This Quality Improvement project aimed to increase documented foot exams for paediatric patients with type 2 diabetes mellitus in a large outpatient endocrine clinic after a new electronic health record system was implemented. We used the Model for Improvement, applying its three guiding questions and iterative Plan-Do-Study-Act cycles to test and refine interventions.

Reducing food waste on general paediatric ward by reducing number of food portions according to inpatient numbers and increasing awareness.

Differences of sex development (DSD) comprise a heterogeneous group of congenital conditions affecting urogenital and reproductive development. Variations in sex determination can cause a mismatch between chromosomal, gonadal and phenotypic sex, leading to atypical internal and/or external genitalia. Presentations are varied and most commonly occur in the newborn period and during adolescence. Clinical care is complex and diagnostic pathways may be protracted. Decisions around sex assignment carry ethical considerations and can place a considerable psychological burden on families.This 15-minute guide summarises a practical, stepwise approach for general paediatric and neonatal teams: when to suspect DSD, how to examine and communicate, the first-line investigations to initiate, when/how to escalate to the multidisciplinary DSD service, and how to support families.

Neonates born with congenital vertical talus ('rocker-bottom foot') are challenging to diagnose and manage. The immediate management is generally based on assessing for Edwards syndrome (trisomy 18) or other similar severe life-limiting chromosomal disorders when there are dysmorphic features suggestive of a genetic syndrome, and no clear neurological focus such as a neural tube defect or spinal muscular atrophy disorder. Often the initial fluorescent in situ hybridisation genetic testing is reported as normal, appearing to exclude a trisomy diagnosis. We use two similar neonatal case scenarios with different diagnoses to discuss the next steps in genetic testing and the use of microarray, karyotyping and whole exome sequencing tools in managing these complex cases.

This article describes a case of warm autoimmune haemolytic anaemia (w-AIHA) in a 16-month-old refractory to first-line treatment. W-AIHA typically responds to systemic corticosteroids. Here, management proved challenging with re-emergence of haemolysis during initial steroid course. Rituximab offered a turning point, demonstrating the utility of targeted anti-CD20 antibody therapy in achieving a sustained haematological response. The patient's clinical course was not without further complications potentially attributable to treatments administered. This paper reviews the management of w-AIHA, beyond steroid therapy, with an additional focus on supportive care measures.

IntroductionTopical oestradiol gel is now widely used in hormone replacement therapy (HRT), but the risk of inadvertent secondary transfer to children is under-recognised. While accidental exposure to testosterone gels has been documented, oestradiol gel transfer as a cause of precocious puberty in prepubertal girls is rare.We undertook a 20-year literature review and discuss the case of a 5-year-old girl presented with Tanner stage 3 breast development, pubic hair stage 2, growth acceleration and mood changes. Laboratory evaluation revealed markedly elevated oestradiol levels with suppressed gonadotrophins, consistent with peripheral precocious puberty. Bone age was advanced by 4 years 6 months. Imaging, karyotype, endocrine and dermatology investigations excluded central precocious puberty, ovarian or adrenal tumours and McCune-Albright syndrome. History, previously not disclosed, revealed daily co-sleeping with her mother, who had been applying oestradiol gel to her upper arms for 18 months as part of HRT. No other oestrogen sources were identified. Maternal oestradiol gel was discontinued and replaced with a transdermal patch. The child's oestradiol levels normalised and pubertal signs regressed over subsequent months.This review highlights a rare but important cause of peripheral precocious puberty due to unintentional transfer of topical oestradiol gel through routine parent-child contact, including co-sleeping. As topical hormone therapies become increasingly common, clinicians must counsel patients on safe application practices and consider exogenous hormone exposure in children presenting with unexplained pubertal development. Switching caregivers from gel to patch formulations can reverse hormone excess in exposed children.

A 4-year-old boy presented with fever and unilateral neck swelling, initially treated as bacterial lymphadenitis with intravenous antibiotics. Over the following days, he developed bilateral non-purulent conjunctival injection, palmar erythema, mucosal changes, raised liver transaminases and rising inflammatory markers. The evolving picture led to a diagnosis of Kawasaki disease in the second week of illness.Cervical lymphadenitis is a common paediatric presentation, with infective aetiology being the most common. However, inflammatory conditions such as Kawasaki disease and haematological malignancy can present similarly. Among these, 'Node-first' Kawasaki disease, in which cervical lymphadenopathy precedes other features, while a recognised phenotype, is a rarer presentation and therefore a diagnostic pitfall. The similarity to infective lymphadenitis, together with overlapping laboratory and imaging findings, may delay definitive treatment and increase the risk of complications. An acute presentation of cervical lymphadenitis in a febrile child with inadequate or no response despite antibiotics and persistent high inflammatory markers should raise suspicion of possible alternative diagnoses like Kawasaki disease.

Neurodevelopmental delay is a common clinical presentation to paediatricians. For some children, there may be an immediately recognisable likely cause such as a severe perinatal infection or hypoxia. For others, the cause may not be obvious, leaving open questions of recurrence risk, developmental prognosis, expected medical and mental health needs and optimal management. Although some children will remain undiagnosed, many will have an underlying genetic diagnosis. In this article, we highlight recent advances in the investigation of children with developmental delay with a particular focus on genomics. We advocate performing next-generation sequencing-based tests as a first-line investigation, alongside basic biochemical and metabolic tests, with an aim for greater equity of testing and more rapid diagnosis.