Paediatrics Revision Guide ✅

👶 Paediatrics is adult medicine plus age, growth, development, family context and safeguarding. Children compensate well and then deteriorate quickly, so clinical assessment must include appearance, work of breathing, circulation, hydration, behaviour and parental concern. For exams and ward work, always ask: how old is the child?, what is normal for this age?, are they feeding/playing/peeing?, and could this be sepsis, non-accidental injury or another time-critical diagnosis?

✅ 1. Paediatric Assessment

👀 1.1 First Impression

• Appearance: alertness, tone, interaction, cry, consolability, colour.
• Breathing: respiratory rate, recession, nasal flaring, grunting, wheeze, stridor, apnoea.
• Circulation: heart rate, capillary refill, skin temperature, pulses, urine output, blood pressure if unwell.
• Hydration: wet nappies/urine, tears, mucous membranes, fontanelle, weight loss, skin turgor.
• Behaviour: feeding, play, sleep, irritability, lethargy, response to parents.
• Parental concern: take seriously - carers often detect subtle deterioration before objective signs are dramatic.

🧠 Exam pearl: A child who is not interacting, not feeding, not passing urine or not responding normally to parents is high risk even if one observation looks acceptable.

📏 1.2 Normal Values Change with Age

📌 Clinical reasoning: Children maintain blood pressure until late shock by increasing heart rate and systemic vascular resistance. Hypotension is therefore a late and dangerous sign.

🌡️ 2. Fever and Sepsis

🚦 2.1 Feverish Child

• Fever is common and usually viral, but the priority is identifying serious bacterial infection, sepsis, meningitis, pneumonia, UTI and safeguarding concerns.
• Use an age-appropriate structured assessment such as the NICE traffic light approach in under-5s.
• Red features include pale/mottled/ashen/blue colour, no response to social cues, appearing ill, weak high-pitched cry, grunting, severe recession, reduced skin turgor or non-blanching rash.
• Amber features include reduced activity, poor feeding, reduced urine output, tachycardia, tachypnoea, moderate fever in young infants and prolonged fever.
• Children under 3 months with fever need a lower threshold for urgent assessment because serious infection risk is higher.

🚨 2.2 Paediatric Sepsis

• Sepsis is life-threatening organ dysfunction due to infection; children may initially show subtle behavioural and perfusion changes.
• Clues: abnormal mental state, mottled/ashen colour, prolonged capillary refill, tachycardia, tachypnoea, hypoxia, reduced urine output, non-blanching rash or hypotension.
• Management principles: senior help, oxygen if needed, IV/IO access, blood cultures if this does not delay treatment, broad-spectrum antibiotics, fluid bolus if shock, glucose check and close reassessment.
• Look for source: meningitis, pneumonia, UTI, abdominal sepsis, skin/soft tissue infection, bone/joint infection.
• Escalate early to paediatrics/PICU if poor response or persistent shock, altered consciousness, severe respiratory distress or rising lactate.

🚨 Exam pearl: Non-blanching rash plus fever is meningococcal sepsis until proven otherwise, but absence of rash does not exclude sepsis.

👶 3. Neonatology

🍼 3.1 Newborn Examination

• Check general appearance, colour, tone, feeding, breathing pattern and temperature.
• Cardiac: femoral pulses, murmurs, cyanosis, saturations if indicated.
• Hips: Barlow and Ortolani manoeuvres for developmental dysplasia of the hip.
• Eyes: red reflex - absent red reflex requires urgent ophthalmology assessment.
• Abdomen: masses, umbilicus, organomegaly, anus patency.
• Genitalia: testes, hypospadias, ambiguous genitalia, hernias.
• Spine/skin: sacral dimples, hair tufts, birthmarks, bruising.

