This is probably a case of protein-induced allergic proctitis, due to dietary protein transmitted through the mother to the breast-fed child. The mother should go on a milk-free and soya-free diet but continue to breast-feed.

Mature human breast milk is nutrient and enzyme rich, optimal for human infants. The average calorie requirement for a one month old infant is about 100kcal/kg/day. Lactose, the most abundant carbohydrate, is beneficial for the baby’s developing gastro intestinal system. The proteins in mature milk are mostly whey (as compared to a high proportion of casein in cows milk), which digests easily. Other proteins found in breast milk include immunoglobulin, lysozyme, lactoferrin and lactalbumin. In terms of micronutrients, while Vitamin K levels are low in breast milk, Vitamin A, C and E are found in higher concentrations than in cow’s milk.

Puberty is the general term for the transition from sexual immaturity to sexual maturity. There are two main physiological events in puberty:- Gonadarche is the activation of the gonads by the pituitary hormones follicle-stimulating hormone (FSH) and luteinizing hormone (LH).- Adrenarche is the increase in production of androgens by the adrenal cortex. It is the term for the maturational increase in adrenal androgen production that normally becomes biochemically apparent at approximately six years of age in both girls and boysA number of other terms describe specific components of puberty:- Thelarche is the appearance of breast tissue, which is primarily due to the action of oestradiol from the ovaries. – Menarche is the time of first menstrual bleed. – Pubarche is the appearance of pubic hair, which is primarily due to the effects of androgens from the adrenal gland. The term is also applied to first appearance of axillary hair, apocrine body odour, and acne.The earliest detectable secondary sexual characteristic on physical examination in most girls is breast/areolar development (thelarche). Ovarian enlargement and growth acceleration typically precede breast development but are not apparent on a single physical examination. Oestrogen stimulation of the vaginal mucosa causes a physiologic leukorrhea, which is a thin, white, non-foul-smelling vaginal discharge that typically begins 6 to 12 months before menarche. Menarche occurs, on average, 2 to 2.5 years after the onset of puberty

Acute lymphoblastic leukaemia (ALL) is an aggressive type of blood and bone marrow cancer which can appear in childhood. Signs of childhood ALL include: Fever, Easy bruising, Petechiae, Bone or joint pain, Painless lumps in multiple areas of the body, Weakness, fatigue or paleness, and Loss of appetite. Blood tests may show elevated white blood cells, decreased values of red blood cells and low platelet count.

Shoulder dystocia occurs when the fetal anterior shoulder impacts against the maternal symphysis following delivery of the vertex. Less commonly, shoulder dystocia results from impaction of the posterior shoulder on the sacral promontory. Risk Factors for Shoulder DystociaMaternalAbnormal pelvic anatomyGestational diabetesPost-dates pregnancyPrevious shoulder dystociaShort statureFetalSuspected macrosomiaLabour relatedAssisted vaginal delivery (forceps or vacuum)Protracted active phase of first-stage labourProtracted second-stage labour

Mild deficiencies of 21-hydroxylase or 3-beta-hydroxysteroid dehydrogenase activity may present in adolescence or adulthood with oligomenorrhea, hirsutism, and/or infertility. This is termed nonclassical adrenal hyperplasia.Late-onset or nonclassical congenital adrenal hyperplasia (NCAH) due to 21-hydroxylase deficiency is one of the most common autosomal recessive disorders. Reported prevalence ranges from 1 in 30 to 1 in 1000. Affected individuals typically present due to signs and symptoms of androgen excess. Treatment needs to be directed toward the symptoms. Goals of treatment include normal linear growth velocity, a normal rate of skeletal maturation, ‘on-time’ puberty, regular menstrual cycles, prevention of or limited progression of hirsutism and acne, and fertility. Treatment needs to be individualized and should not be initiated merely to decrease abnormally elevated hormone concentrations.Normal Ultrasound rules out Turner’s syndrome.

Intussusception is the invagination of one segment of the intestine within a more distal segment. It presents with vomiting, abdominal pain, and a palpable abdominal mass.Intussusception usually affects infants between 6-18 months old. Boys are affected twice as often as girls

The prompt is suggestive of acute appendicitis. The Alvarado score is a clinical scoring system used to determine the likelihood of appendicitis, so this is the correct answer. A score greater than 6 is generally considered at risk for having acute appendicitis. It has 8 different criteria included (symptoms, signs, and lab results) and divides patients into appendicitis unlikely, possible, probable, and definite. The Center Score is a score to access the likelihood that pharyngitis is due to Strep. The Child-Pugh score predicts prognosis in liver cirrhosis. The Glasgow score is two different scores– the Glasgow coma score in trauma, which estimates level of consciousness, essentially, and The Glasgow Imrie Criteria which determines the severity of acute pancreatitis based on 8 lab values. The MELD score predicts the severity of end-stage liver disease.

