UKMLA Paediatrics Essentials: High-Yield Pillar

Paediatrics is one of the most over-represented specialties in the UKMLA. It rewards candidates who can move between three mental models in a single stem — developmental (is this age-appropriate?), physiological (is this child sick?), and safeguarding (is this family safe?). Most IMGs and students who panic in paediatrics stems haven't learnt less — they've learnt it in silos.

This pillar integrates the full UKMLA paediatric surface into one read. It is longer than most and designed to be a reference you return to, not a skim. If you are pressed for time, focus on sections 3, 5, 7, 11, and 12 — those dominate the AKT.

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1. Why paediatrics is over-represented in UKMLA

The GMC content map includes children explicitly in around 18% of presentations — roughly one in five stems. The reason is stewardship: the MLA must certify that a graduating doctor is safe to work in any UK foundation post, and foundation trainees rotate through paediatric assessment units, ED, and GP surgeries where children form a third of the caseload.

Expect to see:

• Fever in under-5s with the NICE traffic-light system.
• Acute wheeze in a preschooler — bronchiolitis vs viral-induced wheeze vs asthma.
• Non-accidental injury patterns requiring safeguarding action before investigation.
• Meningococcal sepsis, often with a subtle non-blanching rash.
• Paediatric fluid prescribing with weight-based calculations.
• Gillick competence and Fraser guidelines in consent stems.

The UKMLA content map is covered in our UKMLA Content Map 2026 pillar — use that to map which paediatric conditions sit in which domain. The NICE guideline set that governs paediatric management is summarised in our NICE Guidelines + UK Prescribing for UKMLA pillar.

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2. Developmental milestones (gross motor / fine motor / language / social)

The AKT does not expect encyclopaedic dates, but it does expect you to recognise when a milestone is significantly delayed and to know a handful of median ages.

Red flags (refer for assessment):

• Not sitting by 9 months, not walking by 18 months, not walking by 24 months (boys — rule out Duchenne, check CK).
• Hand preference before 1 year → pathological; suggests hemiplegia.
• No words by 18 months, no two-word sentences by 2.5 years.
• Loss of skills at any age — regression is a red flag for autism spectrum disorder (Rett, Landau–Kleffner, inborn errors).

Always plot height, weight, and head circumference on UK-WHO growth charts. Dropping two centile lines is a soft warning; dropping three is a safeguarding or chronic-disease flag.

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3. Neonatal emergencies (respiratory distress, jaundice, early-onset sepsis)

Neonatal respiratory distress: tachypnoea (>60/min), recession, grunting, nasal flaring, cyanosis.

Differential priorities:

• Transient tachypnoea of the newborn (TTN) — most common; C-section birth; resolves in 24–48 h.
• Respiratory distress syndrome (RDS) — preterm; surfactant deficiency; ground-glass CXR with air bronchograms.
• Meconium aspiration — post-dates; stained liquor; patchy CXR.
• Early-onset sepsis (EOS) — within 72 h of birth; usually group B strep or E. coli.
• Congenital diaphragmatic hernia — scaphoid abdomen, bowel in chest on CXR, apex shifted right.

Neonatal jaundice timing — the key exam rule:

• <24 hours old → always pathological (haemolysis: ABO/Rh incompatibility, G6PD, sepsis). Urgent bilirubin + DCT + blood group.
• 24 h – 14 days → usually physiological (>14 days if preterm) — check bilirubin against gestation-specific phototherapy thresholds.
• >14 days (term) or >21 days (preterm) → prolonged jaundice. Split conjugated/unconjugated. Conjugated ≥25 μmol/L or ≥20% of total = biliary atresia until proven otherwise — refer for HIDA scan. Kasai portoenterostomy before 60 days of life saves the liver.

Early-onset sepsis (NICE NG195, 2021): any of tachypnoea, poor feeding, temperature instability, lethargy, or maternal risk factors (GBS bacteraemia, rupture >18 h, chorioamnionitis). Empirical treatment: IV benzylpenicillin + gentamicin after blood culture, LP if no contraindication. CRP repeated at 18–24 h.

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4. Paediatric BLS / APLS essentials

Paediatric resuscitation differs from adult in three crucial ways — the AKT will test these differences.

Compression : ventilation ratio — 15:2 in children (any age, healthcare providers); 30:2 only if single lay rescuer.

Always five rescue breaths first (unlike adults where chest compressions come first). Hypoxia is the dominant mechanism in paediatric arrest.

Drug dosing by weight:

• Adrenaline 10 mcg/kg IV/IO (1:10,000), every 3–5 min during CPR.
• Amiodarone 5 mg/kg after 3rd shock in shockable rhythm.
• Fluid bolus 10 mL/kg crystalloid over 10 min (revised from 20 mL/kg after FEAST trial findings — now cautious in sepsis without shock).
• 10% dextrose 2 mL/kg for hypoglycaemia <2.6 mmol/L.