🟡 3.2 Neonatal Jaundice

• Physiological jaundice usually appears after 24 hours and resolves gradually.
• Jaundice in the first 24 hours is pathological until proven otherwise.
• Causes: haemolysis, ABO/Rh incompatibility, G6PD deficiency, sepsis, bruising, prematurity, breastfeeding issues, biliary atresia.
• Assess feeding, weight loss, hydration, stool/urine colour and gestational age.
• Pale stools and dark urine suggest conjugated jaundice/cholestasis and need urgent assessment.
• Treatment may include phototherapy or exchange transfusion depending on bilirubin level, age in hours and risk factors.

🦠 3.3 Neonatal Sepsis

• Early-onset sepsis usually occurs within 72 hours and may be linked to maternal infection, prolonged rupture of membranes or group B streptococcus.
• Late-onset sepsis occurs after 72 hours and may be community or healthcare-associated.
• Features can be non-specific: poor feeding, temperature instability, lethargy, irritability, respiratory distress, apnoea, jaundice or poor perfusion.
• Management: urgent neonatal/paediatric review, cultures and antibiotics according to local neonatal sepsis guidance.

🍬 3.4 Neonatal Hypoglycaemia

• Risk factors: maternal diabetes, prematurity, small/large for gestational age, sepsis, hypothermia, poor feeding.
• Features: jitteriness, lethargy, poor feeding, apnoea, seizures, hypothermia.
• Check glucose early in an unwell neonate.
• Treatment depends on severity: feeding support, dextrose gel or IV glucose according to protocol.

📈 4. Growth and Development

📏 4.1 Growth Assessment

• Plot weight, length/height and head circumference on appropriate growth charts.
• Crossing centiles may be more important than one isolated measurement.
• Failure to thrive/faltering growth may result from inadequate intake, malabsorption, chronic disease, neglect or increased metabolic demand.
• Short stature can be familial, constitutional delay, endocrine, chronic disease or genetic syndrome.
• Head circumference matters: rapidly increasing head size suggests hydrocephalus; falling centiles may suggest impaired brain growth.

🧠 4.2 Developmental Milestones

🚩 4.3 Developmental Red Flags

• No social smile by around 8 weeks.
• Not sitting by 9 months.
• Not walking by 18 months.
• No words by 18 months or no two-word phrases by 2 years.
• Loss of previously acquired skills at any age.
• Persistent asymmetry, early hand preference before 12 months, abnormal tone or persistent primitive reflexes.

🛡️ 5. Safeguarding

Safeguarding is central to paediatrics. The task is not to prove abuse alone, but to recognise concern, document accurately, share information appropriately and escalate through local child protection pathways.

🚩 5.1 Safeguarding Red Flags

• Injury inconsistent with developmental stage, such as bruising in a non-mobile infant.
• History inconsistent, changing, delayed presentation or incompatible with injury pattern.
• Multiple bruises, patterned marks, burns, bite marks or injuries in protected areas.
• Fractures in young children, especially rib fractures, metaphyseal fractures or multiple fractures of different ages.
• Neglect: poor hygiene, malnutrition, missed appointments, unsafe supervision, untreated medical needs.
• Sexual abuse concerns: genital injury, STI, pregnancy, sexualised behaviour, disclosure.
• Fabricated or induced illness: discrepancies between reported and observed symptoms, unnecessary medical interventions, symptoms only witnessed by one carer.

📝 5.2 Documentation

• Record exact words used by child/carer where possible.
• Document site, size, shape, colour and pattern of injuries using body maps if available.
• Record who was present, timing, developmental ability and explanation given.
• Discuss concerns with senior clinician and safeguarding team; follow local policy.
• Do not promise confidentiality if a child may be at risk of harm.

⚠️ Safety pearl: Bruising in a baby who is not independently mobile is a safeguarding concern until clearly explained. “Those who don’t cruise rarely bruise.”

