Rapid-recall takeaways distilled from the DCH question bank, grouped by specialty. One pearl per high-frequency concept. Use it for last-pass revision alongside questions, not as a replacement for them.
745 pearls · 10 specialties · Generated 6 November 2026
Cardiology
80 high-yield facts
large VSD plus failure to thrive plus tachypnoea equals heart failure from left-to-right shunting - medically manage and refer for surgical closure before Eisenmenger develops.
hypertension in a child plus radiofemoral delay equals coarctation - always check four-limb BP and femoral pulses in hypertensive children.
pleuritic chest pain plus friction rub plus widespread ST elevation plus PR depression equals pericarditis - NSAIDs plus colchicine; always echo to exclude significant effusion.
severe neonatal AS with a high gradient equals urgent balloon valvuloplasty - it is palliative; lifelong cardiac follow-up is needed.
catheterisation in children is both diagnostic and therapeutic - interventional cardiology is increasingly replacing surgery for many conditions.
Soft systolic murmur plus asymptomatic child plus normal examination equals innocent murmur - reassure the parents; no echo needed if confident.
infant SVT rate 220-300 bpm - ice to face first, then IV adenosine rapid bolus with flush; synchronised cardioversion if unstable.
fixed split S2 plus pulmonary flow murmur equals ASD - secundum is most common and can often be closed by catheter device.
machinery murmur plus bounding pulses in a premature infant equals PDA - ibuprofen or indomethacin for pharmacological closure.
PDA in a term infant equals transcatheter closure - minimally invasive, high success, avoids thoracotomy.
superior axis plus prolonged PR plus rsR' in V1 equals think AVSD - confirm with echocardiography; this pattern is a strong clue in babies with Down syndrome.
absent femoral pulses plus upper-lower limb BP gradient equals coarctation - in neonates, start prostaglandin E1 immediately.
General Paediatrics
80 high-yield facts
delayed puberty plus anosmia plus low LH/FSH equals Kallmann syndrome - GnRH and olfactory neuron migration failure; MRI shows absent olfactory bulbs; treat with testosterone replacement.
herald patch followed by Christmas tree pattern of oval scaly patches equals pityriasis rosea - self-limiting within 6-12 weeks; reassure and treat itch symptomatically.
limited food range with normal growth in a toddler equals fussy eating - repeated non-pressured exposure with family meals is the evidence-based approach; avoid force-feeding.
child who only sleeps while being fed and wakes frequently equals sleep-onset association - teach self-settling with graduated extinction or camping out; separate feeding from falling asleep.
toxic child refusing to weight-bear with high fever and raised inflammatory markers equals septic arthritis until proven otherwise - urgent aspiration and surgical washout; do not delay antibiotics.
fluoride toothpaste twice daily is the cornerstone of caries prevention - 1000 ppm under 3, 1350-1500 ppm from age 3; supervise until age 7.
slapped cheek plus lace-like rash equals parvovirus B19 - check immunity of any pregnant contacts; the child is no longer infectious once the rash appears.
white plaques that do not wipe off in a young infant equals oral thrush - nystatin suspension after feeds for 7 days and treat the mother's nipples concurrently.
sandpaper rash plus strawberry tongue plus circumoral pallor equals scarlet fever - treat with penicillin V for 10 days and notify public health.
honey-coloured crusts around nose and mouth equals non-bullous impetigo - topical hydrogen peroxide 1% cream is now NICE first-line for localised disease.
nappy rash involving skin creases with satellite lesions equals candidal infection - topical clotrimazole or miconazole for 7-14 days.
Neurology
80 high-yield facts
ataxic CP affects the cerebellum - characterised by hypotonia, intention tremor, and wide-based gait; always exclude progressive conditions if symptoms worsen.
seizure triggered by flickering visual stimuli with a photoparoxysmal response on EEG is photosensitive epilepsy - advise on trigger avoidance and treat with valproate or lamotrigine if needed.
focal onset, >15 minutes, recurrence within 24 hours, or Todd paresis makes a febrile seizure complex - investigate more thoroughly and provide rescue medication.
Simple febrile seizure → epilepsy risk only 1-2% (vs 0.5-1% background); recurrence ~30%; no brain damage; outgrown by age 5-6 - reassure per NICE CKS.
NICE NG217 - focal seizures first-line is lamotrigine or levetiracetam; carbamazepine is now second-line; avoid valproate in females of childbearing potential (MHRA PPP); ethosuximide only for absence seizures.
buccal midazolam is first-line for convulsive status when IV access is unavailable - escalate to IV lorazepam, then IV phenytoin, then RSI if seizure persists.
bilateral pressing headache without migrainous features in a stressed child is tension-type - manage with trigger modification and appropriate analgesia use.
after two benzodiazepine doses, escalate to IV phenytoin 20 mg/kg over 20 minutes with cardiac monitoring - never give a third benzodiazepine.
folic acid 400 micrograms before conception reduces NTD risk - high-risk women need 5 mg; myelomeningocele requires lifelong multidisciplinary management.
unilateral LMN facial weakness (including forehead) with acute onset and no other cranial nerve signs - Bell palsy, excellent prognosis in children, provide eye care.
botulinum toxin A is first-line for focal spasticity in CP - combine with physiotherapy and orthotics for optimal functional outcome.
Respiratory
80 high-yield facts
wheezy child not responding to treatment plus poor growth equals reconsider the diagnosis - always investigate for CF, PCD, and structural causes.
lost right heart border equals right middle lobe; lost left heart border equals lingula - the silhouette sign is your localisation tool.
moderate-severe allergic rhinitis equals intranasal corticosteroid - more effective than antihistamines alone, particularly for congestion.
one puff at a time, good seal, breathe normally through the spacer for 5-10 breaths - and wash the spacer in detergent monthly.
PEF 50-75% best = yellow zone / moderate acute asthma - give oral prednisolone 1-2 mg/kg and increase salbutamol via spacer; arrange medical review within 48 hours (BTS/SIGN 158).
spacer is as good as nebuliser for most children - ten puffs of salbutamol via spacer is equivalent to one nebuliser.
always check the basics before stepping up treatment - technique, adherence, and trigger avoidance are the three pillars of asthma management.
always aim for the minimum effective treatment - step down gradually when well controlled, and review regularly to confirm ongoing stability.
the single most impactful advice for parents of wheezy children is stop smoking - it reduces respiratory illness more than any other intervention.
steatorrhoea in CF means optimise enzymes first - check dose, timing, and adherence before escalating treatment.
F508del is the commonest CF mutation - class II folding defect; CFTR modulators are transforming outcomes, especially Kaftrio.
green sputum plus falling FEV1 plus weight loss in chronic Pseudomonas equals IV anti-pseudomonal antibiotics - always use combination therapy for at least 14 days.
Gastroenterology
80 high-yield facts
severe dehydration with shock requires IV 0.9% sodium chloride 20 mL/kg bolus - reassess after each bolus and escalate if no improvement after 40 mL/kg.
MMR is safe in egg allergy, including anaphylaxis - it is grown in fibroblast cells, not eggs, and can be given in primary care without special measures.
sensitisation does not equal allergy - never remove a tolerated food based on a positive skin prick test alone; clinical history is the key determinant.
for EoE, fluticasone is swallowed not inhaled - puff into the mouth, swallow, and avoid eating/drinking for 30 minutes; no spacer needed.
Clinical dehydration is managed with ORS 50 mL/kg over 4 hours plus maintenance - reserve IV 0.9% sodium chloride boluses for shock or when ORS fails.
acidic stool pH <5.5 with positive reducing substances and a positive hydrogen breath test confirms lactose intolerance - identify and treat the underlying cause.
fever, distension, and explosive diarrhoea in a child with Hirschsprung disease is HAEC until proven otherwise - treat with IV fluids, antibiotics, and rectal washouts.
Kayser-Fleischer rings plus low caeruloplasmin in a young person with liver disease is Wilson disease - treat with copper chelation lifelong and screen siblings.
TB screening is mandatory before starting anti-TNF therapy - reactivation of latent TB is a life-threatening risk.
episodic midline abdominal pain with pallor, vomiting, and a family history of migraine in a well child - think abdominal migraine.
ondansetron is the antiemetic of choice if persistent vomiting prevents ORS intake in paediatric gastroenteritis (off-label) - metoclopramide is avoided due to extrapyramidal risk.
dysphagia and food impaction in an atopic child with >15 eosinophils/HPF on oesophageal biopsy is eosinophilic oesophagitis - treat with dietary exclusion or topical corticosteroids.
Neonatology
80 high-yield facts
heart rate below 60 after effective ventilation equals chest compressions - 3:1 ratio with breaths at 120 events per minute; neonatal bradycardia is almost always due to hypoxia, so effective ventilation is paramount.
tiny white firm papules on the nose and cheeks in a neonate equals milia - keratin cysts, self-resolving, no treatment; Epstein pearls and Bohn nodules are the mucosal equivalents.
more than 10% weight loss by day 4-5 is significant - check sodium urgently; hypernatraemic dehydration is the key danger; correct sodium slowly; assess and support feeding.
oxygen dependency at 36 weeks corrected age in a preterm baby equals BPD - manage with careful oxygen weaning, nutrition optimisation, and RSV prophylaxis with palivizumab.
NLS algorithm equals dry, assess, open airway in neutral, five inflation breaths - the lungs are the priority in neonatal resuscitation; most babies respond to effective ventilation alone.
loud pansystolic murmur with thrill equals refer for echocardiography - likely VSD; normal saturations do not exclude left-to-right shunts; innocent murmurs are soft with no thrill; when in doubt, refer.
GBS meningitis equals at least 14-21 days IV antibiotics - repeat LP at 48-72 hours; mandatory hearing screen and neurodevelopmental follow-up; IAP reduces but does not eliminate GBS disease risk.
screen IDM, SGA, LGA, and preterm babies - pre-feed glucose checks from 2-4 hours of birth; maintain above 2.0 then 2.6 mmol/L; early feeding is key.
blood glucose below 2.6 mmol/L equals neonatal hypoglycaemia - feed first, recheck; if below 2.0 or symptomatic, give IV dextrose; infants of diabetic mothers are high-risk due to hyperinsulinism.
therapeutic hypothermia at 33-34°C for 72 hours within 6 hours of birth - TOBY trial evidence; for moderate-to-severe HIE at 36 weeks or above; slow rewarming; MRI at 5-14 days.
Endocrinology
80 high-yield facts
always treat the patient, not just the number - if symptoms and CGM disagree, do a fingerprick.
recurrent DKA from insulin omission for weight control - diabulimia; requires urgent specialist eating disorder and psychological support alongside diabetes management.
Hypertension in Turner syndrome is dangerous - investigate promptly, image the aorta, treat aggressively, and continue lifelong cardiovascular surveillance because aortic dissection risk is the key concern.
never stop insulin when ill - check glucose and ketones frequently, give correction doses, push fluids, and seek help if ketones rise above 3 mmol/L.
goitre plus hypothyroidism plus positive anti-TPO antibodies - Hashimoto thyroiditis; treat with levothyroxine and monitor for associated autoimmune conditions.
Graves disease in children - carbimazole first-line with propranolol for symptoms; warn about agranulocytosis; treatment course 18-24 months.
precocious puberty before age 8 in girls, with elevated LH/FSH and bilateral ovarian enlargement - central precocious puberty; treat with GnRH agonist.
virilised 46,XX neonate with salt-wasting crisis - classic CAH from 21-hydroxylase deficiency; 17-OHP is the diagnostic marker; treat with hydrocortisone and fludrocortisone.
polyuria with dilute urine that concentrates after desmopressin - cranial diabetes insipidus; MRI pituitary to identify the cause; treat with desmopressin.
DAFNE teaches carbohydrate counting and insulin dose adjustment for dietary flexibility - essential for quality of life and glycaemic control in T1DM.
cardiac defect plus cleft palate plus hypocalcaemia (low PTH) plus immunodeficiency - 22q11.2 deletion (DiGeorge syndrome); CATCH-22 mnemonic.
microalbuminuria in T1DM - confirm on repeat samples, start ACE inhibitor for renoprotection, and intensify glycaemic control.
Emergency Paediatrics
80 high-yield facts
Bronchiolitis CXR (when performed) shows hyperinflation plus bilateral perihilar infiltrates; severe disease = SpO2 <92%, RR >60/min or marked recession; prematurity is a key risk factor; CXR is not routinely indicated (NICE NG9).
IM adrenaline for anaphylaxis - under 6 years 150 micrograms, 6-12 years 300 micrograms, over 12 years 500 micrograms, repeated at 5-minute intervals if needed.
Anaphylaxis = airway/breathing/circulation features + skin changes - give IM adrenaline into the vastus lateralis immediately (<6yr 150 mcg, 6-12yr 300 mcg, >12yr 500 mcg, RCUK 2021); discharge with two auto-injectors and an action plan.
