anterolateral thigh)
4. High-flow oxygen
5. IV fluid bolus if hypotensive
6. Consider second adrenaline dose after 5 minutes

Adrenaline Doses (1:1000):

Age	Dose	Volume (1:1000)
<6 months	150 micrograms	0.15ml
6 months-6 years	150 micrograms	0.15ml
6-12 years	300 micrograms	0.3ml
>12 years	500 micrograms	0.5ml

Seizures & Status Epilepticus▼

Status Epilepticus Definition:

Seizure lasting >5 minutes OR recurrent seizures without full recovery between episodes

Emergency Management:

1. Ensure safety, protect airway
2. High-flow oxygen
3. Check blood glucose
4. If seizure >5 minutes: Midazolam buccal or Diazepam rectal
5. Call 999 if first seizure, prolonged, or not recovering
6. Consider IV access and further anticonvulsants

Anticonvulsant Doses:

Drug	Age/Weight	Dose	Route
Midazolam	1-5 years	5mg	Buccal
	5-10 years	7.5mg	Buccal
	10-18 years	10mg	Buccal
	All ages	0.5mg/kg (max 20mg)	IV
Diazepam	1 month-2 years	5mg	Rectal
	2-12 years	5-10mg	Rectal
	12-18 years	10-20mg	Rectal

Respiratory Emergencies▼

Severe Asthma Features:

• Can't complete sentences
• Pulse >125/min (>5 years) or >140/min (2-5 years)
• Respirations >30/min (>5 years) or >40/min (2-5 years)
• Use of accessory muscles
• Peak flow 33-50% best or predicted

Life-threatening Asthma:

• Silent chest, cyanosis, poor respiratory effort
• Hypotension, exhaustion, confusion
• Peak flow <33% best or predicted
• SpO2 <92%

Emergency Treatment:

1. High-flow oxygen
2. Salbutamol nebulizer 2.5-5mg
3. Prednisolone 1-2mg/kg (max 40mg) PO
4. If severe: Ipratropium 250 micrograms nebulized
5. Consider IV salbutamol or aminophylline
6. Call for senior help early

🦠 Childhood Infections

Common Viral Exanthemata

Condition	Incubation	Rash Description	Other Features	Complications
Measles	10-14 days	Maculopapular, starts behind ears, spreads down	Koplik spots, cough, conjunctivitis, fever	Pneumonia, encephalitis
Rubella	14-21 days	Fine pink maculopapular, face to body	Lymphadenopathy, mild fever	Congenital rubella syndrome
Chickenpox	10-21 days	Vesicular, crops, different stages	Fever, malaise, itching	Secondary bacterial infection
Fifth Disease	4-20 days	Slapped cheek, lacy rash on limbs	Mild fever, headache	Aplastic crisis in sickle cell
Roseola	5-15 days	Rose-pink maculopapular after fever settles	High fever 3-4 days, then rash	Febrile convulsions
Hand, Foot & Mouth	3-7 days	Vesicles on palms, soles, mouth	Fever, sore throat, malaise	Dehydration, viral meningitis

Specific Infections

Kawasaki Disease:

Criteria (≥5 days fever plus ≥4 of):

• Bilateral conjunctival injection
• Oral mucosa changes
• Peripheral extremity changes
• Polymorphous rash
• Cervical lymphadenopathy

⚠️ Risk of coronary artery aneurysms

Henoch-Schönlein Purpura:

• Palpable purpuric rash (buttocks, legs)
• Arthritis (knees, ankles)
• Abdominal pain, GI bleeding
• Nephritis (haematuria, proteinuria)

Monitor BP and urine for 6 months

🩸 Renal Involvement:

• Approximately 30-50% of children with HSP develop some degree of renal involvement
• Microscopic haematuria ± proteinuria is the most common manifestation
• The majority (>95%) resolve without long-term sequelae
• However, ~1% can develop severe nephritis progressing to chronic kidney disease

🩺 Why Check Blood Pressure?