Shockable rhythms (VF/pulseless VT) — 4 J/kg biphasic. Reassess every 2 minutes.

The classic APLS mnemonic for reversible causes is still 4Hs and 4Ts: Hypoxia, Hypovolaemia, Hypothermia, Hypo/Hyperkalaemia/metabolic; Thrombosis, Tension pneumothorax, Tamponade, Toxins.

For the management of adult emergencies including ABCDE framework, see our UKMLA Acute & Emergency Presentations pillar.

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5. Acute wheeze: bronchiolitis vs viral-induced wheeze vs asthma

This trio is the single most tested paediatric clinical pattern.

Bronchiolitis management (NICE NG9):

• Supportive — oxygen if SpO₂ <92%, NG feeding if poor feeding, high-flow nasal cannula if severe.
• No antibiotics, no steroids, no bronchodilators. Nebulised hypertonic saline is not recommended.
• Admission criteria: SpO₂ <92%, <50% normal feeding, dehydration, apnoea.
• High-risk groups (admit early): ex-prem, cardiac disease, immunocompromised, age <3 months.

Acute asthma severity (BTS/SIGN ≥5 yrs):

Management ladder: salbutamol 10 puffs via spacer (or nebulised) → ipratropium + steroid (oral prednisolone 1–2 mg/kg, or IV hydrocortisone) → magnesium sulphate → IV salbutamol/aminophylline → PICU. Admit if inadequate response after 1 hour.

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6. Croup vs epiglottitis — severity ladder and red flags

Croup (laryngotracheobronchitis):

• Parainfluenza virus, 6 months – 6 years.
• Barking cough, stridor, hoarse voice, mild fever.
• Worse at night.
• Management (Westley score): oral dexamethasone 0.15 mg/kg is first-line for all severities. Nebulised budesonide if vomiting. Nebulised adrenaline for severe stridor at rest, while arranging senior airway review.

Epiglottitis (now rare post Hib vaccine):

• Sudden onset, high fever, drooling, tripod position, stridor, no cough.
• Toxic-looking child.
• Do NOT examine the throat. Do NOT cannulate. Do NOT distress.
• Call anaesthetist + ENT — controlled intubation in theatre. IV cefotaxime or ceftriaxone after airway secure.

Bacterial tracheitis — thick exudate, staph aureus — presents between croup and epiglottitis. ICU.

Trap: do not miss a foreign body aspiration masquerading as croup — sudden onset, choking history, unilateral wheeze or reduced air entry. Rigid bronchoscopy.

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7. Fever in under-5s (NICE traffic-light system)

The NICE traffic-light tool for under-5s with fever (NG143) is the most directly testable NICE algorithm in paediatrics. Memorise the red features:

Red (high-risk, refer to paediatric assessment):

• Pale/mottled/ashen/blue skin.
• No response to social cues; appears ill; weak/high-pitched cry; reduced conscious level.
• Grunting; RR >60; moderate-severe recession.
• Reduced skin turgor; tachycardia.
• Age <3 months with temperature ≥38°C.
• Age 3–6 months with temperature ≥39°C.
• Non-blanching rash.
• Bulging fontanelle.
• Neck stiffness.
• Status epilepticus.
• Focal neurological signs or focal seizures.

Amber features (partial list — clinician judgement on admit vs safety-net): pallor reported, not responding normally, reduced activity, dry mucous membranes, poor feeding, nasal flaring, tachypnoea, cap refill ≥3s.

Investigations for any child <3 months with fever — FBC, CRP, blood culture, urine, CXR if respiratory, LP unless contraindicated. Empirical IV antibiotics (ceftriaxone or cefotaxime + amoxicillin if <1 month to cover Listeria).

Meningococcal red flag: non-blanching rash + fever → IM/IV benzylpenicillin immediately in community, transfer to hospital, ceftriaxone on arrival, notify public health. See emergency presentations pillar for sepsis six adaptation.

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8. Kawasaki disease & HSP — criteria and complications

Kawasaki disease diagnostic criteria: fever ≥5 days PLUS four of five (CRASH + BURN):

• Conjunctivitis (bilateral, non-purulent).
• Rash (polymorphous).
• Adenopathy (cervical, ≥1.5 cm, usually unilateral).
• Strawberry tongue/mucosal changes.
• Hands and feet (swelling, erythema, desquamation).
• Plus BURN = fever.

Complication: coronary artery aneurysms in up to 25% untreated.

Treatment: IVIG 2 g/kg single infusion + aspirin (high-dose until afebrile, then low-dose antiplatelet until echo clear). Aspirin is one of the only paediatric indications — normally contraindicated due to Reye's syndrome.

