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Applied
Knowledge in
Paediatrics
MRCPCH Mastercourse
Martin Hewitt
BSc BM MD MRCP FRCPCH
Consultant Paediatric Oncology & Paediatric Medicine
Nottingham Children’s Hospital
Nottingham University Hospital NHS Trust
Nottingham UK
Senior Theory Examiner (AKP)
RCPCH
London UK
Roshan Adappa
MB BS MD FRCPCH
Senior Attending Physician Neonatology
Sidra Medicine
Doha Qatar
Honorary Senior Lecturer Cardiff University
Cardiff UK
© 2022, Elsevier Inc. All rights reserved.
No part of this publication may be reproduced or transmitted in any form or by any means, electronic or
mechanical, including photocopying, recording, or any information storage and retrieval system, without per-
mission in writing from the publisher. Details on how to seek permission, further information about the Pub-
lisher’s permissions policies and our arrangements with organizations such as the Copyright Clearance Center
and the Copyright Licensing Agency, can be found at our website: www.elsevier.com/permissions
The book entitled figures from Levine MRCPCH Mastercourse is in the public domain.
The following figures are from MRCPCH: 2.4, 2.7-2.9, 2.11-2.13, 4.2, 4.3, 5.1, 5.2, 5.4, 8.3, 16.5, 16.10- 16.12, 18.1,
19.2, 20.1, 20.2, 23.1,23.3, 23.5-23.8, 23.11, 25.1, 25.3, 25.5, 28.5.
Notices
Practitioners and researchers must always rely on their own experience and knowledge in evaluating and
using any information, methods, compounds or experiments described herein. Because of rapid advances in
the medical sciences, in particular, independent verification of diagnoses and drug dosages should be made.
To the fullest extent of the law, no responsibility is assumed by Elsevier, authors, editors or contributors for
any injury and/or damage to persons or property as a matter of products liability, negligence or otherwise, or
from any use or operation of any methods, products, instructions, or ideas contained in the material herein.
ISBN: 978-0-7020-8037-1
Printed in China
Ibtihal Abdelgadir, MB BS MD MSc Usama Al-Kanani, MB ChB FRCEM Barbara Blackie, MD MEd FRCPC
FRCPCH PEM Dip Senior Attending Physician Paediatric
Attending Physician Paediatric Attending Physician Paediatric Emergency Medicine
Emergency Medicine Emergency Medicine Sidra Medicine
Sidra Medicine Sidra Medicine Assistant Professor
Assistant Professor Doha Qatar Weill Cornell Medicine
Weill Cornell Medicine Doha Qatar
Doha Qatar Louise Allen, MB BS MD FRCOphth
Consultant Paediatric Ophthamology Gillian Body, BSc MB BS MMedSci
Roshan Adappa, MB BS MD FRCPCH Cambridge University NHS Trust FRCPCH
Senior Attending Physician Neonatology Associate Lecurer Consultant Paediatric Medicine
Sidra Medicine University of Cambridge Noah’s Ark Children’s Hospital for Wales
Doha Qatar Cambridge UK Cardiff UK
Honorary Senior Lecturer Cardiff
University Roona Aniapravan, MB BS FRCPCH Subarna Chakravorty, MB BS PhD
Cardiff UK Attending Physician Paediatric MRCPCH FRCPath
Emergency Medicine Consultant Paediatric Haematology
Sudhakar Adusumilli, MB BS DCH, Sidra Medicine King’s College Hospital
MRCP FRCPCH Assistant Professor Weill Cornell Medical London UK
Senior Attending Physician Paediatric College
Emergency Medicine Doha Qatar Vince Choudhery, MB ChB FRCS
Sidra Medicine MRCPCH
Doha Qatar Karen Aucott, MB ChB MRCPCH Consultant Paediatric Emergency
Consultant Paediatric Medicine Medicine
Shakti Agrawal, MB BS MRCP Nottingham Children’s Hospital Royal Hospital for Children
MRCPCH Nottingham University Hospital NHS Glasgow UK
Consultant Paediatric Neurology Trust
Birmingham Children’s Hospital Nottingham UK Angus Clarke, BM BCh DM MA FRCP
Birmingham UK FRCPCH
Ramnath Balasubramanian, Professor Medical Genetics
Juliana Chizo Agwu, MB BS MSc MB BS DNB MRCPCH University of Cardiff
MRCP FRCPCH PCME Consultant Paediatric Nephrology Cardiff UK
Consultant Paediatric Medicine & Birmingham Children’s Hospital
Diabetes Birmingham UK Lucy Cliffe, MB ChB FRCPCH
Sandwell and West Birmingham NHS Consultant Paediatric Immunology &
Trust Srini Bandi, MB BS MD MSc FRCPCH Infectious Diseases
West Bromwich UK Consultant Paediatric Medicine Nottingham Children’s Hospital
Leicester Royal Infirmary Nottingham University Hospital NHS
Rulla Al-Araji, MB ChB MRCPCH Leicester UK Trust
Consultant Paediatric Gastroenterology Nottingham UK
Great Ormond Street Hospital for Sybil Barr, MB BCh MSc FRCPCH
Children Senior Attending Physician Neonatology
London UK Sidra Medicine
Doha Qatar
iii
Contributors
iv
Contributors
Kah Yin Loke, MB BS MMed(Paed) Moriam Mustapha, BSc RD Jane Ravescroft, MB ChB MRCGP
MD MRCP FRCPCH Neonatal Dietitian MRCP
Associate Professor Paediatric Sidra Medicine Consultant Paediatric Dermatology
Endocrinology Doha Qatar Nottingham Children’s Hospital
National University of Singapore Nottingham University Hospital NHS Trust
Singapore Vrinda Nair, MB BS MD FRCPCH Nottingham UK
Consultant Neonatology
Andrew Lunn, BM MRCPCH James Cook University Hospital Muthukumar Sakthivel, MB BS
Consultant Paediatric Nephrology South Tees Hospitals NHS Trust MD FRCPCH
Nottingham Children’s Hospital Middlesborough UK Attending Physician Paediatric
Nottingham University Hospital NHS Trust Emergency Medicine
Nottingham UK Khuen Foong Ng, MB BS MRCPCH Sidra Medicine
Registrar Paediatric Infectious Diseases & Assistant Professor
Prashant Mallya, MB BS MD Immunology Weill Cornell Medicine
MRCPCH Bristol Royal Hospital for Children Doha Qatar
Consultant Neonatology University Hospitals Bristol NHS
James Cook University Hospital Foundation Trust Nafsika Sismanoglou, Ptychio
South Tees Hospitals NHS Trust Bristol UK Iatrikes, (MD) MSc MRCPCH
Middlesborough UK Registrar Paediatric Immunology &
Amitav Parida, BSc MB BS MRCPCH Allergy
Stephen Marks, MB ChB MD MSc Consultant Paediatric Neurology Northern General Hospital
MRCP DCH FRCPCH Birmingham Children’s Hospital Sheffield, UK
Reader Paediatric Nephrology Birmingham UK
University College London Elisa Smit, MD FRCPCH
Consultant Paediatric Nephrology Sathya Parthasarathy, MB BS Consultant Neonatology
Great Ormond Street Hospital for MRCOG Cardiff and Vale University Health Board
Children Consultant Obstetrician (Fetal Medicine) Clinical Senior Lecturer Cardiff University
London UK James Cook University Hospital Cardiff UK
South Tees Hospitals NHS Trust
Eleanor Marshall, BSc MB BCh PhD Middlesbrough UK Alan Smyth, MA MB BS MD MRCP
MRCPCH FRCPCH
Consultant Paediatric Allergy Colin Powell, MB ChB MD DCH Professor of Child Health
Sheffield Children’s Hospital FRACP MRCP FRCPCH University of Nottingham
Sheffield UK Senior Attending Physician Paediatric Honorary Consultant Paediatric
Emergency Medicine Respiratory Medicine
Katherine Martin, BSc MB ChB Sidra Medicine Nottingham University Hospitals NHS
MRCPCH Doha Qatar Trust
Consultant Paediatric Neurodisability Honorary Professor of Child Health Nottingham UK
Nottingham Children’s Hospital Cardiff University
Nottingham University Hospital NHS Trust Cardiff UK Sibel Sonmez-Ajtai, MD MSc
Nottingham UK MRCPCH Dip Clin Ed
Andrew Prayle, BMedSci BM BS Consultant Paediatric Allergy
Flora McErlane, MB BCh MSc PhD MRCPCH DipStat Sheffield Children’s Hospital
MRCPCH Clinical Associate Professor Sheffield UK
Consultant Paediatric Rheumatology Paediatric Respiratory Medicine
Great North Children’s Hospital University of Nottingham Jothsana Srinivasan, MB BS DCH
Newcastle upon Tyne UK Nottingham UK MRCPCH
Consultant Paediatric Medicine &
Nazakat Merchant, MBBS MD DCH Ruth Radcliffe, BMedSci BM BS Paediatric Dermatology
FRCPCH MRCPCH Nottingham Children’s Hospital
Consultant Neonatology Consultant Paediatric Medicine Nottingham University Hospital NHS Trust
West Hertfordshire NHS Trust University Hospitals of Leicester NHS Nottingham UK
Hon Senior Clinical Lecturer Trust
King’s College London Leicester UK
London UK
v
Contributors
Richard Stewart, MB BCh BAO MD Sunitha Vimalesvaran, MB BS Lisa Whyte, MB ChB MSc MRCPCH
FRCS FRCS(Paed) MSc MRCPCH Consultant Paediatric Gastroenterology
Consultant Paediatric Surgery GRID Registrar Paediatric Hepatology Birmingham Children’s Hospital
Nottingham Children’s Hospital King’s Colle Hospital Birmingham UK
Nottingham University Hospital NHS Trust London UK
Nottingham UK Kate Adel Wilson, MNutrDiet BSc
Joanna Walker, MBE BA FRCP Dietitian
Amy Taylor, BMedSci MB ChB FRCPCH Sidra Medicine
MRCPCH Consultant Paediatric Endocrinology Doha Qatar
Consultant Paediatric Neurodisibility Portsmouth Hospitals University NHS
Nottingham Children’s Hospital Trust Damian Wood, MB ChB DCH FRCPCH
Nottingham University Hospital NHS Trust Portsmouth UK Consultant Paediatric Medicine
Nottingham UK Senior Theory Examiner (AKP) Nottingham Children’s Hospital
RCPCH Nottingham University Hospital NHS Trust
Robert Tulloh, BA BM BCh DM London UK Nottingham UK
FRCPCH FESC
Professor Congenital Cardiology Timothy Warlow, MB ChB, BMedSc,
University of Bristol FRCPCH DipPallMed
Consultant Congenital Cardiology Consultant Paediatric Palliative Medicine
University Hospitals Bristol and Weston University Hospitals
NHS Trust Southampton UK
Bristol UK
vi
Acknowledgements
The editors would like to thank the following individuals for their helpful comments on the text or
their contribution of images and clinical scenarios.
Dr Gillian Body
Dr Will Carroll
Dr Mark Fenner
Dr Amy Kinder
Sheran Mahal (Question Bank and Quality Assurance Manager RCPCH)
Dr Eloise Shaw
Professor Harish Vyas
Dr Joanna Walker
Dr David White
Dr Nigel Broderick provided many of the radiological images and appropriate explanations of
the appearances.
We are also grateful to Sue Hampshire (Director of Clinical and Service Development Resuscita-
tion Council UK) for her support and the permission to use the management flow-charts produced
by the Resuscitation Council UK.
Some of the images used in this book are taken from MRCPCH Mastercourse (volumes 1 and 2),
edited by Professor Malcolm Levene published by Churchill Livingstone/Elsevier in 2007. We are
grateful to the many paediatricians who sourced the images in that publication and trust that the
images continue to contribute to their educational aims.
Martin Hewitt
Roshan Adappa
vii
Foreword
This book forms part of the Mastercourse in Paediatrics series produced by the Royal College of
Paediatrics and Child Health with each book aimed at covering the topics outlined in the relevant
RCPCH examination syllabus. It has been written by experienced specialist authors and outlines
core information of presentation, assessment and management of conditions affecting all systems
plus information on ethics, UK law, clinical governance and evidence-based paediatrics. Although
written for candidates preparing for the Applied Knowledge in Paediatrics examination, the book
will also provide useful information and knowledge for the practicing paediatrician.
Supporting children and young people and helping them achieve their full potential requires
many skills. These include the ability to engage with the patient and their carers, the need to assess
the extent and type of problems presented and the knowledge to provide current and effective
treatments.
The training of a paediatrician must, therefore, aim to develop these skills and ensure a sound
knowledge of clinical conditions and their management. The practicalities of such management also
require the recognition of the urgency and priority of any proposed investigation and treatment.
This book covers many of these important topics.