• Renal involvement in HSP can cause hypertension as a sign of nephritis or nephrotic syndrome
• Hypertension indicates significant renal inflammation requiring urgent assessment
• Raised BP may be the first sign that renal disease is more serious than initially apparent
• Urine dipstick for blood and protein should be checked at presentation and every 2-4 weeks for 6 months

Scarlet Fever:

• Sandpaper-like rash
• Strawberry tongue
• Fever, sore throat
• Circumoral pallor

Treatment: Penicillin V 10 days

🫁 Common Acute Conditions

Asthma▼

Diagnosis (BTS/NICE/SIGN NG245 2024):

• Recurrent wheeze, cough, breathlessness
• Symptoms worse at night/early morning
• Triggered by exercise, allergens, viral infections
• Family history of asthma/atopy
• Response to bronchodilators

Management (Updated 2024):

1. Step 1: SABA as required
2. Step 2: Low-dose ICS or MART (Maintenance and Reliever Therapy)
3. Step 3: MART or ICS + LABA
4. Step 4: Medium-dose ICS + LABA ± LTRA
5. Step 5: High-dose ICS + additional therapies

New 2024: Earlier introduction of MART therapy

Type 1 Diabetes▼

Presentation:

• Polyuria, polydipsia, polyphagia
• Weight loss, fatigue
• Recurrent infections
• DKA: vomiting, dehydration, Kussmaul breathing

Diagnosis:

• Random glucose >11.1 mmol/L + symptoms
• Fasting glucose >7.0 mmol/L
• HbA1c >48 mmol/mol (6.5%)
• Ketones in blood/urine

Emergency Management of DKA:

1. IV fluid resuscitation (0.9% saline)
2. Insulin infusion (0.1 units/kg/hour)
3. Potassium replacement
4. Monitor glucose, ketones, pH
5. Urgent paediatric referral

Bronchiolitis vs Croup▼

Comparison Table:

Feature	Bronchiolitis	Croup
Age	<2 years (peak 2-6 months)	6 months - 6 years (peak 1-2 years)
Cause	RSV (most common), parainfluenza	Parainfluenza, RSV, rhinovirus
Site	Small airways (bronchioles)	Larynx, trachea, bronchi
Cough	Persistent, dry	Barking, seal-like
Stridor	Absent	Inspiratory stridor
Wheeze	Fine expiratory wheeze	Usually absent
Voice	Normal	Hoarse
Fever	Low-grade or absent	Low-grade fever
Worse at night	No particular pattern	Yes, symptoms worse at night

Bronchiolitis Management (NICE NG9 - Updated 2021):

• Supportive care (most important)
• Ensure adequate feeding and hydration
• Oxygen if SpO2 <92% (updated threshold)
• No antibiotics unless secondary bacterial infection
• No bronchodilators or steroids routinely

Croup Management:

• Mild: supportive care, steam inhalation
• Moderate/Severe: oral dexamethasone 0.15mg/kg
• Severe: nebulized adrenaline + dexamethasone
• Hospital if stridor at rest, severe respiratory distress

Febrile Convulsions▼

Key Facts:

• Age 6 months - 5 years, temperature >38°C
• Usually generalized, <15 minutes
• Simple vs complex
• Recurrence risk 30%
• Parental education important

Simple vs Complex:

Feature	Simple	Complex
Duration	<15 minutes	>15 minutes
Type	Generalised	Focal or multiple
Frequency (24h)	Single episode	Recurs within 24 hours
Post-ictal deficit	No	May be present

Rule of Febrile Thirds:

• 1/3 Will NOT have any more febrile convulsions
• 1/3 Will experience ONE more febrile convulsion
• 1/3 Will have REPEATED bouts with future febrile illnesses

Management & Advice:

• Reassure parents - usually self-limiting
• First febrile seizure → admit for investigation to exclude meningitis
• Complex febrile seizure → always refer
• Paracetamol/ibuprofen for fever comfort, NOT proven to prevent recurrence
• Educate parents: recovery position, do not restrain, time the seizure, call 999 if >5 minutes
• Long-term risk of epilepsy slightly increased (~2-5% vs 1% background)

🤱 Abdominal Pain in Children

🚨 Red Flags - Urgent Referral:

• Bile-stained vomiting
• Signs of intestinal obstruction
• Severe dehydration
• Peritonitis signs
• Palpable mass
• Testicular pain/swelling
• Non-blanching rash

Age-Specific Causes

Infants (0-2 years):

• Colic
• Intussusception
• Pyloric stenosis
• Incarcerated hernia
• Testicular torsion
• UTI

Preschool (2-5 years):

• Viral gastroenteritis
• Constipation
• UTI
• Appendicitis (rare <3 years)
• Intussusception
• Pneumonia

School age (5+ years):

• Appendicitis
• Gastroenteritis
• Constipation
• UTI
• Functional abdominal pain
• Mesenteric adenitis

