Paediatrics: Infections

• The febrile child: Fever in Children Under 5 | Fever in Babies Under 3 Months | Sepsis in Children | Bacterial Meningitis | Meningococcal Disease | Encephalitis
• Common infections: Gastroenteritis and Dehydration | Rashes in Childhood | Measles | Chickenpox and Shingles | Other Viral Rashes | Skin Infections and Infestations
• Inflammatory and other: Kawasaki Disease | PIMS-TS and Toxic Shock | Tuberculosis in Children | Threadworms and Gut Parasites | The Returning Traveller | Prescribing Antimicrobials in Children
• Revision: Drug Reference Table | Spot the Diagnosis | Exam-style Scenarios | Key Points | Guidelines and Further Reading

🌡️ Infections in children — fever is one of the commonest reasons children are seen. Most have self-limiting viral illnesses, but a small number have serious bacterial infection (sepsis, meningitis, pneumonia, UTI), which can progress within hours. Use the NICE traffic light system, take parents' concerns seriously, look for a non-blanching rash, and always give clear safety-netting advice.
Your four questions for every child: How old are they (under 3 months is high risk)? Are there red (or amber) features on the traffic light system? Is there a focus of infection — and could this be sepsis or meningitis? Is there a rash — and does it blanch?

Fever in Children Under 5

• Fever — temperature 38 °C or above. Use an electronic thermometer in the armpit (under 4 weeks) or an infrared tympanic or armpit thermometer (4 weeks to 5 years). Parents' report of fever counts.
• NICE traffic light system (NG143) — assess colour, activity, breathing, circulation and hydration:

• Also measure — heart rate, breathing rate, capillary refill, temperature; consider BP; oxygen saturation.
• Management:
  • Red — urgent hospital assessment (same-day, often emergency transfer); tests and treatment as for possible sepsis.
  • Amber — face-to-face assessment by a paediatric specialist, or a clear safety net and follow-up; tests may include urine, FBC, CRP, blood culture, chest X-ray (if signs).
  • Green — manage at home with safety-netting; test urine if no clear focus.
• Look for a focus — ears, throat, chest, urine, skin, joints, abdomen; test urine in children with unexplained fever.
• Antipyretics (paracetamol or ibuprofen):
  • Use for distress, not just to lower the number.
  • Don't use to prevent febrile seizures (they don't).
  • Don't give both at the same time; consider switching if distress continues before the next dose is due.
  • Avoid tepid sponging; keep the child comfortable, encourage fluids.
  • Response to antipyretics doesn't tell you whether an infection is serious.
• Safety-netting — return if: a fit, a non-blanching rash, the child becomes harder to wake or more unwell, signs of dehydration, fever for 5 days or more, or parents are worried. Give written information.

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Fever in Babies Under 3 Months

• High risk of serious bacterial infection (UTI, bacteraemia, meningitis) — signs are often subtle.
• Any baby under 3 months with a temperature of 38 °C or more needs urgent assessment by a paediatrician.
• Under 1 month — full septic screen and IV antibiotics:
  • Blood culture, FBC, CRP, urine, lumbar puncture (unless contraindicated), chest X-ray if breathing signs, lactate.
  • IV cefotaxime (or ceftriaxone if over 28 days old) plus amoxicillin (for Listeria).
• 1–3 months — blood and urine tests for all; LP and IV antibiotics if unwell, or white cell count under 5 or over 15 × 10⁹/L (or raised CRP).
• Consider HSV (aciclovir) in neonates with seizures, vesicles, or raised liver enzymes.
• Low temperature (hypothermia) in a young baby can also mean sepsis.

⚠️ Safety Pearl: A febrile baby under 3 months may look well and still have meningitis or bacteraemia. Never dismiss fever in a young infant — they all need urgent paediatric assessment.

