Emergency Medicine: Paediatric emergency medicine

• Assessment: How Children Differ | The Seriously Ill Child — ABCDE | Weight Estimation and Drug Doses | Fever in Under-5s — the Traffic Light System | Paediatric Sepsis and Meningococcal Disease
• Breathing: Bronchiolitis | Croup and Upper Airway Obstruction | Acute Asthma and Preschool Wheeze
• Other presentations: Gastroenteritis and Dehydration | Febrile Convulsions and Status Epilepticus | Head Injury in Children | The Limping Child | Abdominal Pain and the Unsettled Infant | Safeguarding and Non-accidental Injury
• Revision: Paediatric Emergencies at a Glance | Spot the Diagnosis | Exam-style Scenarios | Key Points | Guidelines and Further Reading

🧸 Paediatric emergency medicine . About a quarter of ED attendances are children. Most have minor, self-limiting illness, so the skill is spotting the few who are seriously ill — often with subtle signs — and recognising when an injury doesn't fit the story. Children compensate well and then deteriorate suddenly, so trends in observations and parental concern matter.
Your four questions for every child in the ED: How sick is this child right now (ABCDE, traffic light)? What is their weight — and what are the doses? Could this be sepsis, meningitis or another "can't miss" diagnosis? Does the story fit the injury — is there a safeguarding concern?

How Children Differ

• Airway — large head and occiput (neck flexes when supine — use a shoulder roll in infants), large tongue, small, soft airway (small swelling causes large obstruction), infants are preferential nose breathers; the narrowest point was traditionally the cricoid.
• Breathing — higher respiratory rate, horizontal ribs and a compliant chest wall (recession is an early sign), diaphragm-dependent breathing (abdominal distension impairs breathing), less oxygen reserve — desaturate quickly.
• Circulation — higher heart rate; cardiac output depends on heart rate; blood pressure is maintained until late — hypotension is a pre-terminal sign; circulating volume about 80 mL/kg.
• Bradycardia in a sick child usually means hypoxia — a pre-arrest sign.
• Most paediatric cardiac arrests are hypoxic (respiratory) rather than cardiac — hence 5 rescue breaths in paediatric BLS.
• Other — large surface area to weight ratio (heat loss, hypothermia), hypoglycaemia risk (low glycogen stores) — "DEFG" — Don't Ever Forget Glucose.
• Normal values (APLS — approximate):

  Age	Respiratory rate	Heart rate	Systolic BP
  Under 1 year	30–40	110–160	70–90
  1–2 years	25–35	100–150	80–95
  2–5 years	25–30	95–140	80–100
  5–12 years	20–25	80–120	90–110
  Over 12 years	15–20	60–100	100–120

• PEWS (Paediatric Early Warning Score — the national System-wide PEWS is being rolled out in England) — age-specific charts that trigger escalation; parental concern is part of the escalation.

The Seriously Ill Child — ABCDE

• First impression (paediatric assessment triangle — appearance, work of breathing, circulation to the skin) — from the door before touching the child.
• Airway — is it open (talking or crying)? Stridor, drooling? Head tilt–chin lift (neutral in infants, "sniffing" in older children), jaw thrust, suction, airway adjuncts.
• Breathing — effort (rate, recession — subcostal, intercostal, sternal; head bobbing, nasal flaring, grunting — a sign of severe distress in infants, tracheal tug), efficacy (air entry, chest expansion, SpO₂), effects (heart rate, skin colour, mental status). Exhaustion — falling rate and effort with worsening state — is pre-arrest.
• Circulation — heart rate, capillary refill time (centrally on the sternum — over 2 seconds is abnormal), pulse volume, skin temperature and colour, BP (late), urine output.
  • Fluid bolus — 10 mL/kg of balanced crystalloid (or 0.9% saline) over less than 10 minutes, then reassess (APLS / NICE); 5 mL/kg in neonates, cardiac disease or DKA per local guidance; blood for haemorrhage.
  • IO access if IV access fails (within about 90 seconds or two attempts in a shocked child).
• Disability — AVPU (P or U — protect the airway), pupils, posture, tone, glucose (treat if under 3 mmol/L — 2 mL/kg of 10% glucose).
• Exposure — rash (non-blanching), temperature, injuries (bruises in non-mobile infants), history from parents.
• Get help early — paediatric registrar and consultant, anaesthetist, PICU retrieval team (e.g. via regional paediatric transport services).
• Paediatric BLS (RCUK) — 5 rescue breaths, then 15 compressions to 2 breaths (healthcare providers); compress by at least one-third of the chest depth; 100–120 a minute.

