The first holistic transition checklist in the UK, designed specifically to address the wider multidisciplinary needs of young people with special educational needs (SEN), was co-produced with young people and their parents/carers.
Transition is the purposeful, planned movement of adolescents and young adults with chronic health conditions from child-centred to adult healthcare services. For young people with SEN, transition can present additional challenges, as they often have complex, individualised needs requiring coordinated multidisciplinary input across services. In England, over 1.7 million pupils (20%) are identified as having SEN, with 5% having an Education, Health and Care Plan indicating complex needs.
Implementation of early delivery room continuous positive airway pressure (CPAP) and delivery room less invasive surfactant administration (LISA) to reduce intubation rates in preterm neonates in a tertiary neonatal unit.
The National Neonatal Audit Programme (NNAP) data identified that rates of bronchopulmonary dysplasia (BPD) in our unit were around 10% above the national average.
The overall aim of the project was to optimise early non-invasive respiratory support for preterm neonates born at <32 weeks’ gestation through DR CPAP and DR LISA. The primary outcome measure was DR intubation rate, with secondary outcomes including exposure to invasive ventilation during the first...]]>
Topical oestradiol gel is now widely used in hormone replacement therapy (HRT), but the risk of inadvertent secondary transfer to children is under-recognised. While accidental exposure to testosterone gels has been documented, oestradiol gel transfer as a cause of precocious puberty in prepubertal girls is rare.
We undertook a 20-year literature review and discuss the case of a 5-year-old girl presented with Tanner stage 3 breast development, pubic hair stage 2, growth acceleration and mood changes. Laboratory evaluation revealed markedly elevated oestradiol levels with suppressed gonadotrophins, consistent with peripheral precocious puberty. Bone age was advanced by 4 years 6 months. Imaging, karyotype, endocrine and dermatology investigations excluded central precocious puberty, ovarian or adrenal tumours and McCune-Albright syndrome. History, previously not disclosed, revealed daily co-sleeping with her mother, who had been applying oestradiol gel to her upper arms for 18 months as part of HRT. No other oestrogen sources were identified. Maternal oestradiol gel was discontinued and replaced with a transdermal patch. The child’s oestradiol levels normalised and pubertal signs regressed over subsequent months.
This review highlights a rare but important cause of peripheral precocious puberty due to unintentional transfer of topical oestradiol gel through routine parent-child contact, including co-sleeping. As topical hormone therapies become increasingly common, clinicians must counsel patients on safe application practices and consider exogenous hormone exposure in children presenting with unexplained pubertal development. Switching caregivers from gel to patch formulations can reverse hormone excess in exposed children.
]]>A term girl was referred at 2 months of age for persistent noisy breathing noted since birth, worse with feeding and in the supine position, with brief apnoeic pauses, occasional perioral cyanosis, poor coordination of mixed breast and formula feeding and faltering growth from the 25th to the 2nd centile. She had no fever, cough or choking, and her birth and neonatal periods were unremarkable. She had previously been managed with nasal saline, nasal decongestant and intranasal steroid, without improvement.
demonstrates the patient’s breathing pattern. No dysmorphic features were noted, and the physical examination was otherwise normal. Oxygen saturation was 100% on room air.
During the clinic visit, nasal saline irrigation was attempted and marked resistance was immediately noted. After repeated attempts, the infant suffered cardiorespiratory arrest and was successfully resuscitated on site. She was then admitted for observation and work-up.
Question 1: What is the most...]]>
Cervical lymphadenitis is a common paediatric presentation, with infective aetiology being the most common. However, inflammatory conditions such as Kawasaki disease and haematological malignancy can present similarly. Among these, ‘Node-first’ Kawasaki disease, in which cervical lymphadenopathy precedes other features, while a recognised phenotype, is a rarer presentation and therefore a diagnostic pitfall. The similarity to infective lymphadenitis, together with overlapping laboratory and imaging findings, may delay definitive treatment and increase the risk of complications. An acute presentation of cervical lymphadenitis in a febrile child with inadequate or no response despite antibiotics and persistent high inflammatory markers should raise suspicion of possible alternative diagnoses like Kawasaki disease.
]]>In recent decades therapeutic antibodies have become recognised as an effective form of systemic therapy in the management of many paediatric conditions from Crohn’s disease to asthma and cancer.