Intussusception

Clinical Features:

• Peak age 6-18 months
• Severe colicky abdominal pain
• Child draws knees to chest
• Vomiting (may become bile-stained)
• Redcurrant jelly stools (late sign)
• Palpable sausage-shaped mass (RUQ)
• Lethargy between episodes

⚠️ Emergency - requires urgent surgical referral

🏥 Chronic Conditions

Long-term conditions requiring ongoing management

Cystic Fibrosis:

• Recurrent chest infections
• Failure to thrive
• Steatorrhoea
• Nasal polyps
• Family history

Diagnosis: Sweat test, genetic testing

Cerebral Palsy:

• Motor impairment
• Abnormal tone/posture
• Developmental delay
• Feeding difficulties
• Seizures (30%)

Management: MDT approach

Juvenile Idiopathic Arthritis:

• Joint swelling >6 weeks
• Morning stiffness
• Systemic features
• Growth problems
• Eye complications

Urgent rheumatology referral

🧬 Congenital & Genetic Conditions

Conditions present from birth or with genetic basis

Down Syndrome:

• Characteristic facial features
• Intellectual disability
• Cardiac defects (40%)
• GI abnormalities
• Increased infection risk
• Thyroid problems

Congenital Heart Disease:

• Cyanosis (central vs peripheral)
• Heart murmur
• Feeding difficulties
• Poor weight gain
• Breathlessness
• Clubbing

Neural Tube Defects:

• Spina bifida
• Anencephaly
• Encephalocele
• Associated with folate deficiency
• Prevention: folic acid supplementation

👶 Neonatal Care

Care of newborns in the first 28 days of life

Normal Newborn:

• Birth weight 2.5-4.5kg
• Length 48-52cm
• Head circumference 33-37cm
• Heart rate 120-160/min
• Respiratory rate 30-60/min
• Temperature 36.5-37.5°C

Neonatal Jaundice:

• Physiological: day 2-14
• Pathological: <24 hours or >14 days
• Causes: haemolysis, infection, metabolic
• Treatment: phototherapy, exchange transfusion
• Monitor bilirubin levels

🩺 GP Management: Jaundice >14 Days (Prolonged Jaundice)

Prolonged jaundice = >14 days in term infants, >21 days in preterm. Always requires investigation.

• First-line investigations: Split bilirubin (total + conjugated), TFTs, FBC + blood film, LFTs, G6PD screen (if at risk), urine culture (MSU or clean catch)
• ⚠️ Red flag - pale/chalky stools + dark urine: Suspect biliary atresia → same-day urgent paediatric referral. Surgical emergency if not treated before 60 days of age.
• Conjugated hyperbilirubinaemia (conjugated bilirubin >20% of total, or >25 micromol/L): Always pathological → urgent paediatric referral
• Unconjugated hyperbilirubinaemia: More likely physiological or breast milk jaundice, but still requires investigation to exclude hypothyroidism and haemolysis
• Breast milk jaundice: Do NOT advise stopping breastfeeding unless directed by a specialist
• Congenital hypothyroidism: Should have been identified on newborn blood spot - recheck if not done or result not received
• Also check: Weight gain adequate? Feeding well? Urine and stool colour (ask parent to photograph nappies)

Neonatal Sepsis:

• Poor feeding, lethargy
• Temperature instability
• Respiratory distress
• Apnoea, bradycardia
• Hypoglycaemia
• Urgent antibiotic treatment

🫘 Gastro Conditions

Gastrointestinal conditions in children

Gastroenteritis:

• Diarrhoea ± vomiting
• Assess dehydration
• Oral rehydration therapy
• Continue normal feeding
• Avoid anti-diarrhoeals
• Probiotics may help

Constipation:

• <3 stools per week
• Hard, painful stools
• Dietary advice
• Laxatives: movicol, lactulose
• Toilet training issues
• Exclude organic causes

💊 Laxative Dosages

Movicol Paediatric Plain (Macrogol 3350):

• Not recommended under 2 years
• Disimpaction:
- – 2–5 years: up to 4 sachets/day, increase by 2 sachets/day every 2 days (max 4), over max 7 days
- – 5–12 years: up to 8 sachets/day (max), over max 7 days
- – 12+ years: Movicol adult sachets up to 8 per day over max 3 days
• Maintenance:
- – 2–5 years: ½ to 1 sachet daily, adjusted to produce 1–2 soft stools/day
- – 5–12 years: 1–2 sachets daily, adjusted
- – 12+ years: 2–4 Movicol adult sachets daily