⚠️ Safety Pearl: In children, hypotension and bradycardia are late, pre-terminal signs. Tachycardia, tachypnoea, prolonged capillary refill and altered behaviour are the early warnings — and a worried parent is a red flag in its own right.

Weight Estimation and Drug Doses

• Weigh the child whenever possible; if not (emergency), use a weight estimate — parent's recent weight, the Red Book, or a formula or length-based tape (e.g. Broselow).
• APLS weight formulae (approximate — 2010 onwards):
  • 0–12 months — (0.5 × age in months) + 4
  • 1–5 years — (2 × age in years) + 8
  • 6–12 years — (3 × age in years) + 7
• Common emergency doses (check BNFc and local charts):

  Drug or fluid	Dose (approximate — always check)
  Fluid bolus	10 mL/kg crystalloid, reassess
  Glucose (hypoglycaemia)	2 mL/kg of 10% glucose
  Adrenaline (cardiac arrest)	10 micrograms/kg IV/IO (0.1 mL/kg of 1 in 10,000)
  Adrenaline IM (anaphylaxis)	Under 6 months 100–150 micrograms; 6 months–6 years 150 micrograms; 6–12 years 300 micrograms; over 12 years 500 micrograms
  Defibrillation	4 J/kg
  Midazolam (seizures)	Buccal about 0.3 mg/kg (age-banded — e.g. 1–4 years 5 mg; 5–9 years 7.5 mg; 10 years and over 10 mg)
  Lorazepam IV	0.1 mg/kg (max 4 mg)
  Ceftriaxone (sepsis or meningitis)	80 mg/kg (max 4 g) once daily
  Intranasal fentanyl	1.5 micrograms/kg
  Paracetamol oral	15 mg/kg (max 4 doses a day; age-banded doses on packets)
  Ibuprofen oral	5–10 mg/kg (up to 3 times a day)

• Prescribing safety — weight on every chart, mg/kg and total dose, decimal point and unit errors (10-fold errors), double-check high-risk drugs, never exceed the adult dose.

Fever in Under-5s — the Traffic Light System

• Fever — 38°C or above; measure with an electronic axillary thermometer in under-4-week-olds and an electronic axillary or tympanic thermometer (or chemical dot) in older children (NICE NG143).
• NICE traffic light system (NG143) — assess colour, activity, respiratory, circulation and hydration, and other features:

  	Green — low risk	Amber — intermediate risk	Red — high risk
  Colour	Normal	Pallor (reported by parent)	Pale, mottled, ashen or blue
  Activity	Responds normally, content, smiles, stays awake, strong cry	Not responding normally, no smile, wakes only with prolonged stimulation, reduced activity	No response to social cues, appears ill to a clinician, doesn't wake or stay awake, weak, high-pitched or continuous cry
  Respiratory	Normal	Nasal flaring, tachypnoea (RR over 50 at 6–12 months; over 40 over 12 months), SpO2 95% or less, crackles	Grunting, RR over 60, moderate or severe chest indrawing
  Circulation and hydration	Normal skin and eyes, moist mucous membranes	Tachycardia, CRT 3 seconds or more, dry mucous membranes, poor feeding, reduced urine	Reduced skin turgor
  Other	None of amber or red	Age 3–6 months with temperature 39°C or more; fever 5 days or more; rigors; swelling of a limb or joint; non-weight-bearing	Age under 3 months with temperature 38°C or more; non-blanching rash; bulging fontanelle; neck stiffness; status epilepticus; focal neurology or seizures