Bispecific antibodies are a growing area in immunotherapy and show promise in advancing treatment of paediatric conditions. Unlike conventional monoclonal antibodies, which recognise and bind a single target, bispecific antibodies are engineered to have two distinct antigen binding domains with specificity to different molecular targets, providing dual specificity and function for therapeutic advantage.
Monoclonal antibodies are based on endogenous antibodies and include two identical antigen binding domains, which bind a specific molecular target, and a stem (Fc region) (
Adrenal insufficiency (AI) is a disorder characterised by inadequate cortisol production due to dysfunction of the adrenal glands or impairment of the hypothalamic–pituitary–adrenal (HPA) axis. It is classified as primary AI, caused by intrinsic adrenal disease, or secondary/tertiary AI, resulting from reduced adrenocorticotropic hormone (ACTH) or corticotropin harmone (CRH) secretion. Because symptoms are often non-specific, diagnosis may be delayed, increasing the risk of adrenal crisis, a potentially life-threatening complication requiring prompt recognition and treatment.
This guideline
Key learning points
Delandistrogene moxeparvovec is the first gene-replacement therapy for Duchenne muscular dystrophy (DMD) and requires careful patient selection and structured monitoring. Ambulation, defined clinically as the ability to complete the 10-metre walk/run in <30 s, is currently required for treatment eligibility. Acute lung injury remains the most frequent safety concern; enhanced baseline hepatic assessment and early steroid escalation are essential. Younger children may show higher micro-dystrophin expression, but long-term durability is uncertain. Clinical vignettes highlight the value of interpreting trends rather than absolute values during early monitoring. Ongoing pharmacovigilance and real-world data are essential to refine protocols, particularly regarding age at dosing, redosing strategies and combination with other DMD therapies.
Duchenne muscular dystrophy (DMD) is a severe, progressive X-linked disorder caused by pathogenic variants in the DMD gene, resulting in the absence or markedly reduced dystrophin.
We developed a quality improvement project (QIP) switching neonates with culture-negative early onset sepsis (EOS) on the postnatal ward from intravenous to oral antibiotics, reducing length of stay (LOS). We report our findings and QI experience in accordance with SQUIRE (Standards for Quality Improvement Reporting Excellence) 2.0 reporting guidelines.
In 2024, 8.3% (330/3993) of babies born at St George’s Hospital were treated with intravenous antibiotics for suspected EOS on the postnatal ward. Of these, 39.5% had an elevated C-reactive protein (CRP)>10 mg/L with negative blood cultures. The majority (77%, n=100 annually) were clinically well within 36 hours yet completed 5–7 days of intravenous antibiotics—a long-established national practice. Prolonged postnatal admissions have significant cost and workload implications and disrupt early family bonding in an unfamiliar environment.
We aimed to reduce LOS for...]]>
This toolkit represents a major shift in attitude in how we approach children with learning disabilities in our emergency departments (EDs). There are over 1.5 million people living with learning disabilities in the UK, making up 2.5% of the UK population.
The Equality Act of 2010 states that healthcare organisations and professionals have a legal obligation to make reasonable adjustments in order to allow people with disabilities to access the same healthcare as those who do not.
The Learning Disabilities Toolkit was published by the Royal College of Emergency Medicine and Dr Liz Herrieven, Consultant in Emergency Medicine (Sheffield Children’s...]]>
Abusive head trauma is a leading cause of traumatic death in infants. Retinal haemorrhages (RHs) can be the earliest and only clinically visible evidence of the aetiology, making the ophthalmic examination a critical component in triggering child protection pathways.
The current guideline was commissioned and published in 2024 by the Royal College of Ophthalmologists (RCOphth), with endorsement of the Royal College of...]]>
A boy aged 5 years old presented with a 6-week history of intermittent painless rectal bleeding. Clinical examination was unremarkable, and initial investigations including full blood count, faecal calprotectin and Meckel’s scan were normal. The parents discovered a spontaneously expelled fleshy mass in his stool (
Colonoscopy revealed a large 2 cm pedunculated, cauliflower-shaped polyp in the caecum (
This article is the first in a series on neurodevelopmental follow-up of infants born preterm or those born at term but admitted to neonatal intensive care. The discussions in this series also apply to infants and children with developmental or early acquired brain injuries or those with congenital disorders, such as congenital cardiac disorders, that increase their risk of neurodevelopmental problems. The focus is exclusively on central nervous system pathologies; peripheral nervous system and neuromuscular disorders are excluded.