Lactulose:

• Under 1 year: 2.5ml twice daily
• 1–5 years: 2.5–10ml twice daily
• 5–10 years: 10ml twice daily
• 10+ years: 15ml twice daily
• Adjust dose to produce 1–2 soft stools per day
• Takes 2–3 days to work; warn parents of bloating initially

🦴 Musculoskeletal Conditions

Musculoskeletal disorders in children and adolescents

Developmental Hip Dysplasia (DDH):

• Risk factors: breech, family history
• Barlow and Ortolani tests
• Asymmetric skin folds
• Limited hip abduction
• Early treatment crucial
• Ultrasound screening

Perthes Disease (Legg-Calvé-Perthes):

• Avascular necrosis of the femoral head
• Age 4–10 years; boys >> girls (4:1)
• Insidious onset of hip pain, groin pain, or referred knee pain
• Painless limp, limited internal rotation and abduction of hip
• X-ray: flattening, sclerosis, or fragmentation of femoral head (may be normal early — MRI more sensitive)
• Refer to orthopaedics; management ranges from physiotherapy to surgery depending on age and severity
• Prognosis better in younger children (<6 years)

Osgood-Schlatter Disease:

• Traction apophysitis of the tibial tubercle
• Age 10–15 years; active adolescents, especially during growth spurts
• Boys more commonly affected
• Pain, tenderness and swelling directly over tibial tubercle (just below knee)
• Worse with activity (running, jumping, kneeling), relieved by rest
• X-ray may show fragmentation of tibial tubercle (not always needed)
• Management: relative rest, analgesia (NSAIDs), physiotherapy, ice
• Usually self-limiting; resolves when growth plates close
• Rarely needs surgical referral

SUFE (Slipped Upper Femoral Epiphysis):

• Displacement of the femoral head through the growth plate (capital physis)
• Age 10–16 years; overweight males more commonly affected
• Presents with hip, groin, or referred knee pain — always examine the hip in a child with knee pain
• Limping; hip held in external rotation
• Restricted and painful internal rotation of the hip
• X-ray: AP + frog-leg lateral view shows posterior/medial displacement of epiphysis ("ice cream falling off cone" appearance)
• ⚠️ Do NOT weight bear — risk of avascular necrosis
• Urgent orthopaedic referral — surgical fixation (in-situ pinning) required
• Screen the contralateral hip (bilateral in ~25%)

🧠 Neurological Conditions

Neurological disorders in children

Headaches in Children:

• Primary: tension, migraine
• Secondary: raised ICP, infection
• Red flags: early morning, vomiting
• Neurological signs
• Personality change
• Consider imaging if concerning

🚩 Red Flag Headache Features (refer urgently):

• Waking from sleep or early morning headache (raised ICP)
• Progressive worsening over weeks
• Associated vomiting (especially without nausea)
• Headache worsened by coughing, sneezing, bending
• New neurological symptoms or signs (diplopia, ataxia, papilloedema)
• Personality or behaviour change
• Very young child or <3 years (primary headache rare at this age)
• Thunderclap (sudden severe onset) → SAH until proven otherwise

Migraine in Children:

• Often bilateral (not always unilateral like adults)
• Pulsating quality, moderate-severe severity
• Associated nausea/vomiting, photophobia, phonophobia
• Duration often shorter than adults (2–48 hours)
• Acute treatment: ibuprofen or paracetamol, rest in dark quiet room
• Triptans licensed from age 12 (nasal sumatriptan from age 12)
• Refer if frequent (>4/month), unresponsive to treatment, or atypical features

Epilepsy in Children:

• Recurrent unprovoked seizures
• Types: focal, generalised, absence, tonic-clonic
• EEG and MRI brain as part of workup
• Paediatric neurology referral
• Common syndromes: childhood absence epilepsy, juvenile myoclonic epilepsy, rolandic epilepsy
• SUDEP counselling for families
• School and lifestyle implications (swimming, cycling etc.)