The authors have provided a presentation of many of the common conditions seen in clinical
practice at an appropriate level for the paediatric trainee. It is well recognised, however, that such
basic knowledge requires continued revision. Consequently, every encounter with a child or young
person must be seen as an opportunity for the paediatrician to learn and improve their understand-
ing of the patient and their family, the problem presented and the appropriate management for that
problem.
This book, therefore, contributes to that growth of clinical skills and professional development
of the paediatric trainee and will help them as they prepare for the AKP exam.
Dr Camilla Kingdon
President of the Royal College of Paediatrics and Child Health
viii
Preface
This book, Applied Knowledge of Paediatrics: MRCPCH Mastercourse, has been written specifically for
trainees in paediatrics who have around 18–24 months of clinical experience and who may be pre-
paring for the Applied Knowledge in Practice (AKP) examination. It forms part of the Mastercourse
in Paediatrics series that was established by the RCPCH and joins the Science of Paediatrics book
edited by Lissauer and Carroll. Both books are written with the prime aim of helping trainees pre-
pare for specific RCPCH theory examinations but they will also be of value to paediatric trainees as
part of their everyday practice.
Membership of the Royal College of Paediatrics and Child Health (MRCPCH) is a postgraduate
qualification in Paediatric Medicine that is recognised in the UK and internationally. The award of
the qualification indicates that a trainee has achieved a high standard of practice and is able to start
Higher Specialist Training.
The AKP examination assesses the candidate’s knowledge of the presentation, investigation and
management of a wide range of conditions affecting children and young people. This level of under-
standing comes from clinical exposure to patients, reading about the details of the clinical condi-
tions presented and taking the opportunity to discuss issues with experienced colleagues.
The chapters in Applied Knowledge of Paediatrics cover all the systems and each starts with the
points listed in the RCPCH AKP syllabus. The subsequent chapter was then written by the specialist
authors to ensure these topics were addressed.
Within each chapter there are Practice Points that capture important issues relevant to clinical
practice or that may include explanations using examples.
Clinical Scenarios are also presented and are based on known, but modified, clinical stories to
outline some of the issues that may present themselves to the clinician. Some of the issues presented
are not resolved and so reflect the reality of current practice.
At the end of each chapter there are Important Clinical Points that provide a list of some of the
significant points raised in the chapter.
Images are used throughout the chapters. These will demonstrate many important features that
may appear in the examination but they should also act as a prompt to the reader to seek out further
examples of the appearances shown. The adage ‘One swallow doesn’t make a summer’ could be
adapted to make the point that ‘One image doesn’t capture all the relevant features’.
Each chapter finishes with a short list for Further Reading to allow the reader to explore reviews
and topics in more detail. Many chapters have drawn information from current guidelines pub-
lished by the National Institute for Health and Care Excellence (NICE). Clearly these guidelines may
change over time and it is the responsibility of every clinician to ensure that the most up-to-date
version is consulted.
The first chapter provides some advice on preparing for the AKP examination including some
insight into the process of producing the actual exam papers, assessing the questions and the post-
examination review. The aim is that by understanding how the papers are constructed from items in
the RCPCH Question Bank and how the results are reviewed after the exam, the candidate will gain
some understanding of the structure of the examination.
The final chapter provides 50 AKP exam-style questions presented in random order along with
itemised answers that aim to provide clarification on how answers can be assessed and the correct
ones chosen. The reader may wish to use this as a practice examination but must remember that
ix
Preface
questions in the real examination have different weightings allocated depending on various factors
such as length, complexity and format.
We would like to thank all the authors of each of the chapters for sharing their knowledge and
expertise, and for their understanding as we made changes and requested further reviews of their
text.
Our thanks also to Alexandra Mortimer, Shivani Pal and the larger team at Elsevier for their sup-
port and guidance during the production of this book.
Finally, our thanks must go to our families for their patience and tolerance as we committed time
to working on this project.
We hope the book proves valuable to all trainees and contributes to the improvement in the care
and treatment of the many children who will come under their care.
Martin Hewitt
Roshan Adappa
x
Chapter |1|
Preparing for the AKP exam
Martin Hewitt
1
Chapter |1| Preparing for the AKP exam
Candidates will obviously need to build their knowledge for example, most candidates choose an answer differ-
base by further background reading. ent from the allocated correct answer, this suggests that
the phrasing of the question is ambiguous and points
to more than one acceptable valid answer. The panel
Examination structure would review that question in detail and, if it is agreed
that phrasing of any part of the question is ambiguous
and therefore unfair, then the question is removed from
The examination is a curriculum-driven, computer-based that examination. The question is sent for review rather
assessment that takes place three times each year. There than returned to the question bank.
are two separate papers sat on the same day with each
paper lasting 2.5 hours. In total there are 120 questions
across the two papers. The exam does not use negative Question types
marking—a wrong answer scores zero. The allocation of
topics across the various syllabus headings is set by the
“Theory Examination Blueprint” that allows specific map- There are different question types used in the examina-
ping of questions to the syllabus and aims to provide a tion. Examples of these can be seen on the RCPCH web-
balanced selection of questions across the entire syllabus site and in Chapter 35 of this book. Some information on
in each exam. each question type is offered here.
2
Preparing for the AKP exam Chapter |1|
questions do not ask for more than three answers and the commonly in certain ethnic groups or in certain geograph-
list of options provided will be up to a maximum of 10 ical locations.
answers available. An awareness of the indications, contraindications and
long-term consequences of some of the drugs adminis-
tered to children is important. Candidates are advised to
Multipart question (MPQ) use the BNFc during their normal working day as part of
This question structure follows the format of the single best their revision and to look at contraindications and com-
answer but there are usually two questions joined to the ini- mon side effects.
tial scenario and each question is independent of the other. Many questions will contain images such as clinical
The answer to part one does not give a clue to the answer of photos, radiographs and ECGs.
part two. Clinical photographs will cover a range of features
including specific syndromes and disease-related abnor-
malities. The ability to identify a series of clinical features
Extended matching questions (EMQ) in a child and recognise the underlying syndrome is a skill
This format provides an introductory statement that that many geneticists and paediatricians take many years
explains the general topic for the question. Examples to develop. However, recognising the features of a small
would include cardiac diagnoses, drugs for epilepsy or group of syndromes is required for the AKP exam and
investigations for hypernatraemia. these are presented in this book. Trainees are advised to
The question then presents the first statement or clini- review as many images as possible of these syndromes
cal scenarios followed by a list of 10 potential answers. to ensure they can identify the major features. Similarly,
The second scenario is then presented followed by the wherever a condition which has recognised clinical fea-
same list of 10 answers and finally the third question with tures is described in the text, the candidate should seek
the same 10. It is possible that one of the answers may be out example images or descriptions.
chosen for more than one of the questions—each ques- There are questions that require the ability to inter-
tion is independent of the other two. pret radiographs although it is accepted practice that it
is the radiologist who will provide the definitive opin-
ion and final report. Trainees, however, do need to iden-
Detailed advice tify common radiological abnormalities that require
Some questions may seem to have one or two obvious an immediate response and management such as the
answers and the candidate needs to look for further clues presence of a pneumothorax, a pneumonia, or necrotis-
in the question stem to support one or the other. For ques- ing enterocolitis. MRI and CT scans must be reported
tions where there is no obvious answer, one approach by radiology staff but an AKP candidate must have an
would be to ask the ‘reverse question’ and identify those understanding of the common abnormalities to allow
answers which clearly do not fit the clinical scenario in the explanation of the findings to patients, carers and col-
question stem. Having removed these answers, the can- leagues usually following a discussion with the radiolo-
didate can then work on those remaining to identify the gist. Trainees should attend as many radiology meetings
appropriate and correct answer. as possible and be prepared to ask radiologists to explain
All questions in the examination that include results important features.
of laboratory investigations will also show the normal
ranges for each of the listed test. These ranges may be
slightly different from those used at the candidate’s insti-
Evidence-based paediatrics
tution but these are the ones agreed for examination. In The AKP examination will contain two questions about
practice, this is not a problem as the provided results, evidence-based practice in each paper. The questions usu-
where appropriate, are obviously abnormal or obviously ally present information from a published paper but with
normal. the methodology and results summarised. The data can
The candidate should read the stem very carefully be complex and each answer should be compared in turn
as it often contains specific details to guide the candi- with the given results to determine whether the answer
date towards particular conditions that may occur more statement can be supported.
3
Chapter |1| Preparing for the AKP exam
Marking Results
• arks awarded for each question are different and
m • normal ranges are shown for each test
weighted for complexity
• a wrong answer scores zero Images
• r eview as many images as possible of syndromes
Single best answer • review as many images as possible of clinical signs and
• understand the exact phrase of the question being asked described lesions
Further reading
4
Chapter |2|
Neonatology
Authors: Mithilesh Lal, Elisa Smit, Nazakat Merchant
Contributions from: Sunitha Vimalesvaran, Vrinda Nair, Prakash Loganathan, Prashant Mallya, Rohit Kumar,
Janakiraman Sundaram, Sathya Parthasarathy
After reading this chapter you should be able to diagnose age in the second half of pregnancy. This definition does
and manage: not distinguish the normal, constitutionally small fetus
• birth injury (small for gestational age [SGA]) from the small fetus
• short and long-term consequence of preterm birth whose growth potential is restricted. The latter fetus is
• common medical conditions at increased risk of perinatal morbidity and mortality
• common surgical conditions whereas the former is not.
• congenital anomaly
• common postnatal problems IUGR may be:
and Symmetrical IUGR (20%–30% of small fetuses) that re-
• know the effect of prenatal and perinatal events on
fers to a growth pattern in which all fetal organs are
neonates
decreased proportionally and is thought to result from
a pathological process manifesting early in gestation.
Asymmetrical IUGR (70%–80 % of small fetuses) where
Antenatal assessment of fetal there is a relatively greater decrease in abdominal size
growth (liver volume and subcutaneous fat tissue) than in head
circumference and is thought to occur late in gestation.
5
Chapter |2| Neonatology
6
Neonatology Chapter |2|
7
Chapter |2| Neonatology
8
Neonatology Chapter |2|
maintenance of a normal body mass index and longer that clamping the cord after a good respiratory effort is
intervals between pregnancies established is more effective than time based delayed cord
• low-dose aspirin may reduce the risk of spontaneous clamping. Positive End Expiratory Pressure (PEEP) sup-
preterm birth port has been shown to be beneficial by establishing a
• cervical cerclage placement may prolong gestation for functional residual capacity in the lungs. Routine airway
women with a history of preterm birth suction with or without meconium has no benefit and is
therefore not recommended.
Management of preterm labour
The diagnosis of preterm labour is based on clinical cri- Medical conditions in the preterm
teria of regular painful uterine contractions accompanied
by cervical dilation or effacement. Tocolytics can be used
neonate
to try and delay preterm labour so that antenatal steroids
and magnesium sulphate can be given.
Respiratory distress syndrome
Management of the high-risk Respiratory distress syndrome (RDS) is primarily seen
in premature babies and is the result of surfactant defi-
pregnancy ciency and immature lung development and therefore
Preterm birth can result in significant health consequences in the incidence decreases with increasing gestational age.
both the short and long term. Pregnancies that are likely to Risk factors for RDS include prematurity, maternal dia-
produce infants at high risk of problems include those with: betes, absence of labour and lack of antenatal steroids.
• intrauterine growth restriction—from maternal, placen- Antenatal steroids, surfactant therapy and noninvasive
tal or fetal causes respiratory support have resulted in reduced mortality
• prolonged preterm rupture of membranes, presenting as from RDS.
infection or risk of infection or related poor lung growth The preterm infant with RDS will have tachypnoea,
• congenital malformations from syndromic association grunting, chest wall retractions, nasal flaring and ‘head
• chronic maternal illness—maternal diabetes and other bobbing’. As the condition becomes more severe the baby
medical conditions becomes cyanotic and pale and may have apnoeic epi-
• acute fetal compromise—placental abruption, cord pro- sodes.
lapse
• twin or higher order pregnancy
Differential diagnosis
Initial assessment and intervention in the delivery room:
• pregnancies at risk of difficulties should occur in a hos- • t ransient tachypnoea of newborn (TTN)
pital with a level 3 NICU. Antenatal steroid administra- • aspiration
tion for lung maturation and magnesium sulphate for • pneumonia or sepsis
neuroprotection should also be administered to the ex- • cyanotic congenital heart disease
pectant mother.
• delivery room temperature needs to be kept above 25oC
Investigations
and the use of a plastic covering for the preterm infant
will help maintain better thermal control. Each degree The chest x-ray will show the recognised changes of RDS
below 36.5oC is associated with increased mortality in with the reticulogranular pattern (ground glass) in the
preterm babies of about 28%. lung fields, an air bronchogram and low lung volumes
(Figure 2.3).
