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Background Antibiotics are commonly prescribed for children with respiratory symptoms when a bacterial infection is suspected, or the patient is felt to be at higher risk of complications. However, in the context of the significant threat posed by antimicrobial resistance, it is vital for clinicians to avoid over-prescription. In November 2021, the CAP-IT randomized clinical trial reported that lower-dose and shorter duration prescriptions (3 days) of amoxicillin for community acquired pneumonia (CAP) was noninferior to higher-dose and longer-duration (7 days), with regards to the primary outcome of later need for antibiotic re-treatment. Consequently, we wanted to audit the prescribing habits for inpatient children at our hospital in relation to our trust guidelines, which at the time recommended 5–7 days of amoxicillin in simple cases of CAP. Methods We conducted a retrospective audit of children treated with antibiotics for a community acquired pneumonia on the inpatient ward of our district general hospital, between 1 November and 15 December 2021. Audit registration number was 3204–3892. We collected information on antibiotics prescribed, route of administration, allergies, duration of antibiotics, infection markers, febrile episodes, oxygen requirement, past medical history and details of X-ray performed. Results We identified a total of 30 children within the time period fulfilling inclusion criteria with a median age of 2 years (range 2 months–12 years). 12 (40%) of these children received at least one dose of IV or IM antibiotics, 18 (60%) received oral antibiotics only. 12 (40%) received amoxicillin only, 8 (26.7%) received co-amoxiclav only, and the remainder (33.3%) received a combination of antibiotics. No child had any allergy to antibiotics. The median duration of the course of antibiotics (including any prescribed as a TTA) was 7 days (range 1–9), and seven children (23.3%) received greater than 7 days of antibiotics. The median length of stay in hospital was 2 days (range 1–8 days). The median peak white cell count was 12.05, median CRP was 44. Overall 20 children (66%) required oxygen, and 6 children (20%) required high-flow oxygen. Eleven (36.7%) children were never febrile during their admission and only 3 (10%) of children had a severe underlying chronic disease. 28 (93.3%) of children had a chest X-ray performed, of which nine (32.1%) had no focal changes on the formal X-ray report, despite all receiving antibiotics. Conclusions From this audit, we identified that many children are receiving prolonged courses of antibiotics for community acquired pneumonia (7 days or more) and many are receiving antibiotics despite no focal changes identified on chest X-ray. Prescribing decisions are complex and relate to many factors including the degree of clinical concern. However, we believe this audit identified a degree of over-prescribing, particularly in the context of the results of the CAP-IT trial. Following this audit we implemented a change in trust guidelines via Paediatric Microguide, allowing prescription of a 3 day course of amoxicillin for appropriate cases of CAP. It is our aim that this will reduce over-prescribing and hence improve antimicrobial stewardship in future, with a re-audit planned for Winter 2022–23.

Aim Tramadol is a synthetic opioid widely used to treat pain in adults and children over 12 years old. Extensive research on the toxicity of tramadol in adults has been published but the adverse effects in children are less well documented. We aimed to describe the clinical presentation of tramadol intoxication in children. Methods Retrospective analysis of case notes of children who presented to our hospital with tramadol intoxication, from January to September 2013. Results Four females aged 10 months to 14 years presented to A&E with tramadol overdose. Three cases were accidental, but in all of them, the medication belonged to an adult within the household. The average time of presentation was 2.5 h with a median dose of 14.8 mg/Kg of tramadol (range 5.2 to 32.5 mg/Kg). The most common symptoms were drowsiness (100%), dry mouth /feeling thirsty (75%), nausea/vomiting (75%), pruritus/rash (50%) and miosis (50%). The patient, who took the highest dose of tramadol, developed respiratory depression one hour after the ingestion and experienced a generalised tonic-clonic seizure 6 h later. Treatment used was: activated charcoal in 2 patients who arrived within 1 h of ingestion, Naloxone to reverse the episode of respiratory depression and intravenous fluids. There were no remarkable changes in the patients’ biochemistry profile. The patients were observed for an average of 22.6 h. Conclusion This case series illustrates the most common symptoms reported in children with tramadol overdose. The patients were all symptomatic on presentation and the severity of their symptoms was proportional to the amount of tramadol consumed. Our treatment focused on the primary goal of resuscitation and supportive care, but a basic understanding of tramadol’s pharmacological profile was essential. Recent reports show a rise in tramadol prescription and misuse in the adult population and a recent advice issued by the MHRA contraindicates the use of codeine for treatment of pain in children. An increase in paediatric tramadol prescribing and the number of adverse events associated with tramadol toxicity in children may be anticipated, so awareness of the clinical presentations is important for paediatricians.

responsible for 73.8% of assaults and father by 44.3%, and in some cases both are equally liable. Conclusion This study draws attention to the magnitude of the problem to be faced by those in the routine is responsible for the comprehensive care for the child's health.