Oral high-dose amoxicillin is first-line for uncomplicated childhood CAP (BTS guideline); reserve macrolides for suspected atypical/Mycoplasma infection and IV therapy for severe disease; chest X-ray is not routine for mild-moderate CAP.
A child attending with an exacerbation on SABA alone needs a regular low-dose ICS preventer started - never a LABA alone and never long-term oral steroids; reinforce inhaler technique, give a written action plan, and arrange GP review within 48 hours.
Paediatric appendicitis (NICE CKS / RCEM) = central pain migrating to RIF + anorexia + localised peritonism + positive Rovsing's; ultrasound first-line in children; IV antibiotics and laparoscopic appendicectomy.
in children, 3 or more discrete episodes of vomiting counts as a single risk factor - observe for at least 4 hours; escalate to CT within 1 hour only if a second risk factor is present or the child deteriorates (falling GCS, further vomiting, or further drowsiness).
biconvex = extradural, crescent = subdural - rapid recognition and neurosurgical referral are life-saving.
cool the burn, calculate the fluid, refer early - time starts from the burn, not from hospital arrival.
if in doubt, sit them out - no child should return to contact sport while symptomatic.
Infectious Diseases
70 high-yield facts
Avoid ibuprofen in chickenpox - risk of necrotising fasciitis; supportive care only in healthy children.
notification is a legal duty - notify on clinical suspicion, do not wait for lab confirmation.
febrile neutropenia = antibiotics within 1 hour - this is a time-critical emergency (NICE CG151).
Sandpaper rash + strawberry tongue + Pastia's lines + GAS = scarlet fever - phenoxymethylpenicillin V for 10 days, notify UKHSA, school exclusion 24 hours after starting treatment (NICE CKS / UKHSA).
LTBI is not infectious but must be treated to prevent future active disease - IGRA is more specific than Mantoux after BCG.
antibiotics are NOT a reason to delay vaccination - common misconceptions cause unnecessary missed opportunities.
8 weeks = 6-in-1 + rotavirus + MenB - the starting point of the UK schedule.
12 weeks = 6-in-1 (second dose) + rotavirus (second and final dose) + PCV13 (first dose).
Gardasil 9 is one of the most effective cancer-prevention vaccines - gender-neutral, single dose in UK.
LAIV is a LIVE vaccine - contraindicated in immunosuppressed children.
herd immunity depends on high vaccination coverage - every unvaccinated child weakens community protection.
Sub-Saharan Africa travel in children - prescribe appropriate chemoprophylaxis per NaTHNaC/Green Book plus bite prevention; chloroquine alone is inadequate in most of Africa.
sepsis = time-critical - deliver the Sepsis 6 within 1 hour, every hour of delay increases mortality.
BCGosis highlights the danger of live vaccines in immunodeficiency - SCID screening saves lives.
Child Development
35 high-yield facts
Hyper- or hypo-sensitivity to sensory input is a core, DSM-5 recognised feature of ASD; assess with occupational therapy and adapt the environment (NICE CG170) rather than treating the child as non-compliant.
In Down syndrome, arrange neonatal echocardiography for every baby (congenital heart disease in 40-50%, AVSD most common per DSMIG surveillance guidance); also monitor thyroid function annually, screen hearing and vision, and plot growth on Down syndrome-specific charts.
At 12 months the next fine motor milestone is scribbling (13-15 months); transfer between hands should already be present from 6-7 months.
Sustained tachycardia, BP above the 95th centile for age, palpitations, syncope or chest pain on ADHD stimulants - withhold the drug and arrange urgent cardiovascular assessment including ECG per NICE NG87; atomoxetine also raises HR/BP and is not a 'safe' default alternative.
For sleep-onset insomnia in ASD, trial at least 4 weeks of sleep hygiene first, then offer melatonin (Slenyto is the licensed prolonged-release option, aged 2-18) - avoid benzodiazepines and chloral hydrate for long-term use.
Continue Makaton alongside speech in children with Down syndrome - AAC does NOT delay spoken language and acts as a bridge during emerging speech; use a 'total communication' approach, always pairing sign with spoken word (RCSLT, Down's Syndrome Association).
In a child with daytime urinary frequency or urgency, a palpable suprapubic mass, and a negative dipstick, think constipation first - treat with a macrogol (NICE CG99) and reassess the urinary symptoms before any urological work-up.
Under NICE NG87, review ADHD medication at least annually and consider a trial off treatment, timed during term, to judge whether ongoing pharmacotherapy is still needed.
The Red Book (PCHR) is a parent-held record of growth, development, and immunisations supporting the Healthy Child Programme - it complements rather than replaces clinical records, and parents should bring it to every health contact.
PGE1 in coarctation bypasses the obstruction via the ductus - femoral pulses improve, acidosis resolves, and the infant stabilises for surgical repair.
continuous murmur in the neck that disappears lying down equals venous hum - it is innocent; differentiate from PDA by its location and positional variability.
Duct-dependent pulmonary lesions cause profound cyanosis when the duct closes; duct-dependent systemic lesions cause circulatory collapse when the duct closes - prostaglandin E1 keeps the duct open as a bridge to intervention.
confident clinical diagnosis of innocent murmur equals reassure - no echo needed; but if in doubt, refer; there is no harm in seeking a specialist opinion.
pulmonary regurgitation is the legacy of TOF repair - monitor with MRI, and plan pulmonary valve replacement when the RV dilates significantly.
Williams syndrome equals elfin facies plus supravalvar AS plus infantile hypercalcaemia from an ELN (7q11.23) deletion - beware coronary artery involvement and increased anaesthetic risk.
failing to thrive on maximal medical therapy equals refer for surgery - do not escalate medical treatment as a substitute for definitive repair.
Fever >36-48 h after first IVIG in Kawasaki disease = give second IVIG 2 g/kg; escalate further if still febrile.
post-viral heart failure plus elevated troponin plus ECG changes equals myocarditis - supportive care; ECMO may be needed for fulminant cases.
short PR plus delta wave equals WPW - treat SVT with adenosine; consider ablation for definitive cure; never give verapamil or digoxin in pre-excited AF.
cardiac arrest in a young person plus prolonged QTc plus family history of sudden death equals LQTS - beta-blockers and ICD for survivors; screen the entire family.
prodrome plus trigger plus rapid recovery plus normal ECG equals vasovagal syncope - educate, hydrate, and reassure; but always look for cardiac red flags.
AV dissociation on ECG equals complete heart block - in children, consider maternal anti-Ro antibodies and structural CHD; pace if symptomatic or rate is inadequate.
superior axis plus prolonged PR plus rsR' in V1 plus Down syndrome equals AVSD - confirm with echocardiography; all Down syndrome babies need an echo.
QTc = QT / √RR - above 460 ms in females or 450 ms in males is prolonged; above 500 ms is high-risk for arrhythmia.
S. aureus is now the commonest cause of IE in children - suspect it in acute presentations, take three sets of blood cultures before antibiotics, and treat with prolonged IV therapy with surgery if complicated.
end-stage heart failure despite maximal therapy equals consider transplantation - VADs bridge to transplant; lifelong immunosuppression is required.
DMD equals progressive cardiomyopathy - start ACE inhibitors by age 10, echo annually, and cardiac MRI for early detection; multidisciplinary care improves survival.
Stable broad complex tachycardia in children → IV amiodarone 5 mg/kg over 20-60 min; unstable → synchronised DC shock 1 J/kg; pulseless → defibrillation 4 J/kg. Always treat as VT until proven otherwise (APLS / RCUK).
heart rate decreases with age - always use age-appropriate ranges; a rate of 100 bpm is normal for a toddler but may be tachycardic in an adolescent.
SpO2 difference more than 3% between right hand and foot equals ductal-level right-to-left shunt - echo urgently; consider prostaglandin E1 if CHD suspected.
infant SVT with WPW equals prophylactic flecainide or propranolol; avoid verapamil in infants; many outgrow it by 12-18 months.
prolonged PR alone in an asymptomatic child with normal echo equals first-degree AV block - usually benign; reassure and allow sports; monitor if very prolonged.
hypertension in a young child plus renal abnormalities equals renal parenchymal disease - ACE inhibitors are first-line; always investigate for secondary causes.
echo at diagnosis, 2 weeks, and 6-8 weeks - coronary Z-scores guide follow-up; giant aneurysms need lifelong monitoring and anticoagulation.
all pulmonary veins drain to the wrong place in TAPVD - obstructed infracardiac is the most urgent; the snowman sign is classic for supracardiac type.
prenatal diagnosis of critical CHD saves lives - planned delivery, immediate PGE1, and early intervention prevent the catastrophic collapse from unexpected duct closure.
NICE says no routine antibiotic prophylaxis for dental procedures in most CHD - good oral hygiene is the best prevention for endocarditis.
sweating during feeds plus tachypnoea plus hepatomegaly in an infant equals heart failure - echocardiography is the key diagnostic tool.
broad complex tachycardia in a child equals VT until proven otherwise - defibrillate if pulseless, cardiovert if unstable, amiodarone if stable; investigate urgently for underlying cause.
neonatal ECG looks like right heart disease in adults - right axis, tall R in V1, and T inversion in V1-V3 are all normal at birth.
SpO2 below 95% or difference above 3% between right hand and foot equals refer for echo - pulse oximetry screening catches CHD that clinical examination misses.
T-wave inversion beyond V1 in an adolescent is a red flag - investigate with echo, cardiac MRI, and Holter before allowing competitive sport.
secondary prophylaxis with benzathine penicillin prevents recurrent ARF - duration depends on cardiac involvement; this is one of the most cost-effective interventions in global health.
fever plus new murmur plus positive blood cultures plus vegetation equals IE - modified Duke criteria confirm; treat with prolonged IV antibiotics.
chest pain in children is rarely cardiac - musculoskeletal is most common; use red flags to identify the rare cardiac cases; reassure the majority.
suitable secundum ASD equals transcatheter device closure - minimally invasive, high success rate, and rapid recovery.
Down syndrome plus CHD - think AVSD first; complete AVSD needs early repair to prevent pulmonary vascular disease.
TGA equals arterial switch within 2 weeks - timing is everything; prostaglandin E1 and Rashkind septostomy bridge to surgery.
HLHS equals no functional left heart - prostaglandin E1 is life-saving; staged Norwood palliation is the standard surgical pathway.
right-to-left shunt equals cyanosis, left-to-right shunt equals acyanotic (initially) - the hyperoxia test differentiates cardiac from respiratory causes.
post-streptococcal migratory arthritis plus new murmur equals rheumatic fever - apply Jones criteria; secondary prophylaxis is lifelong or until adulthood.
fever for 5+ days plus 4 of 5 clinical features equals Kawasaki disease - IVIG within 10 days saves coronary arteries.
cyanosed neonate unresponsive to oxygen equals suspect TGA - start prostaglandin E1 and arrange Rashkind septostomy urgently if atrial mixing is inadequate.
Turner syndrome equals bicuspid aortic valve, coarctation, and aortic dilatation risk - cardiac imaging at diagnosis and lifelong cardiovascular surveillance are mandatory.
cyanosis plus boot-shaped heart plus oligaemic lungs plus ESM equals TOF - the commonest cyanotic CHD; know tet spell management.
severe coarctation-like presentation plus associated anomalies equals consider interrupted aortic arch - test for 22q11.2 deletion (DiGeorge).
cyanosis unresponsive to 100% oxygen equals cardiac until proven otherwise - start prostaglandin E1 and arrange urgent echocardiography.
individualise exercise advice - most children with CHD should be active; formal cardiology assessment guides specific restrictions; do not over-restrict.
normal coronary arteries at 6-8 weeks equals stop aspirin and discharge from cardiac follow-up - but counsel about cardiovascular health; giant aneurysms need lifelong monitoring.
Peaked T waves + widened QRS + K+ >6.5 mmol/L = give IV calcium gluconate first to protect the heart, then shift K+ in (insulin/dextrose, salbutamol), then remove (resonium, dialysis) - APLS hyperkalaemia algorithm.
irregularly irregular plus no P waves equals AF - uncommon in children but important in post-surgical and structural heart disease; WPW plus AF is dangerous.
coved ST elevation in V1-V2 plus family history equals Brugada - avoid triggers (especially fever and certain drugs); ICD for symptomatic patients.