Following birth
Treatment and management
Most preterm or term infants will not need any inter-
vention. The management outlined in the Resuscitation Antenatal steroids reduce the incidence and severity of
Council UK algorithm should be followed if intervention RDS and the consequent need for mechanical ventilation.
is required (Figure 2.2). Current recommendation is for them to be offered to all
Specific aspects of the assessment of the newborn women between 24+0 and 33+6 weeks of pregnancy who
require consideration. are at risk of preterm delivery within 7 days. The ideal
Clamping of the cord can be delayed for up to 3 min- therapeutic window for administration is when delivery is
utes in the preterm infant, although there is good evidence expected 1 to 7 days after a complete course of treatment.
9
Chapter |2| Neonatology
Birth
Preterm Delay cord clamping if possible
Approx 60 seconds
Maintain temperature
Acceptable Reassess
pre-ductal SpO2 If no increase in heart rate, look for chest movement
2 min 65%
If the chest is not moving
5 min 85%
• Check mask, head and jaw position
10 min 90% • 2 person support
• Consider suction, laryngeal mask/tracheal tube
• Repeat inflation breaths
• Consider increasing the inflation pressure
Reassess
Titrate oxygen to achieve target saturations
Fig. 2.2 Newborn Life Support algorithm (Reproduced with permission from the Resuscitation Council UK 2021)
10
Neonatology Chapter |2|
11
Chapter |2| Neonatology
and bowel gases have tracked along the tissue planes. Sen- recognised by the onset of apnoeic episodes, seizures, or
tinel bowel loops (fixed loops) may indicate bowel necro- cardiovascular collapse with significant acidosis due to the
sis without pneumatosis. acute blood loss.
Severity
grade 1 germinal matrix haemorrhage with or
without IVH (less than 10% of ventricle
filled with blood) (Figure 2.5).
grade 2 IVH (10%–50% of ventricle filled with blood),
typically without ventricular dilation.
grade 3 IVH (greater than 50% of ventricle filled with
blood) typically with ventricular dilation
(Figure 2.6a and 2.6b).
grade 4 periventricular haemorrhagic infarction. Fig. 2.5 Para-sagittal view of a small GMH-IVH (grade 1 IVH)
(Copyright – Dr Mithilesh Lal - used with permission)
13
Chapter |2| Neonatology
A B
Fig 2.6a and Fig. 2.6b. Coronal and parasagittal view of grade 3 IVH (Copyright – Dr Mithilesh Lal - used with permission)
The condition is initially asymptomatic and only iden- severe ROP, and 1% will develop blindness. Classification
tified on routine cranial USS but can later lead to abnor- of ROP is based on anterior-posterior location (zone),
malities of tone, poor feeding and seizures. severity (stage), extent (number of clock hours of ROP
along the circumference of retina), dilation and tortuosity
of posterior pole vessels.
Treatment and management Signs indicative of ROP activity including increased
Strategies to prevent PVL include antenatal steroids and venous dilation and arteriolar tortuosity of the posterior
antenatal magnesium sulphate given to the mother when retinal vessels. These features may later increase in severity
preterm delivery is imminent. Once born, management to include iris vascular engorgement, poor pupillary dila-
will include delayed clamping of cord, optimum resusci- tion (rigid pupil) and vitreous haze.
tation and stabilisation and gentle ventilation to avoid Screening criteria in UK advise that all babies less than
extremes in CO2 and O2 levels. Adequate management 32 weeks gestational age (up to 31 weeks and 6 days) or
to maintain normal levels of blood pressure, temperature less than 1501 g birth weight should be screened for ROP.
and blood glucose are important steps in early manage-
ment that help prevent neurological damage.
Treatment and management
Laser ablation is the current treatment of choice as this
Neurodevelopmental outcome prevents progression of the lesions to retinal detachment
Cystic PVL often leads to spastic diplegia. It is easier to and blindness. Intraocular injections of anti-VEGF agents
predict neuromotor outcomes than other domains of such as bevacizumab are considered as first-line treatment
neurodevelopmental problems, including cognitive and for localised central ROP as laser ablation is ineffective in
behavioural issues relating to more common and wide- the prevention of retinal detachment.
spread diffuse WMI.
14
Neonatology Chapter |2|
15
Chapter |2| Neonatology
16
Neonatology Chapter |2|
measurement is repeated 12–18 hours after stopping pho- atresia must occur before 6 weeks of age to minimise
totherapy to identify a marked rebound. the chance of liver cirrhosis. Liver dysfunction is man-
Double volume exchange transfusion is indicated for aged medically by preventing bleeding disorders and
bilirubin levels above the exchange treatment line, for rap- hypoglycaemia.
idly rising levels or if signs of acute bilirubin encephalopa-
thy develop.
Neonatal sepsis
Neonates with evolving sepsis usually present with non-
Complications specific signs although certain features in the history
Acute bilirubin encephalopathy can present with sei- should raise the suspicion of an infective cause for the
zures and variations in tone. Some infants will go on to clinical signs. These include:
develop a kernicterus-spectrum disorder with an athetoid • parenteral antibiotic treatment to the mother during la-
cerebral palsy, sensorineural hearing loss and cognitive bour or postpartum period
delay. • invasive group B streptococcal infection in a previous
baby
• maternal group B streptococcal in current pregnancy
Conjugated hyperbilirubinemia • premature rupture of membranes more than 18 hours
This is usually identified in those neonates who remain in preterm and 24 hours in term baby
jaundiced at 2 weeks of age and have a conjugated bili- • preterm birth
rubin over 25 micromol/litre. The cause is always patho- • intrapartum fever higher than 38°C
logical and requires further investigations. A differential • chorioamnionitis
diagnosis would include: Clinical indicators of possible early- onset neonatal
• bacterial sepsis infection are respiratory distress starting within 4 hours
• biliary obstruction after birth, seizures or signs of shock, whilst more subtle
• hypothyroidism and hypopituitarism indicators of sepsis would include temperature instabil-
• metabolic disease—galactosaemia and tyrosinaemia ity, glycaemic instability, episodic cyanosis, apnoea, early
The infant with jaundice and pale stools is likely to jaundice, early signs of encephalopathy, abnormal coagu-
have a biliary obstruction whilst those with jaundice with- lation and metabolic acidosis.
out obviously pale stools are likely to have elevated liver
enzymes and have a neonatal hepatitis syndrome. Impor-
Investigations
tant extrahepatic signs that will aid a diagnosis include dys-
morphic features, cardiac murmurs (babies with Alagille A full infection screen including blood culture, CRP and
syndrome have a peripheral pulmonary artery stenosis) lumbar puncture is required.
and hypoplastic male genitalia which are seen with panhy-
popituitarism. An ill infant with liver failure will develop a
Treatment and management
coagulopathy unresponsive to intravenous vitamin K.
The administration of antibiotics will follow local proto-
cols. Intravenous benzylpenicillin with gentamicin is the
Investigations first-choice antibiotic regimen for empirical treatment of
Clarification of the underlying aetiology for the conju- suspected infection. If there is microbiological evidence of
gated hyperbilirubinaemia requires a broad range of inves- gram-negative bacterial sepsis, cefotaxime should replace
tigations including: benzylpenicillin. If meningitis is suspected and the causa-
• FBC and clotting profile tive pathogen is unknown, then intravenous penicillin
• liver function tests and cefotaxime is advised.
• metabolic screen—amino acids, organic acids, gal1-put, Late-onset sepsis occurs at 4–90 days of life and may be
alpha-1-antitrypsin caused by coagulase-negative staphylococci, group B strep-
• congenital infection screen tococci or gram-negative organisms.
• thyroid function and cortisol
• US scan liver and biliary system
Neonatal seizures
Seizures are seen with relative frequency in neonatal prac-
Treatment and management tice and may be the result of a wide range of conditions.
Most disorders affecting the major bile ducts require Prompt assessment and treatment is important as contin-
surgical correction and, in particular, surgery for biliary ued seizure activity may lead to further neurological insult.
17
Chapter |2| Neonatology
18
Neonatology Chapter |2|
19
Chapter |2| Neonatology
20
Neonatology Chapter |2|
Exomphalos
An exomphalos is protrusion of the abdominal content
Fig. 2.11 Term infant with exomphalos showing midline
through the umbilical ring and are therefore midline
position and peritoneal sac covering of intestines.
abnormalities. They are usually covered by peritoneum
although this may tear during delivery (Figure 2.11). It
is usually diagnosed during the 20-week anomaly scan.
Other congenital abnormalities are common. Surgi-
Anorectal malformations cal repair is required and may take place over multiple
An imperforate anus is usually identified during the new- stages.
born physical examination and can be isolated or part of
the VACTERL association. The passage of meconium does
not exclude an anorectal malformation as fistulas can
Gastroschisis
occur between the bowel and vagina or urethra. Surgical The abdominal wall defect in gastroschisis is para-
repair is required and may be staged with an early colos- umbilical and the exposed abdominal contents lack a
tomy and a later reconstruction. peritoneal covering (Figure 2.12). The bowel wall is thick-
ened, often scarred and covered with a thick fibrous peel
containing multiple adhesions.
Vacterl association
The acronym describes a recognised cluster of congenital
Treatment and management
anomalies that may be found together in a newborn. It is
usual to identify at least three of the characteristic features At birth the defect should be covered immediately to pre-
before the term is used. vent fluid and heat loss and the eviscerated organs sup-
• vertebral anomalies—hemi-or fused vertebrae, rib ported to avoid twisting. Plastic film wrap is commonly
anomalies, sacral agenesis used to achieve this.
• anal atresia The abdominal wall opening is usually relatively small
• cardiac defects—VSD, Tetralogy of Fallot compared to the protruding intestine and there is a risk
• tracheo-oesophageal fistula of compromised blood flow to the bowel. Urgent surgical
• renal anomalies—absent, dysplastic ectopic or horse- correction is therefore performed to protect the exposed
shoe kidney intestine and reduce fluid losses. Many infants show
• limb abnormalities—radial hypoplasia or agenesis, po- delayed gut motility and take many weeks to establish full
ly-or syndactyly enteral feeds.
21
Chapter |2| Neonatology
Further reading
22
Chapter |3|
Adolescent medicine
Damian Wood, Karen Aucott
23
Chapter |3| Adolescent medicine
in place which promote the health needs of adolescents The key to understanding the legal framework is the
and young adults issue of context. There is no single piece of UK legisla-
• research and innovate to enhance the health of young tion that defines adulthood, rather a series of different
people and improve access to developmentally appro- pieces of legislation that define when a young person
priate healthcare through meaningful and ethical par- can acquire the right to adult responsibilities. From a
ticipation healthcare perspective, it is crucial that paediatricians
• promote the health and safety of young people, respect have expertise in the legal framework of consent and
their individual rights, reduce health inequalities and confidentiality in relation to children and young people.
tackle the social determinants of health as this is likely This topic is presented in more detail in Chapter 32 on
to have important health and economic consequences Ethics and Law.
into the future.
The use of formal interview tools can help discussions
with adolescents and ensure that important areas that may Risk-taking behaviour
impact on health are addressed. One such tool is the struc-
tured HEEADSSS method of interview developed by Drs
Goldenring and Rosen that provides introductory phrases
Substance abuse
for each of the listed topics. Substance misuse by adolescents and young adults is a
major public health concern as it contributes to morbid-
ity and mortality in adolescence. Over the lifetime of an
PRACTICE POINT – the HEEADSSS structured individual, much of the morbidity and mortality attrib-
interview uted to alcohol, tobacco and other drugs can be traced to
behaviours that begin during adolescence. Substance use
• - Home environment
H is also associated with risks of abuse, poor educational
• E - Education and Employment and employment outcomes, criminality, disrupted peer
• E - Eating and family relationships as well as a range of mental and
• A - Activities (peer related) physical health disorders.
• D – Drugs Alcohol, tobacco and cannabis are the substances most
• S – Sexuality often used by adolescents although trends in drug use do
• S - Suicide/depression vary over time. There have been recent reductions in prev-
• S - Safety alence of adolescent alcohol use and smoking in the UK
but with increases in the use of cannabis, novel psychoac-
tive substances and vaping. Shifting trends in drug use are
predictable and cyclical, although they are influenced by
Legal framework population level factors such as legislation, taxation and
As young people acquire independence during the tran- law enforcement activity.
sition to adulthood, they are permitted greater rights The period of adolescence includes the ongoing state
as citizens and this includes the right to vote, the right of brain development and is a time of risk-taking and
to work and the right to make decisions for themselves sensation-seeking behaviours. Such behaviour would
free from parental involvement. They are also granted include substance use that may lead to permanent
the right to participate in a range of activities that are changes. The CRAFFT screen is a brief screening tool that
prohibited for children such as consensual sexual inter- has been validated in the adolescent primary care setting
course, getting married, driving motor vehicles, buying to identify problematic substance use and uses a series of
alcohol and tobacco, gambling and obtaining financial six questions to explore the topic and help identify those
credit. young people who may need support.