• Management:
  • Green — home with safety-netting advice (antipyretics for comfort, fluids, when to return).
  • Amber — clinical assessment by a senior; consider FBC, CRP, blood culture, urine, chest X-ray; provide a safety net or admit.
  • Red — urgent paediatric assessment; full septic screen as indicated.
• Under 1 month with fever — full septic screen (FBC, CRP, blood culture, urine, lumbar puncture, chest X-ray if respiratory signs) and IV antibiotics (cefotaxime plus amoxicillin — cover Listeria).
• 1–3 months with fever — FBC, CRP, blood culture, urine; IV antibiotics if unwell, WCC under 5 or over 15; LP as indicated.
• Urine — test urine in any child with an unexplained fever (UTI is the commonest serious bacterial infection in infants).
• Antipyretics — for distress, not to prevent febrile seizures; don't give paracetamol and ibuprofen together routinely (switch if the first doesn't help); don't tepid sponge.
• Kawasaki disease — fever for 5 days or more plus conjunctivitis, mucosal changes (strawberry tongue, cracked lips), rash, extremity changes and cervical lymphadenopathy — IV immunoglobulin and aspirin (coronary aneurysms).

Paediatric Sepsis and Meningococcal Disease

• Suspect sepsis in any unwell child with fever (or hypothermia) — NICE NG51 risk stratification (behaviour, RR, HR, SpO₂, CRT, mottling, non-blanching rash, age under 3 months with fever).
• Management — high-flow oxygen, IV or IO access, bloods (blood culture, FBC, CRP, gas with lactate and glucose, clotting), IV antibiotics within 1 hour (ceftriaxone; add amoxicillin under 3 months), 10 mL/kg fluid boluses with reassessment; early inotropes (peripheral adrenaline) and PICU if fluid-refractory (after about 40–60 mL/kg).
• Meningococcal disease (Neisseria meningitidis):
  • Septicaemia — fever, cold hands and feet, leg pain, pallor and mottling, prolonged CRT, a non-blanching petechial or purpuric rash (glass test), shock.
  • Meningitis — headache, neck stiffness, photophobia, bulging fontanelle, irritability, drowsiness, seizures; infants often have non-specific signs.
  • Prehospital — IM or IV benzylpenicillin if meningococcal disease is suspected (don't delay transfer).
  • Hospital — IV ceftriaxone; dexamethasone for bacterial meningitis (with or shortly after the first antibiotic, if over 3 months — avoid in septicaemia without meningitis); LP if no contraindications (shock, raised ICP, coagulopathy, purpura — delay LP).
  • Public health — notify UKHSA; chemoprophylaxis (ciprofloxacin) for close contacts.
• Non-blanching rash with fever — treat as meningococcal disease until proven otherwise; other causes (viral, Henoch–Schönlein purpura, ITP, leukaemia, coughing/vomiting petechiae in the SVC distribution, NAI).
• Toxic shock syndrome — fever, rash (erythroderma), shock after a minor burn, wound or tampon use — antibiotics with clindamycin, IV immunoglobulin.

Bronchiolitis

• Cause — mainly respiratory syncytial virus (RSV) — winter epidemics — in infants under 1 year (peak 3–6 months); diagnosis up to 2 years (NICE NG9).
• Features — coryza for 1–3 days, then cough, tachypnoea, recession, widespread fine crackles and/or wheeze, poor feeding, apnoea (young infants); worst at days 3–5; cough can last 3–4 weeks.
• Risk of severe disease — prematurity, age under 3 months, chronic lung disease, congenital heart disease, neuromuscular disease, immunodeficiency.
• Admit if (NICE NG9) — apnoea, persistent SpO₂ under 92% in air, RR over 70, severe recession or grunting, central cyanosis; consider if feeding less than 50–75% of normal, dehydration, RR over 60, or risk factors and social concerns.
• Treatment — supportive:
  • Oxygen if SpO₂ persistently under 92% (90% in children over 6 weeks and on the ward, depending on local practice).
  • Feeding support — small frequent feeds, nasogastric tube (or IV fluids if NG not tolerated).
  • Nasal suction if secretions cause distress or feeding problems.
  • High-flow nasal cannula oxygen or CPAP for increasing work of breathing or impending respiratory failure; intubation if apnoeas or failure.
  • Not recommended — salbutamol, adrenaline, hypertonic saline (ED), ipratropium, steroids, antibiotics, chest physiotherapy.
• Capillary blood gas in severe distress (rising CO₂).
• RSV prevention — nirsevimab (long-acting monoclonal antibody) for high-risk infants; maternal RSV vaccine (from 28 weeks of pregnancy) in the UK programme from 2024.
• Discharge — feeding adequately, SpO₂ stable in air, safety-netting (worsening breathing, poor feeding, fewer wet nappies, apnoea).