Qp:Qs above 1.5:1 plus right heart dilatation equals close the ASD electively - earlier if symptomatic; transcatheter closure for suitable secundum defects.
chorea plus emotional lability weeks after a sore throat equals Sydenham chorea - it is rheumatic fever until proven otherwise; start secondary prophylaxis.
most paediatric DCM is idiopathic - investigate for treatable causes (carnitine deficiency, metabolic disease), screen the family, and manage heart failure aggressively.
sudden collapse in a young athlete plus asymmetric septal hypertrophy equals HCM - the most common cause of SCD in the young; screen the family.
cyanosis plus clubbing plus previously acyanotic CHD equals Eisenmenger syndrome - an irreversible consequence of late or missed diagnosis; early repair prevents this tragedy.
ESM at the upper left sternal edge with ejection click equals pulmonary stenosis - mild is benign; balloon valvuloplasty for significant stenosis.
loud pansystolic murmur plus thriving infant equals small VSD - reassure and monitor; the louder the murmur with a small VSD, the more restrictive and benign it is.
pansystolic plus thrill equals pathological - always investigate; innocent murmurs are soft, systolic, and thrill-free.
Fontan equals passive pulmonary blood flow - staged over three operations; it is palliative, not curative; lifelong monitoring for Fontan-associated complications is essential.
catheterisation before VSD closure with pulmonary hypertension equals assess PVR to determine operability - too high means Eisenmenger risk; too low means proceed safely.
exercise syncope without prodrome plus family history of cardiac disease plus abnormal ECG equals cardiac until proven otherwise - never dismiss as vasovagal or epilepsy.
BP at or above the 95th centile on 3 occasions equals hypertension - use age-appropriate centiles; look for secondary causes in young children.
cyanosed or collapsed neonate plus suspected CHD equals start prostaglandin E1 immediately - it buys time for diagnosis and intervention; do not wait for echo confirmation.
obese child over 6 with hypertension plus normal renal investigation equals primary hypertension - lifestyle modification first; medication if persistent or end-organ damage.
oral ulcers plus vesicles on palms and soles in a nursery-age child equals HFMD - supportive care only; watch for dehydration.
recurrent periumbilical pain in a well school-age child with normal examination and investigations equals functional abdominal pain - validate the pain, reassure, and encourage normal activity.
prolonged settling and frequent night waking needing parental presence in a toddler equals behavioural insomnia - consistent bedtime routine and teaching self-settling are the treatment.
macrogol maintenance for at least several months - reduce gradually; premature stopping causes relapse; establish a regular toilet routine and follow up regularly.
annular plaque with central clearing and scaly raised edge plus pet contact equals tinea corporis - topical terbinafine or clotrimazole is first-line.
large flaccid bullae in a neonate or young infant equals bullous impetigo - oral flucloxacillin is required; distinguish from SSSS which causes widespread exfoliation.
ear pain worsened by tragal pressure plus canal inflammation plus intact tympanic membrane equals otitis externa - topical antibiotic-steroid drops are first-line.
nephritic syndrome 1-3 weeks after sore throat with low C3 and high ASOT equals post-streptococcal glomerulonephritis - mainly supportive management with excellent prognosis in children.
treat all household contacts simultaneously with permethrin 5% cream - two applications 7 days apart; warn that itching may persist for weeks after successful treatment.
soft systolic murmur that varies with posture in an asymptomatic well child equals innocent - reassure parents; no echo or referral needed if clinically confident.
any murmur detected in the neonatal period requires echocardiography per NIPE guidance - do not assume it is innocent without imaging in this age group.
three-zone target lesions on the extremities following herpes labialis equals erythema multiforme minor - supportive management; consider aciclovir prophylaxis if recurrent.
tall adolescent boy with small firm testes plus gynaecomastia plus learning difficulties equals Klinefelter syndrome - confirm with karyotype; testosterone replacement from puberty.
screaming episodes 1-2 hours after sleep onset with no recall equals night terrors - reassure parents; ensure safety; they are benign and self-limiting.
macerated peeling skin between toes in an adolescent using communal changing rooms equals tinea pedis - topical terbinafine first-line plus hygiene measures.
Centor score 3 suggests approximately 35% chance of streptococcal infection - consider a delayed prescription; clinical judgement alongside the score guides management.
disimpaction equals escalating macrogol over 7 days per NICE - then maintenance for months; do not stop laxatives too early as relapse is common.
waddling gait with limited hip abduction and limb length discrepancy in a toddler equals late DDH - X-ray confirms; treatment is more complex than early-detected DDH.
wet combing with a detection comb confirms diagnosis - treat only if live lice are found; school exclusion is not required for head lice.
bilateral limb pains in the evening or night with a normal examination and normal investigations equals growing pains - reassure, massage, and give analgesia as needed; unilateral pain, limp, or systemic features need urgent investigation.
unilateral tonsillar swelling with trismus and uvular deviation equals peritonsillar abscess - urgent ENT referral for drainage plus IV antibiotics.
severe croup equals nebulised adrenaline plus dexamethasone plus observation for minimum 2 hours - watch for rebound after adrenaline wears off.
toxic child with drooling plus no barking cough plus tripod position equals epiglottitis - do not examine the throat; call for expert airway management immediately.
eyelid swelling with normal eye movements and vision equals periorbital cellulitis - co-amoxiclav and close review; escalate if any orbital signs develop.
facial swelling with dental pain and draining sinus equals dental abscess - antibiotics for spreading infection plus urgent dental referral for definitive management.
recurrent thrush beyond infancy plus recurrent infections equals investigate for immunodeficiency - check immunoglobulins, lymphocyte subsets, and HIV as a minimum.
perianal itch worse at night in a school-age child with visible white worms equals threadworm - mebendazole plus hygiene measures for the whole household.
dimeticone 4% lotion is first-line for head lice - physical mode of action avoids resistance; always apply a second treatment at 7 days.
crusted hyperkeratotic rash with thousands of mites in an immunocompromised patient equals crusted scabies - oral ivermectin plus topical permethrin; extremely contagious requiring isolation.
eczematous change around molluscum papules equals molluscum dermatitis - this is a good sign suggesting immune-mediated resolution; treat with emollients and mild topical steroid.
painful flat lesion on the sole with black dots and disrupted skin lines equals plantar wart - topical salicylic acid daily for up to 12 weeks is first-line.
palpable purpura on buttocks and legs plus joint pain plus abdominal pain plus normal platelets equals HSP - monitor renal involvement closely for 6-12 months.
non-blanching purpura plus fever plus signs of shock equals meningococcal septicaemia - give parenteral antibiotics immediately in the community; do not wait for investigations.
Spreading erythema with warmth and pain equals cellulitis - oral flucloxacillin is first-line; mark the erythema margin and review at 48 hours.
Widespread tender erythema with epidermal peeling plus a positive Nikolsky sign and no mucosal involvement equals SSSS - IV flucloxacillin and supportive care are essential.
Pearly umbilicated papules in a child equals molluscum contagiosum - reassurance that it is self-limiting is the mainstay of management; treatment is rarely needed.
punched-out monomorphic vesicles and erosions on eczematous skin with fever equals eczema herpeticum - start aciclovir immediately; this is a dermatological emergency.
cradle cap plus flexural erythema plus nappy rash in a young infant equals seborrhoeic dermatitis - self-limiting; treat candidal component with topical antifungal.
pregnant contact of parvovirus - check IgG and IgM urgently; IgG positive equals immune; IgM positive equals refer to fetal medicine for monitoring.
loud murmur with thrill plus feeding difficulty and faltering growth equals pathological murmur requiring urgent echocardiography - never ignore a murmur with symptoms.
tall stature with arachnodactyly plus lens subluxation plus aortic root dilatation equals Marfan syndrome - regular echocardiography is essential to monitor aortic dimensions.
snoring plus witnessed apnoeas plus daytime behavioural problems in a child with large tonsils and adenoids equals OSAS - adenotonsillectomy is first-line treatment.
spreading erythema and pain around chickenpox vesicles equals secondary bacterial infection - treat with flucloxacillin; avoid ibuprofen and aspirin in varicella.
daily temper tantrums in a 2-year-old with normal development equals normal behaviour - stay calm, consistent limits, distract, ignore, and praise positive behaviour.
persistent angry defiant behaviour for more than 6 months across settings equals ODD - parent training programmes are first-line per NICE; distinguish from conduct disorder which involves more serious rule violations.
papules and pustules centred on hair follicles equals folliculitis - mild cases respond to antiseptic washes; swimming pool exposure suggests Pseudomonas.
patchy hair loss with scaling and broken hairs in a child equals tinea capitis - oral antifungal is essential; topical alone is ineffective.
recurrent croup warrants ENT referral for airway assessment - exclude subglottic stenosis, haemangioma, and other structural lesions with flexible laryngoscopy.
immunocompromised child exposed to varicella equals VZIG urgently - live vaccine is contraindicated; monitor for 21 days and start IV aciclovir promptly if rash develops.
food avoidance causing weight loss and nutritional deficiency without body image concern equals ARFID - multidisciplinary management including dietitian, psychology, and paediatrics.
post-viral limp in a well child with low inflammatory markers and no Kocher criteria equals transient synovitis - rest, ibuprofen, and review in 48 hours.
clunk on Ortolani or Barlow test equals DDH - urgent hip ultrasound within 2 weeks; Pavlik harness for infants under 6 months with reducible dislocation.
post-viral acute limp in a well child with no Kocher criteria equals transient synovitis - rest and ibuprofen; review at 48 hours to ensure improvement.
Scarlet fever = penicillin V for 10 days - it is a notifiable disease (UKHSA); the child returns to school 24 hours after starting antibiotics (NICE NG84; BNF for Children; UKHSA scarlet fever guidance).
hypo-pigmented patches with fine scale on the trunk in an adolescent plus spaghetti and meatballs on KOH equals pityriasis versicolor - ketoconazole shampoo as body wash is practical first-line.
A dull, retracted tympanic membrane with a fluid level and a flat tympanogram equals glue ear - watch and wait for around 3 months before ENT referral.
treat the whole household with mebendazole simultaneously plus repeat at 2 weeks - hygiene measures for 6 weeks are equally important to prevent re-infection.
overweight adolescent with groin or knee pain plus obligatory external rotation on hip flexion equals SUFE - urgent orthopaedic referral for surgical fixation; check the contralateral hip.
cough, coryza, conjunctivitis plus Koplik spots equals measles - notify public health and check vaccination status of contacts.
mild croup equals single dose oral dexamethasone 0.15 mg/kg plus parental safety-netting - steam is not recommended; most cases resolve within a week.
avulsed permanent tooth equals reimplant immediately or store in milk - time is critical; never reimplant primary teeth; emergency dental review is essential.
~25-30% of children present in DKA at first diagnosis - this is preventable; recognise the 4 T's (toilet, thirsty, tired, thinner); check capillary glucose in any symptomatic child.
dry cough persisting 4-8 weeks after a viral URTI in a well child equals post-infectious cough - reassurance; no treatment needed; investigate if cough is wet or persistent beyond 8 weeks.
daily soiling with palpable faecal mass and history of constipation equals overflow soiling - disimpact with macrogol then maintain for months; never punish soiling.
croup worsening despite treatment with high fever plus toxic appearance plus purulent secretions equals bacterial tracheitis - IV antibiotics and close airway monitoring are essential.
proptosis plus painful eye movements plus reduced vision equals orbital cellulitis - this is an emergency requiring IV antibiotics and specialist review.
tall child with tall parents and height consistent with mid-parental height equals constitutional tall stature - reassure; investigate only if features suggest a pathological cause.
continuous murmur in the neck that disappears with jugular compression and lying flat equals venous hum - innocent finding; differentiate from PDA by location and response to compression.
weight loss plus nocturnal pain plus rectal bleeding plus raised calprotectin equals red flags for organic disease - refer urgently to paediatrics; functional pain does not wake children from sleep.
ischaemic stroke in sickle cell disease - TCD screening from age 2, chronic transfusions if velocities >200 cm/s, and exchange transfusion for acute stroke.
progressive neurological deterioration with symmetrical white matter changes on MRI and affected siblings - leukodystrophy; early diagnosis may allow HSCT in some types.