In England and Wales, the Children Act 1989 applies
to all children and young people up to their 18th birthday
and outlines the responsibility of the state and parents in
Alcohol
this regard. There is, however, other UK legislation that Alcohol is the drug most commonly used by adolescents
permits young people to receive adult responsibilities at and is a CNS depressant that stimulates the endorphin and
ages younger than 18yrs. For example, young people can dopaminergic reward systems. It is rapidly absorbed and
apply for a provisional driving licence at 17yrs of age, has physical, mood and cognitive effects.
can legally have consensual sex from 16yrs of age and are Recent UK data show that although rates of alcohol use
assumed to have mental capacity to make some decisions continue to rise with increasing age, the number of young
from age 16ys or earlier. people who drink and the amount that they drink appears
24
Adolescent medicine Chapter |3|
to be decreasing gradually over time. Similarly rates of • r ecurrent alcohol use resulting in a failure to fulfil major
hospitalisation of young people for alcohol-related condi- role obligations
tions are falling. • continued alcohol use despite having social or interper-
Alcohol use increases with age and, among 15 year sonal problems caused by alcohol
olds in England, 18% report drinking in the previous • important social, occupational or recreational activities
week. Alcohol use in young people remains a serious pub- are given up because of alcohol use
lic health concern as alcohol contributes to preventable • recurrent alcohol use in situations in which it is physi-
deaths and injury and alcohol use established in adoles- cally hazardous
cence tracks into adulthood. If alcohol misuse is identified as a potential problem,
Alcohol use in young people has been associated with then a brief assessment of the duration and severity of
the following: the alcohol misuse is required. Young people under 16
• injury—motor vehicle accidents, falls, interpersonal years of age with alcohol use disorder should be referred
violence to a specialist child and adolescent mental health service
• victim of physical/sexual assault (CAMHS).
• sexual risk behaviours
• criminality
• self-harm and suicidality
Tobacco and vaping
Alcohol is neurotoxic and whilst the extent of the Smoking is the primary cause of preventable morbid-
effects on the developing adolescent brain have not been ity and mortality in the UK, accounting for one in six of
fully elucidated, it is known that binge drinking and heavy all deaths. One in five young people try smoking at some
alcohol use in adolescence has effects on brain structure point; however, regular smoking is less common and there
and function including impaired learning, impaired mem- has been recent and significant downward trend in smok-
ory and disruption of the sleep-wake cycle. Young people ing by young people.
do appear to be more tolerant of the acute intoxicating Risk factors for smoking in adolescence include
effects of alcohol and show fewer acute withdrawal effects • low socioeconomic status
than adults. • low educational attainment
Children of parents with an alcohol use disorder are • parental, sibling or peer smoking
four to ten times more likely to develop the same prob- • those with low self-esteem or depression
lem. The perceptions of parental approval of alcohol use • lesbian, gay and bisexual young people
and the parents’ use of alcohol have been identified as risk Nicotine is a highly addictive substance and abstinence
factors for adolescent initiation of drinking behaviours. leads to withdrawal symptoms:
Early initiation of alcohol before 14 years of age is associ- • cravings
ated with an increased risk of alcohol use disorder. • increased appetite
Marketing and media influences have a substantial • depression
effect on alcohol use by young people. This includes alco- • poor concentration
hol industry–sponsored advertising but also the depiction • irritability/aggression
of alcohol use in media and exposure to alcohol use by • sleep disruption
peers and older adults through the internet and social All young people who smoke should be advised to
media. stop and should be offered referral to a local smoking
cessation service or given information on how to access
such services. Interventions can increase the chances of
Alcohol use disorders
smoking cessation and generally fall into two categories:
The diagnostic criteria for alcohol use disorders describe a medication and psychological support. The evidence sug-
maladaptive pattern of substance use leading to clinically gests that smokers are four times more likely to quit suc-
significant impairment or distress, as manifested by two or cessfully by using a combination of pharmacological and
more of the following, occurring at any time in the same psychological intervention.
12-month period:
• alcohol often taken in larger amounts or over a longer
period than was intended
Nicotine replacement therapy
• persistent desire or unsuccessful efforts to cut down or Nicotine replacement therapy (NRT) works by substi-
control alcohol use tuting the nicotine provided in cigarettes, alleviating
• excess time is spent in obtaining alcohol, using alcohol nicotine withdrawal symptoms and allowing users to grad-
or recovering from its effects ually reduce their dependence on nicotine. NRT includes
• craving for, or a strong desire to use alcohol nicotine-containing chewing gum, transdermal patches,
25
Chapter |3| Adolescent medicine
lozenges, mouth spray, inhalator and nasal spray and is Short-term effects may include impairments of
usually taken for 8 to 12 weeks. • short-term memory which will affect learning and re-
tention of information
• motor coordination—increasing the risk of injury
E-cigarettes and vaping through accidents
Electronic cigarette use (also known as vaping) is increas- • judgment and risk perception—increasing the risk of
ing amongst adolescents and young adults and there is injury, assault and potentially harmful or risky sexual
emerging evidence that they may be effective in helping behaviours
adult smokers to quit. NICE advises that young people Repeated use of cannabis leads to tolerance, and a
wishing to stop smoking should be advised that whilst cannabis withdrawal syndrome has been described with
the safety and quality cannot be assured, e-cigarettes are symptoms of withdrawal being similar to those of nico-
likely to be less harmful than cigarettes. Recent reports tine withdrawal. They typically appear within one day of
of vaping-associated lung injury have added to concerns cessation, peak after one week, and may last up to two
regarding their safety. weeks. Withdrawal symptoms include irritability, depres-
sion, anxiety, restlessness, reduced appetite, sleep prob-
Illicit drugs lems and weight loss.
Repeated exposure to cannabis in adolescence leads
Cannabis to neurotoxic effects in brain structure and function
Marijuana is derived from the dried seeds, stems, leaves which persist into adulthood and may not be entirely
and flowering tops of the plant Cannabis sativa and is the reversible. This includes an association between frequent
most commonly used illegal substance in the UK. It may use of cannabis and a significant decline in IQ whilst
be smoked, vaped or ingested with smoking being the heavy cannabis use has also been associated with poor
most common route (table 3.1). educational and social outcomes. Given the importance
of educational attainment to adolescent development
and outcomes, the cognitive effects of cannabis are of
Table 3.1 Cannabis names and methods of intake particular concern.
Adolescent-onset cannabis use is associated with men-
Methods Names
tal disorders including a risk of developing a psychotic
smoked: weed hash or hashish disorder (including schizophrenia) which is increased in
spliff or joint – rolled in a pot ganja those with a family history. Regular use in adolescence is
cigarette paper dope bud also associated with anxiety, depression, suicidality and
blunt – a hollowed out cigar grass pollen deterioration in symptoms in those who already have
bowl – a pipe skunk bhang depression, bipolar disorder or schizophrenia.
bong – a water pipe resin sensi Assessment should include enquiring about cannabis
ingested: (brownies/cakes) puff sensimiella use in the past year and this may be incorporated into
adolescent psychosocial screening tool such as HEEADSSS.
If the young person endorses use in the last year, then the
Onset of use typically occurs in adolescence although CRAFFT questions can help to elicit problematic substance
the peak prevalence of use is among young adults. Adoles- misuse. Cannabis use is detectable on urine toxicology
cents and young adults are more susceptible than adults testing although this is not true for synthetic cannabi-
to the adverse effects of marijuana use and more likely to noids. Emergency presentations related to cannabis are
develop cannabis use disorders. rare. For those with acute marijuana intoxication, support-
The effects of inhalation are usually apparent within 30 ive care is all that is required.
minutes and typically lasts 2–3 hours, but with ingestion There are no specific pharmacotherapies available to
the effect-onset is delayed and lasts longer. The recognised treat cannabis use disorder and intervention is based on
effects of acute intoxication from cannabis are: motivational enhancement and cognitive behavioural
therapies, which may be delivered in individual or group
• e uphoria • s edation settings.
• distorted perception • increased appetite
• reduced inhibition • tachycardia
• anxiety • orthostatic Other drugs of abuse
• psychotic symptoms hypotension Use of other drugs of abuse such as opioids, MDMA
• cognitive impairment • supine hypertension (ecstasy), benzodiazepines, amphetamines, LSD, ketamine
• processing difficulties • conjunctival injection and novel psychoactive substances is much less common
26
Adolescent medicine Chapter |3|
in adolescence, but they are all associated with significant Nitrites including amyl, butyl and isobutyl nitrites are
potential harms. known as ‘poppers’. They lead to vasodilatation, increased
Novel psychoactive substances are synthetic drugs that sexual pleasure and a mild high or ‘rush’.
are designed to mimic the effects of other psychoactive In recent years, abuse of ‘laughing gas’—nitrous
substances. They can be grouped into four main catego- oxide—has increased as the drug is sold in balloons or
ries—stimulants, cannabinoids, hallucinogens and depres- canisters and is inhaled for a rapid onset. Inhalants are
sants—and all can be taken in a number of ways. Toxicity not detected by routine urine drug screenings.
is a significant concern for novel psychoactive substances
and they are not “safe” alternatives.
Self-harm
Self-harm is defined as self-poisoning or self-injury irre-
Inhalants spective of the apparent purpose of the act and includes
Inhalants are most frequently used by younger adolescents any form of behaviour that leads to self-injury. National
(10–12yrs) and use decreases with age. The four groups of guidance avoids the use of the term ‘deliberate’ and other
inhalants are volatile solvents, aerosols, nitrites and medi- descriptions that imply the presence or absence of suicidal
cal gases. They have a rapid onset of action, low cost and intent such as ‘attempted suicide’, ‘parasuicide’, ‘non-
are often readily available in legal products such as spray suicidal self-injury’.
paint, glues, cleaning fluid, permanent markers and deo- Community- based studies estimate around 10% of
dorants. They are typically inhaled from a plastic bag young people reported self- harm whilst other UK and
(“bagging”) or saturated cloth (“huffing”). European studies have suggested rates between 15% to
Indicators of inhalant abuse may be subtle and it may 22%. Young females report two to four times higher rates
only be suspected when potential inhalants are discov- of self-harm than young males and there has been a trend
ered by parents/carers. Abusers may have chemical odours of increasing hospitalisations in young people for self-harm
on the breath or clothes, show a change in behaviour or (Figure 3.1). Most young people who do self-harm do not
develop a marked decrease in appetite. Young people may attend hospital and many do not seek or access medical or
exhibit confusion, poor concentration, depression, irri- psychological treatment. Suicide is a leading cause of death
tability, hostility and paranoia and inhalation of solvents in young people and the risk is greater for boys than girls.
may lead to peri-nasal and peri-oral rashes and epistaxis. Young people may not be able to explain why they
Social and educational decline and neglect of personal self-harm and this is not surprising when self-harm itself
care are commonly seen. Initially they cause stimulation is a way of communicating, coping or adapting to intense
progressing to depression and their use often escalates as emotional or psychological distress. The act of self-harm
the ‘high’ is short lived. Inhalant abuse can lead to sudden may serve a number of purposes in relation to the intense
death and for chronic users may lead to irreversible neuro- distress including distracting, self-punishing, communicat-
logical, renal, cardiac or hepatic injury. ing, controlling and distracting.
700
Age specific rate per 100,000
600
500
400
300
200
100
0
2011/12 2012/13 2013/14 2014/15 2015/16 2016/17 2017/18
10–14 15–19 20–24
Fig. 3.1 Hospitalisation for self-harm rates among 10–24 year olds in England (Source: Public Health England Hospital Episode
Statistics 2017/18. Permission to use via Open Government Licence.)
27
Chapter |3| Adolescent medicine
Risk factors for self-harm suicide and the risk of repetition as well as to document
• female gender any other risks to the young person.
• affective or depressive symptoms In addition to identifying the current resources, coping
• onset of sexual activity abilities and protective factors of the young person and
• sexual and gender identity family the assessment should also consider the needs of
• adverse childhood experiences such as abuse, bullying, the young person and family in relation to safeguarding
parental separation or death risks, mental health issues, drug or alcohol use and finan-
• mental health disorders cial needs. It is important that paediatric and CAMHS ser-
• drug and alcohol use vices collaborate closely with colleagues in social care and
health professionals with safeguarding expertise.
The focus of paediatric management is:
• emergency assessment of the method, extent, timing
Safety planning
and context of the self-harm
• emergency management of the injury or poisoning Parents and carers should be advised regarding safe stor-
• initial assessment of psychosocial risks and resilience age of medicines and removal of sharps and provided with
and risk of abuse or neglect contacts for local and national crisis support services.