🫁 6. Paediatric Respiratory Disease

🫧 6.1 Bronchiolitis

• Common viral lower respiratory tract infection in infants, usually caused by RSV.
• Typical age: under 2 years, peak 3–6 months.
• Features: coryza, cough, poor feeding, tachypnoea, recession, crackles and/or wheeze.
• Apnoea may be the presenting feature in very young infants.
• Management is supportive: oxygen if hypoxic, feeding support, fluids if needed and monitoring.
• Routine bronchodilators, steroids and antibiotics are not used unless another diagnosis/complication is suspected.
• Risk factors for severe disease: prematurity, chronic lung disease, congenital heart disease, young age, immunodeficiency, neuromuscular disease.

🌬️ 6.2 Viral-Induced Wheeze and Asthma

• Preschool viral wheeze is common and may not become asthma.
• Asthma is more likely with interval symptoms, atopy, family history, triggers and recurrent episodes.
• Acute severe asthma signs: inability to talk/feed, severe recession, exhaustion, SpO₂ low, silent chest, altered consciousness.
• Management: oxygen if hypoxic, inhaled salbutamol, ipratropium in severe attacks, oral/IV steroids, magnesium/ICU escalation if poor response.
• Check inhaler technique and spacer use; poor technique is a frequent cause of poor control.

🦠 6.3 Pneumonia

• Symptoms: fever, cough, tachypnoea, increased work of breathing, abdominal pain, poor feeding.
• Signs: focal crackles, bronchial breathing, dullness, hypoxia or signs of sepsis.
• Viruses are common in younger children; bacterial pneumonia more likely with high fever, focal signs and toxicity.
• Management depends on age, severity, oxygenation, hydration and local antimicrobial guidance.

🗣️ 6.4 Croup and Upper Airway Obstruction

• Croup: barking cough, hoarse voice and inspiratory stridor, usually viral.
• Severity clues: stridor at rest, recession, agitation, fatigue, hypoxia, cyanosis.
• Treatment: corticosteroid; nebulised adrenaline for severe symptoms with observation.
• Drooling, toxic appearance, tripod position or severe dysphagia suggests epiglottitis/deep neck infection - do not distress the child; call senior airway help.

🍽️ 7. Paediatric Gastroenterology

🚽 7.1 Gastroenteritis and Dehydration

• Most acute gastroenteritis is viral and self-limiting.
• Assess dehydration: reduced urine, dry mucosa, no tears, lethargy, sunken eyes/fontanelle, tachycardia, prolonged capillary refill.
• Oral rehydration solution is first-line for mild/moderate dehydration if tolerated.
• IV fluids are needed for shock, severe dehydration, persistent vomiting or inability to tolerate oral/NG fluids.
• Avoid anti-diarrhoeal drugs in young children.
• Red flags: bilious vomiting, blood in stool, severe abdominal pain, distension, sepsis, non-GI diagnosis.

🍼 7.2 Gastro-Oesophageal Reflux

• Physiological reflux is common in infants and usually improves with time.
• Red flags: faltering growth, blood in vomit/stool, bilious vomiting, forceful vomiting, recurrent aspiration, apnoea, severe distress.
• Conservative management: feeding review, avoid overfeeding, positioning advice while awake, thickened feeds in selected cases.
• Consider cow’s milk protein allergy when reflux-like symptoms coexist with eczema, blood/mucus in stool or significant distress.

🌀 7.3 Pyloric Stenosis

• Usually presents at 2–8 weeks with projectile non-bilious vomiting.
• Baby remains hungry after vomiting.
• May cause hypochloraemic hypokalaemic metabolic alkalosis.
• Palpable “olive” may be felt in epigastrium; ultrasound confirms diagnosis.
• Correct fluids/electrolytes before pyloromyotomy.

🍓 7.4 Intussusception

• Telescoping of bowel, usually ileocolic.
• Features: episodic severe crying, drawing knees up, vomiting, lethargy, pallor; “redcurrant jelly” stool is late.
• May have sausage-shaped abdominal mass.
• Ultrasound shows target/doughnut sign.
• Management: air/contrast enema reduction if stable; surgery if perforation, peritonitis or failed reduction.