Becker has partially functional dystrophin (in-frame mutation), Duchenne has absent dystrophin (frameshift mutation) - both are X-linked dystrophin gene disorders.
motor plus vocal tics with premonitory urge and suppressibility - tic disorder (Tourette if >1 year); behavioural therapy (HRT/CBIT) is first-line treatment.
psychiatric symptoms plus seizures plus movement disorder in a young person - consider anti-NMDA receptor encephalitis; check for ovarian teratoma and treat with immunotherapy.
dilatation of all four ventricles after meningitis - communicating hydrocephalus from arachnoid granulation scarring; treat with VP shunt and monitor development.
acute bilateral weakness with sensory level and urinary retention - transverse myelitis; IV methylprednisolone first-line, test for AQP4 and MOG antibodies.
reduced visual acuity in NF1 - suspect optic pathway glioma; annual ophthalmological screening is recommended; treat progressive symptomatic OPGs with chemotherapy.
every child with epilepsy needs an individualised healthcare plan at school - include seizure description, first aid, rescue medication protocol, and activity guidance.
post-meningitis follow-up requires hearing assessment within 4 weeks, developmental monitoring, hydrocephalus surveillance, and psychosocial support - pneumococcal meningitis has the highest risk of hearing loss.
opsoclonus-myoclonus-ataxia in a young child - urgently exclude neuroblastoma with imaging and urinary catecholamines; paradoxically, OMS-associated neuroblastoma has a better cancer prognosis.
single seizure = 6 months seizure-free for Group 1 licence; epilepsy = 12 months seizure-free; document that driving advice has been given.
widespread blistering rash with mucosal involvement on carbamazepine - SJS/TEN, stop the drug immediately and manage as a dermatological emergency.
early cardiomyopathy in DMD - start ACE inhibitor promptly to slow progression; regular echocardiographic and respiratory monitoring from age 6-10.
childhood absence epilepsy has 70-80% remission - withdraw AEDs gradually after 2 years seizure-free under specialist guidance.
uncontrolled nocturnal GTCS are the biggest SUDEP risk factor - optimise seizure control, discuss SUDEP openly, and consider nocturnal monitoring.
ibuprofen early in the attack with an antiemetic if needed is first-line for paediatric migraine - no imaging needed with normal neurology.
non-ambulant CP children have up to 90% hip displacement risk - systematic surveillance with X-rays enables early intervention before painful dislocation occurs.
non-blanching rash plus fever plus meningism - give IV ceftriaxone immediately, do not delay for CT or LP, and notify Public Health.
early morning myoclonic jerks plus GTCS in an adolescent with polyspike-and-wave on EEG is JME - valproate is highly effective but lifelong treatment is usually needed.
V1 port-wine stain - MRI brain to exclude leptomeningeal angioma (Sturge-Weber), and ophthalmological screening for glaucoma.
dilated lateral and third ventricles with normal fourth ventricle - aqueductal stenosis causing obstructive hydrocephalus; treat with VP shunt or ETV.
headache, vomiting, drowsiness, and non-filling shunt reservoir in a child with a VP shunt - shunt blockage until proven otherwise, requires urgent neurosurgical assessment.
Sixth nerve palsy causes inability to abduct the eye - in children, exclude a brain tumour (especially brainstem glioma) with MRI before attributing to a benign post-viral cause.
Alternating hemiplegia with onset in infancy, dystonia, and resolution with sleep - AHC from ATP1A3 mutation; flunarizine may reduce episodes.
developmental regression with loss of hand skills, hand-wringing stereotypies, and breathing irregularities in a girl - Rett syndrome from MECP2 mutation.
Medulloblastoma - surgery plus craniospinal radiotherapy plus chemotherapy; molecular subtyping (WNT/SHH/Group 3/Group 4) guides prognosis; avoid radiation under age 3.
rescue midazolam for febrile seizures is indicated when seizures last ≥5 minutes or access to emergency care is limited - not for all febrile seizures.
a single unprovoked seizure is not epilepsy - refer to a specialist, arrange EEG, but do not start AEDs unless recurrence risk is high.
progressive ataxia plus telangiectasia plus immunodeficiency plus raised AFP - ataxia-telangiectasia from ATM mutation; avoid unnecessary radiation exposure.
Happy demeanour, absent speech, ataxia, seizures, and microcephaly - Angelman syndrome from maternal UBE3A loss on chromosome 15.
breakthrough seizures on therapeutic levels - check adherence, reconsider diagnosis and classification, and involve a specialist before changing or adding medications.
serial FVC monitoring is critical in GBS - a declining FVC is the best early indicator of respiratory failure, do not rely on oxygen saturation alone.
Rolandic epilepsy - facial/oropharyngeal seizures from sleep with centrotemporal spikes, excellent prognosis, remission by mid-teens, treatment often unnecessary.
pneumococcal meningitis has the highest risk of hearing loss - assess hearing before discharge, consider cochlear implantation early for severe bilateral loss.
floppy infant with tongue fasciculations, areflexia, preserved cognition, and SMN1 deletion - SMA type 1; early treatment with gene therapy or nusinersen is transformative.
the COCP reduces lamotrigine levels by 50% - risk of breakthrough seizures; enzyme-inducing AEDs reduce COCP efficacy - risk of contraceptive failure.
Encephalopathy with multifocal white matter lesions 1-4 weeks post-infection - ADEM; treat with IV methylprednisolone; usually monophasic with good prognosis.
sodium valproate is teratogenic - the Pregnancy Prevention Programme applies to all females of childbearing potential, and risks must be discussed even for prepubertal girls.
Fever with seizures and temporal lobe changes on MRI - start IV aciclovir immediately for suspected HSE; do not wait for PCR confirmation.
Gowers manoeuvre, calf pseudohypertrophy, and massively elevated CK in a young boy - Duchenne muscular dystrophy, X-linked recessive, absent dystrophin.
≥6 café-au-lait macules plus axillary freckling with family history - NF1, autosomal dominant on chromosome 17, requires annual multi-system surveillance.
encourage normal activities with sensible precautions - never swim alone, shower preferred, helmet for cycling, and school must have a seizure management plan.
headache with papilloedema, normal MRI, and raised opening pressure in an obese adolescent - IIH; weight loss is key, acetazolamide reduces CSF pressure, and monitor vision closely.
simple febrile seizures are benign - reassure parents, treat the infection, no EEG/MRI needed, and antipyretics do not prevent recurrence.
brief staring spells with immediate recovery, provoked by hyperventilation, showing 3 Hz spike-and-wave on EEG - childhood absence epilepsy, treat with ethosuximide.
clusters of flexion spasms on waking with developmental regression and hypsarrhythmia is West syndrome - treat urgently with corticosteroids (or vigabatrin for TSC).
progressive morning headache with vomiting, papilloedema, and cerebellar signs - urgent MRI to exclude posterior fossa tumour.
levetiracetam's main drawback is behavioural side effects (irritability, aggression) - warn families and monitor, but it has the advantage of minimal drug interactions.
spastic CP with legs more affected than arms in an ex-premature infant is spastic diplegia - multidisciplinary management with physiotherapy, spasticity treatment, and hip surveillance.
suspected meningococcal disease in the community - give IM benzylpenicillin immediately, call 999, and do not delay for IV access or investigation.
ash leaf macules, cortical tubers, subependymal nodules, and infantile spasms - tuberous sclerosis complex, treat spasms with vigabatrin.
dyskinetic CP with basal ganglia injury on MRI - typically results from acute profound hypoxia-ischaemia at term, distinct from PVL-related spastic diplegia.
ring-enhancing brain lesion in a child with cyanotic heart disease - think brain abscess from haematogenous spread; treat with prolonged IV antibiotics and surgical drainage.
unsafe swallowing with aspiration and faltering growth in severe CP - gastrostomy feeding is the appropriate long-term nutritional intervention.
IIH with sixth nerve palsy - acetazolamide plus weight loss are first-line; monitor vision closely and escalate to surgery if vision deteriorates.
buccal midazolam - squirt into the buccal space (cheek pouch), not swallowed; child in recovery position; maximum two doses before calling 999.
corticosteroids in DMD prolong ambulation by 2-3 years and preserve respiratory/cardiac function - monitor for significant side effects including weight gain, osteoporosis, and adrenal suppression.
large head, normal development, soft fontanelle, family history of big heads, and enlarged subarachnoid spaces - benign external hydrocephalus, self-limiting, monitor and reassure.
suprasellar cystic/solid mass with calcification, bitemporal hemianopia, and endocrine deficiencies in a child - craniopharyngioma; lifelong endocrine replacement is usually needed.
weight gain, acne, and irregular periods in a girl on valproate - think valproate-associated PCOS; consider switching AED, especially given teratogenic concerns for the future.
screaming from sleep in the first third of the night with no recall - night terrors, a benign NREM parasomnia; reassure parents and ensure consistent sleep routine.
progressive ataxia, absent ankle reflexes with upgoing plantars, pes cavus, cardiomyopathy, and GAA expansion - Friedreich ataxia; cardiac disease is the leading cause of death.
propranolol is first-line migraine prophylaxis in adolescents - trial for 2-3 months, continue for 6-12 months if effective, then taper gradually.
myelomeningocele requires closure within 24-72 hours, VP shunt for progressive hydrocephalus, and lifelong multidisciplinary care - latex precautions are essential.
Ascending weakness with areflexia post-infection, CSF albuminocytological dissociation, and demyelinating nerve conduction - GBS; treat with IVIG per RCPCH guidance.
Chorea after streptococcal pharyngitis with carditis - Sydenham chorea as part of rheumatic fever; long-term penicillin prophylaxis is essential to prevent recurrent carditis.
fatigable ptosis and diplopia worsening through the day with positive AChR antibodies - myasthenia gravis; pyridostigmine for symptoms, immunosuppression for disease control.
Kaftrio corrects the protein folding AND potentiates channel function - it is transforming CF outcomes for most patients.
pneumothorax in CF requires CF team input - balance between preventing recurrence and preserving transplant eligibility.
chronic Pseudomonas plus frequent exacerbations equals consider inhaled anti-pseudomonal antibiotics - always do a supervised test dose first.
persistent OSA after adenotonsillectomy equals CPAP - optimise mask fit, address weight, and monitor closely with repeat sleep studies.
toxic child plus drooling plus no cough plus tripod position equals epiglottitis - do not examine the throat; call for senior airway help immediately.
obese child plus severe OSA plus small tonsils equals CPAP plus weight management - address both the symptom and the cause.
collapse with ipsilateral shift equals complete obstruction; hyperinflation with contralateral shift equals ball-valve - both require urgent bronchoscopy.
lobar consolidation plus high fever in a child equals S. pneumoniae until proven otherwise - first-line treatment is oral amoxicillin.
SpO2 below 92% plus inability to feed plus significant recession equals severe pneumonia - admit, oxygenate, and treat with IV antibiotics.
pus plus low pH plus low glucose plus high LDH equals empyema - drain with fibrinolytics or VATS, and treat with prolonged antibiotics.
smear-positive TB equals urgent contact tracing - screen all close contacts, treat LTBI, and refer active cases for full treatment.
BCG can cause false-positive Mantoux - use IGRA to clarify; a negative IGRA in a BCG-vaccinated child means the Mantoux is likely BCG-related.
6-8 URTIs per year in a preschool child is normal - reassure parents, but investigate if infections are serious, recurrent, or associated with poor growth.
failed pharmacotherapy plus confirmed specific allergy equals consider immunotherapy - it modifies the allergic disease trajectory and provides lasting benefit.
loud cough only when awake plus disappears during sleep plus normal investigations equals habit cough - reassure, explain, and consider suggestion therapy.
unilateral smelly discharge in a preschool child = nasal foreign body - always exclude a button battery as a time-critical emergency.
anterior epistaxis from Little's area is common and benign - pinch the nose for 10-15 minutes, use antiseptic cream for prevention.
OME for 3 months plus hearing loss affecting function equals grommets - antibiotics and decongestants do not help.
tonsillectomy requires documented episodes meeting frequency thresholds - URTIs alone are not an indication; OSA is the most common reason in young children.
reduced ratio plus significant reversibility equals asthma - use spirometry to confirm the diagnosis and monitor treatment response.
normal spirometry does not exclude asthma - use PEF variability, exercise challenge, or FeNO to demonstrate variable obstruction or airway inflammation.
CTR above 0.50 in children over 1 year equals cardiomegaly - check an echo; in neonates, the thymus may mislead.
morning dip pattern with greater than 20% variability equals asthma - PEF monitoring is a simple, accessible tool for diagnosis and monitoring.
proportionally reduced FEV1 and FVC with preserved ratio equals restriction - confirm with lung volumes and assess the underlying cause.
elevated FeNO equals eosinophilic airway inflammation - supports asthma diagnosis and predicts steroid response; use as one piece of the diagnostic jigsaw.
the sail sign in an infant equals normal thymus - do not mistake it for pathology; the thymus involutes with age and stress.
bilateral hilar lymphadenopathy plus elevated ACE plus negative Mantoux equals sarcoidosis - biopsy shows non-caseating granulomata; most cases respond to corticosteroids.
the growth effect is small and non-progressive - the benefits of asthma control greatly outweigh the 1 cm height difference.
most preschool wheezers grow out of it - but those with atopy and interval symptoms are more likely to develop persistent asthma.
croup that worsens despite treatment plus high fever plus toxic child equals bacterial tracheitis - secure the airway, start IV antibiotics, and admit to PICU.
barking cough plus hoarse voice plus stridor equals croup - dexamethasone for all, nebulised adrenaline for moderate-severe.
in preschool children, trial ICS for 8 weeks and measure the response - clear improvement supports the diagnosis, no change means reconsider.
pertussis in young infants equals admit, monitor for apnoea, give macrolide, and notify - maternal vaccination is the best prevention strategy.
neonatal distress plus chronic wet cough plus glue ear plus dextrocardia equals suspect PCD - nasal NO plus ciliary analysis confirms the diagnosis.
physiotherapy is the single most important non-pharmacological treatment for bronchiectasis - daily clearance prevents the vicious cycle of infection and inflammation.
pertussis is notifiable on clinical suspicion - notify the HPT, prophylax vulnerable contacts, and remember maternal vaccination is key to protecting newborns.
chronic wet cough in a preschooler that responds to antibiotics equals PBB - treat with prolonged co-amoxiclav, but investigate further if recurrent.