Breath-Holding Attacks:

• Age 6 months – 6 years
• Triggered by pain, frustration, fright
• Cyanotic type: child cries, then holds breath, goes blue, may lose consciousness briefly
• Pallid type: child becomes pale, loses tone after minor head injury
• Self-limiting, recovers quickly, not epileptic
• Reassure parents; check iron deficiency (iron treatment reduces cyanotic attacks)
• No specific treatment needed; resolve spontaneously

🧴 Paediatric Dermatology

Common skin conditions in children

Eczema (Atopic Dermatitis):

• Dry, itchy, inflamed skin
• Flexural distribution
• Associated with asthma, allergies
• Emollients (mainstay)
• Topical steroids for flares
• Avoid triggers

Impetigo:

• Superficial bacterial infection
• Golden crusted lesions
• Highly contagious
• Topical fusidic acid
• Oral antibiotics if extensive
• School exclusion until treated

Molluscum Contagiosum:

• Small, pearly papules
• Central umbilication
• Viral infection (poxvirus)
• Self-limiting (6-18 months)
• No treatment usually needed
• Avoid scratching

Dermatomyositis:

• Rare autoimmune inflammatory condition affecting skin and muscle
• Peak age 5–10 years; girls slightly more affected
Skin features:
- – Heliotrope rash: purple/violaceous discolouration of upper eyelids ± periorbital oedema
- – Gottron's papules: raised, erythematous papules over knuckles, elbows, knees
- – V-sign (chest) and shawl sign (upper back/shoulders)
- – Nailfold capillary changes (dilated, irregular capillaries)
Muscle features: Proximal muscle weakness (difficulty climbing stairs, rising from chair, combing hair), muscle tenderness
Other features: Calcinosis (calcium deposits in skin/muscle — common in juvenile form), dysphagia, dysphonia
Investigations: Raised CK, LDH, aldolase; ANA often positive; MRI muscle; EMG; muscle biopsy; nailfold capillaroscopy
⚠️ Red flag: Unlike adult dermatomyositis, juvenile form is NOT associated with malignancy
Management: Urgent paediatric rheumatology referral; high-dose corticosteroids ± methotrexate/IVIG; sun protection; physiotherapy

🧠 Learning Disabilities

Assessment and support for learning difficulties

ADHD:

• Inattention, hyperactivity, impulsivity
• Symptoms in multiple settings
• Impact on functioning
• Behavioural interventions first
• Medication if severe
• School support important

Autism Spectrum Disorder:

• Social communication difficulties
• Restricted, repetitive behaviours
• Sensory sensitivities
• Early intervention crucial
• Multidisciplinary assessment
• Family support

Dyslexia:

• Difficulty with reading, spelling
• Normal intelligence
• Phonological processing problems
• Educational assessment
• Specialized teaching methods
• Early identification important

😴 Sleep in Children

Sleep patterns and sleep disorders in children

Normal Sleep Requirements:

Age	Total Sleep (hours)	Night Sleep	Daytime Naps
Newborn (0-3 months)	14-17 hours	8-9 hours	Multiple short naps
Infant (4-11 months)	12-15 hours	10-12 hours	2-3 naps
Toddler (1-2 years)	11-14 hours	10-12 hours	1-2 naps
Preschool (3-5 years)	10-13 hours	10-13 hours	0-1 nap
School age (6-13 years)	9-11 hours	9-11 hours	None

Common Sleep Problems

Sleep Regression:

• Common at 4, 8-10, 18 months
• Developmental milestones
• Usually temporary (2-6 weeks)
• Maintain consistent routine
• Avoid creating new sleep associations

Night Terrors:

• Age 3-8 years typically
• Occur in deep sleep (first third of night)
• Child appears awake but confused
• No memory of event
• Usually outgrown
• Ensure safety, don't wake child

Sleep Apnoea:

• Snoring, breathing pauses
• Restless sleep
• Daytime sleepiness
• Behavioural problems
• Often due to enlarged tonsils/adenoids
• May need ENT referral

Sleep Hygiene Advice

• Consistent bedtime routine
• Regular sleep and wake times
• Comfortable sleep environment (cool, dark, quiet)
• Avoid screens 1 hour before bedtime
• No caffeine in children
• Regular physical activity (but not close to bedtime)
• Avoid large meals before bedtime
• Use bedroom only for sleep

💊 Pharmacological Approaches to Sleep

🌙 Melatonin — When to Prescribe:

Indications:

• Insomnia in autism, ADHD, neurodevelopmental disorders
• Circadian rhythm delay
• Sometimes short-term severe insomnia after behavioural strategies fail

Age: Usually >2–3 years

Doses:

Age	Starting dose	Max
2–5 yrs	1 mg nocte	3 mg
6–12 yrs	1–2 mg nocte	5 mg
≥12 yrs	2–3 mg nocte	10 mg

• Slenyto (prolonged-release melatonin): licensed for children aged 2–18 years with ASD or Smith-Magenis syndrome
• Circadin (modified-release): licensed for adults; used off-label in children
• Typical initiation: By specialist (paediatrics, CAMHS, paediatric neurology) or under a shared care agreement
• Low side effect profile; can cause morning drowsiness at higher doses
• Not recommended as first-line treatment for typical childhood insomnia without an underlying neurodevelopmental condition

⚠️ Promethazine (Phenergan) — Use with Caution:

Often used short term for occasional sleep disturbance.

Age: >2 years only (MHRA warning under 2)

Doses:

Age	Dose
2–5 yrs	5–15 mg nocte
6–12 yrs	10–20 mg nocte
>12 yrs	20–25 mg nocte

Notes:

• Antihistamine sedative
• Short courses only (few nights)
• Contraindicated under 2 years — risk of respiratory depression and sudden death (MHRA warning)
• Not licensed as a hypnotic in children
• Risk of paradoxical excitation (especially in young children) — can make sleep worse
• Avoid in children with epilepsy, liver disease, or those taking other CNS depressants

🌿 Piriton (Chlorphenamine) — Sometimes Used:

Sometimes used but less sedating than promethazine.

Doses:

Age	Dose
1–5 yrs	1 mg nocte
6–12 yrs	2 mg nocte
>12 yrs	4 mg nocte

Max: Usually single night dose

Notes:

• Evidence for sleep is weak
• Mainly antihistamine
• Not indicated for sleep problems in isolation — sedation is a side effect, not an approved indication
• Appropriate use: When sleep is disrupted by allergy, urticaria, or eczema itch
• Not recommended under 1 year
• Paradoxical excitation can occur, particularly in young children
• Does not improve sleep architecture; tolerance to sedation develops quickly

💜 Hydroxyzine — Specialist Use:

Dose:

• 0.5 mg/kg nocte

Notes:

• Occasionally used in paeds neurodevelopment clinics
• Antihistamine with anxiolytic and sedative properties
• May be helpful in children with anxiety-related sleep difficulties alongside neurodevelopmental conditions
• Not a first-line treatment — typically initiated by specialist
• Caution: QT prolongation risk; avoid in children with cardiac conditions or on other QT-prolonging drugs

💧 Urine — UTIs & Nocturnal Enuresis

UTI in Girls vs Boys▼

👧 UTI in Girls:

• Much more common than in boys due to shorter urethra and proximity to perianal flora
• Ascending infection with bowel flora — E. coli accounts for ~80%
• Risk factors: constipation, dysfunctional voiding, bubble baths, wiping technique
• Older girls: dysuria, frequency, urgency, suprapubic pain
• Under 3 years: may present non-specifically (fever, vomiting, poor feeding, irritability)
• Single UTI in a girl >3 years with normal USS: treat and observe; further investigation only if recurrent
• Any UTI in a girl <3 years: refer for USS kidneys and bladder

👦 UTI in Boys:

• Less common than in girls (especially post-infancy), more likely to indicate underlying structural abnormality
• Any UTI in a boy warrants investigation
• Consider: vesicoureteric reflux (VUR), posterior urethral valves, duplex kidney, phimosis
• Under 3 months: urgent same-day admission regardless of clinical state
• Under 1 year: refer for renal USS ± MCUG
• Common organisms: E. coli; unusual or recurrent organisms suggest structural anomaly
• Circumcision significantly reduces UTI risk in boys

Single UTI — Management▼

Urine Collection (before starting antibiotics):

• Clean catch mid-stream urine (preferred) — most reliable for culture
• Urine collection pads — acceptable if clean catch not possible; process promptly
• Avoid bag specimens for culture — very high false positive rate due to contamination
• Catheter specimen: if urgent and child unable to provide clean catch
• Send for microscopy, culture and sensitivities (MC&S)
• Dipstick: nitrites + leucocytes = likely UTI; nitrites alone or leucocytes alone = equivocal

Antibiotic Treatment (follow local guidelines):