• establishing whether the young person is fit for a compre-
hensive psychosocial assessment and any issues relating
Outcomes
to legal framework such as consent and confidentiality
• ensuring a comprehensive psychosocial assessment of Suicide is uncommon before 15 years of age but increases in
risk and need is undertaken and the results shared ap- prevalence with age, and it is clear that rates of death from
propriately between professionals, young person and suicide are increasing in young people. The strongest predic-
parents/carers tors of suicide in young people are self-harm, cannabis and
• a care plan is established with the young person to pro- other drug use, exposure to self-harm in others and personal-
mote their safety and well-being and reduced the risk of ity type. Specific groups who are at increased risk are:
death or serious harm • children looked after
Working with young people who self-harm can induce • bereaved young people (especially those bereaved by
a range of negative emotions (including anger, frustration suicide)
and sadness), and paediatricians and other health profes- • LGBT+ young people
sionals need to be aware of the potential for this and to • university and college students
understand how it may influence a professional response.
28
Adolescent medicine Chapter |3|
All three features must be present to make the diagno- The initial assessment includes:
sis, but the presence of two would lead to a diagnosis of • assessment of the degree of malnutrition—height,
atypical anorexia nervosa. weight, BMI centile, rate of weight loss
The young person with anorexia nervosa will restrict • identification of abnormal cognitions around food and
their energy intake relative to requirements which leads to weight
a significantly low body weight in the context of age, sex, • evaluation of the potential medical complications
development and physical health. • psychosocial assessment (HEEADSSS)
They demonstrate a fear of gaining weight or becom- • identification of associated conditions such as depres-
ing fat or display persistent behaviour that interferes with sion or obsessive-compulsive disorders
weight gain, even though they are underweight. They are • assessment for other medical conditions which may ac-
often worried that if they eat normally they will become count for the weight loss
fat, so they often start altering their diet by avoiding fatty
foods and carbohydrates with the aim of losing weight.
Investigations
They may also change behaviours to achieve weight loss
such as excessive exercise, self-induced vomiting and laxa- When a young person presents with a suspected eating
tive abuse. disorder, initial investigations should be focused on:
They also display a disturbance of body image, • excluding other causes for weight loss
with undue influence of body weight or shape on self- • seeking evidence of malnutrition
evaluation or denial of the seriousness of the current low • seeking acute medical complications—bone marrow
body weight. Young people with anorexia nervosa will suppression, renal and liver impairment, electrolyte ab-
often see themselves as being overweight despite being normalities.
a healthy weight or underweight. They see themselves as Initial investigations should include a full blood count,
being good or bad depending on how much they have inflammatory markers, thyroid function, coeliac serology,
eaten and how much they weigh and may also feel that renal function, liver function, bone profile and magne-
others are judging them in the same way. sium.
29
Chapter |3| Adolescent medicine
the Children Act 1989 with parental consent (best inter- catabolic to an anabolic state and carbohydrates become
ests) or by use of the Mental Health Act. the primary energy source again. The subsequent insu-
Food and nutrition are the treatments for all of the lin secretion leads to a rapid shift of electrolytes from
manifestations associated with being underweight and extracellular to intracellular compartments. Phosphate
medications are not used routinely to treat eating dis- is needed for glucose metabolism, and the increased use
orders. Occasionally anxiolytics will be prescribed for of phosphate combined with total body depletion leads
a young person with an eating disorder with the aim of to extracellular hypophosphataemia (the hallmark of
decreasing the eating disorder cognitions, and the pre- biochemical refeeding syndrome). Low phosphate levels
scribing is usually led by CAMHS. impact on metabolic processes and can affect all systems,
leading to clinical refeeding syndrome. Potassium moves
into cells to give hypokalaemia. Clinical features of the
Potential complications syndrome include:
Young people who have been starved and had restricted • delirium with visual and auditory hallucinations
intake for a period of time are at risk of refeeding syn- • dyspnoea
drome which is a serious and potentially fatal complica- • paraesthesia
tion. During starvation, the body is energy depleted and • generalized weakness and fatigue
once glycogen stores have been consumed, the body starts • peripheral oedema
to break down fats, protein and muscle as an alternative • seizures
energy source. With refeeding, the body changes from a • coma
30
Adolescent medicine Chapter |3|
31
Chapter |3| Adolescent medicine
small for gestational age. They are less likely to be breast targeted prevention for more vulnerable groups as well as
fed and are at an increased risk of poor nutrition. They are coordinated support for young parents, including contra-
twice as likely to be hospitalised due to accidental injuries ceptive advice.
up to the age of 5 years and are in the highest risk group
for behavioural problems.
Sexually transmitted infection
• h elping all young people to protect themselves is a ma-
Reducing teenage pregnancy jor public health issue
It is important that young people receive high quality edu- • in England, sexually transmitted infections in hetero-
cation about sex and relationships in primary and second- sexuals are highest in 15–24 year olds (Figure 3.2)
ary school and out of school settings. This should focus • those under 25 years accounted for 63% of all new chla-
on providing knowledge and skills such as delaying age of mydia cases in 2016
first sex, the risks of unprotected sex and effective contra- • chlamydia is the most frequent STI diagnosis, followed
ception and condom use. Parents also need to be provided by genital warts and gonorrhoea
with information and skills to be able to talk to their • the introduction of the HPV vaccinations in adolescent
children about sex and relationships. Health practition- girls may potentially have had an impact on recent
ers working with young people require training on sexual trends in new diagnoses of genital warts. This is now
health and relationships. being offered to adolescent boys as well
Paediatricians should be able to provide informa- • in 2017, there was a reduction of 40% of new HIV diag-
tion to young people on their contraceptive choices and noses among those aged 15–24 years
to consider their specific contraceptive and sexual health Reinfection with acute STIs is a particular problem with
needs. In particular, paediatricians should know how to young people, but the risk decreases with increasing age.
facilitate access to contraceptive and sexual health services Chlamydia causes an infection that is often symptom-
including timely access to emergency contraception and less but may be associated with vaginal bleeding, dis-
management of unplanned pregnancy. charge, abdominal pain, fever and inflammation of the
Young people need easy access to confidential, youth- cervix in women and watery discharge from the penis in
friendly, sexual health services. NICE guidance recommends men. Long-term complications may be severe, particularly
5000
4500
4000
3500
3000
2500
2000
1500
1000
500
0
13-14 15-19 20-24 25-34 35-44 45-64 65+
Male Female Age group
Fig. 3.2 Rates (per 100,000) of new STI diagnoses by age group and gender in England 2019 (Source: Public Health England
annual report. Permission to use via Open Government Licence.)
32
Adolescent medicine Chapter |3|
in women, as it can lead to pelvic inflammatory diseases, • h ormones—exogenous: progesterone-only pill; endog-
ectopic pregnancy and infertility. enous: polycystic ovarian syndrome
Gonorrhoea has an incubation period of only a few • menstruation
days, and males and females may experience a urethral • drugs—steroids, anticonvulsants, ciclosporin
discharge. Women are at risk of long-term serious com- • greasy emollients
plications such as infertility and ectopic pregnancy and it Clinical assessment should address the distribution of
is possible to have long-term infection without obvious acne, type and severity of lesions and the impact on well-
symptoms. being and quality of life. Young people will often under-
Syphilis has an incubation period ranging from a few estimate the impact that the condition has and may not
days to 3 months. Symptoms are nonspecific, though ill- volunteer this information. It is good practice to use the
ness usually begins with painless, highly infectious sores HEEADSSS assessment to open up conversations on this
anywhere around the body but usually at the site of issue.
infection.
Genital warts are caused by the human papillomavirus
(HPV) and are found around the penis, anus and vagina.
Management
Certain types of HPV are associated with cervical cancer There is no proven evidence to suggest that hygiene, diet
and head and neck cancers. Warts often disappear without or sweating cause acne.
treatment but can also be removed by freezing, burning • lifestyle advice:
and laser treatment. ○ wash face twice daily with a mild cleanser
Genital herpes is a common infection caused by Her- ○ avoid squeezing or picking at spots as this may cause
pes simplex virus type 2 or 1. Symptoms include small blis- scarring
ters in the genital area, which break down to give painful ○ oil-free moisturisers are advised
ulcers. Herpes may cause pain on urination. • medications
Treatment of acne varies depending on the severity and
the lesion type.
Acne Those with mild acne are treated with topical treat-
Acne vulgaris is a common problem in adolescence and is ments such as benzoyl peroxide, topical retinoids and top-
a multifactorial inflammatory disease affecting the pilose- ical antibiotic.
baceous follicles of the skin. The management of moderate acne requires the addi-
Increasing androgen production associated with tion of oral tetracycline or a macrolide. For young females
puberty stimulates sebum production, and this can block the combined oral contraceptive pill is another alternative
the pores and result in inflammation of the surrounding if there are no contraindications.
skin. The spots are caused by Propionibacterium acnes, a Topical treatment needs to be applied to the acne-
common bacterium on the skin that colonises sebaceous prone areas and not just individual spots and should be
areas. This bacteria feeds on sebum and produces waste continued for at least 6 weeks to see benefit. If a response
products and fatty acids that irritate the sebaceous glands is seen, the treatment should be continued for at least 6
and make them inflamed. months.
The clinical features include For those with severe, scarring or resistant acne, treat-
• seborrhoea—increased grease production ment with oral isotretinoin is usual. In the UK this treat-
• noninflammatory comedomes—open (blackheads) ment should only be delivered by a specialist dermatology
and closed (whiteheads) service with expertise in monitoring therapy with oral reti-
• inflammatory lesions (papules, pustules and cysts) noids. Young people usually receive treatment for around
Acne can be painful, itchy and sore and can lead to 6–8 months, and the treatment requires monitoring of
irreversible scarring if not treated appropriately. In addi- mood, blood count, liver function and serum lipids. The
tion to the physical morbidity, it can also have a signifi- major safety concerns are the potential effect on mood
cant impact on the psychological well-being of a young and teratogenicity. Young people with the potential for
person, leading to poor self-esteem, depression and anxi- pregnancy need careful discussion regarding the need for
ety. It can lead to young people avoiding meeting up with effective contraception. A referral to a dermatology ser-
friends and leave them relatively isolated. vice should be undertaken if the acne is extensive, nodu-
Factors which can exacerbate acne include: locystic, scarring or shows no improvement to the initial
• stress or emotional tension treatment
• picking at spots
33
Chapter |3| Adolescent medicine
CLINICAL SCENARIO
A 15-year-old female who was known to have epilepsy and The issues that need consideration are multiple and
dyslexia presents to clinic for a routine review. She reports interrelated. Initially it is important to establish a healthcare
that her seizures have been well controlled but she is feeling appropriate for her maturity and development including
fed up and tearful. Her acne is becoming worse and she the need for an independent consultation and reassurance
is embarrassed to go out with her friends. Her mother is about confidentiality. A formal HEEADSSS assessment would
concerned about her daughter’s appetite and feels that she be important along with obtaining details about her mental
may have lost weight. The family are also concerned about health, nutritional intake and attitudes to food which would
a change in her mood and increased anxiety about school. all allow a comprehensive approach to be developed. Active
Her periods started when she was 12 years of age and she treatment of her acne would also all help her to regain her
had established a regular pattern but has now not had a self-confidence.
period for 2 months. Early investigations were undertaken and excluded
On examination, she looked thin and had lost 2 kgs some of the listed medical conditions. It became clear
since her appointment 3 months previously. She was dressed that she had developed thoughts and behaviours typical
in a baggy long-sleeved hoody despite it being a warm day. of anorexia nervosa and was significantly restricting her
Her blood pressure was 94/55 and her heart rate was 46 calorie intake.
bpm. She had cold hands with a capillary refill of 3 seconds She was admitted for acute management of her
peripherally, a low volume pulse and a scaphoid abdomen. condition by the multidisciplinary team and a comprehensive
She made little eye contact throughout the consultation and care plan was developed in collaboration with the patient
had a flat affect. Her BMI was 14.6 which was below the and her parents. This included ensuring that all the issues
0.4 centile for her age. identified were addressed.
A differential would include an eating disorder, It was recognised that her problems were likely to
depression, potential side effects of medication and possible require longer term support and therefore planning for
underlying medical illnesses such as inflammatory bowel transition to adult services would need to be considered.
disease, coeliac disease or thyroid abnormalities.
Further reading
Eating disorders: recognition and treatment NICE guideline Contemporary Pediatrics. Published January 2014.