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Sepsis in Children

• Sepsis — life-threatening organ dysfunction from infection. Children compensate well and BP falls late — tachycardia, fast breathing, prolonged capillary refill and altered behaviour are earlier signs.
• Recognition — use a paediatric early warning score (PEWS) and sepsis screening tools (age-specific heart and breathing rates).
• Red flags — mottled or ashen skin, non-blanching rash, cold extremities, lethargy or reduced consciousness, breathing rate very high, heart rate very high or low, oxygen saturation under 90% in air, no urine for 18 hours (or under 1 mL/kg/hour if catheterised), lactate over 2 mmol/L.
• Management — within 1 hour:
  • ABC; high-flow oxygen; senior help.
  • IV or intraosseous access — IO if IV fails after 2 attempts (or 90 seconds).
  • Bloods — blood culture, FBC, CRP, U&E, glucose, lactate (venous gas), clotting.
  • IV antibiotics — e.g. ceftriaxone 80 mg/kg (cefotaxime plus amoxicillin under 3 months), per local policy.
  • Fluid bolus — 10 mL/kg of balanced crystalloid (or 0.9% saline) over 5–10 minutes, reassessing after each; escalate to PICU and inotropes after 40–60 mL/kg.
  • Check glucose and treat hypoglycaemia (2 mL/kg of 10% glucose).
  • Monitor urine output.
• Look for the source — chest, urine, CNS, abdomen, skin and soft tissue, bones and joints, lines.
• Toxic shock syndrome (staphylococcal or streptococcal) — add clindamycin; consider IVIG.

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Bacterial Meningitis

• Organisms:
  • Under 3 months — group B streptococcus, E. coli, Listeria, pneumococcus.
  • Over 3 months — Neisseria meningitidis (meningococcus), Streptococcus pneumoniae; Hib (now rare — vaccine).
  • TB meningitis (gradual onset, high-risk contacts).
• Features:
  • Babies — non-specific: fever or hypothermia, poor feeding, vomiting, irritability, high-pitched cry, lethargy, bulging fontanelle, seizures, floppiness.
  • Older children — fever, headache, neck stiffness, photophobia, vomiting, confusion, reduced consciousness, seizures.
  • Kernig's and Brudzinski's signs (unreliable in young children).
  • Non-blanching rash (meningococcal).
• Before arriving at hospital — if meningococcal disease is suspected (non-blanching rash), give IM or IV benzylpenicillin straight away (unless there is anaphylaxis to penicillin) without delaying transfer.
• Lumbar puncture — when safe. Don't do an LP if:
  • Signs of raised intracranial pressure — reduced or fluctuating consciousness (GCS under 9 or falling), focal neurology, abnormal posturing, unequal pupils, papilloedema, bradycardia with hypertension.
  • Shock; extensive or spreading purpura.
  • After a convulsion until stabilised.
  • Coagulopathy or low platelets; local infection at the site; respiratory compromise.
• CSF findings:

• Treatment (NICE NG240):
  • Over 3 months — IV ceftriaxone (80 mg/kg once daily, or as per local policy).
  • Under 3 months — IV cefotaxime plus amoxicillin (Listeria).
  • Dexamethasone (0.15 mg/kg four times daily for 4 days) — in children over 3 months with suspected or confirmed bacterial meningitis (e.g. frankly purulent CSF, high white cells, or bacteria on Gram stain), ideally with or before the first antibiotic dose (within 12 hours). Reduces hearing loss and neurological damage. Not for meningococcal septicaemia without meningitis.
  • Fluids — treat shock; then normal maintenance (don't restrict unless raised ICP or SIADH).
  • Aciclovir if encephalitis is possible.
• Public health — notify UKHSA; prophylactic antibiotics (e.g. single-dose ciprofloxacin) and sometimes vaccine for close contacts of meningococcal disease.
• Complications — sensorineural hearing loss (formal hearing test within 4 weeks), seizures, learning and behaviour problems, hydrocephalus, cerebral palsy, subdural effusion, cerebral abscess, SIADH, death.

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Meningococcal Disease

• Neisseria meningitidis — causes meningitis, septicaemia, or both. Groups B (most UK cases — MenB vaccine), W, Y and C (MenACWY).
• Peak ages — under 1 year, and 15–19 years (students — MenACWY at 14 and before university).
• Meningococcal septicaemia:
  • Can progress from flu-like illness to shock within hours.
  • Early signs — fever, cold hands and feet, leg pain, abnormal skin colour (pallor, mottling), rapid breathing.
  • Rash — may start as a blanching maculopapular rash, then becomes non-blanching petechiae and purpura (glass test — the rash doesn't fade under a glass).
  • Shock — tachycardia, prolonged capillary refill, low BP (late), reduced urine output.
  • Purpura fulminans — widespread purpura with DIC; limb and digit necrosis.
• A non-blanching rash with fever — treat as meningococcal disease until proven otherwise:
  • Prehospital — benzylpenicillin IM or IV; emergency transfer.
  • Hospital — IV ceftriaxone; fluid boluses; early PICU involvement (inotropes, ventilation); correct clotting, glucose, electrolytes.
• Other causes of non-blanching rash — viral infection (enterovirus), forceful coughing or vomiting (petechiae above the nipple line only — superior vena cava distribution), ITP, leukaemia, HSP, NAI.
• Low risk (can be observed) — a well child with a few petechiae, normal blood tests and no spreading after 4–6 hours of observation.

