Does having the a worried mum or fretful dad in the room with you make a lumbar puncture less likely to succeed? It’s an interesting question, and one that has been posed following an evening on call in Yorkshire. What’s the opinions of folk out there - and any evidence that you can quote to substantiate them?

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Have you ever been involved with a debate with a partner or colleague, travelling from one place to another, and when the course they took has got you to the destination safely, they turn to you and say “So, [add endearment here], you see my way was right.”? If you have, I doubt that you took the opportunity to explain that they may be suffering from a methodological reasoning problem, of which the conterfactual argument and the possibility of differential verification bias may be important to consider. more…

In the window of the Wellcome Collection in London artists work to interpret and explain science: it’s an impressive experience to the irregular visitor. When faced with the presenting problems of a child & family, we are faced with trying to do the reverse. We have the sometimes inaccurate recollections of history, the variable responses of clinical examination and our own bias-riddled minds to bash, through the ‘art of diagnosis’ into a suitable explanation for the predicament and onwards into a management strategy. Can this really be evidence based?

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Jamie, a 13-year-old girl with cystic fibrosis (CF), has been referred to the Paediatric Diabetes clinic because of an abnormal oral glucose tolerance test (OGTT) in her recent CF Annual Review. It showed impaired glucose tolerance. Continuous glucose monitoring system (CGMS) over three days showed normal fasting and pre-prandial glucose but frequent post-prandial glucose excursions between 11.1 mmol/l and 16.0 mmol/l. In retrospect, although Jamie’s previous OGTT carried out at Annual Review were normal, her lung function had gradually deteriorated over the past three years. This had been attributed to increasing episodes of infective exacerbations. You wondered for how long Jamie has had abnormal glucose metabolism which had gone undetected in her previous OGTT. more…

A 7-year-old boy was referred for medical assessment as part of the process of producing a statement of special educational needs. There had been no medical concerns in the past and there was no family history of note. On examination, the boy was noted to be micro cephalic with head circumference on the 0.4^th centile, while his height and weight were on the 50^th centile. Neurological examination was normal. Should this boy be referred for an MRI scan of the brain? more…

You diagnose a 5-year-old with Autistic spectrum disorder. His examination is unremarkable and there is no family history of learning difficulties. Should you perform a molecular genetic screen for FMR1 mutations (fragile X)?

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In examining a diagnostic test, we make the assumption that the characteristics of the test - its sensitivity and specificity (or likelihood ratios, the way I prefer to think) - will stay constant across different populations, although the positive and negative predictive values will change * . This is sort of true, and sort of false.

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A 3 year old boy presents to the Emergency Department with a limp. He has been reluctant to weight bear on his right leg during the day and has a temperature of 37.9°C. Hip examination is painful. What clinical or laboratory tests could help discriminate between septic arthritis and transient synovitis?

Of course, you could just ring up orthopaedics and ask them to take him to theatre and wash out the hip - but you may not win many friends that way. How do you decide there is enough ‘clinical suspicion’ to make the call? more…

In children suspected of having a UTI, what clinical and radiological features diagnoses pylonephritis, and what mode of antibiotic treatment is necessary to produce clinical improvement and avoid chronic renal impairment?

With the publication of the NICE guidance in the UK on the management of UTI in childhood, many paediatricians have been spurred to review their understanding of the evidence underpinning certain aspects of the clinical pathway. more…

Do infants born with an isolated clubfoot (talipes equinovarus) require radiological investigations to rule out congenital hip dysplasia?
You are a neonatal SHO. The midwife asks you to see a term baby who has just been born. She has noticed the baby to have a clubfoot and wants you to examine the baby.Physical examination confirms a clubfoot and there are no other abnormalities. Both hips are stable on clinical examination using the Ortolani and Barlow’s test.

Your registrar asks you to request a hip ultrasound or hip X-ray for this baby to rule out DDH. You are not used to this practice and decide to appraise the evidence behind it. more…