🚽 7.5 Constipation

• Very common; often functional with stool withholding after painful defecation.
• Features: infrequent stools, hard stools, overflow soiling, abdominal pain, reduced appetite.
• Red flags: delayed meconium, faltering growth, abnormal neurology, severe distension, ribbon stools, bilious vomiting.
• Management: education, disimpaction if needed, maintenance laxatives, toilet routine, fluids/fibre support and prolonged treatment to prevent relapse.

🫘 8. Paediatric Renal and Urology

🦠 8.1 Urinary Tract Infection

• Infants may present non-specifically: fever, poor feeding, vomiting, lethargy or irritability.
• Older children may have dysuria, frequency, abdominal pain, loin pain or new wetting.
• Diagnosis depends on age, symptoms and urine testing method; avoid contaminated samples where possible.
• Febrile UTI suggests upper tract involvement/pyelonephritis.
• Recurrent or atypical UTI may need imaging according to age and NICE/local pathways.
• Consider constipation and bladder dysfunction in recurrent UTI.

💧 8.2 Nephrotic Syndrome

• Most childhood nephrotic syndrome is minimal change disease.
• Features: periorbital oedema, peripheral oedema, ascites, frothy urine, heavy proteinuria, hypoalbuminaemia.
• Complications: infection, thrombosis, hypovolaemia and AKI.
• Usually steroid-responsive, but needs paediatric/renal guidance and urine protein monitoring.

🩸 8.3 Haematuria

• Causes: UTI, stones, trauma, glomerulonephritis, IgA nephropathy, post-streptococcal GN, hypercalciuria.
• Cola-coloured urine suggests glomerular bleeding.
• Blood plus protein, hypertension or reduced renal function needs urgent assessment.

🧠 9. Paediatric Neurology

⚡ 9.1 Febrile Seizures

• Common between 6 months and 5 years.
• Simple febrile seizure: generalised, less than 15 minutes, single episode in 24 hours, child recovers fully.
• Complex features: focal, prolonged, recurrent within 24 hours or incomplete recovery.
• Always identify source of fever and exclude meningitis/sepsis if concerning features.
• Reassure parents: simple febrile seizures are frightening but usually benign.

🚨 9.2 Meningitis and Encephalitis

• Features may include fever, headache, neck stiffness, photophobia, vomiting, confusion, seizures, non-blanching rash.
• Infants may present with poor feeding, irritability, bulging fontanelle, lethargy or temperature instability.
• Do not delay antibiotics in a seriously unwell child for lumbar puncture or imaging.
• Encephalitis suggests brain inflammation: altered behaviour, focal neurology, seizures or reduced consciousness.

🧩 9.3 Epilepsy

• Take detailed witness history: onset, movement, awareness, colour, breathing, duration, recovery, triggers.
• Differentiate seizure from syncope, breath-holding, reflux, tics, parasomnias and functional episodes.
• Management depends on seizure type, syndrome, EEG/imaging findings and impact.
• Safety advice includes bathing, swimming supervision, heights, cycling and rescue medication plans where appropriate.

🍬 10. Paediatric Endocrinology and Diabetes

🍭 10.1 Type 1 Diabetes

• Symptoms: polyuria, polydipsia, weight loss, tiredness, nocturia or secondary enuresis.
• Children can deteriorate rapidly into DKA.
• Always check capillary glucose and ketones in an unwell child with vomiting, dehydration, weight loss or altered consciousness.
• Management involves insulin, glucose monitoring/CGM, carbohydrate education, sick-day rules and family/school support.

🚨 10.2 Diabetic Ketoacidosis

• Features: dehydration, vomiting, abdominal pain, Kussmaul breathing, ketotic breath, drowsiness.
• Management is protocolised: careful fluids, insulin infusion, potassium monitoring and cerebral oedema vigilance.
• Do not give an insulin bolus in paediatric DKA unless specifically directed by a specialist protocol.
• Cerebral oedema red flags: headache, bradycardia, hypertension, falling GCS, abnormal pupils, seizures.