• First-line oral options: Trimethoprim or Nitrofurantoin (check local sensitivity patterns and contraindications)
• Nitrofurantoin: avoid if eGFR low or systemic infection suspected (not effective for pyelonephritis)
• Lower UTI / cystitis: 3–7 days oral antibiotics
• Upper UTI / pyelonephritis (fever, loin pain, systemic upset): 7–10 days; oral co-amoxiclav or cefalexin, or IV if unwell
• Under 3 months: IV antibiotics + same-day admission
• Review MC&S result and adjust if needed

NICE Guidance on Imaging After First UTI:

Child	USS Kidneys/Bladder	DMSA Scan	MCUG
Under 6 months	Yes (within 6 weeks)	4–6 months post-UTI if abnormal USS	If abnormal USS or DMSA
6 months – 3 years, responds well	No routine USS	No	No
6 months – 3 years, atypical or recurrent	Yes (during acute illness)	Yes	Consider
Over 3 years, responds well	No routine USS	No	No
Over 3 years, atypical or recurrent	Yes (within 6 weeks)	Yes (if recurrent)	No (unless USS/DMSA abnormal)

Atypical UTI: unusual organism, poor response within 48 hours, septicaemia, raised creatinine, abdominal or bladder mass

Recurrent UTI — When to Investigate Further▼

Definition of Recurrent UTI:

• ≥2 episodes of upper UTI (pyelonephritis)
• ≥3 episodes of lower UTI (cystitis)
• 1 upper UTI + ≥1 lower UTI

Investigation:

• Renal USS: Assess kidney size, scarring, structural abnormality, bladder residual
• DMSA scan (dimercaptosuccinic acid): Gold standard for detecting renal scarring; performed 4–6 months after acute UTI
• MCUG (micturating cystourethrogram): Detects vesicoureteric reflux (VUR) and bladder/urethral abnormalities — consider if USS or DMSA abnormal
• MAG3 renogram: assess differential renal function and drainage if obstruction suspected
• Check BP, urine protein, renal function (eGFR/creatinine)

Management of Recurrent UTI:

• Treat acute episode as above
• Antibiotic prophylaxis: Consider trimethoprim 2mg/kg once daily at night (or nitrofurantoin) in children with recurrent UTIs, especially if VUR present
• Address modifiable risk factors: constipation, dysfunctional voiding, fluid intake, hygiene
• Bladder retraining if dysfunctional voiding
• Refer to paediatric nephrology or urology if: structural abnormality, significant renal scarring, poor response to treatment, high-grade VUR
• Long-term follow-up: monitor BP and renal function annually in children with renal scarring

Nocturnal Enuresis (Bedwetting)▼

Background & Prevalence:

• Primary nocturnal enuresis: Child has never achieved consistent nighttime dryness
• Secondary (onset) enuresis: Child was dry for >6 months then relapsed — consider stress, UTI, diabetes mellitus/insipidus, constipation, safeguarding
• Prevalence: approximately 15% at age 5, ~5% at age 10, ~1% at age 15; spontaneous resolution common
• Normal not to achieve consistent nighttime dryness until age 5 — do not investigate or treat before this age
• Strong genetic component: if both parents had enuresis, child has 77% chance

Assessment — Exclude Secondary Causes:

• Urine dipstick: Exclude UTI, glycosuria (diabetes mellitus)
• Constipation: Very common contributor — full rectum compresses bladder
• Ask about daytime symptoms (frequency, urgency, daytime wetting — suggests overactive bladder)
• Fluid intake pattern and type of drinks
• Sleep quality (snoring, sleep apnoea)
• Family history; emotional stressors; school/home situation
• Bladder diary for 2–4 weeks (useful to assess volumes and frequency)

Management — Stepwise Approach:

Step 1 — General Measures (all children):
- • Adequate daytime fluid intake (1–1.4L/day for school-age children); avoid fizzy drinks and caffeine
- • Regular daytime voiding every 2–3 hours; void before bed
- • Treat constipation if present
- • No lifting (taking child to toilet at night) as long-term strategy — does not help the child learn to wake
- • Positive reward systems (star charts for agreed behaviours, NOT for dry nights)
- • Reduce parental/child anxiety — reassurance that this is common and usually resolves
Step 2 — Enuresis Alarm (first-line active treatment, >5 years):
- • Most effective long-term treatment — achieves dryness in ~60–70% with sustained response
- • Requires motivated child and family
- • Should be used for minimum 3 months or until 14 consecutive dry nights
- • Available via continence services
Step 3 — Desmopressin (short-term or when alarm not appropriate):
- • Synthetic ADH — reduces urine production at night
- • Oral tablet: 0.2mg at bedtime; may increase to 0.4mg if partial response
- • Sublingual melt (DDAVP Melt): 120–240 micrograms at bedtime
- • Particularly useful for sleepovers, camps, short-term situations
- • Fluid restriction required: restrict fluids from 1 hour before to 8 hours after dose — risk of hyponatraemia if not followed
- • Stop during vomiting/diarrhoea illness (hyponatraemia risk)
- • Review after 3 months; consider trial off treatment
Step 4 — Combination or Specialist Referral:
- • Alarm + desmopressin for refractory cases
- • Refer to continence service, paediatric enuresis clinic, or CAMHS if: secondary enuresis, daytime symptoms, psychological impact, or failure of above measures
- • Oxybutynin may be added if overactive bladder component identified