Croup and Upper Airway Obstruction

• Croup (laryngotracheobronchitis) — parainfluenza virus — 6 months to 3 years — autumn; barking ("seal-like") cough, hoarse voice, inspiratory stridor, coryza, low-grade fever, worse at night.
• Severity (Westley score) — mild (barking cough, no stridor at rest), moderate (stridor and recession at rest, no agitation), severe (stridor at rest, marked recession, agitation or lethargy), impending respiratory failure (decreased consciousness, cyanosis, falling effort).
• Treatment:
  • Keep the child calm — with a parent; don't examine the throat or force a mask or cannula if severe.
  • Oral dexamethasone 0.15 mg/kg (some use 0.6 mg/kg for severe) for all severities — prednisolone 1–2 mg/kg or nebulised budesonide alternatives.
  • Severe — nebulised adrenaline (1 in 1,000 — 0.4 mL/kg, max 5 mL) — effect lasts about 2 hours (observe for rebound); oxygen; senior anaesthetic and ENT help.
  • Humidified air isn't effective.
• Other causes of stridor:

  Cause	Features	Action
  Epiglottitis	Rare since Hib vaccine — toxic, high fever, drooling, sitting forward ("tripod"), soft stridor, no cough	Don't examine the throat; senior anaesthetist and ENT; secure airway in theatre; IV ceftriaxone
  Bacterial tracheitis	Croup-like illness but toxic, high fever, poor response to treatment	Airway support, IV antibiotics, PICU
  Inhaled foreign body	Sudden choking episode, toddler, unilateral wheeze or reduced breath sounds	Choking algorithm; bronchoscopy
  Anaphylaxis	Allergen exposure, urticaria, angioedema, wheeze	IM adrenaline
  Retropharyngeal abscess	Fever, neck stiffness, torticollis, drooling, dysphagia	Lateral neck X-ray or CT; ENT

• Choking child (RCUK) — effective cough — encourage coughing; ineffective cough and conscious — 5 back blows then 5 chest thrusts (infants) or 5 abdominal thrusts (children over 1); unconscious — open the airway, 5 rescue breaths, CPR.

Acute Asthma and Preschool Wheeze

• Severity (BTS/SIGN/NICE 2024 — children 2 years and over):

  Severity	Features
  Moderate	SpO2 92% or more; PEF over 50% best or predicted; able to talk
  Severe	SpO2 under 92%; PEF 33–50%; can't complete sentences or too breathless to feed; HR over 140 (2–5 years) or over 125 (over 5); RR over 40 (2–5 years) or over 30 (over 5); accessory muscles
  Life-threatening	SpO2 under 92% plus any of — PEF under 33%, silent chest, poor respiratory effort, cyanosis, hypotension, exhaustion, confusion, agitation

• Treatment:
  • Oxygen to keep SpO₂ 94–98%.
  • Salbutamol — via spacer (2–10 puffs, one at a time, up to 10) for moderate attacks; nebulised (2.5 mg under 5 years, 5 mg over 5 years) for severe or life-threatening; repeat every 20–30 minutes (back-to-back if needed).
  • Ipratropium nebulised (250 micrograms) added if poor response — first hour.
  • Oral prednisolone — 1–2 mg/kg (e.g. 20 mg for 2–5 years, 30–40 mg over 5) for 3 days; IV hydrocortisone if vomiting.
  • Second line (senior and PICU input) — IV magnesium sulfate (40 mg/kg, max 2 g, over 20 minutes), IV salbutamol bolus then infusion (watch for lactic acidosis and hypokalaemia), IV aminophylline in PICU.
  • Chest X-ray only if pneumothorax, consolidation or life-threatening features; capillary gas in severe cases (a normal or rising CO₂ is ominous).
• Discharge — stable on salbutamol every 3–4 hours, SpO₂ over 94%, inhaler technique checked, written asthma action plan, GP review within 2 working days, preventer review.
• Preschool wheeze (under 5) — viral-induced (episodic) or multiple-trigger — salbutamol via spacer and mask; oral steroids only if severe or admitted; montelukast or inhaled steroids for recurrent episodes.