📏 10.3 Growth and Puberty Problems

• Short stature: familial, constitutional delay, chronic disease, coeliac disease, hypothyroidism, growth hormone deficiency, Turner syndrome.
• Tall stature: familial, obesity-related, Marfan syndrome, precocious puberty, endocrine causes.
• Delayed puberty: no testicular enlargement by 14 in boys or no breast development by 13 in girls.
• Precocious puberty: pubertal signs before 8 in girls or 9 in boys; needs assessment.

🩸 11. Paediatric Haematology and Oncology

🩸 11.1 Anaemia

• Iron deficiency is common and may result from diet, prematurity, cow’s milk excess or blood loss.
• Symptoms: pallor, fatigue, irritability, poor feeding, pica, breathlessness.
• Microcytic anaemia: iron deficiency or thalassaemia trait are common considerations.
• Macrocytosis suggests B12/folate deficiency, marrow disease or medication effect.

🧬 11.2 Sickle Cell Disease

• Complications: painful crisis, acute chest syndrome, sepsis, stroke, splenic sequestration, priapism.
• Fever in sickle cell disease is high risk due to functional asplenia.
• Acute chest syndrome: chest pain, fever, respiratory symptoms, hypoxia and new infiltrate.
• Management of crises includes analgesia, hydration, oxygen if hypoxic and specialist haematology input.

🎗️ 11.3 Childhood Cancer Red Flags

• Persistent unexplained fever, weight loss, night sweats or fatigue.
• Bone pain, limp, refusal to walk or night pain.
• Unexplained bruising, pallor, recurrent infections or petechiae.
• Lymphadenopathy that is persistent, hard, fixed, supraclavicular or associated with systemic symptoms.
• Headache with early morning vomiting, neurological signs or papilloedema.
• Abdominal mass, testicular mass or unexplained distension.

🦴 12. Paediatric MSK and Rheumatology

🦵 12.1 Limping Child

• Always consider age, fever, trauma and ability to weight bear.
• Emergency causes: septic arthritis, osteomyelitis, non-accidental injury, malignancy.
• Common causes: transient synovitis, trauma, Perthes disease, slipped upper femoral epiphysis, Osgood-Schlatter disease.
• Septic arthritis: fever, severe pain, reduced range, inability to weight bear - urgent orthopaedic assessment.
• SUFE: adolescent, often overweight, hip/groin/knee pain, externally rotated leg; avoid forced movement and refer urgently.

🔥 12.2 Juvenile Idiopathic Arthritis

• Arthritis lasting more than 6 weeks with onset before age 16 after excluding other causes.
• Features: swollen joints, morning stiffness, limp, reduced activity; pain may be less prominent than adults expect.
• Complication: uveitis, especially in ANA-positive oligoarticular disease.
• Management is specialist-led with NSAIDs, steroid injections, methotrexate or biologics depending on subtype/severity.

🟣 12.3 Henoch-Schönlein Purpura / IgA Vasculitis

• Small-vessel IgA vasculitis, often after URTI.
• Features: palpable purpura on buttocks/legs, abdominal pain, arthralgia/arthritis and renal involvement.
• Monitor urine and blood pressure because nephritis can occur.
• Severe abdominal pain may indicate intussusception.

🧠 13. Child and Adolescent Mental Health

🌧️ 13.1 Depression, Anxiety and Self-Harm

• Presentations may include irritability, withdrawal, school refusal, sleep change, somatic symptoms, risk-taking or self-harm.
• Ask directly about self-harm and suicidal thoughts; this does not “put the idea in their head”.
• Assess immediate safety, intent, planning, access to means, protective factors and safeguarding context.
• Involve parents/carers appropriately, but consider confidentiality and Gillick competence in adolescents.
• Escalate urgently for current suicidal intent, psychosis, severe self-neglect, safeguarding risk or inability to maintain safety.