This first article introduces key concepts of typical and atypical development, discusses what can go wrong in development (‘atypical development’), who is at particular risk of atypical development, and outlines the importance of structured neurodevelopmental follow-up (
Key messages The developing brain is vulnerable to adversities; however, heightened neuroplasticity offers opportunities for intervention. The timing of brain injury or exposure to adverse environmental conditions determines the clinical phenotype of...]]>
Most readers will know this, but what type of care can best meet these challenges? ‘Integrating care is not just an improvement but a necessity’, as the authors of the first paper in the series published in this edition state. The three articles in this series describe the rationale for integrated neighbourhood care for children, its value, describing several detailed case studies and presenting evidence of effectiveness, together with some of the practical steps required for implementation. These pieces help towards providing a compelling case for its wider adoption as a preferred paradigm of care.
Families are presenting, in increasing numbers, to their general practitioners (GPs) with a wide range...]]>
Key messages
Development of neonatal standard concentration infusions was recommended to improve neonatal drug safety and service efficiency in the National Health Service England Getting It Right First Time Neonatology national specialty report. ‘Smart pumps’ and electronic prescribing can support this change; however, these are not available to everyone and require significant time and resource to implement. The major opportunities for error with standard concentration infusions are in calculating the rate of infusion with dose changes. This is relatively simple to overcome, and we provide a simple aide memoire for practitioners to use.
There is a national debate about how we transition our neonatal units to standard concentration infusions (SCIs) to improve safety and efficiency. This paper sets out the background on how the current frameworks of neonatal SCIs were developed, and how safe prescribing can be supported in practice without using complex technologies.
Traditionally, intravenous infusions for neonates are...]]>
Blood pressure: 99/50 mm Hg. Blood glucose: 5.8 mmol/L. Respiratory rate: 32 breaths per minute. Saturations: 98% in air. Heart rate: 130 beats per minute. Temperature: 37.1°C.
An urgent awake encephalogram and CT of the head demonstrated no abnormalities. The following day, he underwent an MRI of...]]>
Integrated care addresses multidimensional needs—physical health, mental wellbeing, education and social development—while reducing fragmentation and inefficiency. This approach enables early intervention and improves health equity. Key benefits include streamlined access for families, reduced hospital admissions and better outcomes for vulnerable groups, such as children with complex conditions or those facing social and economic challenges.
The evolution of UK child health policy, from the 1959 Platt Report to the 2025 National Health Service 10-Year Health Plan for England, underscores the growing emphasis on multidisciplinary, community-based models. By adopting a whole-population approach—segmenting children by health and social needs rather than rigid pathways—integrated care enables every child to be supported and cared for.
Ultimately, integrated care is not just an improvement but a necessity, addressing rising demand, workforce pressures and persistent inequities. It fosters proactive, collaborative systems that prioritise children’s wellbeing, offering a sustainable future for child health and care services in England.
]]>We present a quality improvement project to improve junior paediatric resident doctors’ confidence in neonatology in preparation for working on the Tier 2 rota, by implementing a neonatal study day into a regional paediatric education programme.
In 2022–2023, 4.3% of 375 foundation posts contained a neonatal rotation; therefore, many paediatric resident doctors enter their first neonatal rotation without previous experience.
To improve junior paediatric resident doctors’ confidence in neonatal skills through a 1-day face-to-face course.
Pruritus is a common distressing symptom in Progressive Familial Intrahepatic Cholestasis (PFIC) and Alagille syndrome. Severe itching often results in bleeding excoriations, sleep deprivation, poor school performance, impaired mood and social behaviour, resulting in poor quality of life for both the child and their family. For decades, management has relied on general supportive measures and off-label pharmacotherapy, with limited success (
Nitrous oxide (N2O) or more commonly known as ‘laughing gas’ is a short-acting anaesthetic agent. It has been used both in medicine and recreationally for over 200 years for its analgesic and antianxiety properties. In the year ending March 2020, use in the last 12 months was reported by 2.4% of adults aged 16–59, and 8.7% of adults aged 16–24.
There is inconsistent national data regarding N2O use and reported deaths. However, more recent anecdotal evidence suggests an increase in hospital admissions related to N2O chronic toxicity, although mortality rates are low.