Henoch–Schönlein purpura (IgA vasculitis):

• Classic tetrad: palpable purpura (buttocks/legs), arthralgia (knees/ankles), abdominal pain (± intussusception), nephritis (haematuria, proteinuria).
• Usually post-URTI, 3–10 years.
• Most self-limiting. Monitor urinalysis and BP weekly for 6 months then monthly to 12 months — the long-term risk is IgA nephropathy.
• Admit if severe pain, GI bleed, renal involvement, or diagnostic uncertainty.

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9. UTI in children — imaging thresholds per NICE

NICE NG224 (2022) thresholds — the AKT tests these precisely:

Investigations at first UTI:

• <6 months — USS within 6 weeks (within 6 weeks even if responds well to treatment).
• Atypical UTI at any age (non-E.coli, poor stream, septic, raised creatinine, failure to respond in 48 h) — USS during acute illness + DMSA at 4–6 months + MCUG if <6 months.
• Recurrent UTI at any age — USS within 6 weeks + DMSA at 4–6 months + MCUG if <6 months.

Treatment: oral antibiotics for 3 days (lower UTI) or 7–10 days (upper UTI/pyelonephritis). Trimethoprim or nitrofurantoin first-line per local sensitivity. IV co-amoxiclav or cefotaxime if <3 months or systemically unwell.

Sample collection: clean-catch urine preferred; "wee-bag" samples have high contamination and should prompt clean-catch before diagnosis. Dipstick is unreliable <3 months; always send microscopy and culture in this group.

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10. Common childhood rashes (measles, chickenpox, scarlet fever, meningococcal)

Safety-net advice for parents: tumbler test for non-blanching rash → immediate 999/111 call. Fever + rash always warrants review.

For comprehensive rash pattern recognition and malignancy flags, see our upcoming UKMLA Dermatology Red Flags pillar.

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11. Child safeguarding & NAI flags (bruising patterns, disclosure)

Safeguarding is a guaranteed AKT topic and usually appears in a stem where the "correct" answer is escalate before investigating further.

Key NAI flags:

• Bruising in a non-mobile baby (under 6 months, or not yet crawling) → NAI until proven otherwise.
• TEN-4-FACES rule: bruising to Torso, Ears, Neck in under-4s; Frenulum, Angle of jaw, Cheek, Eyelids, Subconjunctivae at any age.
• Inconsistent history, delayed presentation, changing story, blame on siblings/self.
• Spiral long-bone fractures, posterior rib fractures, metaphyseal corner fractures, multiple fractures at different ages.
• Cigarette burns, immersion burns with clear tide lines, burns in glove/stocking distribution.
• Shaken baby: retinal haemorrhages + subdural haemorrhage + encephalopathy triad.
• Disclosure by the child: listen, believe, document verbatim, do not promise confidentiality, refer immediately.

Actions on suspicion:

1. Document injuries with body maps and measurements.
2. Senior review (ST4+/consultant).
3. Referral to children's social care (no delay).
4. Skeletal survey for <2 years, ophthalmology for retinal exam, CT head for suspected abusive head trauma.
5. Strategy meeting within 48 hours.

Never accept a "reasonable" parental explanation as closure — your duty is to refer; investigation is for social care.

FGM and forced marriage are also mandatory-reporting concerns — 0–18 years FGM has a statutory duty to report to police (section 5B, FGM Act 2003 as amended).

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12. Paediatric fluid prescribing — maintenance + bolus calculations

The UKMLA will test Holliday–Segar maintenance fluid calculations (NICE NG29 for children):

• First 10 kg: 100 mL/kg/day
• Next 10 kg (11–20 kg): 50 mL/kg/day
• Each kg above 20: 20 mL/kg/day

Worked example: 23 kg child → (10 × 100) + (10 × 50) + (3 × 20) = 1000 + 500 + 60 = 1,560 mL/day (≈65 mL/hr).

Use isotonic fluids (0.9% NaCl + 5% dextrose, ± potassium if established urine output). Hypotonic fluids are obsolete — hyponatraemia risk.

Bolus (shocked child): 10 mL/kg crystalloid over 10 min. Reassess after each bolus. Avoid large volumes in DKA and in resource-limited septic shock (FEAST trial — mortality increase with aggressive bolus).

Deficit + maintenance in gastroenteritis:

• 5% dehydration → 50 mL/kg replacement over 24 h.
• 10% dehydration/shock → bolus 10 mL/kg, then 100 mL/kg over 24 h.

DKA in children (BSPED 2021):

• First bolus 10 mL/kg if shocked (once only).
• Deficit + maintenance over 48 hours (not 24 — slower than adults to prevent cerebral oedema).
• Insulin 0.05–0.1 units/kg/hr 1 hour after fluids (not immediately).
• Watch for cerebral oedema: headache, reduced GCS, bradycardia, hypertension → mannitol or 3% saline, urgent CT.

