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Hi, everyone. Thank you very much for joining. My name is and I'm part of Beamer's Academics team as well as UCL S Medical Society. Today, we have Doctor John Derek taking our final er session on the pediatrics clinical teaching series and today he'll be covering child health in general practice. So as always, please be active on the chat if you've got any questions or want to answer any of John's questions, please do that on the chat. I know that he's also got mental meter um planned for today. So please do log into that. That would be very helpful. And as always all the feed um after the feedback forms have been done, then you'll have access to the slides and to the recording. Ok, thank you very much. I'm just gonna hand over to John. Hello. Hi, everyone. Nice to meet everyone virtually. My name is John and I am a pediatric registrar at the Whittington in North London and I've been asked today to talk uh for around an hour on uh common pediatric presentations you might encounter in general practice. Um Please do interrupt at any point if you've got any questions and I'll try and answer them as best as I can. Um, so I'll just try to get us started. Bear with me one moment. Not really. Ok. And then, right. Can everyone see the screen so far? But I need to no messages? I see. Yeah. Ok. I can see it myself. Ok. Right. So, like I said, I'm gonna cover some of the common presentations in pediatrics you might see in primary care, um, discuss some of the common differential diagnosis, some of the initial investigations and approach to management in general practice for common pediatric presentations. Um and when to refer to secondary care and what as a pediatrician myself, we generally would like to know um from primary care. Um So I thought I'd start off with try and make it a little bit interactive and try to discuss a bit some of the common reasons of why parents bring their Children to appointments um at their GP. So I will switch screens on to ment meter. Um and we will pop it on. So if you join at um, oh, there you go, Minty Code. And if you use 17207675, and you just have to type in why you think um parents bring their Children for GP appointments. What, what do you think the some of the most common reasons might be? Ok. Yeah. Rash, limp, fever, developmental issues. Yeah. Cough sinusitis, asthma. Yeah. So cough is actually the number one reason. Um, sadly we're not gonna talk about cough in the presentation, but it is the number one reason. Um, and fever is another common reason and immunizations as well. Oh, we still going. Ok. Yeah, ear infection, vomiting, uh developmental issues. Yeah. Asthma limp. Yeah. Um, so yeah, some of the most common reasons for uh, Children presenting to uh the general practitioner, uh mentioned, some of the other big ones are um abdominal pain, um eye problems, skin problems. Um as he talks about limp fever, vaccinations and then lower down is sort of uh genitourinary um problems and then there's sort of quite a big category uh of sort of miscellaneous, different things. Um So you've got some of the, the common ones. Um Oh no, this is the next one is the case. So I'll go back to my presentation that as good. Yeah, so the most common causes said cough, respiratory muscle or skin gi problems, nonspecific eye, um gastrointestinal fits and then other, other the top nine. So as I'm talking also, I'll go through um all of the reference used at the end as well. Um OK, so we'll start off with um abdominal pain, which is one of the big common ones. So your approach to abdominal pain in a child um in the first instance, is not too dissimilar to how you would approach it in adults. So, um you need to do the key in what you think the likely diagnosis is and what the likely dialis is gonna be is all in the history. Um, and we go a lot more when we look after Children in really good histories and exams, in doing lots and lots of investigations and tests, which sometimes happens more frequently in adult medicine. Um, so really good Socrates and the other point I would men mention is that Children when you're thinking about abdominal pain need to be um fully exposed. Um particularly um if it's around where the hip might be because sometimes hip pain or lower abdominal pain can actually be in young boys, testicular pain. It can be a sign of testicular torsion or in um young women or girls, it can be actually ovarian or gyne pathology. And if you're not fully exposed, sometimes you'll miss that. If there's a concern about maintaining dignity, you can always ask for a chaperone. But I would always say you need to fully expose and also in um babies or neonatal cases, sometimes it can be around um um an anus that isn't fully patent or is in the wrong position. If you're not fully exposed to the child, you'll never know that. Um So that's what I'd say. And also in babies make sure you look at their back as well as part of an Abdo pain history. Um So generally, you need to have an approach to it and my general approach to it. And I think lots of pediatricians approaches is you need to figure out is the abdominal pain, you know, an acute issue or is it a chronic issue? Um, not to say that chronic abdominal pain in Children doesn't need to be investigated and isn't serious, but the majority of chronic abdominal pain in Children isn't down to a serious underlying pathology. Um, and equally most acute abdominal pain in Children is infection based and they do get over it by themselves, but it's important not to miss the sort of red flag diagnosis. The other thing you need to think about is, is this a surgical issue or is it a non surgical issue? And do they need to see a, a surgical doctor and not just a pediatrician or not just their GP? Um and I tend to approach abdominal pain in Children based on their age because in Children, um different age Children tend to percent with different problems. Um