A guideline on suspected N2O toxicity in emergency departments (EDs) was produced by the Royal College of Emergency Medicine (RCEM) in April 2023 to promote emergency medicine clinicians to consider N2O toxicity as a differential and how to appropriately investigate this early to support diagnosis. No previous guidelines existed specifically for suspected N2O toxicity in...]]>
This 2024 collaborative guideline between the British Association for Sexual Health and HIV (BASHH) and the Royal College of Obstetricians and Gynaecologists (RCOG) provides new recommendations on the management of genital HSV in pregnant people, their partners/contacts and neonates.
This guideline supersedes ‘Management of...]]>
Effective simulation begins with a targeted needs assessment and the development of achievable learning outcomes. New educators should avoid ‘the fidelity trap’ where an over-reliance on expensive or complex simulation tools and technology counterintuitively reduces educational value, and instead focus on simplified low-cost scenarios with high-impact patient outcomes. Scenario design can be enhanced by adapting real-life cases, using free online resources and cautiously incorporating generative artificial intelligence for content creation. Quality and safety must be prioritised through rigorous review, ensuring relevance to local practices, whichever method of scenario generation is taken.
Task trainers, simulated monitors and audiovisual cues can all be created using cheap, accessible tools which can immerse participants in the scenario without breaking departmental budgets.
This article aims to empower new simulation educators to deliver impactful, accessible simulation through careful planning and creative resource development.
]]>Key points
While pain is relatively common in children who are life-limited or life-threatened, they may present with a wide range of symptoms including agitation/distress, dystonia, sleep problems, feed-related problems, gastrointestinal symptoms and breathlessness. Pharmacological treatment is only one aspect of palliative care symptom management. Writing a tailored symptom management plan with non-pharmacological approaches included may help give parents or young people agency and optimise symptom control. Consider the best route of administration for medications for the child and adapt with changing conditions.
With a rising number of children living with life-limiting conditions in the UK,
Poisoning can present with a variety of symptoms and should be considered as a cause in perplexing presentations. In general, deliberate self-harm with known substances is commoner than exposure to an unknown substance. However, children are at higher risk of accidental ingestion of inadequately secured medications or household products. They are also at increased risk of transdermal and respiratory absorption of toxins due to their different anatomy (higher body surface area to volume ratio) and physiology (increased respiratory rate).
This is a Royal College of Emergency Medicine (RCEM) Best Practice Guideline published with the National Poisons Information Service (NPIS) in April 2025. It outlines a general approach for assessing and treating all patients suspected of being poisoned by an unknown substance.
This 2025 guideline should be used alongside TOXBASE and the NPIS which provide up to date guidelines which are poison specific. Advice on antidote...]]>
It is a common perception that, in parallel with clinical training pressures and requirements, creating a window for undertaking research outside of a formal academic appointment is unachievable.
In this piece which, though primarily aimed at clinicians, is generic to all healthcare staff, I would like to try to demonstrate that research can be and should be accessible to all.
A reasonable working definition is that research is ‘the means of asking a relevant question and having the tools to answer it.’ The prerequisite is the final common pathway: improving care for children.
No one would dispute that training one’s mind to be able to articulate relevant questions and finding ways of answering them makes a paediatrician, or anyone involved in providing care for children, better equipped and more rounded as a doctor.
None of this needs to require a doctoral degree, training scheme or...]]>
A 26-day-old male neonate presented with a 3-day history of low-grade fever (maximum 38.5°C), increased irritability, decreased oral intake and skin eruptions. The patient was born at 39 weeks’ gestation following an uncomplicated pregnancy and spontaneous vaginal delivery, weighing 3.7 kg. The neonatal period was unremarkable until presentation. On examination, vital signs included temperature of 38.2°C, heart rate of 145 beats per minute, respiratory rate of 42 breaths per minute and oxygen saturation of 98% on room air. The infant appeared alert but irritable. Cardiovascular, respiratory, abdominal and neurological examinations were within normal limits. The striking skin findings consisted of multiple well-demarcated, annular erythematous lesions with central clearing distributed over bilateral lower extremities (
Introduction of a visual communication toolkit into child protection medical assessments (CPMAs) to ensure that verbal communication is never a barrier to being heard—a multi-agency quality improvement project co-designed with children and young people (CYP).
The importance of the voice of the child in safeguarding procedures is undisputed; it is a legal duty in the Children Act 2004
When children are experiencing abuse, they are often required to share painful and...]]>
The genomics revolution is ever evolving. We explored ways to support the different levels of genomic literacy and upskill colleagues based in our Community Child Health service.
We each have 3–4 million variants in our genome and these are innocent until proven guilty.