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13. Consent, Gillick competence, Fraser guidelines

Gillick competence applies to any medical decision in a child under 16. A Gillick-competent child can consent to treatment if they understand:

1. The nature of the treatment.
2. Its purpose and benefits.
3. The risks and alternatives.
4. The consequences of not treating.

Fraser guidelines specifically govern contraceptive/sexual health advice to a child under 16 without parental knowledge. All must apply:

1. Understands advice.
2. Cannot be persuaded to tell parents.
3. Likely to have intercourse with or without contraception.
4. Physical/mental health will suffer without advice.
5. Best interests to give advice without parental consent.

Key rules:

• A Gillick-competent child can consent to treatment.
• A Gillick-competent child cannot refuse life-saving treatment — parents or courts can override.
• At 16–17: the child has adult consent rights (Family Law Reform Act 1969), but refusal can still be overridden in serious cases.
• Confidentiality is maintained unless safeguarding overrides (e.g., a 13-year-old in a sexual relationship with a 17-year-old → refer).

For the adult capacity framework (MCA 2005, DoLS, four-stage test), see our upcoming Consent, Capacity & MCA pillar.

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14. UK vaccination schedule 2026 + catch-up

The UK schedule (Green Book, 2026) — high-yield points only:

6-in-1 covers: diphtheria, tetanus, pertussis, polio, Hib, hepatitis B.

Catch-up for incomplete schedules is age-specific — use the Green Book chapter 11 algorithms. An unimmunised 5-year-old starts the schedule at their age and is not given infant-schedule doses.

Contraindications: anaphylaxis to a previous dose or component. Not contraindications: mild URTI, family history, breastfeeding, current steroid (<2 weeks), pregnancy for inactivated vaccines. Live vaccines (MMR, rotavirus, BCG, varicella) avoided in pregnancy and significant immunocompromise.

Common AKT trap: egg allergy is NOT a contraindication to MMR — the virus is grown in chick fibroblasts, not egg protein. Yellow fever and some influenza vaccines are egg-based — refer if anaphylactic egg allergy.

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15. Exam technique: paediatric SBA patterns

Five repeatable paediatric stem archetypes:

1. "3-month-old with fever 38.5°C" → answer is always paediatric assessment + full septic screen (LP, blood culture, urine, CXR, empirical IV antibiotics). Never "paracetamol and safety-net".
2. "Wheeze in an under-1" → bronchiolitis → supportive, admit if hypoxic or feeding <50%.
3. "Bruising on a 4-month-old not yet rolling" → NAI; safeguarding referral before imaging.
4. "8-year-old boy with limp + refusing to weight-bear" → consider septic arthritis (Kocher criteria: fever >38.5, non-weight-bearing, ESR >40, WCC >12,000); urgent US and joint aspiration. Transient synovitis is a diagnosis of exclusion.
5. "14-year-old requesting contraception without parental consent" → Fraser guidelines; assess five criteria; prescribe if met; safeguard if partner concerns.

Paediatric SBA traps to avoid:

• Never choose "await parental consent" in an emergency.
• Never choose "imaging only" when NAI flags are present.
• Never choose "oral antibiotics" in a <3-month-old with fever.
• Never choose "bronchodilator + steroid" for bronchiolitis.
• Never choose "examine the throat" in suspected epiglottitis.

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How to revise paediatrics efficiently

The specialty is wide, but the examinable core is narrow:

• Learn the NICE traffic-light by heart. It is tested almost every sitting.
• Drill the six wheeze/stridor/cough differentials until the management ladder is reflexive.
• Memorise the APLS drug doses (adrenaline, dextrose, fluid bolus, insulin).
• Rehearse five safeguarding scripts so you never hesitate in a stem.
• Carry a Holliday–Segar calculator in your head — do two maintenance sums a day for a week.

Pair this pillar with our NICE Guidelines pillar for prescribing depth, and with the UKMLA Emergency Presentations pillar for sepsis six and paediatric resus integration.

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Summary — five reflexes that win paediatric SBAs

1. Fever + under-3-months → full septic screen, IV antibiotics, LP. No exceptions.
2. Non-mobile baby with bruising → safeguard before investigating.
3. Bronchiolitis is supportive. No steroids, no bronchodilators, no antibiotics.
4. Croup — dexamethasone for all severities. Nebulised adrenaline for severe.
5. Gillick competence enables consent, not refusal. Parents and courts can override refusal.

These five rules alone cover a substantial fraction of the paediatric marks in the AKT. Build outward from them. Paediatrics rewards breadth, but pattern-recognition reflexes win the time-pressured questions that decide the borderline.