Cow’s milk differs in composition to human breast milk. The sodium content of cows milk is too high, which can easily overwhelm a baby’s developing kidneys and lead to hypernatremia and dehydration. In addition to its iron content being too low, cows milk can cause further increase iron deficiency anaemia by irritating the baby’s intestinal lumen and causing blood loss per rectum. After 12 months a baby’s gastrointestinal tract and organs are able to tolerate cows milk.

Blood culture and sensitivity will distinguish the bacteria that is responsible for the infection and the effective antibiotic treatment to which the bacteria is sensitive.

The clinical picture suggests that the baby has Beckwith-Wiedemann Syndrome, which predisposes the individual to cancer. The most common childhood tumour that a person with Beckwith-Wiedemann Syndrome may develop is Wilms’ tumour. Typical features include: macrosomia, asymmetric limb growth, macroglossia, neonatal hypoglycaemia, umbilical hernias or other abdominal wall deformities.

Atopic dermatitis is an allergic condition which is more apparent in those children who have a positive family history in their 1st or 2nd degree relatives. In some cases, there might be a positive history of bronchial asthma. The best treatment option in this case would be topical application of 1% hydrocortisone ointment to the affected areas of the child. We cannot prescribe a strong ointment to the face because it may lead to skin atrophy, telangiectasia and other steroid related topical complications.

Glandular fever (Infectious Mononucleosis) is caused by Epstein–Barr virus (EBV). Leucocytosis rules in infectious mononucleosis and thrombocytopenia is not an uncommon association. ESR is elevated in most of the cases. Paul-Bunnell test is a rapid test for infectious mononucleosis due to Epstein–Barr virus (EBV).

Codman’s triangle is the triangular area of new subperiosteal bone that is created when a lesion, often a tumour, raises the periosteum away from the bone. The main causes for this sign are osteosarcoma, Ewing’s sarcoma, eumycetoma, and a subperiosteal abscess.

In this case scenario, the pH is too low to be fully explained by a respiratory acidosis. Usually, if there is a metabolic acidosis, the respiratory system will try to compensate by hyperventilation and reduced pCO2. In this case, however, the pCO2 is raised suggesting the presence of a respiratory component.Therefore, this boy has mixed metabolic and respiratory acidosis, most probably due to severe exacerbation of this asthma, which led to diabetic ketoacidosis.Note:Normal values:pH: 7.35 – 7.45pO2: 10 – 14 kPapCO2: 4.5 – 6 kPaBase excess (BE): -2 – 2 mmol/LHCO3: 22 – 26 mmol/L

The symptoms of excessive salivation and diarrhoea, along with hypotension, bradycardia, and bronchoconstriction, indicates excess parasympathetic nervous system activity. The patient is showing features of acetylcholine toxicity. Pesticides typically contain organophosphates that are potent inhibitors of acetylcholinesterase. This enzyme is responsible for the metabolism of acetylcholine. Acetylcholine is the neurotransmitter used in the neuromuscular junction, as well as at select points in the autonomic nervous system. The autonomic acetylcholine receptors can be nicotinic (more sensitive to nicotine) or muscarinic (more sensitive to muscarine). The most relevant receptors in this scenario are the muscarinic receptors as the majority are located in the parasympathetic nervous system smooth muscle, exocrine glands, and cardiac conduction system.Other options:- Accordingly, to cause the symptoms described, there must be an abundance of acetylcholine which stimulates the muscarinic receptors to enhance the parasympathetic effects. Therefore the reduction in the formation of acetylcholine option must be incorrect as this would produce the opposite effect. – Noradrenaline is the primary neurotransmitter in the sympathetic nervous system, and both answer options relating to noradrenaline would increase the neurotransmitter and potentiate the sympathetic nervous system effects, making them incorrect.Features can predict the accumulation of acetylcholine (mnemonic = SLUD):- Salivation- Lacrimation- Urination- Defecation/diarrhoeaCardiovascular symptoms include hypotension and bradycardia. The patient can show associated small pupils and muscle fasciculationManagement:- Atropine- The role of pralidoxime is still unclear – meta-analyses to date have failed to show any clear benefit.

Pulmonary arterial hypertension (PH) is noted in 9 to 35 % of patient with a secundum type ASD. The haemodynamic definition of PH is a mean pulmonary arterial pressure (mPAP) of ≥25 mmHg at rest by means of right heart catheterization. In ASD, The findings on physical examination depend on the degree of left-to-right shunt and its hemodynamic consequences, which, in turn, depends on the size of the defect, the diastolic properties of both ventricles, and the relative resistance of the pulmonary and systemic circulations.Blood flow across the atrial septal defect (ASD) does not cause a murmur at the site of the shunt because no substantial pressure gradient exists between the atria. However, ASD with moderate-to-large left-to-right shunts results in increased right ventricular stroke volume across the pulmonary outflow tract creating a crescendo-decrescendo systolic ejection murmur. This murmur is heard in the second intercostal space at the upper left sternal border.Patients with large left-to-right shunts often have a rumbling mid-diastolic murmur at the lower left sternal border because of increased flow across the tricuspid valve.ASD is an acyanotic lesion. Thus, the patient should be normally saturated. In the rare case of severe pulmonary arterial hypertension, atrial shunt reversal (Eisenmenger syndrome) may occur, leading to cyanosis and clubbing

Proteinuria refers to an increased amount of protein excretion in urine, which should be greater than 100mg/m2 per day on a single spot urine collection. The limit is even more relaxed for infants and neonates. Proteinuria is a prominent manifestation of cystinosis, acute tubular necrosis, Fanconi syndrome, and celiac disease. Landau-Kleffner syndrome is a rare childhood convulsive disorder, associated with acquired aphasia and auditory verbal agnosia.