⚠️ Safety Pearl: In a feverish child, cold hands and feet, leg pain and unusual skin colour can come before the rash. A non-blanching rash with fever is meningococcal disease until proven otherwise — give antibiotics immediately.

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Encephalitis

• What it is: Inflammation of the brain tissue, usually viral (herpes simplex, enteroviruses, VZV, influenza, measles) or autoimmune (anti-NMDA receptor encephalitis).
• Features:
  • Fever, headache.
  • Altered behaviour, confusion, drowsiness.
  • Seizures (especially focal).
  • Focal neurological signs.
• Tests — LP (CSF lymphocytes, HSV PCR), MRI (temporal lobe changes in HSV), EEG, autoimmune antibodies.
• Treatment — IV aciclovir started immediately on suspicion (don't wait for results); supportive care; immunotherapy for autoimmune causes.
• Neonatal HSV — skin, eye and mouth, CNS or disseminated disease; IV aciclovir.

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Gastroenteritis and Dehydration

• Causes — mostly viral: norovirus, rotavirus (much less common since the vaccine), adenovirus. Bacterial — Campylobacter, Salmonella, Shigella, E. coli O157.
• Features — sudden diarrhoea (usually 5–7 days, up to 2 weeks) with or without vomiting (1–2 days), fever, abdominal pain.
• Think of other causes if:
  • Vomiting without diarrhoea — UTI, meningitis, DKA, raised ICP, intussusception, pyloric stenosis, appendicitis.
  • Bilious (green) vomiting — surgical (malrotation, obstruction).
  • Blood in stools — bacterial infection, intussusception ("redcurrant jelly"), HUS, IBD.
  • Severe abdominal pain, distension, or a mass.
  • Diarrhoea over 7 days.
• Assessing dehydration (NICE CG84):
  • Higher risk — under 1 year (especially under 6 months), low birth weight, 6 or more stools or 3 or more vomits in 24 hours, not tolerating fluids, signs of malnutrition.
  • Clinical dehydration — appears unwell, altered responsiveness (irritable, lethargic), sunken eyes, dry mucous membranes, tachycardia, tachypnoea, reduced skin turgor, reduced urine output.
  • Clinical shock — decreased consciousness, pale or mottled skin, cold extremities, very fast heart rate, weak pulses, prolonged capillary refill, low BP.
• Management:
  • No dehydration — continue breastfeeding and usual fluids; encourage drinking; oral rehydration solution (ORS) if at risk; avoid fruit juices and fizzy drinks.
  • Clinical dehydration — ORS 50 mL/kg over 4 hours (small, frequent sips) plus maintenance fluid; NG tube if not drinking or vomiting; ondansetron (single oral dose) in hospital can reduce vomiting.
  • Shock — IV fluid bolus (0.9% saline, e.g. 10–20 mL/kg), then IV rehydration; check U&E and glucose.
  • Hypernatraemic dehydration (sodium over 150 — "doughy" skin, jittery, irritable, drowsy, seizures) — correct slowly over 48 hours (rapid correction causes cerebral oedema).
  • Reintroduce food as soon as rehydrated; full-strength milk.
  • No antidiarrhoeals (loperamide) in children.
  • Antibiotics only in specific cases — suspected sepsis, Salmonella in babies under 6 months or immunocompromised, Shigella, C. difficile, extra-intestinal spread.
• Stool culture — blood or mucus in stools, recent travel abroad, immunocompromise, suspected septicaemia, diarrhoea over 7 days.
• Haemolytic uraemic syndrome (HUS) — E. coli O157 (bloody diarrhoea, then 5–10 days later pallor, reduced urine, bruising): AKI, low platelets, haemolytic anaemia. Avoid antibiotics and antimotility drugs. See the Paediatric Renal, Urology and Endocrine chapter.
• Infection control — handwashing; stay off school or nursery for 48 hours after the last episode of diarrhoea or vomiting.

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Rashes in Childhood

• Always check whether a rash blanches, and whether the child is unwell.
• Pregnant contacts — measles, chickenpox, rubella and parvovirus can harm a pregnancy; advise exposed pregnant women to contact their midwife or GP.