3 seconds minimum for children, blast start, no hesitation - quality spirometry requires trained staff, patience, and child-friendly approaches.
symptoms more than twice a week or nocturnal waking equals Step 2 - start low-dose ICS with a spacer.
TB meningitis equals 12 months treatment plus steroids - early treatment improves survival; BCG vaccination prevents the most severe forms.
choking episode plus persistent unilateral signs equals foreign body - rigid bronchoscopy is both diagnostic and therapeutic.
chronic cough plus night sweats plus weight loss plus hilar lymphadenopathy in a child from a TB-endemic country equals TB until proven otherwise.
exercise is beneficial for asthmatic children - two puffs of salbutamol before sport, a good warm-up, and appropriate preventer therapy enable full participation.
in preschool wheeze, your clinical assessment is the severity tool - observe the whole child, not just the numbers.
CF equals fat malabsorption equals supplement A, D, E, K - monitor levels annually and adjust doses accordingly.
Stridor from birth that worsens with crying and improves prone equals laryngomalacia - reassure, but investigate if feeding or growth are compromised; supraglottoplasty for severe cases.
more than 2-3 episodes of severe croup or stridor between episodes equals investigate for structural cause - especially subglottic stenosis or haemangioma.
bronchiolitis is supportive care only - oxygen if needed, fluids if not feeding, and patience; do not prescribe antibiotics or salbutamol.
Positive Mantoux/IGRA + normal CXR + asymptomatic = LTBI; treat with NICE NG33 chemoprophylaxis (3HR or 6H) to prevent progression; IGRA distinguishes true infection from BCG; LTBI is not infectious.
most AOM is self-limiting - analgesia first, antibiotics only when indicated, and refer to ENT for recurrent episodes.
nasal polyps in a child equals sweat test for CF - this diagnosis must not be missed; treat with topical steroids and surgery if needed.
flucloxacillin from diagnosis, enzymes with food, vitamins, physiotherapy, and high calories - early comprehensive care improves survival.
chronic productive cough plus recurrent pneumonia in the same lobe plus signet ring sign on HRCT equals bronchiectasis - investigate the underlying cause.
beard distribution haemangiomas plus progressive stridor equals suspect subglottic haemangioma - treat with oral propranolol and monitor the airway.
children swallow sputum - early-morning gastric aspirates on 3 consecutive days are the standard for TB diagnosis in young children.
inspiratory equals extrathoracic, expiratory equals intrathoracic, biphasic equals fixed obstruction - the phase tells you the level.
asthma plus nasal polyps in an adolescent equals consider AERD - ask about aspirin/NSAID reactions and refer for specialist assessment.
air bronchograms equal consolidation - the bronchi are visible because the surrounding alveoli are opacified with inflammatory material.
ipsilateral mediastinal shift equals volume loss (collapse); contralateral shift equals volume gain (effusion/mass) - this simple rule helps interpret chest X-rays.
steeple sign equals subglottic narrowing in croup - but croup is a clinical diagnosis; do not delay treatment for imaging.
positive newborn screen is not a diagnosis - the sweat test confirms CF; counselling and early specialist referral are priorities.
Frequent bronchiectasis exacerbations despite standard care = consider long-term azithromycin per BTS guidance - always exclude NTM infection before starting macrolide prophylaxis.
standard paediatric TB treatment is 2RHZE/4RH - 6 months total for pulmonary TB, longer for TB meningitis and bone/joint TB.
first Pseudomonas equals eradication therapy - 3 months of cipro plus nebulised anti-pseudomonal; early treatment prevents chronic colonisation.
CF children need 120-150% calories with a high-fat diet - nutritional status directly predicts lung health and survival.
asthma diagnosis requires a consistent history plus objective evidence of variable airflow obstruction - spirometry with reversibility is the gold standard.
severe asthma not responding to salbutamol equals add ipratropium and consider IV magnesium - escalate early to PICU if deteriorating.
maternal pertussis vaccination at 16-32 weeks equals passive protection for the newborn - safe, effective, and saves infant lives.
macrogol is first-line for paediatric constipation - combine with dietary advice and regular toileting habits as per NICE CG99.
disimpaction uses escalating macrogol doses over 1-2 weeks - follow with maintenance therapy for months and reduce gradually.
gradual laxative weaning over months is key - stopping too soon is the commonest cause of relapse in paediatric constipation.
soiling without constipation is non-retentive faecal incontinence - investigate developmental and psychological factors rather than prescribing laxatives.
jaundice within 24 hours is pathological - investigate urgently, commence phototherapy, and monitor closely against NICE thresholds.
coeliac diagnosis without biopsy requires tTG ≥10x ULN plus positive EMA on a second sample in a symptomatic child - the ESPGHAN no-biopsy pathway.
stereotypical episodes of intense vomiting with complete wellness between episodes and a migraine association - think cyclical vomiting syndrome.
mild allergic reaction (skin only, no respiratory/cardiovascular compromise) - treat with oral antihistamine, observe, and refer to allergy clinic for formal assessment.
pneumatosis intestinalis on X-ray in a premature neonate with abdominal distension and bloody stools is NEC - stop feeds, antibiotics, decompress, and get surgical review.
anaphylaxis = IM adrenaline first, then call 999 - do not delay adrenaline for any other treatment, and observe for 6-12 hours post-event.
after-meal toileting on a footstool with positive reinforcement is the behavioural cornerstone - never punish or force prolonged toilet sitting.
Always check total IgA alongside tTG - IgA deficiency is common in coeliac disease and causes false-negative results, and the child must be eating gluten when tested.
back arching with feed refusal in an infant with reflux is Sandifer syndrome - escalate from reassurance to alginate therapy as the first pharmacological step.
delayed meconium passage plus explosive decompression on rectal exam is Hirschsprung disease until proven otherwise.
Most infant reflux is physiological and self-limiting - reassurance, positional advice, and feed review are the cornerstones of management in thriving infants; acid suppression is only for true GORD with red flags.
norovirus requires the 48-hour exclusion rule, thorough hand washing with soap and water, and bleach-based environmental cleaning.
a thriving toddler with loose stools and high juice intake has toddler's diarrhoea - manage with the 'four Fs' and reassurance.
CF with pancreatic insufficiency requires PERT with all meals, a high-fat high-calorie diet, and ADEK vitamin supplementation - never restrict fat.
negative skin prick test does not exclude CMPA - non-IgE-mediated CMPA is diagnosed by elimination and rechallenge, not by allergy testing.
perianal disease, skip lesions, and transmural inflammation distinguish Crohn from UC - EEN is first-line in paediatric Crohn.
excessive cow's milk (>400 mL/day) in toddlers causes iron deficiency - limit intake and encourage iron-rich weaning foods.
bilious vomiting plus double bubble sign with no distal gas equals duodenal atresia - associated with Down syndrome in 30% of cases.
CF is caused by defective CFTR chloride channel - sweat chloride >60 mmol/L is diagnostic, and CFTR modulators are transforming outcomes for eligible patients.
periumbilical pain with normal growth and no red flags in a school-age child is most likely functional - validate, reassure, and avoid over-investigation.
coeliac disease requires a lifelong gluten-free diet - annual review should include serology, nutritional bloods, growth, and screening for associated autoimmune conditions.
EEN is first-line for paediatric Crohn induction - it matches steroid efficacy without growth-suppressing side effects.
Foul-smelling fatty stools + no fever or blood + camping or foreign travel = giardiasis → stool microscopy/antigen, treat with metronidazole 5-7 days; consider IgA deficiency in chronic or relapsing disease.
for suspected non-IgE CMPA, trial eHF first - soy is avoided under 6 months, and diagnosis is confirmed by elimination and re-challenge.
ultrasound 'target sign' confirms intussusception - air enema is both diagnostic and therapeutic with 75-80% success.
pale stools and conjugated jaundice - urgent liver ultrasound and specialist referral to exclude biliary atresia before the Kasai window closes.
refeeding syndrome is characterised by hypophosphataemia, hypokalaemia, and hypomagnesaemia - start feeds slowly, monitor electrolytes daily, and give thiamine prophylaxis.
bloody diarrhoea followed by anaemia, thrombocytopenia, and renal failure is HUS - do not give antibiotics for STEC, and avoid platelet transfusion.
the milk ladder starts with baked milk (most denatured, least allergenic) and progresses to fresh milk - always under healthcare professional supervision.
Kasai success depends critically on early surgery - ideally before 60 days - hence the urgency of investigating conjugated jaundice in neonates.
painless rectal bleeding in a well child aged 2-10 is most likely a juvenile polyp - solitary polyps are benign but juvenile polyposis syndrome requires surveillance.
faltering growth requires a detailed feeding history, growth chart review, and baseline investigations - most cases are related to inadequate intake rather than organic disease.
rickets shows low calcium, low phosphate, very high ALP, and low vitamin D - treat with high-dose vitamin D loading followed by maintenance supplementation.
constipation from birth that fails optimal medical management - always consider Hirschsprung disease and refer for rectal suction biopsy.
terminal ileum resection causes permanent B12 malabsorption - lifelong IM hydroxocobalamin every 2-3 months is essential, and never give folate without B12.
150 micrograms IM adrenaline for children 7.5-25 kg, always carry two auto-injectors, and observe for at least 6-12 hours post-anaphylaxis for biphasic reactions.
passing a baked milk challenge means introducing baked milk regularly at home and progressing through the milk ladder - do not skip to fresh milk.
CoNS (S. epidermidis) is the commonest CLABSI organism - take paired cultures, treat empirically, and remove the line for Candida or S. aureus infections.
mesalazine (oral plus topical) is first-line for mild-to-moderate paediatric UC - EEN works for Crohn, not UC.
abdominal ultrasound is the gold standard for pyloric stenosis - pyloric muscle thickness >3 mm and channel length >15 mm are diagnostic.
azathioprine requires TPMT checking before initiation and regular FBC/LFT monitoring - myelosuppression is the most serious dose-dependent adverse effect.
pale stools plus dark urine plus jaundice beyond 2 weeks equals conjugated jaundice - refer urgently to exclude biliary atresia, as Kasai success depends on early surgery.
oral aversion in ex-NICU infants is caused by negative oral experiences - multidisciplinary management with SALT-led desensitisation is the cornerstone of treatment.
PUCAI ≥65 is acute severe colitis - admit for IV methylprednisolone, monitor daily PUCAI, and consider rescue therapy by day 3 if no response.
soiling in a constipated child is overflow incontinence - disimpact first, then maintain long-term laxatives with behavioural support.
family-based lifestyle change is first-line for childhood obesity - in the UK the clinical obesity threshold is the 98th BMI centile, and acanthosis nigricans should prompt screening for insulin resistance.
intermittent mild unconjugated jaundice triggered by illness/fasting with normal LFTs and no haemolysis is Gilbert syndrome - reassure that it is benign.
PiZZ A1AT deficiency - liver disease in children is due to protein accumulation in hepatocytes, not enzyme deficiency; only 10-15% develop significant liver disease.
E. coli sepsis plus jaundice plus positive urine reducing substances in a neonate is galactosaemia - stop lactose immediately and switch to soy-based formula.
acute pancreatitis on azathioprine is an idiosyncratic reaction - stop the drug permanently and never rechallenge, as it will recur.
bile duct paucity, characteristic facies, cardiac defect, butterfly vertebrae, and posterior embryotoxon - Alagille syndrome, an autosomal dominant JAG1 mutation.
constipation from birth in a child with Down syndrome and an empty rectum on PR exam - investigate for Hirschsprung disease with rectal suction biopsy and anorectal manometry.
chronic abdominal pain and loose stools in a child consuming sugar-free products - think sorbitol-induced osmotic diarrhoea and take a detailed dietary history.
live vaccines are generally contraindicated during immunosuppression - give inactivated injectable influenza vaccine instead of the live nasal spray, and ensure household contacts are fully vaccinated.
a blanching maculopapular rash in an improving child after viral gastroenteritis is a benign post-viral exanthem - reassure and safety-net.
reintroduce food gradually over 2-3 weeks while tapering EEN and starting maintenance immunomodulation - abrupt cessation risks relapse.
rising bilirubin on PN is IFALD - maximise enteral feeds, cycle PN, reduce soy lipid, consider fish oil lipids, and treat sepsis aggressively.
perianal Crohn disease requires a combined surgical and medical approach - antibiotics plus EUA with seton drainage, escalating to infliximab for refractory fistulae.