Polycythaemia is described as an abnormal increase in the red cell mass. As this influences hyper-viscosity, a peripheral venous sample of blood haematocrit can be used to determine the packed cell volume. Polycythaemia is present if the venous haematocrit is >65% or <22g/dl if converted into a haemoglobin value. Though it is the method of choice for screening, capillary blood samples obtained though heel pricks in new-born may be as much as 15% higher than venous samples and thus high values must be confirmed with a venous sample.

According to NICE guidelines:Do not offer lithium to women who are planning a pregnancy or pregnant, unless antipsychotic medication has not been effective.If antipsychotic medication has not been effective and lithium is offered to a woman who is planning a pregnancy or pregnant, ensure:the woman knows that there is a risk of fetal heart malformations when lithium is taken in the first trimester, but the size of the risk is uncertain. Lithium levels may be high in breast milk with a risk of toxicity for the baby.If a woman taking lithium becomes pregnant, consider stopping the drug gradually over 4 weeks if she is well. Explain to her that:stopping the medication may not remove the risk of fetal heart malformations and there is a risk of relapse, particularly in the postnatal period, if she has bipolar disorder.If a woman taking lithium becomes pregnant and is not well or is at high risk of relapse, consider:switching gradually to an antipsychotic or stopping lithium and restarting it in the second trimester (if the woman is not planning to breastfeed and her symptoms have responded better to lithium than to other drugs in the past) or continuing with lithium if she is at high risk of relapse and an antipsychotic is unlikely to be effective. If a woman continues taking lithium during pregnancy:- check plasma lithium levels every 4 weeks, then weekly from the 36th week. Adjust the dose to keep plasma lithium levels in the woman’s therapeutic range- ensure the woman maintains an adequate fluid balance- ensure the woman gives birth in the hospital- ensure monitoring by the obstetric team when labour starts, including checking plasma lithium levels and fluid balance because of the risk of dehydration and lithium toxicity- stop lithium during labour and check plasma lithium levels 12 hours after her last dose.

The most probable diagnosis in this patient would be pulmonary stenosis. Pulmonary Stenosis:Pulmonary valve murmurs are heard in the upper left sternal edge, associated with a thrill but no desaturation in the absence of an additional shunt. The ECG changes suggest right ventricular hypertrophy. Pulmonary stenosis is often well tolerated in childhood unless severe. These should be monitored with serial echocardiography, and balloon pulmonary valvoplasty should be considered once the pressure gradient reaches 64 mmHg.Other options:- Atrial septal defect: While atrial septal defects are associated with right ventricular outflow tract murmurs, they would not cause a thrill.- Patent ductus arteriosus: PDA murmurs can be audible in the left upper sternal edge, but would normally be audible in the left infraclavicular area and be continuous rather than ejection systolic. This left to right shunt would not cause desaturation but does cause left-sided volume loading and hence left-sided ECG changes.- Tetralogy of Fallot: Ventricular septal defect, overriding aorta, subpulmonary stenosis, and right ventricular hypertrophy. This would often cause a ULSE murmur with a thrill and RVH on ECG. However, this degree of obstruction would cause shunting from right to left, and this child would be desaturated.- Ventricular septal defect: Isolated ventricular septal defects cause pansystolic murmurs at the left lower sternal edge. They would have left-sided ECG changes and normal saturations (in the absence of pulmonary hypertension).

Lypohypertrophy is the most common skin-related complication of insulin injection.

Pyloric stenosis affects infants, typically in the second to fourth weeks of life and is caused most commonly by hypertrophy and thickening of the pylorus. It usually presents with projectile vomiting and failure to thrive. The infant usually has a normal appetite. Features include: ‘projectile’ vomiting, typically 30 minutes after a feed, constipation and dehydration may also be present and a palpable mass may be present in the upper abdomen.

Complement activation plays a key role in the pathophysiology of SLE and it is recommended to continue monitoring serum levels of C3 and C4 to assess for disease activity. However, it is important to note that decreased serum complement is not consistently associated with disease flares.

The most probable diagnosis for this patient would be Kawasaki disease.Kawasaki disease:It is an acute systemic disorder of childhood that predominantly occurs in Japan (800 cases per million in children under the age of 5 years). The causative factor is not known, but mycoplasma and HIV infection may be associated in some cases. Clinical Features:The principal clinical features are fever persisting for more than five days, bilateral non-purulent conjunctival congestion, cervical lymphadenopathy, polymorphous rash, arthralgia, palmar erythema and strawberry tongue. Other options:- Diffuse cutaneous systemic sclerosis is associated with skin, renal and gut involvement. Arthralgia, morning stiffness and flexor tenosynovitis are common. – Behçet syndrome is a vasculitis of unknown aetiology that characteristically targets venules. – Felty syndrome is the association of splenomegaly and neutropenia with rheumatoid arthritis. Lymphadenopathy is common, and there is a predisposition to recurrent infections.