[NG69]. Published: May 2017. Updated: December 2020. HEEADSSS 3.0: The psychosocial interview for adolescents
https://www.nice.org.uk/guidance/ng69/chapter/Recommen updated for a new century fuelled by media https://www.co
dations ntemporarypediatrics.com/view/heeadsss-30-psychosocial-
Junior MARSIPAN: Management of Really Sick Patients under 18 interview-adolescents-updated-new-century-fueled-media
with Anorexia Nervosa Royal College of Psychiatrists. London. Suicide and suicide attempts in adolescents. Benjamin Shain and
https://www.rcpsych.ac.uk/docs/default-source/improving- Committee on adolescence Pediatrics. 2016; 138(1) https://pe
care/better-mh-policy/college-reports/college-report-cr168.pdf diatrics.aappublications.org/content/138/1/e20161420
34
Another random document with
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put him off by telling him I imagined the french were resolved to renew the
Expedition soon and so friends did not care to write least any discovery
should ensue, but could easily see that the Answer was not att all
satisfactory. I returned that same night to the Country, and during a few
days that I stayed, prepared for my journey.
N.B.—This is a fragment of a letter written by Mr. Murray to the
Pretender soon after the miscarriage of the French Expedition.
It was looked upon by some as certain,
and thought necessary by all, that Mr.
Watson[198] should come over, as he was the Murray to the
Chevalier
person who had gone through the whole
Highlands and gott the engagements of the Several Gentlemen
at his first leaving Scotland, and surely had any of them been
so little as to flinch from what they engaged to him, he was the
natural and indeed the only person that could have upbraided
them into their Duty. My Lord says he could trust to no
conveyance, and so could not soonner give us any information
your Majestys friend is here, upon Mr. D[rummond] not coming,
expected immediately after the Embargo was taken of in france
that some one or other would have been dispatched to our
Coasts with an account of what had passed, and what was to
be hoped for, that so we might have regulate our fortunes
Conduct accordingly. The neglect of this, Sir, greatly surprises
your Majestys friends in generall, and gives the Gentlemen in
the concert a good deal of Umbrage, as they thereby think
themselves slighted and neglected, whereas, they being the
first promoters of the whole scheme, they humbly think entitled
them to have the most expidetious information. His Lordship
next supposes that we are fully satisfied of the french sincerity,
which indeed is entirely otherwise, especially from the Reasons
he assigns that it was owing to the commandants neglect or
disobedience to his Instructions. We never can bring ourselves
to believe that any man (especially a french subject) grown old
with an untainted and great Reputation, durst have disobeyed
what seems to have been the only Material part of his
Instructions to block up Portsmouth, and surely, if not for this
one Errand his Voyage to the Chunnel must rather do harm
than good, which was evidently seen by the Government being
put timeously upon their Guard. As to his next paragraph
relating to the frenches cautious delay purposely to see what
Influence the powers of the Court would have upon your
Majestys friends here, and that the above cautious delay was
grating to the Prince; no wonder indeed his Royal Highness
had too penetrating an Eye not to see that it would be
impossible to recover this Time and opportunity he was losing.
But what really quite astonishes us is his Lordships saying that
from the light it was represented in, their caution seemed to be
well grounded. We cant pretend to take their Reasons to
[heart] as they are not told us, but we are affraid they consist
more in plausible pretences, dressed up with a little french
Rhetorick, than in strong and solid Arguments. We are in this
Climate generally accustomed to the plainer sort of speach,
and we cannot help thinking ourselves judges of it. Did not the
french Court know of Comns.?[199] Did they not know that that
Majority would pass all Bills that might seem their Master? Did
they not know that the repeal of the Habeas Corpus act would
naturally be the first step and that by that Repeal they were
enabled to take up every person they suspected? Did they not
know that the principal men in England, of your Majestys
friends, were in the house and that not one of them durst object
to any method that was proposed as their offering. Such would
have been an open declaration of their principles, and must
consequently have caused their confinement. Did they not
know that the English are a fickle sort of people, and that they
had a natural abhorence of the french nation, and thay could
not be ignorant that this was giving them time to frighten them
by the fear of a french Influence that State pretence and
thereby to make friends in the City of London. If they were
Ignorant of all these they ought surely to have been told, and
we must be of opinion that these as such Indisputable Reasons
that no Sound Arguments could be adduced to confute them,
which, when rightly observed, makes their Schemes of
delaying it for a little time appear vain and frivolous pretences
and absolutely contradictory to all Right Reason. We are
convinced that his Royal Highness, keeping so quiet has
effectually deceived the Government, that it is entirely owing to
his own matchless address, and indeed upon decyphering the
Letter My Lord T[ra]q[uai]r and I thought that we was in the
next line to have had orders to keep in readyness to favour a
discent to be made, upon the D[uke] of H[amilton] and the
Dutch troops going over; but to our unexpressible Surprise he
proposes new assurances to be given both from Scotland and
England. In the name of Wonder what can all this mean?
Where are the Grounds? Where the Reasons, where the
necessity leading to such a demand? The assurances from
Scotland were thought sufficient by the K[ing], by C[ardinal]
F[leury] and by Mr. Amalot. From the first moment the
assurances carried over by Mr. Butler last year from England
were thought sufficient, otherwise the french would not have
carried the Expidition so far. If this is the case (which we have
all along been made believe) what is the necessity for any
Renewal of them? What a horrid and Gloomy prospect must
such a Scheme carry along with it, things have been carried on
for some years with great Secrecy and caution, tho’ with
danger of Life and fortune to those concerned, and must they
now recommence such another tedious and dangerous
Negotiation? I am afraid, Sir, if your Majesty should find it
necessary it will be next to impossible, at lest my Lord
T[ra]q[uai]r never can take a hand doing any thing in England,
he is already strongly suspected and it wanted but little he was
not taken up some moneths ago. The express he sent to
London with a Letter to Watson[200] was seized, which was
occasioned by one from him which left us quite in the dark as
to what assistance we were to have, and that within 3 weeks of
the Expidition, but not till he had delivered his Packet; and had
he not luckyly said he believed it Related to a marriage which
was then the talk of the town, his Lordship had surely been
arested. But if the English are so well satisfied with the
procedure of the french, and the open discovery of any plot,
why cant they find one amongst themselves to do the
Business? I shall be sorry to think they have only a view to gain
time till they see whither they are able to carry on the War in
spite of Brittain, and then tell us that the Zeal shown for the
present Government in the time of the Expidition contradicts all
the assurances we advanced to the contrary, which will be the
Result of their Cautious and well delay for a little time. This is
harsh, but other people have seen, and I have read of france
doing the like in other cases. As to the troops to be landed in
Scotland, suppose it to be impossible to converse with all the
concert on it att any time in two moneths, and all present not to
be done at all, yett I can take upon me to affirm that they still
continue in the same mind as to every Article. 3000 men
landed, one half near Sir J[ames] Cam[pbe]ll to command
Argyle Shire, the other half near Inverness, a L[ochie]l may join
them to command the north, or if the one half can’t reach near
to Sir J[ames] C[ampbell], lett them be all landed together with
4 feild pieces, 15 or 20,000 Stand of Arms, Gones, Pistoles
and broad Swords, yett from the inquiry I have made I am
satisfied 10,000 Guns or less, 10,000 Broad Swords and as
many Pistoles will sufficiently do the Business, as all the Isles
are lately Armed with Guns and most of them Swords,
Likewise, as for the Inland Country, they want Swords and
Pistoles very much. It gives us great uneasiness that my Lord
M[arischal] should be so unhappy as to fly in the face of every
Scheme, if he himself does not project. Sed quos Deus vult
perdere dementit prius, but we cannot help thinking oddnt,
when the money was had to pay Sir J[ames] Mr. Watson did
not care to remit it. This to be sure required no Conveyance, a
Bill was sufficient. He knows the miserable Situation he is in,
and tho’ the rest of the Concert are in no such Indigent
Situation, yett their Circumstances are not so opulent as to
assist him. The Gentlemen in the Highlands were so desirous
to know if any accounts were come that Locheal gave a
Commission to St[ewart] of A[rdshiel] who came expressly to
meet with me and indeed I was so Anxious for the Situation of
your Majestys friends, that I resolved upon a journey abroad to
inform myself of every thing, upon the pretence of going to see
the Army to some who had a title to be a little more Curious
upon pretence of making more interest for a Company in the
Dutch in case of any new levies, so that it was an accident I
either mett with that Gentleman or saw my Lord S[emple] letter.
He complained heavily that we had no Accounts from abroad,
and indeed I never had more difficulty to excuse our friends.
However, I told that our having none looked well as it
portended that the expidition had surely suffered some short
delay from the bad weather that had happened at the time, and
as it was soon to be resumed, they thought it needless to send
us any information in case of discoveries, which nevertheless
cou’d observe did not entirely Satisfie him. My Lord T[raquair]
desired me to assure your Majesty that there is nothing he
would not undertake which might further your Majestys
interest but that he cannot come from his own house to
Edinburgh without being suspected, which renders it
impossible for him to negotiate any thing in England, and at the
same time desires me to observe that he cannot reconceal that
part of my Lord S[emple’s] Letter, where he tells him that
nothing will be fixed with relation to the expidition till he hear
from him with his proposals of fresh assurances from your
Majestys friends here. In short, Sir, I must say that this letter is
of such a nature that I do not take it upon me to intimate it to
the Gentlemen in the Concert as in the present Situation Your
Majestys Wisdom, the inexpressible Character the Prince has
acquired as being of so brave and enterprising a Spirit,
together with their own Suspence and hopes are what keep up
their Spirits, but was I to make it knowen to them I am afraid it
would throw them into a fatal Despondency, so till I have your
Majestys orders am resolved to keep it private. Never was
there a people more anxiously concerned about a princes
happiness and welfare than this nation when she heard of
Highness imbarkation, nor do I believe Scotland ever made a
more unanimous Appearance than they would have done then,
provided the Conditions promised them had been performed,
but we have been told here, how justly I won’t say, that there
was only 3000 Muskets designed for us without any troops,
indeed, we are able, at any time, to command our own Country
with Arms and officers, especially now when there is only four
Regiments of foot and two of Dragoons, and each of these 100
Men draughted to flanders. I am sorry to be obliged to trouble
your Majesty with so long a paper, but I am hopefull your
Majesty will be of opinion our present Situation required it
especially after receiving the inclosed, nor do I fear your
Majestys being angry upon that account as I most humbly beg
leave to say that an honest and loyal Subject can never explain
himself too fully and Clearly to a wise Prince, and since the
Receipt of Lord S[emple] letter I am more fully resolved to
make my journey abroad as I think there is more Reason for
full and pointed explications on every Article, and if I don’t
thereby hurt your Majestys affairs of what at present I have no
idea I shall be quite indifferent as what may be the
consequence with regard to myself, being Void of all other
Views but that of promoting your Majestys Interest, which I
shall ever endeavour to do att all hazard. I most humbly beg
this letter may not be made known to my Lord S[emple] and
Mr. W[atson][201] least it unreasonably make differences
amongst those concerned in your Majestys affairs, but if
sending them a Copy will in your Majestys opinion be of any
Service, I can with great Satisfaction sacrifice the private
Regard of any man to the trueth and to my King and Country.
This seems to be a Copy of a Letter which Mr. Murray wrote after his
return from France and Flanders in the Moneths of September or October,
1744, To the young Pretender, then in France.[202]
Sir,—It gives me the most Concern I
should have been so long in this Country
without having it in my power to acquaint your Murray to
Royal Highness with what has passed since I Prince Charles
left France, except in the short Letter I was necessitate to write
from London under Cover to Mr. Lumly or Maxwell.[203] I dont
now remember whilst being then able to find no other
conveyance and since my Arrival here, there has been no
Occasion till the present tho’ I have laid myself out to find one,
as I might not so distinctly as I incline, acquaint your Royal
Highness of every thing by way of letter. I have taken the
Liberty to write in form of a journal with opinions of the several
Persons I have had occasion to talk to.
I sett out from Senlis[204] on Wednesday morning and on
Thursday night came to Brussels. From thence I went next day
to Termonde, where I mett with 636, 616, 1614, 12, 30, 1392,
[205] who I spoke to as ordered by Mr. Burnet.[206] He seemed
a little Timerous at first, but nevertheless promised to do all in
his power with his Brother Officers, and to write Mr. Fisher[206]
under the name of Burnet subscribing himself Cuming. On the
Saturday I went to 425, 1876, 1614,[207] in Company with Mr.
434, 1054, 1730,[208] to whom I spoke all night and found him
so frank as to give me his word of honour that he would come
over immediately upon my writing to him that he would use his
Interest with the 1495 of his 598, 1614,[209] and go to
Charleroy and talk with Some of Coaliers[210] and promised
likewise to Send me over a list of the recruiting officers for this
year, with a mark to those that might be spoke to. From that
came to Rotterdam on Saturday where he informed me that
there was nothing easier than to gett Arms of all kinds by
applying to any Jew att Amsterdam who would oblige himself
upon a penalty to give any number att whatever port in Holland
we desired, and that as this was done dayly, it would create no
Suspicion. There mett with 1389, 1051, C13,[211] to whom I
repeated what had passed from the time I left him, and
delivered him two letters from Mr. Burnet[206] with which he
seemed exceedingly well pleased. I had many conversations
with him on these Subjects, and upon the whole he was, and
still is of Opinion that the English will not be brought to enter
upon any Scheme without a foreign force, and that Mr.
