An infant was born at 38+5 weeks of gestation via elective caesarean section due to concerns regarding a possible antenatal diagnosis of osteogenesis imperfecta type 3. Antenatal skeletal abnormalities included poor bone mineralisation and multiple intrauterine fractures. Her initial biochemistry demonstrated: alkaline phosphatase (ALP): 17 U/L (83–248) with a normal adjusted calcium, phosphate, magnesium, parathyroid hormone and vitamin D. Her initial skeletal survey was grossly abnormal. She was discharged with a guarded prognosis. At 6 months of life she presented unwell with vomiting, constipation and irritability, she was hypotonic. Her blood tests were repeated and demonstrated ALP: 12 U/L (122–469), adjusted calcium: 3.53 mmol/L (2.2–2.6), phosphate: 1.88 mmol/L (1.47–2.54). Figure 1 is an image from her skeletal survey at the time. Figure 1 An image from her skeletal survey showing bowing of both femora and tibiae, multiple healing fractures and demineralisation of her skeleton

Preterm birth is the biggest cause of infant mortality and morbidity in the UK.1 Evidence has shown that optimal cord management (OCM), defined here as deferring cord clamping for at least 60 s following delivery, can reduce the risk of death in preterm babies by nearly one-third, reduce the need for blood transfusion by 10% and encourage haemodynamic stability, therefore reducing the need for inotropic support following delivery.2–4 OCM is a British Association of Perinatal Medicine quality standard, recorded as part of the National Neonatal Audit Programme (NNAP) and is an essential part of perinatal optimisation now included in the Newborn Life Support course.5–7 NNAP data published for 2021 identified our neonatal intensive care unit (NICU) as a national outlier for OCM. Only 20% of infants born<34 weeks gestation received a minimum 60 s deferred cord clamping, well below the national average of 43%.8 To improve deferred cord clamping rates from 20% to 80% and embed OCM as the stan

A thyroid function test (TFT) is a common investigation, often undertaken by general paediatricians and general practitioners. TFT involves the measurement of serum free thyroxine (fT4) and thyroid stimulating hormone (TSH) to guide the diagnosis and management of hypothyroidism and hyperthyroidism, requiring treatment with medications such as levothyroxine (LT4) and carbimazole. Thyroid hormones play a crucial role in early life neurodevelopment; therefore, the correct interpretation of TFT is required to optimise treatment outcomes. TFT needs to be contextualised to influencing factors such as intercurrent illness, diet, presence of obesity, assay interference and non-adherence to treatment.

(21 November, 2024) Free Neelam Gupta (27 June, 2024) Arvind Nagra, Isabella Darshani Fuller, Gary Connett, Ben C Reynolds, Kay Tyerman, Dean Wallace, Evgenia Preka, Kirsten Armstrong, Neeta Patel, Sarah Shameti, James Edelman, Rosemary Dempsey, Caroline Elizabeth Anderson, Rodney Gilbert, Mushfequr R Haq, Matthew Harmer, Yincent Tse (21 March, 2024) Beatrice Lorenzon, Francesca Burlo, Ludovica Barbi, Gianluca Tamaro, Gianluca Tornese (9 April, 2024) Helen Thomas, Daniel Cromb, Hannah Jacob, Anastasia

(21 November, 2024) Free Neelam Gupta (27 June, 2024) Arvind Nagra, Isabella Darshani Fuller, Gary Connett, Ben C Reynolds, Kay Tyerman, Dean Wallace, Evgenia Preka, Kirsten Armstrong, Neeta Patel, Sarah Shameti, James Edelman, Rosemary Dempsey, Caroline Elizabeth Anderson, Rodney Gilbert, Mushfequr R Haq, Matthew Harmer, Yincent Tse (21 March, 2024) Beatrice Lorenzon, Francesca Burlo, Ludovica Barbi, Gianluca Tamaro, Gianluca Tornese (9 April, 2024) Helen Thomas, Daniel Cromb, Hannah Jacob, Anastasia

Neonatal bradycardia is characterised by a heart rate below 80 bpm, irrespective of gestational age. It is generally self-resolving but, in some cases, represents an underlying pathology which may be cardiac or non-cardiac in origin. The common causes for bradycardia are non-cardiac in origin such as autonomic immaturity in premature infants, electrolyte imbalances, hypothyroidism and medications. Cardiac causes include—sinus bradycardia, conduction system abnormalities, congenital heart disease and channelopathies. Diagnostic investigations typically include a standard 12-lead ECG, 24-hour Holter monitor and an echocardiogram. This article aims to provide a practical framework for the management of neonates with bradycardia and guide further investigation and/or referral to specialist paediatric cardiology services.

A 3-year-old female was admitted for 2 days of fever and coryzal symptoms. She had three previous episodes of upper respiratory tract infection but no known immunodeficiency or history of aspiration. Immunisation was up to date. On admission, she was stable in room air, active and spoke complete sentences. Nasopharyngeal swab revealed adenovirus. In addition to her persistent fever, she became increasingly breathless. A contrast CT scan of the thorax revealed gross left parapneumonic effusion with left upper lobe cavitation (figures 1 and 2), so a pigtail catheter was inserted for drainage of the effusion. Empirical broad-spectrum antibiotics were initiated to cover for any secondary bacterial infection since C-reactive protein and procalcitonin values rose drastically, although initial cultures were negative. She continued to deteriorate and required continuous positive airway pressure support; blood gas confirmed type 1 respiratory failure. She was then intubated and transferred to t