E-cigarettes are electronic nicotine delivery systems (ENDS) which mimic tobacco smoking without the combustion of tobacco. These devices have been misleadingly marketed as “less harmful” alternatives to conventional smoking tobacco products. The e-liquid in e-cigarettes include nicotine, a humectant and other additives including flavourings, colourants, or adulterants such as bacterial and fungal products. In this review, we discuss the contrasting views of the tobacco lobby and most professional societies. We describe the epidemiology of the use of these devices, with a widespread and significant rise in youth e-cigarette use seen in both the USA and Europe. We also describe what is known about the toxicity and mechanisms of EVALI (e-cigarette or vaping associated lung injury). This characterised by respiratory failure with an intense inflammatory response. The presentations are diverse and clinicians should consider vaping as a possible cause of any unusual respiratory illness in patients who have a history of vaping or other use of e-cigarette-related products. Second hand exposure to e-cigarettes is also harmful through respiration and transdermal absorption. E-cigarettes have a worse acute toxicity than tobacco and their long-term toxicity is unknown, and we advocate for the immediate, most vigorous anti-vaping legislation possible.

Asthma is a heterogeneous disease, characterised by different phenotypes and endotypes. Precision medicine in asthma refers to the implementation of a targeted therapy for each individual child, based on the identification of treatable traits, including environmental, immunological and genetic factors. Severe asthma in children is associated with increased hospitalisation rates, a lower quality of life, increased healthcare costs and an increased mortality. In the era of new molecular biologics treatments, it is essential to improve deep phenotyping of children with severe asthma in order to deliver the most effective treatment to each individual child. In this review, we discuss the personalised approach to the assessment and management of severe asthma. We explore the indications and use of the currently licensed biologics, as well as the potential of other emerging treatments.

DESCRIPTIONA 14-month-old boy, independently mobile for 1 month, presented after refusing to walk for 2 days. He was afebrile, with no preceding coryzal illness. A diagnosis of transient synovitis was made. Owing to the lack of improvement and ongoing symptoms for 5 weeks, he underwent blood tests, which showed a C reactive protein of 7, an erythrocyte sedimentation rate of 38 and a platelet count of 511.Apart from the inability to weight bear, he was systemically well in himself. Septic arthritis, osteomyelitis 1 and leukaemia were deemed unlikely diagnoses. Serial blood tests showed static infection markers. A pelvic X-ray and an ultrasound of the hips were unremarkable.In view of the possible hip pathology, the child was booked for an MRI of his pelvis, with a plan to include the spine if the oral sedation lasted long enough. The spinal MRI showed L4/L5 discitis (figure 1).Forty-eight hours into intravenous flucloxacillin, he started walking again. His blood cultures were negative. He continued on intravenous antibiotics for 6 weeks.Discitis was not in our top differentials. It is an uncommon disease in toddlers. It is believed to be of infectious aetiology with the haematogenous transfer of the causative organism (most likely Staphylococcus aureus) to the disc space, despite sterile blood cultures. 2Management involves immobilisation and antibiotic therapy.3 It is a selflimiting illness, but awareness of this condition must be raised, with the aim of facilitating its diagnosis and management.Learning points ▸ In a limping child, remember to assess for spinal pathology. ▸ A spinal MRI is the investigation of choice for discitis. ▸ Treatment of discitis entails a prolonged course of antibiotics, even in the presence of negative blood cultures.Competing interests None declared. Patient consent Obtained.Provenance and peer review Not commissioned; externally peer reviewed. REFERENCES1 Fernadez M, Carrol CL, Baker CJ. Discitis and vertebral osteomyelitis in children: an 18-year review.

