A 4-year-old has swollen eyelids and abdominal distension. The urine is frothy. Blood pressure is normal and there is no haematuria. What is the most likely diagnosis? A. Nephritic syndrome B. Nephrotic syndrome C. Congestive cardiac failure D. Protein-energy malnutrition ANSWER: B — nephrotic syndrome. Why: the filter is LEAKY. Heavy protein loss lowers blood albumin, fluid leaves the circulation, and oedema results — classically puffy eyes in the morning, since loose periorbital tissue swells easily after lying flat. Frothy urine reflects the protein. A: nephritic syndrome gives HAEMATURIA and HYPERTENSION, with less protein. FIRST TEST: a urine dipstick. It is the cheapest test in medicine and separates the two syndromes immediately.

A child with known nephrotic syndrome develops abdominal pain and fever. What must be excluded, and why does it happen? ANSWER: SPONTANEOUS BACTERIAL PERITONITIS. WHY IT HAPPENS: the kidney is not losing albumin selectively — it is losing PROTEINS. Immunoglobulins are proteins and are lost too, so the child is functionally immunosuppressed. WHY IT IS MISSED: abdominal pain in a nephrotic child is easily attributed to ascites or constipation. THE SAME MECHANISM explains the other major complication: natural ANTICOAGULANT proteins are lost as well, leaving the blood prothrombotic, so thrombosis is a real risk in a group where it is rarely considered.

A 7-year-old passes tea-coloured urine. Two weeks ago he had a sore throat which resolved. What is the diagnosis, and what is the main danger? ANSWER: POST-STREPTOCOCCAL GLOMERULONEPHRITIS. The LATENT PERIOD of days to weeks is the key feature — the original infection has resolved, so the family sees no connection and does not mention it unless asked specifically. THE MAIN DANGER IS NOT THE HAEMATURIA. It is: - HYPERTENSION, which can cause encephalopathy and seizures - FLUID OVERLOAD, which can cause pulmonary oedema The dramatic symptom is the dark urine; the dangerous problem is the blood pressure. ACTION: measure the blood pressure in every child with dark urine or oedema. Most children recover fully with supportive care.

A 9-month-old has had fever and vomiting for two days with no localising signs. Chest and ears are normal. What investigation is essential? ANSWER: TEST THE URINE. WHY: a baby cannot complain of dysuria. Urinary tract infection in a young child presents as fever with no obvious source, vomiting, poor feeding, irritability, faltering growth, or prolonged jaundice in a newborn. None of those points at the urinary tract, which is why UTI is among the most commonly MISSED serious bacterial infections in small children. WHY IT MATTERS BEYOND THIS ILLNESS: repeated upper tract infection can SCAR a growing kidney. Scarring is permanent and may contribute to later hypertension and impaired renal function. PRACTICAL POINT: collect the sample properly. A contaminated specimen cannot be interpreted and leads either to a missed diagnosis or to a child treated for an infection they never had.

An 18-month-old has a brief generalised seizure during a febrile illness. Afterwards he is drowsy and not fully alert. What is the most important consideration? ANSWER: MENINGITIS must be excluded. This is not simply a febrile seizure. A seizure with fever is meningitis until you have satisfied yourself otherwise, and reaching for the reassuring common label first is exactly how meningitis is missed. FEATURES THAT INCREASE CONCERN, INCLUDING HERE: - NOT returning to full alertness (present in this child) - focal features or a one-sided seizure - prolonged seizure, or more than one in the same illness - a very young child, in whom classic signs are often absent - a child already on antibiotics, which may mask meningitis A child with a SIMPLE febrile seizure recovers to normal alertness. This child has not.

Parents of a child who has had a simple febrile seizure ask whether their child's brain has been damaged. How should they be counselled? ANSWER: acknowledge the fear FIRST, then reassure. 1. Say it aloud: "many parents tell us they thought their child was dying." A family whose fear has not been acknowledged does not absorb the reassurance that follows. 2. Then explain: a simple febrile seizure is frightening to witness but does NOT damage the brain. 3. Most children never have another. 4. Explain how to manage fever, what to do if it happens again, and when to seek help. WHY THE ORDER MATTERS: reassurance delivered before the fear is named sounds dismissive, and parents leave still believing the worst.