Gastroenteritis and Dehydration

• Gastroenteritis — mostly viral (rotavirus — less common since the vaccine; norovirus); diarrhoea usually lasts 5–7 days (stops within 2 weeks), vomiting 1–2 days.
• Red flags for another diagnosis — bilious (green) vomiting (malrotation and volvulus — surgical emergency), blood in stool (intussusception, HUS, bacterial infection), fever over 38°C under 3 months, abdominal distension or tenderness, headache and neck stiffness, signs of DKA (polyuria, Kussmaul breathing — check glucose), prolonged vomiting without diarrhoea, head injury.
• Assessing dehydration (NICE CG84):
  • Clinical dehydration — appears unwell, altered responsiveness, reduced urine, sunken eyes, dry mucous membranes, tachycardia, tachypnoea, reduced skin turgor.
  • Clinical shock — decreased consciousness, pale or mottled skin, cold extremities, marked tachycardia, weak peripheral pulses, prolonged CRT, hypotension.
  • At increased risk — under 1 year (especially under 6 months), low birth weight, 6 or more stools or 3 or more vomits in 24 hours, unable to tolerate fluids, malnutrition.
• Treatment:
  • No dehydration — continue breastfeeding and fluids; avoid fruit juice and fizzy drinks.
  • Clinical dehydration — oral rehydration solution (ORS) 50 mL/kg over 4 hours plus maintenance, small frequent amounts; nasogastric ORS if not tolerated orally; ondansetron (single oral dose) can reduce vomiting and IV need.
  • Shock or deterioration — IV fluid bolus 10 mL/kg (CG84 says 20 mL/kg; current practice 10 mL/kg with reassessment), then IV rehydration with isotonic fluid (deficit plus maintenance); check U&E and glucose.
• Hypernatraemic dehydration — doughy skin, irritability, jittery — correct sodium slowly (over at least 48 hours) to avoid cerebral oedema.
• Maintenance fluids (Holliday–Segar) — 100 mL/kg/day for the first 10 kg, 50 mL/kg/day for the next 10 kg, 20 mL/kg/day thereafter — isotonic fluids with glucose (e.g. 0.9% saline with 5% glucose).
• Haemolytic uraemic syndrome — bloody diarrhoea (E. coli O157) followed by pallor, reduced urine, AKI, thrombocytopenia — don't give antibiotics or antimotility drugs.
• Exclusion — 48 hours after the last episode of diarrhoea or vomiting.

Febrile Convulsions and Status Epilepticus

• Febrile seizure — a seizure with fever in a child aged 6 months to 5 years, without CNS infection or a previous afebrile seizure; affects about 2–5% of children.
• Simple — generalised, under 15 minutes, no recurrence within 24 hours, full recovery within an hour.
• Complex — focal features, 15 minutes or longer, recurrence within 24 hours (or the same illness), incomplete recovery — admit and investigate.
• Assessment — find the source of fever (ears, throat, urine, chest); exclude meningitis (prolonged drowsiness, neck stiffness, bulging fontanelle, non-blanching rash, already on antibiotics — consider LP).
• Management — antipyretics for comfort (don't prevent recurrence); first simple febrile seizure — usually observe in hospital (or discharge after senior review if recovered and source found); reassure and give advice (seizure first aid, buccal midazolam if prolonged — for recurrent prolonged seizures).
• Prognosis — recurrence in about 30%; epilepsy risk only slightly increased (higher with complex seizures, family history, neurodevelopmental problems).
• Convulsive status epilepticus (APLS / NICE NG217):
  • ABC, oxygen, glucose (treat if under 3 mmol/L).
  • 5 minutes — first benzodiazepine — IV lorazepam 0.1 mg/kg, or buccal midazolam (0.3 mg/kg) or IN/IM midazolam if no IV.
  • 10 minutes later — second benzodiazepine dose.
  • Second line — levetiracetam (40–60 mg/kg), phenytoin (20 mg/kg) or sodium valproate (40 mg/kg) over 5–20 minutes.
  • Third line (or after 45 minutes) — rapid sequence induction (thiopental, ketamine or propofol) and PICU.
  • Look for and treat the cause — hypoglycaemia, hyponatraemia, hypocalcaemia, infection, head injury (including NAI), poisoning.