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Measles

• Very infectious (airborne); rising in the UK with falling MMR uptake. Notifiable.
• Incubation — about 10–12 days.
• Prodrome (2–4 days) — high fever, the "3 Cs": cough, coryza, conjunctivitis; miserable child.
• Koplik spots — tiny white spots on a red background on the inside of the cheeks (before the rash).
• Rash — red maculopapular, starting behind the ears and on the face, spreading down the body; becomes blotchy and confluent; fades with brown staining after a week.
• Infectious from 4 days before to 4 days after rash onset.
• Complications (more in under-5s, malnourished, immunocompromised):
  • Otitis media (the commonest).
  • Pneumonia (the commonest cause of death).
  • Diarrhoea; febrile seizures.
  • Encephalitis (about 1 in 1,000).
  • Subacute sclerosing panencephalitis (SSPE) — years later; fatal.
  • Immune "amnesia" — increased infections for years.
• Diagnosis — oral fluid or throat swab PCR, IgM.
• Management:
  • Supportive; isolate (airborne precautions in hospital); notify UKHSA.
  • Vitamin A for some children (e.g. severe disease, malnourished).
  • Treat bacterial complications.
• Contacts — MMR within 72 hours for unvaccinated contacts (from 6 months); human normal immunoglobulin within 6 days for infants under 6 months (sometimes 6–9 months), immunocompromised contacts, and non-immune pregnant women.

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Chickenpox and Shingles

• Varicella zoster virus — incubation 10–21 days; spread by droplets and contact with blisters.
• Features — mild fever and malaise, then itchy crops of red spots → vesicles → crusts, starting on the trunk and face; lesions at different stages.
• Infectious from 1–2 days before the rash until all lesions have crusted.
• Management:
  • Supportive — paracetamol, fluids, calamine or emollients, chlorphenamine (over 1 year) for itch; cut nails.
  • Avoid NSAIDs (ibuprofen) — linked to severe skin and soft tissue infections (including invasive group A strep).
  • Aciclovir — for immunocompromised children (IV), neonates, and consider for adolescents within 24 hours of the rash, or with severe disease.
• Complications:
  • Bacterial skin infection — Staph or group A strep (cellulitis, necrotising fasciitis, toxic shock) — watch for a second fever, spreading redness, or a child getting worse after initial improvement.
  • Pneumonia (more in adults and immunocompromised).
  • Cerebellar ataxia (usually benign, resolves); encephalitis.
  • Disseminated disease in immunosuppression.
• Exposure — immunocompromised children, neonates and non-immune pregnant women need urgent advice (antiviral prophylaxis or VZIG).
• Prevention — varicella vaccine now in the routine schedule (MMRV, 2026).
• Shingles in children — less common; dermatomal; consider immunosuppression; aciclovir if severe or immunocompromised.

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Other Viral Rashes

• Slapped cheek syndrome (erythema infectiosum — parvovirus B19):
  • Mild fever, then bright red cheeks, then a lacy rash on the arms and legs.
  • Infectious before the rash — so no exclusion.
  • Aplastic crisis in children with sickle cell disease or hereditary spherocytosis.
  • Pregnancy — fetal anaemia and hydrops (refer exposed pregnant women).
• Roseola infantum (HHV-6) — 6 months to 2 years; high fever for 3–5 days (febrile seizures common), then a pink rash on the trunk as the fever goes.
• Hand, foot and mouth disease (coxsackie A16, enterovirus 71) — under 10s; mouth ulcers, vesicles on palms and soles (and buttocks); mild; nail shedding weeks later.
• Rubella — mild; pink macular rash from the face down; occipital and post-auricular lymph nodes; joint pains in teenagers. Risk to pregnancies (congenital rubella).
• Glandular fever (EBV) — sore throat, nodes, splenomegaly; rash with amoxicillin. See the Nose and Throat chapter.
• Pityriasis rosea — older children: a single "herald patch" then a "Christmas tree" pattern on the back; self-limiting.