🍽️ 13.2 Eating Disorders

• Red flags: rapid weight loss, bradycardia, syncope, hypothermia, electrolyte abnormality, amenorrhoea, excessive exercise, purging.
• Do not be reassured by normal BMI if weight loss is rapid or behaviours are high risk.
• Assess physical risk: pulse, BP including postural, temperature, ECG, electrolytes, glucose, phosphate.
• Refeeding risk is important in malnourished patients.

💊 14. Paediatric Prescribing and Safety

• Prescribe by weight where appropriate: mg/kg dosing with maximum adult dose checks.
• Use current weight; be cautious with obesity, renal impairment and neonates.
• Check formulation concentration carefully - many paediatric errors involve liquids.
• Avoid decimal errors: write 500 micrograms rather than 0.5 mg when safer.
• Double-check high-risk drugs: insulin, opioids, gentamicin, vancomycin, anticonvulsants, anticoagulants.
• Consider allergies, immunisation status, pregnancy possibility in adolescents and safeguarding context.

⚠️ Prescribing pearl: In paediatrics, the dose, formulation and route are part of the safety-critical diagnosis. A correct drug with the wrong concentration can still be dangerous.

💉 15. Immunisation and Public Health

• Immunisation protects the child and reduces community transmission.
• Check immunisation status in febrile illness, safeguarding assessments, migrants/refugees and chronic disease reviews.
• Live vaccines are contraindicated in significant immunosuppression and require specialist advice.
• Children with asplenia/sickle cell disease need particular infection prevention attention.
• Vaccine hesitancy should be met with respectful explanation, not dismissal.

🦠 15.1 Notifiable and Public Health-Relevant Illness

• Consider public health action for measles, meningococcal disease, pertussis, TB, scarlet fever outbreaks and food poisoning outbreaks.
• Measles: fever, cough, coryza, conjunctivitis, Koplik spots, then rash; highly infectious.
• Pertussis: paroxysmal cough, whoop, post-tussive vomiting; young infants may present with apnoea.
• Scarlet fever: fever, sore throat, sandpaper rash, strawberry tongue.

🚨 16. Paediatric Emergencies

📚 17. OSCE / Exam Pearls

• Children compensate then crash; hypotension is a late sign.
• Parental concern is clinically important.
• Fever in a baby under 3 months needs a lower threshold for urgent assessment.
• Bilious vomiting in a baby is intestinal obstruction until proven otherwise.
• Projectile non-bilious vomiting at 2–8 weeks suggests pyloric stenosis.
• Intermittent severe crying with lethargy suggests intussusception.
• Bronchiolitis is supportive care; routine salbutamol/steroids/antibiotics are not typical management.
• Non-mobile babies should not have unexplained bruising.
• A limping child with fever who cannot weight bear has septic arthritis until proven otherwise.
• Always check glucose in an unwell child with reduced consciousness or seizures.

📌 18. Quick Differentials Table

📚 References

• NICE. Fever in under 5s: assessment and initial management. NG143.
• NICE. Bronchiolitis in children: diagnosis and management. NG9.
• NICE. Suspected sepsis in under 16s: recognition, diagnosis and early management. NG254.
• NICE. Urinary tract infection in under 16s: diagnosis and management. NG224.
• BNF for Children should be checked for all paediatric drug doses, formulations, contraindications and maximum doses.
• Local safeguarding, resuscitation, sepsis, DKA and antimicrobial policies should always be followed.

⚠️ Disclaimer

This article is for medical education and exam revision. Clinical decisions should follow current local paediatric guidelines, safeguarding procedures, antimicrobial policies, resuscitation algorithms, BNFC prescribing, senior advice and national guidance. Paediatric emergencies such as sepsis, meningitis, DKA, anaphylaxis, status epilepticus, severe asthma, upper airway obstruction and suspected non-accidental injury require urgent senior input.