Head Injury in Children

• NICE NG232 (2023) — CT head criteria in children:
  • CT within 1 hour if any of:
    • Suspicion of non-accidental injury.
    • Post-traumatic seizure with no history of epilepsy.
    • GCS under 14 on initial ED assessment, or under 15 at 2 hours after the injury (under 1 year — paediatric GCS under 15).
    • Suspected open or depressed skull fracture, or tense fontanelle.
    • Signs of basal skull fracture (haemotympanum, "panda" eyes, CSF leak, Battle's sign).
    • Focal neurological deficit.
    • Under 1 year — bruise, swelling or laceration over 5 cm on the head.
  • More than one of these — CT within 1 hour; only one — observe for at least 4 hours (CT if any deterioration — GCS under 15, further vomiting, abnormal drowsiness):
    • Loss of consciousness over 5 minutes (witnessed).
    • Abnormal drowsiness.
    • 3 or more discrete episodes of vomiting.
    • Dangerous mechanism (high-speed road collision, fall over 3 metres, high-speed projectile).
    • Amnesia over 5 minutes (anterograde or retrograde).
  • Anticoagulants — consider CT within 8 hours (NICE 2023 for anticoagulants; bleeding disorders per local policy).
• PECARN and CATCH — validated decision rules used internationally.
• Infants — scalp haematoma (especially non-frontal), irritability, poor feeding, bulging fontanelle, vomiting — and always consider NAI (abusive head trauma — subdural haematomas, retinal haemorrhages).
• Discharge — GCS 15, normal examination, no concern; head injury advice given to a responsible adult (vomiting, drowsiness, headache, seizures, fluid from ears or nose — return); concussion advice (graded return to school and sport — "if in doubt, sit them out").

The Limping Child

• Septic arthritis must be excluded in any child with a limp and fever — a surgical emergency.
• Causes by age:

  Age	Key causes (plus trauma, infection, malignancy and NAI at any age)
  0–3 years	Toddler's fracture (spiral tibial fracture), developmental dysplasia of the hip, septic arthritis, NAI
  3–10 years	Transient synovitis (irritable hip — commonest), Perthes' disease (4–8 years, boys), septic arthritis, juvenile idiopathic arthritis
  10–16 years	Slipped capital femoral epiphysis (SCFE — obese adolescent boys; knee pain), Osgood–Schlatter, osteochondritis dissecans, bone tumours (osteosarcoma, Ewing's)

• Kocher criteria for septic arthritis of the hip — non-weight-bearing, fever over 38.5°C, ESR over 40, WCC over 12 (CRP over 20 is often added) — risk rises with each criterion (4 of 4 — about 99%).
• Transient synovitis — well child, 3–10 years, often after a viral illness, low-grade or no fever, reduced range (especially internal rotation), can usually weight-bear — normal or mildly raised inflammatory markers; ultrasound shows an effusion; rest and NSAIDs; resolves within 1–2 weeks; review if not improving.
• Septic arthritis — unwell, febrile, holds the hip flexed and externally rotated, won't move it — bloods (FBC, CRP, ESR, blood culture), ultrasound, urgent joint aspiration and washout (orthopaedics), IV antibiotics (Staph. aureus, Kingella kingae in under-4s).
• Osteomyelitis — bone pain, tenderness, fever — MRI; IV antibiotics.
• SCFE — any adolescent with knee or thigh pain needs a hip examination — frog-leg lateral X-ray (Klein's line); non-weight-bearing and urgent orthopaedic fixation.
• Red flags — fever, night pain, systemic symptoms (weight loss, night sweats, bruising — leukaemia), non-weight-bearing, under 3 years, safeguarding concerns.