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Skin Infections and Infestations

• Impetigo — Staph aureus or Strep pyogenes; very contagious:
  • Non-bullous — red sores that burst, leaving golden-brown ("honey") crusts, often around the mouth and nose.
  • Bullous — fluid-filled blisters (Staph toxins), often in babies.
  • Treatment (NICE NG153) — localised non-bullous: hydrogen peroxide 1% cream (or topical fusidic acid if unsuitable) for 5 days; widespread or bullous or systemically unwell: oral flucloxacillin for 5 days (clarithromycin if allergic).
  • Exclude from school until crusted or 48 hours after starting antibiotics.
  • Complication — post-streptococcal glomerulonephritis.
• Staphylococcal scalded skin syndrome — young children; fever, widespread tender redness, then blistering and peeling (positive Nikolsky sign — skin slides off with gentle pressure); mucous membranes spared. IV flucloxacillin, fluids, analgesia.
• Cellulitis — oral or IV flucloxacillin (or co-amoxiclav for facial or bite-related); periorbital cellulitis — see the Red Eye chapter.
• Eczema herpeticum — herpes simplex in eczematous skin: rapidly spreading painful clusters of punched-out erosions, fever, unwell. Emergency — IV or oral aciclovir; eye check if near the eyes.
• Infected eczema — weeping, crusting; flucloxacillin.
• Molluscum contagiosum — pearly, dome-shaped papules with a central dimple; harmless; resolves in 12–18 months; no treatment usually.
• Tinea capitis (scalp ringworm) — scaly patches with hair loss; kerion (boggy, inflamed swelling); needs oral antifungals (terbinafine or griseofulvin) — topical alone won't work.
• Head lice — wet combing with a fine comb, or dimeticone lotion; treat only if live lice are found; no exclusion.
• Scabies — itchy papules and burrows in finger webs, wrists, armpits; in babies, palms, soles and face. Permethrin 5% to the whole body (including scalp in young children), repeated after 7 days; treat the household. See the Sexual Health chapter.
• Warts and verrucae — self-limiting; salicylic acid or cryotherapy if bothersome.

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Kawasaki Disease

• What it is: A medium-vessel vasculitis of young children (usually under 5); more common in children of East Asian origin. The leading cause of acquired heart disease in children in the UK.
• Diagnosis — fever for 5 days or more plus 4 of 5 features (remember "CRASH"):
  • C — Conjunctivitis — bilateral, non-purulent (no discharge).
  • R — Rash — polymorphous (any type except vesicles).
  • A — Adenopathy — cervical lymph node over 1.5 cm, usually one side.
  • S — Strawberry tongue and mucosal changes — red, cracked lips, red throat.
  • H — Hands and feet — red, swollen palms and soles; peeling of fingers and toes in weeks 2–3.
  • Very irritable child; BCG scar may become red.
• Incomplete Kawasaki — fewer features (more common in infants, who are at higher risk of aneurysms) — consider in any infant with prolonged unexplained fever.
• Tests — high CRP and ESR, high white cells, anaemia, raised platelets (after the first week), low albumin, raised ALT, sterile pyuria; echocardiogram at diagnosis and at 6 weeks.
• Complication — coronary artery aneurysms (in about 25% untreated, about 5% treated) — risk of MI, thrombosis and sudden death, later in life too.
• Treatment (start as soon as possible, ideally within 10 days of fever onset):
  • IV immunoglobulin 2 g/kg as a single infusion.
  • Aspirin — high dose until the fever settles, then low dose (antiplatelet) for 6 weeks (or longer if aneurysms) — one of the few uses of aspirin in children (Reye's syndrome risk otherwise).
  • Corticosteroids — for high-risk children (infants, aneurysms at diagnosis, very high inflammation) or IVIG resistance; infliximab in refractory disease.
  • Avoid live vaccines for 11 months after IVIG (reduced response).

💡 Clinical Pearl: Any child with a fever for 5 days or more and red eyes, red lips or a rash should be assessed for Kawasaki disease — early IVIG prevents coronary aneurysms.

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PIMS-TS and Toxic Shock

• PIMS-TS (paediatric inflammatory multisystem syndrome temporally associated with SARS-CoV-2; also called MIS-C):
  • 2–6 weeks after COVID-19 infection (now less common).
  • Persistent fever, abdominal pain, vomiting and diarrhoea, rash, red eyes, shock, myocarditis, coronary artery dilatation.
  • Very high inflammatory markers, raised troponin and BNP, lymphopenia.
  • Treatment — supportive (PICU), IV methylprednisolone and/or IVIG, aspirin; biologics if refractory.
• Toxic shock syndrome — Staph aureus or Strep pyogenes toxins:
  • High fever, diffuse red rash (like sunburn), hypotension, multi-organ involvement (diarrhoea, vomiting, confusion), later peeling of palms and soles.
  • Sources — infected wounds, burns, chickenpox lesions, tampons (adolescents), nasal packing.
  • Treatment — fluids and PICU; remove the source; broad-spectrum antibiotics plus clindamycin (stops toxin production); IVIG.