Burnet’s[212] coming to Scotland without their concurrence
must be of the worse consequence, as from that quarter alone
their did not appear the least probability of Success; for which
reason, if the french do not putt in Execution the following
Spring what they proposed the passed, he proposes as the
dernier Resort to make an offer to the King of the Crown of
Scotland upon the footing of the Antient Allience with France;
but of this I shall say nothing, leaving to him to explain it
himself, and as to raising a Sum of money is of Opinion it will
be very difficult, if at all possible. On the friday Se-en night,[213]
after leaving Senlis I arrived att London and nixt morning went
to wait of Mr. Moore[214] but missed him, however in the
evening I gott him at home but found him quite a different man
from what I had left him, very reserved and did not offer to
show me any letter he had received during my Absence tho’
Martin[215] informed me he had given him one the post before.
I then talked to him a little different of the frenches intentions,
at least for this Winter season, to which he answered he looked
upon the King of France as a man of honour, and that to be
sure he would not give Mr. Fisher[212] such promises if he did
not seriously intend to serve him. I endeavoured to show him
from the then Situation of the french officers that it was
unreasonable to expect it, but all to no purpose. Then I told him
that Mr. Fisher desired Letters so and so adressed should
Morris,[216] this he said was not in his power for he did not
know the person in the City forwarded them, but promised to
speak with Martin, who was acquainted with, and usually
carried his Letters, who was acquainted with him. I nixt spoke
to him of raising a Sum of money to purchase Arms as likewise
a few thousand pounds for Mr. Burnets[217] Own Use who was
much pinched by the small allowance he had from Mr. Adams.
[218] He told me that was what he could say nothing off, but
that he knew their had been a Sum remitted to him last Spring
by the way of Amsterdam. I then asked him to suppose the
case that the french would do nothing, whether he imagined
Saville[219] would join heartily with Sanderson[220] to bring
about 407. Smith;[221] to which he answered as before, about
the money that he knew nothing about it and so would not give
his Opinion. Upon which I enjoined him upon Mr. Burnets[217]
Name to mention that to none but whom Mr. Bright[222] and he
should agree upon his Coming to Town, and desired to know
how soon he thought that should be, which he still answered as
before. From all which I could plainly see he had gott his
Lesson from the other side. What made this the more obvious
to me, in talking of raising money to purchase Arms, I told him
it would be absolutely necessary, for tho’ in Diepe[223] we had
men and them very willing to fight, yet we had no money, and
Arms for not above 7000 if so many; A number far inferior to
what I had before told him would appear. Upon which he
immediately indeavoured to catch me by saying he hoped I had
got no bad news from Doit[224] to Occasion my Diminishing the
number of Loyalists which obliged me to explain the matter by
telling him that in 1829, 1274, 1381, 1721,[225] a Gentleman
[whose] following consisted perhaps of 800 had not arms for
above one half and so of the rest, by which means they all in
general when spoke to, declared they were not Armed. This, he
no doubt did with Intent to find me out in a Contradiction which
he could not have failed to represent to his friends on the other
side by the first post, who would have made their own use of it
with Mr. Burnet.[226] Two days after, I went again to wait of him
and enquire if he had settled that Correspondence as Mr.
Fisher[226] desired, when he told me with great indifference
that he had never spoke of it, and that the packets were to be
stoped going any Longer from Dover to Calais, so that their
must be a new conveyance settled, but how that was to be
done he did not know. I then left him, and wrote the Short
Letter I before mentioned to Mr. Burnet.[226] Then sett out for
Doit, and on tuesday the 2d of October met with 1443, 1721,
530, 1489, 699, 1051, 1798,[227] a young Gentleman of a very
large fortune, who I acquainted in general with my having seen
Mr. Fisher[226] and what he proposed, upon which he very
frankly offered to raise a sum of Money provided the others
who I told off were to be applyed he would agree to it and that
he would stay some time longer than he proposed, having
intended to go to London, and is now in this place but of
Opinion that nothing can be done without either a foreign force
or the concurrence of Sidley.[228] Upon tuesday the ninth of
October, I sent an Express to Mr. Bright,[229] then at the Earl of
Nidsdales, and upon thursday morning he came to my house
where I acquainted him with everything I had done from my
Arrival at London. He seemed very much concerned that so
many years and so much money had been spent to no
purpose, but as he was obliged to return early nixt morning
would not give his Opinion of the present footing things were
on till his return home. Upon the 16th, I went with an intention
to see Sir 1293, 43C, 1055, 1744, 1045, 1948, 1679, 1778,[230]
and inform him fully of Mr. Burnets[226] resolutions, but found
he was in fife, and his family uncertain of his Return, so
proceeded to Edinburgh from whence I wrote the 18th of
October to Mr. Fergus,[231] begging he would meet me at Mr.
Brights[229] house about the 26th, and one inclosed to Mr. Dan,
[232] desiring him to come immediately. I soon received a letter
informing me that Mr. Dan was come, and desired to see me,
but as at this time my wife was taken very ill, I sent a servant
that same night to town desiring the favour of a visit from him in
the Country, which he declined, thinking it would look too
suspicious as I was so lately come home and he only two days
in Town, so rather choose to delay it for som little time. I
likewise received a letter from Mr. Fergus,[233] telling me he
could not for some weeks see me. I was now become very
uneasy to think I had been for above a moneth in the Country
without being able to do any thing, when luckily, about
the of the moneth Mr. Bright[234] called on me in his very
home and promised to be in town 3 or 4 days after, which
determined me to go nixt day, and that night I mett with Mr.
Bright (who had been called by express) and Mr. Dan, when I
read them a journal of what had passed from my leaving Diepe
the 7th of July, and acquainted them with Mr. Burnets[235]
Resolutions in case the french failed him. They were both well
pleased with the proposal of Sidly and Sanderson[236] acting in
conjuncion, but Equally against Mr. Fisher’s[235] relying upon
Sanderson alone. I nixt day gave Mr. Dan the Letter designed
for Nicolson,[237] which he delivered to him, and made an
apointment to meet with me the same night which he
accordingly did; but as he had drunk a little too much we
differred having any positive answer from him. I told Mr. Dan
there was a necessity for the other Letters being delivered
immediately and that I depended upon him to do it. Found, as
he was then about getting his Charter from the Duke of Argyle,
and had given that for the reason of his coming up, it was
impossible for him to Return without giving Suspicion. I for the
second time had the misfortune to miss Sir 1293, 43C, 1055,
1744, 1045, 948, 1679, 1778,[238] being gone to his house in
the West, nor have I yett been able to see him, as I have
almost ever since been obliged to Stay in this place. I left town
munday 12 and returned thursday the 15th, where Mr. Dan
came to me before dinner and told me that young Kinny[239]
desired to speak with me, so I agreed to meet him that Evening
Att 4 o’Clock, where he informed me that Lord Semple[240] and
Mr. Drummond had refused to do Business any longer, that
they had sent John Drummond[241] to him att Dunkirk to
acquaint him that I had made Mr. Burnet[242] believe they were
not trusted by his friends, and that they had then a prospect on
the Tapis but had given it up, and told him that I had at the
same time perswaded Mr. Fisher[243] to come ovir with the
intent to make himself 1357[244] and leave his father att
Harfleur,[245] which I take God to Witness I never since
mentioned to him as indeed it is one of the things in the world
most against my principles upon which alone I have always
acted in Mr. Ellis’s[246] affairs. Kinnys opinion of them, together
with what I told him, easily convinced him of the folly of their
Story.
Some few days after this Mr. Fergus[247] came to town and
stayed for near two weeks, he has procured the small Vessel
by which this comes, and will order it to and again so often as
Occasion shall offer. I had several conversations with him on
the present State of affairs, but shall confine them all to his
Answer, we shall he Subjoin with that of the rest, having gott
them to putt their several Opinions in writing. I shall there putt
down Mr. Fergus, Mr. Bright[248] and Mr. Dans[249] opinion with
regard to some of the Articles I was charged with in the
memorandum. Which notwithstanding they were (save Fergus)
against Mr. Burnets[243] coming over, at any rate to Doit,[250] I
nevertheless insisted upon it to show that I had not neglected
any particular of my orders, and first as to Mr. Brights[248] going
to London he proposes being there before the end of January,
2ndly The letters wrote to the several persons for money
should be delivered with an Apology, that they could be wrote
to in no other stile in case they had miscarried, 3rdly, The place
Mr. Burnet[243] was to meet should be some small distance
from Aberdeen, upon that part of the Coast lying towards
Dundee, and that we should here be acquainted by one sent
over a moneth before, of the day he determined to sail,
providing the weather favoured him, and the moment he
landed to send an express to Mr. Fergus,[249] and one to Mr.
Dan[247] with instructions what day they were to ...
[Hiatus in MSS.]
4ly as to providing of Swords it is what they dayly do, but
the number to be had so small as not to be regarded. 5tly The
making of Hilts and Targets impossible to be done without a
Discovery and that a few days only is required to make the
Targets so that they can be provided without trouble. 6thly, As
to a ship for Arms, Mr. Fergus engaged to provide it.
MEMORIAL CONCERNING THE
HIGHLANDS WRITTEN BY
ALEXANDER MACBEAN, A.M.
MINISTER OF INVERNESS
Inverness, 10 Octr. 1746.
The Islands of Orkney and Shetland I know little about.[251]
The Shire of Caithness is inhabited chiefly by StClairs and
Dunbars. The Earl of Caithness is Chief of the StClairs who are by
far more numerous than the other. I know not the precise number of
men they can raise but I have heard that at the Battle
of [252]fought by them against the late Earl of Breadalbin, I think in
the reign of King William, they had about 1500 men Horse and Foot.
But several gentlemen of that name living in the Orknies would on
such ocasion with their men join their friends on the Continent. Mr.
James Gilchrist, Minister at Thurso,[253] happened to be walking with
a gentleman in Summer 1744 who found a letter on the road which
when opened was found to be writ in Cypher by a gentleman of the
name of StClair to a correspondent at Edinburgh mentioning that
Shuch and Shuch would be ready at a Call each with his number of
men plainly exprest; all the names were in Cypher nor could I learn
the precise number. Mr. Gilchrist could not prevail with the
gentleman to let him have the keeping of the letter, however this
discovery was useful as it put the Lords Sutherland and Reay on
their guard. ’Twas talked here in time of the Rebellion that the
StClairs would have joined the Pretender but that they durst not pass
through Lord Sutherland’s country[254] as his men were in arms
joined by the McKays, some of the ministers of Caithness can inform
you particularly about this and about Sir James Stewart of
Burrows[255] who lives in the Orknies.
Dunbars of Caithness
I could not as yet be informed how the Dunbars of Caithness
behaved, Sir William Dunbar of Hemprigs their Chief, is the principle
man. He was reckoned well affected to Church and State.
McKays of Strathnavar
Next to Caithness, Southward and on the Western coast, is
Strathnavar the country of Lord Reay, Chief of the McKays,[256] a
zealous Presbyterian and revolutioner; with all his Clan he can raise
as near as I can guess about 600 men. The part he acted last year is
well known. It will be always mentioned to his honour that by his zeal
and diligence he got the large Parish of Diurness divided into three
and Stipends made for each of them by a general Collection through
Scotland and his own liberal assistance though his estate be but
10,000£ scots there is scarce a family in this country but has been
brought to have Family Worship, though that People was of old very
rude and barbarous.
Sutherland of Sutherland
Next to Caithness, Southward on the East coast, is the Earl of
Sutherland’s country, Chief of the name of Sutherland. His Lordship’s
affection to our Constitution in Church and State is well known;[257]
he can raise ’twixt 1200 and 1500 men; his Estate is reckoned about
£3000 scots but somewhat under burden.
McLeods of Assint
As the Shires of Sutherland and Caithness make a Peninsula
formed by the Firth of Tain from the east Sea and an arm of the
Western Ocean, that I may describe the People and the Country
more distinctly I will travel along the Western Coast and then return
Eastward.
Next to Lord Reay’s country on the south side of the Firth called
Edrachaolis and on the west coast is the country of Assint, belonging
of old to a branch of the McLeod Family. This country fell into the
hands of the McKenzies for debt in Charles the Second’s time.[258]
McLeod kept possession violently till Letters of Fire and Sword were
executed against him by the Earl of Seaforth. The Commons there
are chiefly McLeods. McLeod of Ginnies in east Ross is the heir
male of that family. He raised one of the independent Companies
last year and continued in the Government’s service till dismissed a
few weeks ago. His dwelling is about 30 miles east from Assint. After
the battle of Preston McDonald of Barisdale[259] with a few men went
to that country and recruited about 60 men, but the Lord Reay’s or
Lord Sutherland’s people—I’m not sure which—fell upon him and
[recaptured] the men. He and his company were obliged to take to
their heels. This country is an entire parish, and prodigious rough
and mountainous but famous for good pasture and good cattle. A
few of the Earl of Cromarties family lived here and were obliged to
go with him to the Rebellion. Viz. McKenzie of Ardloch.