Rotarix is a live oral vaccine given at 8 and 12 weeks - the course must be completed by 24 weeks of age due to intussusception risk.
all breastfed infants need vitamin D 8.5-10 micrograms daily from birth - the Healthy Start scheme provides free vitamins for eligible families.
painless massive rectal bleeding in a child with a positive Meckel scan indicates ectopic gastric mucosa - surgical excision is the definitive treatment.
hepatitis A is self-limiting - supportive care, notify Public Health, and offer post-exposure prophylaxis (vaccine or HNIG) to contacts within 14 days.
isotretinoin has a reported association with IBD onset/flare - discuss this with the patient and gastroenterologist, and consider alternative acne treatments first.
IM vitamin K is preferred but oral is an alternative - 3 doses required (birth, 1 week, 4-6 weeks for breastfed); counsel about higher failure rate; document decision; respect parental autonomy.
red swollen umbilicus with purulent discharge and fever equals omphalitis - urgent IV antibiotics; risk of necrotising fasciitis and sepsis; admit immediately; do not manage in the community.
family history, NICU stay with ototoxic drugs, congenital infections (especially CMV), craniofacial anomalies, and hyperbilirubinaemia are key hearing loss risk factors - breastfeeding is not; monitor at-risk babies even if they pass screening.
lethargy, high-pitched cry, and opisthotonus in a severely jaundiced neonate equals acute bilirubin encephalopathy - emergency exchange transfusion is required to prevent permanent kernicterus.
tachypnoea after elective caesarean section with fluid in fissures on X-ray equals TTN - self-limiting within 24-72 hours; supportive management; exclude sepsis.
right hand and foot, 95% or above with less than 3% difference is normal - always screen before discharge.
breast milk jaundice is prolonged unconjugated jaundice in a thriving breastfed baby - different from breastfeeding jaundice (first week, inadequate intake); continue breastfeeding; exclude pathological causes.
the Apgar score is subjective and influenced by non-asphyxia factors - never use it alone to diagnose birth asphyxia; cord gases and clinical context are essential.
jaundice appearing after 24 hours, peaking day 3-5, below treatment threshold in a well baby equals physiological - reassure and ensure adequate feeding; jaundice within 24 hours is always pathological.
EONS equals GBS and E. coli (vertical transmission) - LONS equals CoNS and Gram-negatives (nosocomial); empirical antibiotics differ accordingly.
oral morphine is first-line for opioid NAS - dose by Finnegan scores, wean gradually by 10-20%; phenobarbital is second-line; breastfeeding is encouraged if mother is on stable methadone.
preterm babies need fortified breast milk - higher protein, calorie, calcium, and phosphate requirements; fortify once feeds reach 100-150 mL/kg/day; prevents osteopenia and optimises growth.
neonatal TPN provides glucose, amino acids, lipids, electrolytes, vitamins, and trace elements - the biggest risk is line sepsis (CRBSI); TPN cholestasis occurs with prolonged use; early enteral feeding minimises TPN duration.
breastfeed within the first hour with skin-to-skin, ensure correct latch, demand feed, room-in - early initiation and frequent feeding establish supply; colostrum is nutritionally and immunologically vital.
oedema plus weight gain above birth weight plus respiratory deterioration in a preterm baby equals fluid overload - restrict fluids, consider furosemide; liberal fluids increase PDA, BPD, and NEC risk.
positive Barlow or Ortolani equals urgent ultrasound within 2 weeks - breech is the strongest risk factor; Pavlik harness is first-line for infant DDH; clunk is significant, click is not.
keep the cord clean and dry in the UK - no antiseptics needed; fold nappy below the cord; separates in 5-15 days; seek help if red, swollen, or purulent discharge.
multiple café-au-lait macules require NF1 assessment - six or more at more than 5 mm; isolated common birthmarks need reassurance only; document all skin findings in medical records.
tremors and cardiac changes during exchange transfusion equals hypocalcaemia from citrate - give calcium gluconate prophylactically; monitor ECG and electrolytes throughout.
TORCH investigation includes maternal and neonatal serology, CMV urine PCR within 3 weeks, FBC, LFTs, cranial USS, and ophthalmology review - neonatal IgM indicates fetal infection as IgM does not cross the placenta.
kernicterus is largely preventable - systematic bilirubin monitoring using NICE NG98 charts, prompt phototherapy, and adequate follow-up of at-risk babies are the cornerstones of prevention.
abdominal distension plus bloody stools plus pneumatosis intestinalis in a preterm baby equals NEC - nil by mouth, antibiotics, and surgical review; breast milk reduces risk.
V1 port wine stain warrants investigation for Sturge-Weber syndrome - MRI brain and eye examination for glaucoma; not all are syndromic but 10-20% risk; pulsed dye laser for cosmetic treatment.
Sensorineural deafness plus PDA/pulmonary stenosis plus cataracts equals congenital rubella syndrome - first-trimester infection is the most dangerous, it is prevented by MMR vaccination, and affected babies shed virus for months.
blue-grey flat patches on the lumbosacral area in a baby with darker skin equals dermal melanocytosis - document carefully to avoid confusion with NAI; benign and fading over years; no treatment needed.
TTN management equals supportive care - oxygen if needed, NG feeds if tachypnoeic, empirical antibiotics until sepsis excluded; self-resolves 24-72 hours; investigate further if not improving.
adrenaline 10-30 micrograms/kg IV via UVC is the key drug in neonatal resuscitation - given after effective ventilation and compressions fail; consider volume if blood loss suspected.
Apgar scores are a clinical snapshot not a crystal ball - 5-minute and 10-minute scores matter more than 1-minute; improvement is reassuring; do not use Apgar alone to predict long-term outcome.
antenatal betamethasone is the most important intervention before preterm delivery - reduces RDS by 50%, reduces mortality; give between 24 and 34 weeks.
prolonged jaundice requires split bilirubin - conjugated fraction above 25 μmol/L is pathological; urgently exclude biliary atresia as Kasai before 60 days is critical.
non-specific illness within 72 hours of birth with risk factors for sepsis equals early-onset sepsis - IV benzylpenicillin and gentamicin within 1 hour; GBS and E. coli are commonest organisms.
vigorous baby in meconium equals standard newborn care - no routine suctioning or intubation; observe closely for signs of MAS developing; intervene only for non-vigorous babies with failed ventilation.
vitamin K prevents VKDB by activating clotting factors II, VII, IX, X - neonates have low stores; IM injection at birth is the most effective prophylaxis; late VKDB can cause fatal intracranial haemorrhage.
MAS, asphyxia, sepsis, CDH, and maternal SSRI use are key PPHN risk factors - it is predominantly a term baby condition; pulmonary vasoconstriction from hypoxia and acidosis is the common pathway.
refractory PPHN in CDH failing iNO and maximal therapy warrants ECMO - veno-arterial cannulation; available at designated UK centres; survival approximately 50%.
absent or white red reflex equals urgent ophthalmology referral within 2 weeks - exclude congenital cataract and retinoblastoma; surgery for dense cataracts needed within 6-8 weeks to prevent amblyopia.
maternal beta-blocker use causes neonatal bradycardia, hypoglycaemia, and IUGR - monitor glucose and heart rate for 48 hours; supportive treatment; effects are self-limiting; atenolol has the highest placental transfer.
gentamicin 5 mg/kg every 36 hours in term neonates - check trough before second dose, must be below 1 mg/L; nephrotoxic and ototoxic; monitor renal function and hearing.
AOAE is the initial newborn hearing screen - tests cochlear outer hair cell function; refer to AABR if not passed; aim to detect permanent hearing loss by 3 months for early intervention by 6 months.
NIPE screens hips, heart, eyes, and testes - within 72 hours of birth and again at 6-8 weeks; early detection enables early treatment and better outcomes.
Gross type C (OA plus distal TOF) is the most common at 85% - gas in stomach confirms distal fistula; gasless abdomen means pure OA; H-type presents later.
LA:Ao ratio greater than 1.5 plus reversed diastolic flow in the descending aorta equals haemodynamically significant PDA - integrate echo findings with clinical picture.
large-bore NG tube plus plain X-ray confirms OA - tube coils in upper pouch; gas in stomach means distal TOF; gasless abdomen means no distal fistula.
drooling plus inability to pass NG tube plus gas in the stomach equals OA with distal TOF (type C) - Replogle tube on suction, head-up position, and urgent surgical referral.
flat pink blanching mark on the nape, eyelids, or glabella equals naevus simplex - most common vascular birthmark; facial marks fade by 1-2 years; nuchal may persist; no treatment needed.
coordinated suck-swallow-breathe matures at 34-36 weeks - tube feeding before this; non-nutritive sucking promotes oral feeding development; individualise the transition.
evaporation is the biggest heat loss at delivery - dry immediately, warm towels, skin-to-skin or radiant warmer; room temperature 25°C minimum; hat; plastic wrapping for extreme preterms.
hyperalertness with increased tone and brisk reflexes without seizures after a perinatal hypoxic event equals Sarnat grade I (mild) HIE - generally good prognosis; observe closely for progression.
minimum 1 mL blood for neonatal culture - inadequate volume causes false negatives; never delay antibiotics for blood cultures if venepuncture is difficult.
vigorous term baby equals dry, skin-to-skin, delayed cord clamping - no routine suctioning; promote early breastfeeding and bonding.
glucose requirement above 8-10 mg/kg/min equals hyperinsulinism until proven otherwise - critical sample during hypo; diazoxide is first-line medical treatment; refer to specialist centre.
meconium aspiration with rising oxygen requirements and right-to-left shunting equals PPHN - inhaled nitric oxide is the specific pulmonary vasodilator; ECMO is the rescue therapy for refractory cases.
lethargy, hypotonia, and seizures with low cord pH equals Sarnat grade II (moderate) HIE - therapeutic hypothermia within 6 hours of birth reduces death and disability; MRI at day 5-14 guides prognosis.
bilirubin rising despite standard phototherapy equals escalate to intensive phototherapy with multiple light sources - recheck in 4-6 hours; prepare for exchange transfusion if no improvement.
non-vigorous baby in meconium with failed ventilation equals suction under direct vision then reattempt breaths - intubate for tracheal suction if needed; do not routinely suction vigorous meconium-stained babies.
rhythmic focal movements plus subtle phenomena in a baby with perinatal hypoxia equals neonatal seizures - EEG confirms; HIE is the commonest cause in the first 72 hours.
phenobarbital 20 mg/kg IV is first-line for neonatal seizures - additional 10 mg/kg boluses up to 40 mg/kg total; monitor with aEEG; trial pyridoxine for refractory seizures.
preterm babies under 32 weeks go into plastic wrap without drying plus hat plus radiant warmer - target temperature 36.5-37.5°C; room temperature at least 26°C for delivery; hypothermia increases mortality.
hypothermia increases oxygen consumption, causes acidosis and hypoglycaemia from brown fat metabolism - it is independently associated with increased mortality; prevent with humidification, radiant warmers, and appropriate incubator temperature.
irritability, jitteriness, and respiratory distress in a baby exposed to maternal SSRI equals PNAS - self-limiting within 3-5 days; supportive care only; do not stop maternal SSRI without specialist advice.
conjugated bilirubin above 25 µmol/L is always pathological - urgently exclude biliary atresia; Kasai before 60 days is critical; pale stools and dark urine are red flags.
below 95% on screening means repeat in 1-2 hours - if still abnormal, urgent echocardiography; never rely on clinical examination alone to exclude CCHD.
superficial pustules in a well baby with neutrophils and no organisms on smear equals TNPM - self-resolving; hyperpigmented macules are characteristic; more common in darker skin; always exclude herpes and bacterial infection.
oxygen toxicity is the most important modifiable ROP risk factor - careful SpO₂ targeting (91-95%) with pulse oximetry is essential; prematurity itself is the greatest non-modifiable risk.
chorioretinitis plus hydrocephalus plus diffuse calcifications equals congenital toxoplasmosis - treat with pyrimethamine and sulfadiazine; prevention through hygiene; many are asymptomatic at birth.