🚩 When to Refer / Investigate Further:

• Secondary enuresis with no clear cause
• Daytime wetting alongside nocturnal enuresis
• Positive urine dipstick (UTI, glycosuria)
• Suspected diabetes mellitus or insipidus
• Neurological symptoms or signs
• Safeguarding concerns
• Failure to respond to 2 adequate treatment courses

🚨 Same-Day Referrals

When to make urgent paediatric referrals

Immediate 999 Ambulance:

• Compromised airway, breathing, circulation
• Reduced consciousness level
• Status epilepticus
• Suspected meningitis/septicaemia
• Anaphylaxis
• Severe dehydration/shock
• Major trauma

Same-Day Hospital Referral

Respiratory:

• Severe asthma/wheeze
• Stridor at rest
• Significant respiratory distress
• Oxygen saturation <92%
• Suspected pneumonia with complications

Gastrointestinal:

• Bile-stained vomiting
• Signs of intestinal obstruction
• Suspected intussusception
• Severe dehydration
• Acute abdomen

Neurological:

• First seizure
• Prolonged post-ictal period
• Signs of raised intracranial pressure
• Acute neurological deficit
• Suspected non-accidental injury

Other:

• Suspected diabetic ketoacidosis
• Testicular torsion
• Acute joint swelling
• Suspected malignancy
• Safeguarding concerns

Referral Information

Essential Information to Include:

• Child's name, DOB, address, NHS number
• Parent/carer contact details
• Presenting complaint and duration
• Relevant history and examination findings
• Vital signs and observations
• Any treatment given
• Reason for referral and urgency
• Your contact details

🛡️ Safeguarding

Recognising abuse, understanding procedures, and protecting vulnerable children

Please note: There is a whole Bradford VTS webpage devoted to Child Safeguarding. This section is a small summary of key points for quick reference.

🚩 Physical Abuse Red Flags:

• Delay in seeking medical attention
• Story inconsistent with injuries
• Repeated attendances with injuries
• Unusual pattern of injuries
• Injuries in non-mobile child
• Bruising in protected areas
• Grip marks, bite marks
• Burns with clear demarcation
• Fractures in non-mobile child

⚠️ Risk Factors:

Parental factors:

• Substance misuse
• Mental health problems
• Domestic violence
• Social isolation
• Young parents
• History of abuse

Child factors:

• Disability
• Chronic illness
• Premature birth
• Difficult temperament

📝 Action Required:

If concerned:

1. Discuss with safeguarding lead
2. Contact children's services
3. Document everything
4. Follow local procedures
5. Consider immediate safety

Documentation Requirements:

• Date, time, location
• Who was present
• Objective description of injuries
• Exact quotes (child and parent)
• Your observations and concerns
• Actions taken

Emotional/Behavioural Indicators

Child Behaviour:

• Frozen watchfulness
• Excessive compliance or aggression
• Developmental regression
• Self-harm behaviours
• Sexualised behaviour (inappropriate for age)
• Fear of going home

Parent-Child Interaction:

• Inappropriate child-parent interaction
• Parent more concerned about themselves
• Lack of concern for child's distress
• Blaming the child
• Unrealistic expectations

Remember: Your role is to identify concerns and refer appropriately. You are not expected to investigate or prove abuse. When in doubt, seek advice from your safeguarding lead or children's services. The child's safety is paramount.

🎯 Remember: You've Got This!

Paediatrics can feel overwhelming, but with systematic assessment (ABC + RED BURT), good safety netting, and trusting parental instinct, you'll make the right decisions. When in doubt, seek advice - that's what the paediatric team is there for!

☕ Now go reward yourself with that well-deserved coffee