And that's I think the, the the best way of thinking about it, of how old is the child and therefore what the, the likely diagnosis is. So this is a very good resource from uh the Royal Children's Hospital in Melbourne. Um And this is the things you don't want to miss. This is not necessarily what the most common diagnosis are, but if you're a, a GP or, or an A&E doctor, this is things that you don't want to miss um in an acute setting of abdominal pain in age and as you can see, um, the way it's broken down generally is into neonates. Um, so I would sort of classify that as sort of from birth to about three months in age and then infants and Children. So that's all the way from that point up until you're getting into your adolescent age group, which is sort of 1213 onwards, a lot of pediatric practice. Now we still look after Children up to 18. So that's that sort of age group. Um So I'll just give you a, you know, a moment or two and this is some of the, the common diagnoses you see in each age group. Um And as you can see the difficulty in, in children's medicines, I is a lot of these conditions are, are conditions that primarily or more often happen in Children than in adults. There are some conditions that overlap. Um and equally, for example, um appendicitis you see in young adults and also Children, but how it presents in Children can often be a little bit different. It's often uh not quite as classical, it can often be a little bit more nonspecific. Um And sadly, that's the case for lots of children's conditions that they don't necessarily always present quite as classically as the adult presentation. Um OK, so tho those are the main common things that, that you want to make sure you're not missing as a baby, infants and Children. And then adolescents. And as I said, a little bit about the adolescents, you make sure that they're fully exposed because you are thinking more about, uh, testicular torsion and uh, ovarian cysts torsion or ruptures and also ectopic pregnancy. Um, and any adolescents with consent or permission, you should ask if they come in with abdominal pain, if that you can do a urinary pregnancy test. And even if they say they're not sexually active, you still ask for permission if you can do it and to test it because sometimes if they're with their parents, they might not necessarily want to tell their parent or their caregiver that there is a potential they could be pregnant. Um So not all abdo pain in Children is actually, um from what we classically consider abdominal pain. Um So these are some of the important uh mimics that you can get caught out that you think, oh, it's abdo pain and then you, you don't even think about these conditions. Um DK is a very common one in um, adolescents. Um, they come in with, you know, severe abdominal pain. Um And if you're in primary care, um what I would say is what you can do is a urine dipstick and it'll show glycosuria. Um So you don't even need um access to a ABM machine or a blood gas machine. They've got significant glycosuria in a child that isn't normal. Um And it, it, you should, you should assume it's decay until proven otherwise. Um headache. So Children often have something uh what's known as an abdominal migraine and it often runs a little bit in, in families and that can be a may make so vasculitis HSP, as I said, hip pathology, um uh so often hip pathology in Children is reactive. So you get like sinusitis but you can also get things like slipped upper femoral epiphysis or SUFI. Um sometimes if you have a lower lobe uh pneumonia that can cause um radiated pain, that can sometimes feel like abdominal pain. Um, often Children have abdominal pain if they've got environmental stressors that people often don't think about. So if they're being bullied at school, if there's an underlying safeguarding issue, if there's a lot of change in their life, sometimes they present with abdominal pain. So if, if there's a clear trigger and a lot of the, you know, investigations have come back not very um in keeping with a particular pathology, you always need to keep your eye open and think about psychological factors. Um Yeah. Zaps ST sickle cell disease. Um Yeah, toxins UTIs. Ok. Um So my other main message for abdominal pain in Children is most abdominal pain in Children, whether you're seeing them in primary care in A&E or actually as a pediatrician doesn't actually require any investigations whatsoever. If you've taken a really detailed thorough history and examination and it's not clearly going down one of the sort of serious pathology routes. So I wouldn't do investigations just for reassurance in Children. Um, I think if you don't think it clearly fits a specific pathology, I would say to call someone, uh, you know, the pediatrician on call because we're always happy to be contacted instead of doing a raft of tests that might not necessarily lead to a diagnosis. Um, but these are some of the, what I would consider, uh, red flags. This is taken from uh Whittington. Uh oh, have I got a message here? Whoops. Oh no, it's on the chat good. Um So this is from our Whittington Abdominal pain guideline and it's one of some of our red flags which mean that it should prompt a discussion with a senior uh children's doctor. I mean, the clinically at is a subjective matter. But um generally if parents are, are significantly worried about their Children, the vast majority of the time, you know, they are correct and there, there often is something um, well with their child, um uh the weight loss or poor growth. So in Children, it might not necessarily actually be weight loss but they're not maintaining adequate growth velocity. So in Children, you should do um growth charts and centiles and they should follow a centile on a trend. And if they suddenly start dropping off centiles, then that is a flag that there is a problem either in their intake of what they're eating, either they've got increased losses