95% or above in both limbs with less than 3% difference equals normal pulse oximetry screening - screen after 6 hours of age before discharge.
stabilise before surgery in CDH - delayed repair after physiological improvement; mortality relates to lung hypoplasia and PPHN severity, not timing of surgery.
late VKDB at 2-12 weeks is the most dangerous form - 50% have intracranial haemorrhage; exclusively breastfed babies without vitamin K are at risk; IM vitamin K prevents all three forms; consider underlying liver disease.
undescended testis not reaching the scrotum requires surgical referral by 6 months - orchidopexy by 12 months; reduces infertility and cancer risk; distinguish from retractile testis; many descend spontaneously by 3 months.
TORCH equals Toxoplasmosis, Other, Rubella, CMV, Herpes - these congenital infections share overlapping features; CMV is the most common in the UK; timing of maternal infection affects severity.
basal-bolus = long-acting background insulin plus rapid-acting meal-time insulin - offers flexibility, physiological dosing, and better glycaemic control than twice-daily regimens.
Microaneurysms and dot haemorrhages = background retinopathy - optimise HbA1c as the key intervention; annual screening from age 12 in T1DM per NICE NG18.
raised 17-OHP on screening - urgently check karyotype (virilised XX may appear male), monitor electrolytes closely, and start hydrocortisone/fludrocortisone promptly to prevent salt-wasting crisis.
MPH for boys = (father + mother + 13) ÷ 2; for girls = (father + mother − 13) ÷ 2; target range ±8.5 cm.
Elevated cortisol with suppressed ACTH = ACTH-independent Cushing syndrome from an adrenal source; growth arrest distinguishes Cushing from simple obesity.
TIR target >70% with <4% below range - CGM provides continuous glucose data enabling pattern recognition and real-time insulin adjustments.
Low T4 with normal/low TSH = central hypothyroidism, missed by TSH-based screening; exclude cortisol deficiency before starting levothyroxine.
alcohol inhibits gluconeogenesis causing delayed hypoglycaemia - eat carbs, reduce bedtime insulin, check glucose overnight, and make sure friends know about the diabetes.
lifestyle first, family-centred, sustained over time.
metformin targets the metabolic root of PCOS - insulin resistance.
testosterone replacement does not restore fertility but improves quality of life significantly.
no long-acting insulin depot means DKA can develop rapidly with pump failure.
Diabetes transition is a process, not a single event - start planning by age 14 at the latest per NICE NG17; never discharge until adult services are engaged.
thyroid hormone is essential for brain development - early treatment of congenital hypothyroidism prevents irreversible intellectual disability; aim to start levothyroxine within 2 weeks of birth.
DKA - fluids first, then insulin at 0.05-0.1 units/kg/hour (no bolus), potassium replacement, and watch for cerebral oedema.
pre-lunch hyperglycaemia - increase breakfast rapid-acting insulin; match insulin adjustments to the glucose pattern using an insulin-to-carbohydrate ratio.
acanthosis nigricans in an obese child is insulin resistance until proven otherwise.
Turner syndrome requires lifelong multisystem surveillance - thyroid screening is a key component.
Optic nerve hypoplasia plus absent septum pellucidum plus pituitary deficiency equals septo-optic dysplasia - screen for all pituitary hormones, especially cortisol.
intercurrent illness in adrenal insufficiency - double hydrocortisone; if vomiting, give IM hydrocortisone immediately and seek urgent care.
insulin pumps provide programmable basal rates and precise bolus dosing - carb counting and glucose monitoring are still required; hybrid closed-loop systems are the future.
growth arrest with weight gain in a child - always consider Cushing syndrome.
Turner girls need lifelong multidisciplinary endocrine care.
pumps are not first-line but are an important escalation when MDI is suboptimal.
dilute urine + concentrated blood + post-neurosurgery = central DI - desmopressin is the treatment.
suprasellar calcified cyst + visual field defect + panhypopituitarism in a child = craniopharyngioma.
no preceding hypo on CGM + early morning rise = dawn phenomenon, not Somogyi.
new-onset T1DM without DKA - start subcutaneous insulin, educate the family, and involve the multidisciplinary diabetes team from day one.
GHD treatment requires daily injections - adherence support is essential.
Hyponatraemia + hyperkalaemia + hypoglycaemia in a child with CAH during illness = adrenal crisis; immediate IV hydrocortisone, 0.9% saline, and dextrose are life-saving.
always check islet autoantibodies in obese adolescents with new diabetes.
never wait - give IM hydrocortisone first if the child is vomiting, then seek help.
Hypotension + hypoglycaemia + hyperkalaemia + pigmentation = Addison - treat immediately with IV hydrocortisone without waiting for results.
short stature with declining height velocity, delayed bone age, low IGF-1, and central adiposity - investigate for growth hormone deficiency; confirm with stimulation testing.
transition is a gradual process, not an event - start early, address psychosocial needs, maintain engagement, and provide overlap between services.
start oestrogen low and slow.
short stature, webbed neck, delayed puberty, and 45,X karyotype - Turner syndrome; treat with GH for height and oestrogen for puberty.
polyuria with dilute urine and normal glucose - water deprivation test to differentiate cranial DI, nephrogenic DI, and primary polydipsia; MRI pituitary for cranial DI.
short child with short parents, normal growth velocity, normal bone age, and normal investigations - familial short stature; no treatment needed, reassure.
nocturnal hypoglycaemia followed by morning hyperglycaemia - Somogyi effect, reduce evening insulin; dawn phenomenon has no nocturnal hypo, increase evening insulin.
CAH monitoring uses 17-OHP, androstenedione, renin, growth velocity, and bone age - the goal is adequate control without over-treating; growth velocity is the most sensitive clinical indicator.
positive tTG in a child with T1DM - refer for coeliac evaluation even if asymptomatic; T1DM plus coeliac disease share HLA-DQ2/DQ8 susceptibility.
thyroid nodules in children have a higher malignancy rate than in adults - always investigate.
hybrid means the patient still actively participates - it is not fully automated.
diabetes before 6 months = always test genetics - sulphonylureas may replace insulin.
severe hypoglycaemia with inability to swallow - give IM glucagon in the community (never oral glucose if swallowing is unsafe); '4 is the floor' for glucose levels.
raised TSH on newborn screening - start levothyroxine immediately and refer urgently; early treatment prevents intellectual disability.
hyperpigmentation plus hyponatraemia plus hyperkalaemia plus low cortisol - Addison disease; replace hydrocortisone and fludrocortisone, and screen boys for adrenoleukodystrophy.
exercise usually lowers blood glucose in T1DM - reduce preceding insulin, carry glucose, monitor frequently, and beware of delayed hypoglycaemia up to 24 hours later.
do not diagnose PCOS within 2 years of menarche based on irregular cycles alone.
PCOS is a lifelong metabolic condition, not just a reproductive disorder.
delayed puberty with family history, delayed bone age, and low-normal gonadotropins - most likely CDGP; reassure, but exclude pathological causes.
puberty without testicular enlargement in boys = peripheral cause - check adrenal androgens.
always image a goitre in a child - ultrasound first, and keep monitoring thyroid function.
new headache, drowsiness, and pupillary changes during DKA treatment - cerebral oedema; give hypertonic saline or mannitol immediately, reduce fluids, and escalate urgently.
high calcium + high PTH = autonomous PTH secretion - screen for MEN syndromes in children.
never omit steroids - adrenal crisis during surgery is preventable.
the 4-hour observation window starts from the time of injury, not from the time of arrival in ED (NICE CG176/NG232).
the latent phase is deceptive - always monitor for at least 24 hours after significant iron ingestion.
wide QRS plus anticholinergic signs equals TCA - give bicarbonate early, not phenytoin.
CMLs and posterior rib fractures are the hallmark fractures of inflicted injury - always look carefully on skeletal survey.
the classic history plus reluctance to supinate equals pulled elbow - reduce with confident supination-flexion.
Migrating pain + anorexia + right iliac fossa tenderness = appendicitis until proven otherwise - ultrasound is first-line imaging in children (RCR iRefer); appendicectomy is the definitive treatment (RCS Commissioning Guide; BAPS).
pyloric stenosis is a medical emergency before it is a surgical one - correct the alkalosis first.
URTI followed by abdominal pain with no peritonism equals mesenteric adenitis - but always reconsider if the child deteriorates.
an apparently well child after submersion can deteriorate hours later - always observe and never discharge prematurely.
torsion is a clinical diagnosis - do not let imaging delay theatre when the history and examination are consistent.
groin swelling on crying that reduces at rest in an infant equals inguinal hernia - refer promptly for surgical repair.
irreducible hernia plus vomiting plus tender swelling equals incarcerated - attempt gentle reduction, but proceed to emergency surgery if unsuccessful.
obese teenager plus knee pain plus restricted hip rotation equals SUFE - always X-ray the hips when adolescents present with knee pain.
HSP nephritis determines long-term outcome - all children with HSP need regular urinalysis and blood pressure monitoring for at least 6 months.
HSP relapses are common and usually mild - but each relapse demands renewed renal vigilance.
always plot the level on the nomogram at 4 hours - early NAC saves lives.
asymptomatic child plus blunt object equals observe - but always exclude button battery first.
pattern equals weapon - loop marks, tramline bruises, and circular burns are hallmarks of inflicted injury.
One magnet may be observed, but two or more magnets in separate bowel loops is an emergency - retrieve before perforation occurs per RCPCH and NHS patient safety guidance.
the higher the Salter-Harris type, the greater the risk - always counsel about growth monitoring at follow-up.
In drowning, oxygenate first - five rescue breaths, then CPR if needed, and admit for observation per Resuscitation Council UK guidance.
always consider the plausibility of the mechanism - document meticulously and refer urgently.
swelling below and lateral to the pubic tubercle equals femoral hernia until proven otherwise - repair urgently due to the high strangulation risk.
HSP intussusception is ileo-ileal, not ileocolic - air enema will not work; consider surgical management early.
well child plus mild effusion plus normal inflammatory markers plus post-viral equals transient synovitis - reassure, rest, and review.
never induce vomiting after caustic ingestion - protect the airway and assess the damage endoscopically.
safeguard the child first - admit, refer, examine, document, and never discharge into an unsafe environment.
always check bloods before labelling bruises as NAI - leukaemia, ITP, and coagulopathies must be excluded.
skeletal survey plus follow-up at 2 weeks - one negative survey does not exclude abuse.
pulseless supracondylar fracture is an emergency - reduce urgently and reassess vascular status.
children's clavicles heal remarkably well - sling for comfort, painkillers, and reassurance are usually all that is needed.
green vomiting in a neonate is a surgical emergency - never reassure without excluding malrotation.
button battery in any body cavity equals emergency removal - every minute counts in reducing tissue damage.
Pica plus intragastric mass equals bezoar - treat the mass surgically or endoscopically and address the underlying behaviour psychologically per RCPCH guidance.
Sudden choking plus unilateral wheeze plus air trapping equals foreign body - arrange rigid bronchoscopy urgently per RCPCH guidance.
firm dark scrotal mass at birth with absent flow equals prenatal torsion - the priority is contralateral fixation to prevent bilateral loss.
febrile child plus non-weight-bearing plus hip effusion equals septic arthritis until proven otherwise - aspirate urgently and start IV antibiotics.
Per NICE CG84, clinical signs (sunken eyes, reduced skin turgor, dry mucous membranes, tachycardia) without features of shock indicate clinical dehydration (roughly 5-10% deficit) - treat with 50 mL/kg ORS over 4 hours plus maintenance, escalating to IV fluids only for shock or failed oral/NG rehydration.
Meningococcal disease is notifiable - give close contacts single-dose ciprofloxacin as soon as possible, and recall that index cases treated with cefotaxime or penicillin (not ceftriaxone) also need eradication therapy before discharge.
Toxbase first, NPIS telephone for complex cases - never rely on non-specialist sources for poisoning management.
sudden-onset pelvic pain in a girl plus enlarged ovary minus Doppler flow equals torsion - laparoscope urgently.
recurrent food bolus impaction in a child suggests eosinophilic oesophagitis - always biopsy the oesophagus during retrieval endoscopy.
mechanism of injury matters - always assess the forces involved.
After a first unprovoked paediatric seizure with normal examination - observe, give safety advice, and arrange outpatient paediatric review with EEG within 2 weeks; do not start anticonvulsants per NICE NG217.
Simple febrile convulsion (NICE CKS) = generalised, <15 min, single within 24 h, age 6 months-6 years, full recovery - reassure, no investigation, antipyretics for comfort only, recurrence ~30%.
Observe for at least 6 hours after the last dose of adrenaline as a safe default, extend to at least 12 hours for severe, refractory or biphasic-risk cases, and discharge with two adrenaline auto-injectors, an emergency plan and allergy clinic referral - routine steroids are no longer advised (RCUK 2021).
In hypothermic drowning, rewarm to at least 32-34°C before stopping resuscitation (Resuscitation Council UK) - nobody is dead until they are warm and dead.