Distal renal tubular acidosis (dRTA) is characterised by a decreased hydrogen ion excretion from the alpha intercalated cells of the collecting duct of the distal nephron. The resultant acidosis causes Ca and phosphates to be released from bones to buffer the acidosis causing hypercalciuria, thus precipitating calcium compounds in the kidney. Other consequences of the dRTA in children include rickets, hypokalaemia, and polyuria. While dRTA can occur as a result of various pathologies including autoimmune disease, proximal renal tubular acidosis often presents as part of Fanconi’s syndrome. One way to differentiate between the two conditions is with an acid challenge test. In proximal RTA offering the child an acid load will decrease the urinary ph whereas in distal disease the pH will be unaffected due to impairment in hydrogen ion secretion.

The patient shows features of neurofibromatosis. The most likely cause for hypertension in this patient would be renal artery stenosis.Note:Neurofibromatosis is an inherited autosomal dominant disorder which could have affected this girl’s father, and she appears to have the classic skin lesions. A renal bruit might be heard in these patients. Polycystic kidney disease can occur in association with tuberous sclerosis, which also has skin lesions associated (different from those described in this patient). Most causes of hypertension in childhood have underlying renal causes, and a renal ultrasound with doppler is the first-line investigation of choice. Even if this is normal, further imaging would be indicated here, for example, isotope renal scans and angiography.

Hyperkalaemia is not to evaluate or detect AKI but rather the result of it. If one of the rest of the options is present, then AKI would be suspected.

Sturge-Weber syndrome (SWS), also called encephalotrigeminal angiomatosis, is a neurocutaneous disorder with angiomas that involve the leptomeninges (leptomeningeal angiomas [LAs]) and the skin of the face, typically in the ophthalmic (V1) and maxillary (V2) distributions of the trigeminal nerve. The hallmark of SWS is a facial cutaneous venous dilation, also referred to as a nevus flammeus or port-wine stain (PWS).Signs and symptoms:SWS is generally diagnosed clinically, based on the typical cutaneous, central nervous system (CNS), and ocular abnormalities associated with it.Neurological signs include the following:Developmental delay/intellectual disabilityLearning problemsAttention deficit-hyperactivity disorderInitial focal seizures progressing to frequent, secondarily generalized seizuresIncreasing seizure frequency and duration despite the use of antiepileptic drugs (AEDs)Increasing duration of a transient postictal deficitIncrease in focal or diffuse atrophy – Determined by serial neuroimagingProgressive increase in calcificationsDevelopment of hemiparesisDeterioration in cognitive functioningPhysical signs of SWS are as follows:Port-wine stainMacrocephalyOcular manifestationsSoft-tissue hypertrophyHemiparesisVisual lossHemianopsiaOcular involvement in SWS may include the following signs:BuphthalmosGlaucomaTomato-catsup colour of the fundus (ipsilateral to the nevus flammeus) with glaucomaConjunctival and episcleral haemangiomasDiffuse choroidal haemangiomasHeterochromia of the iridesTortuous retinal vessels with occasional arteriovenous communications

The best answer is Henoch-Schönlein Purpura (HSP). This patient has a characteristic rash and the labs are consistent with this diagnosis.

The most serious side effects of IV Lorazepam include hallucinations, agitation, confusion, amnesia and muscle weakness.

The study described in the question is a ‘cohort’ study.Other options:A prospective observational study – When groups are classified according to one or more factors at a given time and followed forward to determine outcomes (usually some health status)- Although there is in one sense a control group (those who do not develop the health problem), this is not generally called a ‘controlled’ trial. – An ecological study would look at outcomes in different groups (countries or regions usually) who follow different practices.

Pale stools suggest obstructive jaundice. Initially, the symptoms of biliary atresia are indistinguishable from those of neonatal jaundice, a usually harmless condition commonly seen in infants. However, infants with biliary atresia develop progressive conjugated jaundice, pale white stools and dark urine.

The most appropriate diagnosis for this patient is appendicular mass. The initial treatment, according to the Ochsner-Sherren regimen recommended by Hamilton Bailey, would be the initiation of intravenous antibiotics.RationaleThe presentation is highly suggestive of appendicular mass. The correct management is broad-spectrum intravenous antibiotics such as co-amoxiclav and amikacin plus observation. Conservative management is the preferred treatment as surgical exploration at this stage can result in increased morbidity.The child should be allowed to eat and drink. If there are on-going temperature spikes, signs of obstruction or severe colicky abdominal pain, then surgery is required. The majority of patients respond to conservative management.Other options:- This is a partially treated appendicitis which has formed an appendix mass. Rather than planning appendectomy immediately| Hamilton Bailey recommended interval appendectomy after 6 weeks post-discharge. However, the need for interval appendectomy is still under debate.- Drainage via interventional radiology is not recommended in this patient as it can lead to swinging pyrexia secondary to peritonitis secondary to the collection.- The patient would have high-grade pyrexia and be constitutionally unwell if the patient was a patient of pyelonephritis. The presentation of the patient is more suggestive of appendicular mass.- The history would be more extended with symptoms of weight loss and altered bowel habit if the patient had Crohn’s disease.