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DESCRIPTIONA 34+4 weeks neonate was born by spontaneous vaginal delivery with normal antenatal scans. Routine neonatal examination revealed the absence of a vaginal opening with bulging of vaginal introitus (figure 1). Urethral and anal openings were patent. A provisional diagnosis of an imperforate hymen with hydrocolpos was considered.Subsequent investigations revealed a deranged renal function at 22 hours of life (creatinine 99 mmol/L, urea 10.2 mmol/L, K 6.6 mmol/L and Na 132 mmol/L). An urgent abdominal ultrasound was arranged to rule out hydronephrosis. The kidneys and lower genitourinary tract were normal.The imperforate hymen was managed surgically through a hymenal incision. Subsequently, the external female genitalia appeared normal (figure 2) and the renal function normalised. A positive family history was noted with an elder sibling who also had an imperforate hymen, which was surgically treated at 5 months.The incidence of imperforate hymen is estimated at 0.014-0.1% and presentation is often late with amenorrhea in adolescence. Hydrocolpos is cystic dilation of the vagina with fluid accumulation due to stimulation of secretory glands of the reproductive tract secondary to vaginal obstruction. Hydrocolpos may lead to obstructive uropathy through the compression of the lower urinary tract, resulting in hydronephrosis and hydroureters. 1Hence early detection is essential as it could be associated with life-threatening renal failure.2 As observed in our report, cases of familial recurrence have been reported. 3A thorough newborn examination is essential to screen for an imperforate hymen, which can result in renal complications in the neonatal period. Learning points▸ A thorough newborn screening examination may enable the detection of rare conditions such as imperforate hymen presenting in the neonatal period. ▸ An imperforate hymen usually presents in adolescence with amenorrhoea, but may be detected in the neonatal period. ▸ Hydrocolpos associated with an imperforate hymen can cause renal failure.Contributors MR and CB conceived the idea. LP wrote the first draft of the article. MR and CB participated in revising the manuscript and all authors approved the final submitted version.Competing interests None declared. Patient consent Obtained.Provenance and peer review Not commissioned; externally peer reviewed. Figure 1 Imperforate hymen noted at birth.

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Advances in therapies and management of conditions encountered by paediatric respiratory specialists have led to improved outcomes and improved survival rates dramatically in chronic diseases such as cystic fibrosis. However, this has also meant an increase in treatment burden. A variety of inhaled treatments are crucial in managing paediatric respiratory diseases, but these patients also have to take many oral medications. It is widely recognised that developing oral formulations appropriate for the paediatric population can affect how well a product is received by patients and their families. Consideration should be given to palatability and the number of medicines to be administered as these can all contribute to treatment adherence.Polypharmacy specifically in the context of management of patients with cystic fibrosis is not a new concept, but the recently introduced cystic fibrosis transmembrane conductance regulator (CFTR) modulator therapies and their potential for interactions and adverse reactions create novel challenges. There are some strategies that families and healthcare professionals can implement to reduce treatment burden. This review will also provide some insight into the life of a teenager with cystic fibrosis and the relative complexities of her treatment and the impacts on daily life.Educational aimsTo describe the difficulties faced by children with long-term respiratory conditions having to take oral medication.To discuss oral drug interactions that may exist within paediatric respiratory medicine and to consider issues with polypharmacy.To highlight strategies that may be used to reduce the burden of care for children on oral medication.

A five-year old boy called Harry, with a past history of well-controlled asthma, presented to hospital with a 4-day history of diarrhoea. The parents stated that the stools became blood-stained on the day prior to admission. The rest of the history did not reveal any recent history of foreign travel, visits to farms or intake of take-away food. On admission, he appeared well hydrated. Harry was generally tender all over the abdomen and observation of the stools revealed blood-stained watery stools. The urine dipstick on admission was clear. A stool sample was sent for culture. He was cannulated and bloods were sent for FBC, U&Es and LFTs. Except for a WBC of 17.8, the other results were unremarkable. Over the next few days on the ward, Harry was encouraged to have oral fluids. But he was opening his bowels up to 60 times a day and was also vomiting. For this reason, he was started on full maintenance fluids. In the meantime, the microbiologist confirmed the presence of ecoli 0157 in the stools. Antibiotics were not advocated and supportive care with IV fluids was continued. He still complained of abdominal pain and the amount of urine he was passing was unclear. The fourth day into his admission, bloods were repeated. This time, he had a WBC of 28.9. Most importantly, his urea had gone up to 11.6, his creatinine to 100, his Na was 130 and K 5.4. His Hb was 15.8 (had been 16.7 on admission) and his platelets went down to 35. An LDH and a blood film were urgently requested on the blood sample. The diagnosis of haemolytic uraemic syndrome was established. This is the triad of microangiopathic haemolytic anaemia, thrombocytopaenia and acute renal failure. 15% of children with confirmed ecoli 0157 progress to HUS. This classically happens 7 days after the onset of diarrhoea. Multisystem complications of HUS are known to occur and account for the 5% mortality rate associated with this condition. The treatment of HUS involves supporting the different body systems. Since Harry's condition was deteriorating, he was transferred to a tertiary centre for dialysis.