SALTR - higher numbers mean worse prognosis and more likely need for surgical intervention.
toddler's fracture is a diagnosis of ambulant children - always assess developmental stage and consistency of the history.
pain out of proportion plus passive stretch pain equals compartment syndrome - do not wait for pulselessness to act.
A toxic child with a rigid abdomen and absent bowel sounds equals perforated viscus - resuscitate and operate urgently per RCPCH emergency surgical guidance.
delayed meconium plus chronic constipation plus explosive rectal examination equals Hirschsprung's - confirm with suction rectal biopsy.
Submersion time and water temperature are the key prognostic factors - cold and brief is better than warm and prolonged, and bystander CPR is one of the strongest predictors of survival.
painless rectal bleeding in a child plus positive Meckel's scan equals ectopic gastric mucosa - the rule of 2s is your friend.
pneumatosis intestinalis in a premature infant equals NEC - stop feeds, start antibiotics, and monitor closely.
Palpable purpura on buttocks/legs + normal platelets = HSP; monitor urine dipstick and blood pressure for at least 6-12 months per NICE CKS to catch late nephritis.
Severe paediatric DKA is pH <7.1 or bicarbonate <5; rehydrate cautiously with 0.9% sodium chloride, start a fixed-rate insulin infusion 1 to 2 hours after fluids and never as a bolus, replace potassium, and watch closely for cerebral oedema (BSPED DKA guideline).
bruising in a baby who cannot move independently should always trigger a safeguarding assessment - if they don't cruise, they rarely bruise.
Skin-only reactions = oral antihistamine, observe, safety-net; airway/breathing/circulation involvement = IM adrenaline 1:1000 (150 mcg <6 yrs, 300 mcg 6-12 yrs).
Severe croup (stridor at rest, recession, agitation, hypoxia) needs nebulised adrenaline (0.4 mL/kg of 1:1000, max 5 mL) for rapid relief while dexamethasone takes effect; monitor for rebound worsening; salbutamol is ineffective and a single dexamethasone dose suffices (NICE CKS Croup; APLS).
colicky pain plus drawing up legs plus redcurrant jelly stool equals intussusception - ultrasound confirms, air enema treats.
progressive limp in a school-age boy plus sclerotic femoral head equals Perthes disease - age at onset and lateral pillar classification predict outcome.
button battery in the oesophagus equals emergency - the clock starts ticking immediately.
Bronchiolitis = coryzal prodrome → fine inspiratory crackles ± wheeze, recession, poor feeding, apnoeas, in an infant <12 months. Per NICE NG9: clinical diagnosis, supportive care only - admit if SpO₂ <92%, intake <50-75%, severe distress, or apnoeas.
raccoon eyes plus haemotympanum plus CSF leak equals basal skull fracture until proven otherwise.
blue dot sign plus intact cremasteric reflex plus upper pole tenderness equals appendix testis torsion - conservative management is appropriate, but explore if in doubt.
gradual scrotal pain plus dysuria plus positive urine equals epididymo-orchitis - but always exclude torsion if in doubt.
tinnitus plus hyperventilation equals salicylate - alkalinise the urine and escalate early.
unexplained illness plus normal investigations plus symptom resolution without the carer equals consider FII - safeguard the child.
Sharp object beyond the oesophagus in an asymptomatic child equals watchful waiting with safety-net advice - but always provide clear instructions to return if symptoms develop per ESPGHAN guidance.
high fever for 3 days then fever breaks and rash appears = roseola - the rash is a reassuring sign of recovery.
pain out of proportion + rapidly spreading + systemic toxicity = necrotising fasciitis - call surgeons immediately.
start smart, then focus - narrowest spectrum, shortest duration, review and de-escalate.
recurrent infections + failure to thrive + maternal HIV = test the child - start ART promptly.
rubella in first trimester = high risk of CRS - deafness, heart defects, cataracts.
pre-school booster = DTaP/IPV + MMR second dose - ensure completion before school entry.
live vaccines + immunodeficiency = risk of vaccine-strain disease - always seek specialist advice.
TB treatment is HRZE for 2 months then HR for 4 months - always prescribe pyridoxine with isoniazid.
a well, alert child with normal observations is green (low risk) - but with fever and no focus, still arrange urine testing and always safety-net (NICE NG143).
amoxicillin rash + EBV is NOT penicillin allergy - do not mislabel the child.
co-amoxiclav is first-line for bite wound prophylaxis - always irrigate thoroughly first.
every dose counts, there is no maximum per visit, and catch-up is always possible - don't miss the opportunity.
Hot swollen joint + fever + raised CRP = septic arthritis until proven otherwise - aspirate urgently, IV antibiotics, urgent surgical washout (BSPAR/BOA).
chemoprophylaxis eradicates carriage, not infection - give within 24 hours to contacts.
UK BCG is targeted, not universal - know the eligibility criteria.
pertussis in young infants is life-threatening - admit, treat with macrolide, notify, and prophylax contacts.
Fever ≥5 days + conjunctivitis + mucosal changes in a young child = Kawasaki - urgent echo, IVIG and aspirin within 10 days (per RCPCH guidance) to prevent coronary aneurysms.
neonatal meningitis organisms are different - always add amoxicillin for Listeria cover.
PUO requires systematic investigation - infections, autoimmune, and malignancy are the big three categories.
HBsAg-positive mother → monovalent HepB vaccine within 24 hours; add HBIG if HBeAg-positive, HBV DNA >10⁶ IU/mL, or preterm/low birthweight - Green Book Chapter 18 schedule, breastfeeding permitted.
barking cough + stridor + hoarse voice = croup - dexamethasone is first-line for all severities.
proptosis + restricted eye movements + periorbital swelling = orbital cellulitis - this is an emergency, not preseptal.
unvaccinated + measles exposure = MMR within 72 hours - or HNIG if MMR is contraindicated.
children swallow sputum - use gastric aspirates for TB diagnosis in young children.
immunocompromised + chickenpox exposure + seronegative = urgent post-exposure prophylaxis (oral antiviral prophylaxis first-line per current UKHSA guidance, VZIG for selected groups) with close monitoring; if chickenpox develops = IV aciclovir.
stone in pond - start with closest contacts and expand outward based on findings.
non-blanching rash + fever + meningism = give antibiotics NOW - every minute counts.
measles herd immunity requires ≥95% - every percentage point below this increases outbreak risk.
the younger the child, the more imaging is needed - under 6 months get the full package.
16 weeks = 6-in-1 (third dose) + MenB (second dose) - give paracetamol with MenB.
pneumonia not improving on antibiotics = consider parapneumonic effusion - request chest ultrasound.
in infants <18 months, use PCR not antibody testing - maternal antibodies give false positives.
strict age limits for rotavirus vaccine exist to minimise intussusception risk - never give outside the window.
Koplik spots are pathognomonic - measles complications include pneumonia, encephalitis, and SSPE.
MenACWY is for adolescents - the second peak age for meningococcal disease; MenB is for infants.
EBV + splenomegaly = no contact sports for 6-8 weeks - counsel clearly.
unilateral parotid swelling + incomplete MMR = think mumps - warn about orchitis in older boys.
bloody diarrhoea followed by anaemia + thrombocytopenia + renal failure = HUS - do NOT give antibiotics for STEC.
MMR is safe in all egg-allergic children - this is a very common parental concern that GPs should address confidently.
Punched-out vesicles rapidly spreading on eczematous skin plus fever = eczema herpeticum - give aciclovir urgently per BAD guidance.
Uncertain vaccination status = assume unvaccinated and vaccinate per Green Book - do not test first, vaccinate first.
Failure to follow a point on the M-CHAT-R/F suggests impaired joint attention - refer for formal ASD assessment; a positive screen is not diagnostic.
GDD means significant delay in two or more domains (>2 SD below mean on standardised testing) in children under 5 - investigate systematically with chromosomal microarray and fragile X testing.
ADOS-2 is the standardised observational component for autism assessment per NICE CG128 - use with ADI-R developmental history in a multidisciplinary team; module selection depends on age and language level.
developmentally excessive distress on separation, refusal to sleep alone, school reluctance and fear of harm to an attachment figure lasting at least 4 weeks equals separation anxiety disorder - first-line treatment is CBT with graded exposure, reserving an SSRI for refractory cases.
Turner syndrome (45,X) = short stature plus ovarian dysgenesis with webbed neck, widely spaced nipples and cubitus valgus; confirm with karyotype; screen for bicuspid aortic valve and coarctation of the aorta and for renal anomalies; treat with growth hormone and timed oestrogen replacement (in line with Turner syndrome clinical practice guidelines).
Tics in Tourette syndrome typically peak around ages 10-12 and then improve - roughly two-thirds of people have significant improvement by early adulthood, but co-morbid ADHD and OCD may persist and become the main source of impairment.
Global developmental delay involves delays across multiple domains with relatively preserved social reciprocity, whereas ASD is defined by core social communication impairment - assess all developmental domains (NICE NG43) before diagnosis.
At 14 months, no words yet, not cruising, and no spoon use can all be normal - assess the whole developmental profile and trajectory.
Difficulty following instructions with apparently normal expressive speech suggests receptive language disorder - refer to SALT; do not mislabel as behavioural non-compliance.
Concern about autism warrants direct referral to the autism diagnostic team per NICE CG128 - assess hearing too, but never delay the referral.
with early identification and amplification (NHSP targets: screen by 3 months, aid by 6 months) plus auditory-verbal and speech and language therapy, many children with moderate sensorineural loss approach the spoken-language level of hearing peers; cochlear implants are reserved for severe-profound loss.
excessive, uncontrollable worry across multiple domains for at least 6 months with somatic symptoms equals generalised anxiety disorder - first-line treatment is CBT, adding an SSRI (sertraline or fluoxetine) under specialist guidance if needed.
Consistent one-sided hand use before 12 months is not normal handedness - suspect contralateral hemiplegia and refer urgently for neurological assessment including MRI brain.
A 2-year-old with fewer than 50 words or no two-word phrases needs SALT referral - preserved gestures and normal social skills are reassuring.
an alert, floppy infant with areflexia, tongue fasciculations and a weak cry suggests SMA type 1 - confirm with SMN1 genetic testing and refer urgently, as early disease-modifying treatment markedly improves outcome.
Alpha-2 agonists (clonidine, guanfacine) are first-line for tic suppression when behavioural therapy is insufficient, especially with co-morbid ADHD; aripiprazole is second-line and haloperidol is no longer first-line; continue CBIT alongside medication; treat based on functional impact rather than complete tic elimination (ESSTS guidelines).
Tourette = multiple motor + ≥1 vocal tic, >1 year, onset <18. Premonitory urge typical. Comorbid ADHD/OCD common. CBIT/HRT first-line; clonidine or aripiprazole if severe.
in ASD with intellectual disability and acutely worsening challenging behaviour, always exclude treatable medical causes of pain (dental, constipation, otitis media, UTI) and complete a functional behaviour assessment with a positive behaviour support plan before considering pharmacological options such as risperidone (NICE CG170).
Developmental coordination disorder (dyspraxia) = motor skills well below age and intelligence affecting daily living, with otherwise normal intelligence; diagnose using DSM-5 criteria and standardised tools such as the MABC-2; manage with occupational therapy, task-oriented practice, and reasonable adjustments at school (consistent with NICE guidance on neurodevelopmental conditions).
Self-harm in a young child is never 'just attention-seeking' - perform a full psychosocial needs and risk assessment (NICE NG225), arrange urgent CAMHS referral, address the bullying via school safeguarding, and reduce access to means while avoiding overly restrictive responses.
Intermittent squint under 3 months may be a normal finding, but any constant squint at any age - or any squint persisting beyond 3 months - warrants ophthalmology/orthoptic referral to prevent amblyopia (NICE CKS Squint in children).
Fragile X is the commonest inherited cause of intellectual disability - look for a long face, large protruding ears and macro-orchidism with an X-linked family history; confirm with FMR1 CGG repeat testing and offer genetic counselling.
indiscriminate over-familiarity with strangers and lack of a preferred attachment figure after early neglect equals DSED - distinguished from the withdrawn presentation of reactive attachment disorder, with management centred on stable, consistent caregiving plus specialist CAMHS input (NICE NG26).
primary monosymptomatic nocturnal enuresis - offer reassurance, fluid and toileting advice and rewards first, then an enuresis alarm as first-line active treatment, with desmopressin where the alarm is unsuitable or for short-term cover (NICE CG111); investigations are not needed.
loss of joint-attention markers - no response to name, no pointing, no following a point, and no showing or sharing by 15 months - is an early red flag for autism; refer to the local autism team (NICE CG128) while also arranging a hearing check.
social anxiety, gaze avoidance and sensory hyperarousal are core features of the fragile X behavioural phenotype - screen for and treat co-occurring anxiety and ASD in their own right rather than attributing everything to one label.