McLeods of Cogach
To the south of Assint is the country of Cogach, a part of the
parish of Loch-Broom formerly belonging to another family of the
McLeods. [Margaret] McLeod of Cogach, the heiress of the family,
was married to George, the first Earl of Cromarty.[260] This Earl, who
was an antiquary, alleged that McLeod of Cogach was Chief of the
whole clan, and consequently he as their representative, in right of
his wife, procured the Title of Lord McLeod from Queen Anne as his
secondary title, and this country continued the property of the family
till now. Out of Cogach and some branches of his family in Loch-
Broom together with the few I have mentioned from Assint, the Earl
of Cromarty raised above 200 men for the late Rebellion. What
number he had altogether will be mentioned when I come to the East
Coast where he dwelt.
McKenzies of Loch-Broom
Next to Cogach is Loch-Broom, belonging to several small
Heritors of the name of McKenzie. John McKenzie of Ardloch and
James McKenzie of Cepoch, the only Papists that I know in all that
tract of ground except the Lady Assint, bred their children
Protestants.
Next is the Country of Gairloch, belonging mostly to McKenzies
of Gairloch.
McKenzies of Applecross and Loch-Carran
To the south of it is Applecross a new erection in the year 1720.
And next to it Loch-Carran. To this last place, the Earl of Seaforth,
[261] as we call him here, retired when the Rebels retreated North
and gathered 600 or 800 of his men about him by which he kept
them in readiness for any service proper for him to do and preserved
them from straggling companies of the Rebels who went about
recruiting men. This last is the property of the Earl.
Mathesons and Murchisons of Loch Ailsh
Next to the South is the country of Loch Ailsh the property of the
Seaforth Family. The McDonalds of Glengarry of old pretended right
to the country and had many battles and skirmishes with the
McKenzies about it. The last was a Sea-fight in Birlins and Boats,
with long poles, corn forks and Lochabyr axes, in which the
McDonalds were defeated, and Glengary with many of his company
killed.[262] This happened before the Reformation. Most of the
Commons are Mathesons and Murchisons but they join the
McKenzies.
McRaes of Kintail
Next to the South is the Parish of Kintail and the Parish of
Muick[263] a new erection in the year 1726 taken from the old Parish
of Kintail. The whole country goes under the name of Kintail. The
bulk of the inhabitants are of the name of McRae, descended from
the Campbells,[264] but they follow the Seaforth Family. Here lies
Glen Shiel.
In all this tract of ground, viz., from Lord Reay’s country on the
north to Glenelg on the south, the people are but late converts to
Presbytery. The old Episcopal Incumbents having lived long, some of
them till the year 29, I could not find that any of them took the oaths
to the Government. The gentlemen are most Episcopal and they or
their predecessors were at Shirefmoor and Glen Sheil with the late
Seaforth.[265] But by the good disposition of the present Seaforth to
our happy establishment, they did not think fit to join in the late
Rebellion, excepting a few younger brothers who had nothing to lose
and are now prisoners in London. The first Presbyterian Minister was
planted in Assint in the year 1727 at Loch-Broom. He landed much
sooner, but though married to a native he was so miserable that he
could not live in the country.
After him Mr. James Smith, now Minister at Creich in Sutherland,
was ordained for the place by the Presbytery of Dingwall. The first
night he came to his Parish both the eyes were plucked out his horse
as his welcome to the country. Applecross, Kintail and Muick were
not planted till the year 1730; Loch Carran in the year 1725. Mr. John
McKilikin was ordained at Dingwall for the parish of Loch Ailsh a
good time ago and though he lived for several years, he never durst
enter his parish, and after his death, the Presbytery who went there
to command the people about filling the parish in the year 1721 or
1722, were made prisoners in the house where they met, by men in
women’s clothes, and their faces blackened. A pledge was
demanded of them that they should never come to that country,
which they refusing, they sent a Guard of this black crew with each
of them towards their respective homes. But in the year 1727 a
minister was planted there who got peaceable possession. In all or
most of these parishes the Sacrament of the Supper has been lately
administered and the Commons are already much recovered from
their blindness and bigotry, and some of the gentlemen.
[The Long Island][266]
In all this tract of ground there are no Papists but what I have
named. I know the country minutely, and ministers are tolerably well
accommodated in Stipend, Manse, and Glebe. I will speak of the
number of men Seaforth can raise when I come to the east side of
the country where his seat stands.
Opposite to the coast I have been describing is the Long Island.
That part of it to the North, called Lewis, belongs to the Seaforth
Family. It was formerly the property of McLeod of Lewis, now extinct.
[267] The People here are Protestants and do not dislike the present
Clergy; there were two new erections made here, Anno 1726, before
the estate of Seaforth was sold by the Government; so that this
country is in a tolerable state of reformation.
The next district of the Long Island is called Harris. The people
Protestants: it belongs to the Laird of McLeod. The next portion
southward is called North Uist. The people Protestants; Sir
Alexander [Macdonald] of Slate, Proprietor, South Uist belongs to
McDonald of Moidart, or the Captain of Clanranald, as they call him.
The present Clanranald lived here: he and his People are Papists, as
is McNeil of Barra,[268] and his People. In the Uists and Barra are
one or two new erections of late; but by the influence of the Gentry,
the diligence and insolence of the Priests, and the bigotry of the
people, the ministers had little success till now. Old Clanranald was
not in arms in the late Rebellion nor could many of his people in Uist
get over to the Continent, for the ships of war that cruised upon the
coast.
[The Macdonalds]
As I have mentioned two families of the McDonalds, I will say
something of them in general. They would be a great Clan and next
to the Campbells in strength and number, if united under one head:
but the several families of them, viz.: Clanranald, the Slate family,
the Glengarry family, the Keppoch family, and even the Glencoe
family, all pretend to be the lineal heir of McDonald of the Isles, Earl
of Ross, who was forfeited in the time of James the Second, for
joining with the Duglases and others in the Great Rebellion that then
happened; and this division makes them less potent and formidable
than otherwise they would be.[269] I once made an abstract of the
several Rebellions and Insurrections of the McDonalds against the
Kings of Scotland, and especially against the Stuart Family; by which
it was very evident this people was seldom loyal to any King on the
throne. If they could find no Pretender, they would find some
pretence or other for war and plunder. But this paper I have lost.
[Skye]
The next Island to the South and East is Skye, the property of
McDonald of Slate, McLeod and McInnin,[270] The people
Protestants, the Commons and most of the Gentry better disposed
than those in Seaforth’s country, on the opposite continent. Here is a
new erection or two made Anno 1726. Egg, Rum, Muick and
Canney, etc., are little Isles adjacent to Sky; the inhabitants Popish.
But about 30 years ago, McLean of Coll is said to have converted a
pragmatical, forward fellow, who misled the rest, by insulting him in
their presence, and on this the inhabitants of that Island became
Protestants.[271] These Isles were erected into a Parish in Anno
1726.[272]
[Glenelg and Knoydart]
The next country southward on the continent is Glenelg, the
property of the Laird of McLeod. The people Protestants and honest,
and generally well disposed: here are Barracks built for two or three
companies of soldiers near the Strait that divides Sky from Glenelg:
this country is fertile in grass and corn. Here are two famous Danish
Forts of dry stone built very high which I have seen.
To the south an arm of the sea called Lochiurn, i.e., Helsloch[273]
runs up ’twixt this country and Cnoidart. This last is the property of
Glengarry, and the most mountainous, craggy, and coarse of all the
Highlands: the roads are so eminently bad that there is no thought of
riding in it, and in some places so steep and rocky, that they have
ropes of withs tied to trees to take hold of, lest passengers should
fall and break their bones. The people all Papists and mostly thieves.
’Tis a part of the parish of Glenelg, but they never give the minister
any trouble, except in collecting his Stipend. Here lived those famous
Cadets of Glengarrie’s family, Barisdale, and Scotos,[274] who had
almost the whole country in bondage, and the people their slaves.
[Moidart and Arisaig]
To the south of Knoidart lies Moidart and Arasag, the property of
Clanranald. The people Popish but not so thievish as in Knoidart.
Next it lies two great glens called Moroirs; the one of them belongs
to Glengarry and the other to McDonald, commonly called McDonald
of Moroir. The Inhabitants Popish. The two principal Cadets of the
Clanranald family are Kinloch Moidart and Moroir, and their
branches,[275] all Popish. These four last countries, viz., Moidart,
Arasag and the two Moroirs are in the parish of Ardnamurchan, and
they with Knoidart are commonly called the Highlands by the other
Highlanders. The people of Lochabyr, Glengarry, and Stratherrick
reckoning their own country level in comparison of these.
Next lies Ardnamurchan in which is the famous Lead Quarry,
Strontian, the property of Murray of Stanhope:[276] it belonged till of
late to Sir Duncan Campbell of Lochnell: and was taken about the
time of the Reformation by Sir Donald Campbell of Ardnamurchan, a
natural son to Calder, from McDonald the old Proprietor. The people
are generally Protestants, but with a mixture of Papists. Many of the
inhabitants are Camerons and McLachlans, and violently Episcopal.
[Ardnamurchan, Morvern and Maclean’s Country]
As I am now arrived at the Cape commonly called
Ardnamurchan, I turn back to the north east, where on the Sound of
Mull lies the country of Morven the property of the Duke of Argyle.
The people Protestants; many of them Camerons, McLachlans and
McLeans: much inclined to Episcopacy, and consequently Jacobites.
There are few or no Papists: of old this country belonged to the
McLean family.
The next country on the north east and still on the Sound of Mull
is Kingairloch, the property of McLean of Kingairloch. He himself was
not in the Rebellion but I saw two or three of his brothers there. The
people Episcopal, and Jacobite.
Next, still north east, and on an arm of the sea lies Ardgour, the
property of McLean of Ardgour; his country lies ten or twelve miles
along the sea-coast till you come to the head of Locheil. He is a well
disposed old man, but as his estate is much out of his hand, his
influence was not great; the people Protestants. Here lived Ludovick
Cameron,[277] Uncle to Locheil, who brought out many of the
inhabitants to the Rebellion, especially the Camerons who lived
here.
Having now travelled on the north side of the Sound of Mull as far
as the sea goes up, the last five miles of which is called Locheil, I go
back to the islands in the Sound, and then will come along the south
coast, and describe the countries inhabited by Rebels; I will
afterwards describe the rest of Argyle if you require it.
[Lismore, Mull, Strathlachlan]
The first island of any note is Lismore; a most fertile soil; all
founded on Limestone, and like garden ground, which the name of
the island imports. Here was the seat of the Bishop of the Isles: it lies
in the Sound opposite to Lorn and Appin; the people Protestants and
well disposed. It is but eight miles long and one broad, and is the
property of ten or twelve heritors. To the west hereof lies Mull, a
large island containing three Parishes, mostly the Property of the
Duke of Argyle; formerly the property of McLean of Dowart. McLean
of Lochbuie has still an estate here, of about 6000 Merks: the people
Protestants mostly and well affected; but from this island, Morvern
and Kingairloch there came about nine score McLeans to the
Rebellion, of whom returned but 38 as a McLean told me.[278] The
islands of Tyree, Coll, Jura, Colonsay, Islay, Gigha, etc. I omit as
there were no men from them in the Rebellion. Only before I come to
the southeast coast of the Sound of Mull, I must not omit a
gentleman who rose with his men from the heart of the country of
Argyle, I mean the Laird of McLachlan;[279] his small country called
Strathlachlan lies to the south of Inverary and on the south side of
Lochfine. He is Chief of the McLachlans, and had as I am informed,
near 300 men in the Rebellion, but of the number I am not quite
sure; Mr. Alexr. Campbell, minister of Inverary, must know.[280] His
people of a long time profest to be of our Communion, but one Mr.
John McLachlan,[281] a most violent Episcopal minister poisoned his
Chief and the gentlemen of his name to a strange degree, and
indeed did more mischief among other clans than any three priests I
ever knew.
[Appin and Glencoe]
I now come as I promised to the coast on the south east side of
the Sound of Mull. The first dissaffected country is Appin, inhabited
by the Stuarts. The Laird of Appin[282] keeps quiet at home but the
gentlemen of his clan and his tenants were in the Rebellion. The
people here are Protestants, but strangely poisoned by the
Nonjurant Episcopal Clergy. Adjacent to Appin is Glencoe; a small
place; McDonald of Glencoe is Superior.[283] He can raise of his