Based on the clinical scenario provided, this patient most probably has impacted gall stones. Gall stones in children can be caused by haematological diseases such as sickle cell anaemia and thalassemia. Cholesterol stones are also becoming more prevalent. A dilated common bile duct (> 10mm in adults) suggests gall stone impaction. The presence of pyrexia indicates cholecystitis.

Puberty is when a child’s body begins to develop and change as they become an adult.The average age for girls to begin puberty is 11, while for boys the average age is 12.It’s completely normal for puberty to begin at any point from the ages of 8 to 14. The process can take up to 4 years.

Anorexia nervosa is an eating disorder defined by restriction of energy intake relative to requirements, leading to a significantly low body weight. Patients will have an intense fear of gaining weight and distorted body image with the inability to recognize the seriousness of their significantly low body weight. Athletes in sports such as ballet, long-distance running, and martial arts are pressured to maintain lean body weights to outperform the competition.

The characteristic cells in granulomatous inflammation are giant cells, formed from merging macrophages and epithelioid cells elongated with granular eosinophilic cytoplasm. Granulomatous reactions are seen in patients with tuberculosis. A tuberculous/caseating granuloma is characterised by a zone of central necrosis lined with giant multinucleated giant cells (Langhans cells) and surrounded by epithelioid cells, lymphocytes and fibroblasts. The caseous zone is present due to the damaged and dead giant cells and epithelioid cells.
Mast cells are only few in number and fibroblasts lay down collagen.
Basophils are not present.
The giant cell made up of macrophages are the most abundant cells in this inflammatory process.

Relative risk = (Incidence in exposed group)/incidence in unexposed group). So in this case RR = (50/100)/(50/200) = 2.

The primary intestinal loop is formed from the midgut which gives rise to the distal half of the duodenum, the jejunum, ascending colon, proximal two thirds of the transverse colon and the ileum.

Hyposplenism usually occurs after the surgical removal of the spleen or in pathological processes where the splenic tissue is replaced with abnormal tissue. It is often associated with diseases such as sickle cell disease, Coeliac disease, SLE and Dermatitis Herpetiformis. Myxoedema however bears no known association with hyposplenism. Patients with hyposplenism are at risk of fulminant bacterial infection.

Certain lesions present on x-ray are suggestive of child abuse including rib, humerus and skull fractures. It is the doctors responsibility to follow up on these cases to determine whether domestic abuse has occurred.

Among the provided options, we would expect a normally developing six-month-old child to have lost Moro’s reflex.Note:The Moro reflex is present from birth and persists until 4 months of age. It is abnormal for the Moro reflex to persist much beyond this stage, and if it does, cerebral palsy should be considered.A normal 6-month old baby should be able to roll over from front to back, readily follow objects with their eyes, transfer objects from hand to hand, recognise parental voices and babble and laugh.Other options:- Having a pincer grip is more typical of a 9-12-month-old.- Although at 6 months babies are often able to sit briefly or with support, sitting steadily is typically seen at 9 months.- Starting to stand with support is more typical of a 9-12-month-old.- Waving bye-bye is more typical of a 9-12-month-old.

Asthma patients have an increased risk of developing complications like pneumonia or collapsed lung. A clear visualization of the lungs through a CXR will define the management necessary for this patient.

Cranial nerves I, II, and VIII are considered purely afferent nerves since they conduct sensory information from the olfactory region, the retina of the eye, and the inner ear structures, respectively.Cranial nerves III, IV, VI, XI, and XII are considered purely efferent due to their motor output to the orbit, the neck, and the tongue.Cranial nerves V, VII, IX, and X are considered mixed cranial nerves due to the presence of afferent and efferent fibres with both sensory and motor components.

The progesterone is primarily responsible for preventing pregnancy. The main mechanism of action is the prevention of ovulation| they inhibit follicular development and prevent ovulation. Progestogen negative feedback works at the hypothalamus to decreases the pulse frequency of gonadotropin-releasing hormone. This, in turn, will decrease the secretion of follicle-stimulating hormone (FSH) and decreases the secretion of luteinizing hormone (LH). If the follicle isn’t developing, then there is no increase in the oestradiol levels (the follicle makes oestradiol). The progestogen negative feedback and lack of oestrogen positive feedback on LH secretion stop the mid-cycle LH surge. With no follicle developed and no LH surge to release the follicle, there is the prevention of ovulation. Oestrogen has some effect with inhibiting follicular development because of its negative feedback on the anterior pituitary with slows FSH secretion| it’s just not as prominent as the progesterone’s effect. Another primary mechanism of action is progesterone’s ability to inhibit sperm from penetrating through the cervix and upper genital tract by making the cervical mucous unfriendly. Progesterone induced endometrial atrophy should deter implantation, but there is no proof that this occurs.

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.