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Tuberculosis in Children

• Usually caught from an adult in the household — always look for the source (contact tracing). Young children (under 5) are at higher risk of severe disease.
• Features:
  • Pulmonary — prolonged cough (over 2–3 weeks), fever, weight loss or faltering growth, night sweats; enlarged hilar nodes on chest X-ray.
  • Lymph node TB — painless, matted neck nodes.
  • Miliary TB and TB meningitis — mainly in young children: gradual onset of fever, headache, irritability, vomiting, drowsiness, cranial nerve palsies.
  • Bone and joint (Pott's disease of the spine), abdominal.
• Tests — chest X-ray; samples (sputum, gastric aspirates in young children, induced sputum) for smear, culture and PCR; Mantoux (tuberculin skin test) or interferon-gamma release assay (IGRA) for infection; HIV test.
• Treatment — rifampicin, isoniazid, pyrazinamide and ethambutol for 2 months, then rifampicin and isoniazid for 4 months (12 months total for TB meningitis, plus steroids). Dispersible child-friendly tablets; directly observed therapy where needed; notify.
• Latent TB (infection without disease) — e.g. rifampicin and isoniazid for 3 months, or isoniazid for 6 months.
• Prevention — BCG for at-risk babies (protects against severe forms like TB meningitis).

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Threadworms and Gut Parasites

• Threadworm (Enterobius vermicularis) — the commonest worm in UK children:
  • Itching around the anus, especially at night; disturbed sleep; vulval itch in girls.
  • Tiny white thread-like worms may be seen in stools or around the anus at night; "sellotape test" if unsure.
  • Treatment — mebendazole single dose (over 6 months; off-label under 2 years) for the child and all household members, repeated after 2 weeks if needed; hygiene measures for 2 weeks (handwashing, short nails, morning baths, wash bedding).
  • Pregnant women and babies under 6 months — hygiene measures only (6 weeks).
• Giardia — prolonged diarrhoea, bloating, failure to thrive; stool tests; metronidazole.
• Other (after travel) — roundworm, hookworm (iron deficiency), tapeworm, schistosomiasis.

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The Returning Traveller

• Fever after travel — always ask about travel in the past year.
• Malaria — the most important diagnosis in a febrile child returning from a malaria area (especially sub-Saharan Africa, often visiting friends and relatives):
  • Fever, headache, vomiting, diarrhoea, cough, lethargy — non-specific.
  • Urgent malaria test (thick and thin blood films or rapid antigen test, repeated 3 times over 48–72 hours if negative).
  • Plasmodium falciparum can become severe quickly — cerebral malaria, severe anaemia, acidosis, hypoglycaemia.
  • Treatment — specialist advice; IV artesunate for severe malaria; oral artemisinin combination therapy for uncomplicated falciparum.
• Others — dengue (fever, headache, rash, low platelets), typhoid (fever, constipation or diarrhoea, rose spots), viral hepatitis, TB, measles, travellers' diarrhoea; viral haemorrhagic fevers (rare — isolate and seek expert advice).
• Prevention advice — bite avoidance, antimalarials, vaccines before travel.

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Prescribing Antimicrobials in Children

• Dose by weight (or age band for common drugs); check the BNF for Children; liquid formulations for young children.
• Avoid in children:
  • Tetracyclines under 12 years (tooth staining).
  • Aspirin under 16 (Reye's syndrome — liver failure and encephalopathy), except in Kawasaki disease.
  • Fluoroquinolones — generally avoided (joint concerns) unless specifically needed (e.g. meningococcal prophylaxis, Pseudomonas in CF).
  • Chloramphenicol (systemic) in neonates — grey baby syndrome.
  • Codeine under 12 years (unpredictable metabolism — breathing depression).
• Antibiotic stewardship — most respiratory infections, sore throats and ear infections are viral; use delayed (back-up) prescriptions where appropriate; give clear safety-netting.
• Gentamicin — check levels; ototoxicity (mitochondrial variant testing in neonates).
• Penicillin allergy labels — many children labelled allergic aren't; a rash during a viral illness on amoxicillin is common and often not true allergy (de-labelling pathways exist).

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Drug Reference Table

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Spot the Diagnosis