Breslow thickness is measured from the top of the granular layer of the epidermis (or, if the surface is ulcerated, from the base of the ulcer) to the deepest invasive cell across the broad base of the tumour (dermal/subcutaneous) as described by Breslow.Margins of excision-Related to Breslow thicknessLesions 0-1mm thick – 1cmLesions 1-2mm thick – 1- 2cm (Depending upon site and pathological features)Lesions 2-4mm thick – 2-3 cm (Depending upon site and pathological features)Lesions >4 mm thick – 3cmMarsden J et al Revised UK guidelines for management of Melanoma. Br J Dermatol 2010 163:238-256.

Various types of birthmarks are commonly seen in children of different age groups. Birthmarks can be broadly classified as pigmented and vascular birthmarks. Port-wine stain (nevus flammeus) is an example of a vascular birthmark, and is characterized by a reddish-purple discoloration of the skin due to abnormal underlying skin vasculature. Port-wine stain has also been associated with vascular diseases like Sturge-weber syndrome, which is a congenital neurocutaneous disorder. In Sturge-weber syndrome, the port-wine stain affects the skin around the ophthalmic branch of trigeminal nerve.

Many of the symptoms favour blast cells: the patient’s young age| a reoccurring sore throat caused by neutropenia and abnormal lymphoblasts| pale conjunctiva due to reduced production of red blood cells (this is because the marrow has been occupied by blast cells). There are no risk factors present for aplastic anaemia, and congenital aplastic anaemia would present itself earlier in life. A bone marrow aspiration would be needed to confirm the diagnosis.

The age of the patient and the presence of immature white blood cells are suggestive of leukaemia. Hodgkin’s disease is unlikely in this age group and it usually presents with lymphadenopathy. In HIV, immature white blood cells are not present in the blood.

The spinal cord ends at L3 in the new-bornmigrates cephalad during childhood to end at L1 – L2 and reaches adult size by the age of 10.

The clinical presentation and leucocytes on the urine dipstick is suggestive of a urinary tract infection. To confirm the diagnosis, urine should be sent for culture and sensitivity.

One of the options of Psoriasis treatment is vitamin D analogues i.e. calcipotriol. Acne is exacerbated by steroids. Erythema nodosum can be caused by various diseases and the treatment of the primary condition resolves the symptoms. Lipomas requires surgery, whereas Steven-Johnson syndrome requires use of steroids and eliminating the culprit drug, which is one of the most common causes.

The most probable cause for the patient’s symptoms is intussusception.Intussusception is a condition in which part of the intestine folds into the section next to it. It most commonly involves the small bowel and rarely the large bowel. Intussusception doesn’t usually require surgical correction. 80% of cases can be both confirmed and reduced using barium, water-soluble or air-contrast enema. However, up to 10% of cases can experience recurrence within 24 hours after reduction, warranting close monitoring during this period.Other options:- Enteric duplication: a duplication cyst could give all these features, although it may contain sufficient gastric epithelium to produce a positive Meckel’s scan. However, this is comparatively rare. – Meckel’s diverticulum: Scintigraphy has poor sensitivity making the possibility of a bleed from a Meckel’s diverticulum a genuine differential for this patient. However, considering the presence of features of bowel obstruction in the patient, a Meckel’s diverticulum bleeding and obstructing at the same time would be a rare phenomenon. – Midgut volvulus: It is also a plausible differential in this patient. However, for the given age group, a midgut volvulus is relatively uncommon compared to intussusception. – Acute appendicitis: While it is true that appendicitis can present acutely with a palpable mass and bowel obstruction, it rarely presents with rectal bleeding.

Usage of inhaled corticosteroids are less associated with systemic adverse effects. However they are associated with local complications including dental caries and most commonly dysphonia.

A lucid interval, in which the patient portrays a temporary improvement in condition after a traumatic brain injury, is especially indicative of an epidural haematoma.

Cystic fibrosis is a genetic disease that interferes with the normal development of the child. It manifests with recurrent episodes of pneumonia accompanied by coughing, wheezing and dyspnoea. The appetite is normal but weight gain seems difficult. This condition also affects bowel habits with repeated gastrointestinal infections. The gold standard for the diagnosis is considered the sweat test which reveals abnormally high levels of Cl-.

The x-ray is suggestive of bronchiectasis. The most probable aetiology especially considering recurrent chest infections at such a young age is cystic fibrosis.

People who are at risk for severe illness and complications from measles, such as infants younger than 12 months of age, pregnant women without evidence of measles immunity, and people with severely compromised immune systems, should receive immunoglobulin. Intramuscular immunoglobulin should be given to all infants younger than 12 months of age who have been exposed to measles. For infants aged 6 through 11 months, MMR vaccine can be given in place of IG, if administered within 72 hours of exposure.