A Pubmed search and an Ovid Medline/Embase search were both performed. The keywords were: 'neonatal' or 'paediatric' or 'pediatric' and 'limb' and 'ischemia' or 'ischaemia' and relevant articles were retrieved and analysed. Articles pertaining to children over the age of 3 years and non-English literature articles were excluded.

A Arshad paediatric specialist registrar 1 , C Powell general practitioner 2 , M P Tighe paediatric consultant 1 This is one of a series of occasional articles highlighting conditions that may be more common than many doctors realise or may be missed at first presentation. The series advisers are Anthony Harnden, university lecturer in general practice, Department of Primary Health Care, University of Oxford, and Richard Lehman, general practitioner, Banbury.To suggest a topic for this series, please email us at easilymissed@bmj.com.A 3 year old boy is brought to his general practitioner again by his worried mother. She is concerned that he remains constipated despite trying a third different laxative. Further history showed that he passed his first meconium only on day 5, and since then has been opening his bowels only weekly, with associated straining. His growth has fallen from the 25th to the 2nd centile for height and weight. On examination he has a distended abdomen with palpable stool throughout the abdomen.