Abdominal Pain and the Unsettled Infant

• Appendicitis — the commonest surgical emergency in children; atypical and perforates early in under-5s; ultrasound first; scores (Paediatric Appendicitis Score, Alvarado).
• Intussusception — 6–18 months — paroxysms of inconsolable crying with drawing up of the legs and pallor, vomiting, lethargy between episodes, "redcurrant jelly" stool (late), sausage-shaped mass — ultrasound (target sign) — air enema reduction (surgery if failed or peritonitis); fluids.
• Malrotation with volvulus — bilious vomiting in a neonate or infant — upper GI contrast study — emergency surgery (gut ischaemia within hours).
• Pyloric stenosis — 2–8 weeks (first-born boys) — projectile non-bilious vomiting after feeds, hungry baby, weight loss, olive-shaped mass — hypochloraemic, hypokalaemic metabolic alkalosis — ultrasound; correct fluids and electrolytes first, then pyloromyotomy.
• Testicular torsion — always examine the testes in boys with abdominal pain — urgent surgical exploration.
• Incarcerated inguinal hernia — especially in premature infants.
• Other causes — constipation (commonest cause of abdominal pain), mesenteric adenitis, UTI, lower lobe pneumonia, DKA, HSP, sickle crisis, gastroenteritis.
• The crying or unsettled infant — full examination (undressed) — hair tourniquet, otitis media, UTI, testicular torsion, hernia, fracture (NAI), intussusception, corneal abrasion, infantile colic (diagnosis of exclusion), reflux, cow's milk protein allergy.
• BRUE (brief resolved unexplained event) — infant under 1 year with a brief (under 1 minute) episode of colour change, breathing change, tone change or altered responsiveness, now well — low risk if over 60 days, born at 32 weeks or later, first event, no CPR — observe and look for causes (reflux, infection, seizure, cardiac, NAI).

Safeguarding and Non-accidental Injury

• Everyone in the ED has a safeguarding duty — think about the child behind every presentation (and children of adult patients — domestic abuse, parental mental illness or substance misuse).
• Features that suggest abuse:
  • History — inconsistent or changing explanation, mechanism doesn't fit the injury or developmental stage, delayed presentation, frequent attendances, unwitnessed injury, blaming a sibling.
  • Bruising in a non-mobile infant ("those who don't cruise rarely bruise") — any bruise in a baby under 6 months needs a safeguarding assessment.
  • Bruising pattern — ears, neck, face, cheeks, buttocks, genitals, abdomen, back, hands; patterned (fingertip, slap, belt, bite marks), clusters.
  • Burns — cigarette burns, immersion scalds (glove-and-stocking distribution, clear tide-marks, sparing of the soles and buttocks).
  • Fractures — in non-mobile children, metaphyseal (corner/bucket-handle) fractures, posterior rib fractures, multiple fractures of different ages, skull fractures with a minor history.
  • Abusive head trauma — subdural haematomas, retinal haemorrhages, encephalopathy (shaking).
  • Torn frenulum in an infant, genital injury, STI, pregnancy in a young adolescent.
• Action:
  • Document carefully (verbatim history, body map, photographs), treat injuries, keep the child safe (admission if needed).
  • Check the Child Protection Information Sharing (CP-IS) system and previous attendances.
  • Discuss with the paediatric consultant and the safeguarding team; refer to children's social care (and the police if a crime is suspected) — you don't need to be certain to refer.
  • Skeletal survey, CT head (under 1 year — or 2 years), ophthalmology for retinal haemorrhages, bloods (clotting, bone profile) and sibling assessment per local protocol.
• Other forms — neglect, emotional abuse, sexual abuse, fabricated or induced illness, female genital mutilation (mandatory reporting to police for under-18s), child sexual and criminal exploitation (county lines).
• Differential diagnoses — osteogenesis imperfecta, bleeding disorders, Mongolian blue spots (document at birth checks), accidental injury, rickets.

💡 Clinical Pearl: A bruise on a baby who can't yet cruise is never "normal". Look carefully, document it, and discuss with the paediatric consultant before the child leaves the department.

Paediatric Emergencies at a Glance