from uh diarrhea or sweating or there's a metabolic process that means they have increased metabolic demands, using up their calories, um, blood in stool, bilious, vomiting, um, unexplained fever, temperature instability. I generally worry if Children have five days of persistent fever over 38 degrees. Um, and more so if there isn't a particular reason for it. So if they're full of cold, it's a little bit different. But if they've got persistent high fever without a clear cause, that's something that worries me not tolerating oral fluids. Again, I would say if it's less than half and if their urine output is less than half, that's something that worries me as well. So the meconium is the, you know, the thick black um first poo that babies have and they should pass it within the 1st 24 hours. So you get worried about conditions like cystic fibrosis and Hirschprung's disease or um a bowel atresia of some degree if they're not passing the cone in within 24 hours. Um Yeah, and then significant vomiting and the abdominal trauma, you get worried about things like splenic, lacerations, pancreatitis, not so common things in Children, um but can cause significant problems. So my general message is the most common diagnosis in uh Children with acute abdominal pain tends to be viral gastroenteritis. Um And the majority of abdominal pain tends to be uh benign and self limiting. These are the things that you need to look out for. So, I thought we do a, a few cases. Uh, so I'll go back to Minter. Ok. And then, right. Ok. So the next one is ok. Sorry, I wasn't, um, I couldn't write a big long spiel on it. Um, but this is a spiel I've done so, a, a four year old boy, they've got central adominal pain. It's colicky. Um, they've got vomiting and diarrhea with fever. They can walk but they're only tolerating about two thirds of their oral fluids. Um, they've done a urine dip sick which should always do if, if you're in GP or A and A with abdominal pain, they've got two plus ketones and it's negative leucocytes and n trunks. Um, so these are some of the options. What do you think it might be? Do you think appendicitis uti testicular torsion? Gastroenteritis? Volvulus? Ok. Yeah. So gastroenteritis. So I'm not trying to trick you. Common things are common. Um That is, you know, a classical 07 that shot up quickly now said it's that. Um So it is gastroenteritis. Um, um, a little bit of an easy one, but I thought I'd start with a classical one. Um So the next one is more a question about what you should do. Um So the next one is a 15 year old girl, uh, who's come in with severe, right? Iliac fossa pain, she's leaked for her period. She's got vomiting and she's got a fever of 39.7. Degrees. So, if you see her in primary care, um, what would your initial investigations be if you do any? And who would you, um, refer them to if you're gonna refer them to someone? Yeah. Ok. So, I think, yeah. Ok. Yeah, some good answers. So, I definitely think pregnancy test. Yeah. Yeah. So we've got a differential there. So, is it an ectopic pregnancy and a urine dipstick? S ti screen sexual health? Yeah. Ok. Yeah. A&E, so I think with that history she probably needs to be seen in, in A&E. I agree. Um, and I think she should have a pregnancy test and I think actually, um, depending on the history, an ST cream may well be a good idea. Um, and a urine dipstick. Um, would it, would anybody else do anything different at the same time? No, full exposure, abdomen exam? Yeah. So the point of this one was also to make you think? Yeah. So I think also appendicitis. So I've made it because she's a teenage girl. And you, you think, oh, is it ectopic? But it could also be appendicitis. Um, so I think you probably, yeah, ultrasound. And I think yes, she'll need an ultrasound when she gets to A&E and I think probably to discuss with both the, um, surgical team and obs and Gynae because that's what you, you need to think about. I think that's your, your common differential. Yeah. Um, bowel changes. So, equally you could always think, um, if that's actually an unusual presentation of IBD is another thing you can think about or a torsion, I think generally you need to think, um, bowel pathology and, um, uh, sort of obstetric and gynecology, pathology of the, probably the two most likely differentials of your approach within that. There's probably a few diagnoses there as well. Ok. Good. What was my next one? Ok. So I've gone on to babies so I've gone to a six week old baby and they've been nonstop crying for two weeks. Um, and they've seen you in, uh, your practice in, in primary care and they say baby has abdominal pain, they're otherwise growing. Well, they haven't got any rashes. They've got a soft tummy, but it is a bit descended. Um, their bowels open, they think rough roughly about three or four days ago and they're a breastfed baby and I've given you some different, you know, options or alternatives. Um, so reassurance, some basic blood tests, blood gas and abdominal film or to refer to the surgeons. So I'll just give it AAA minute or two. I've tried to make these sort of, you know, common and realistic scenarios. Ok. So we're 5050 at the moment. Oh, no, it was changing. Bye. Ok. So a good, a good spread of, of choices except for blood gas, which I clearly haven't done very well in my, um, question writing one option that's not used at all. Um, So, actually, this is AAA reasonably classical description of, of colic. Um, a six week old baby that's, it's been going on for about two weeks and baby is, is crying a lot and they do cry an awful lot with colic. Um, and breastfed baby bowels opening about normally, often they might have some abdominal distension, they're not vomiting, they're growing well. Um, and it's really troublesome for parents. Um, and I think as long as you've taken a really detailed history, which is a bit of a nuance because I've not given you in this, in this stem. Um, and they examine otherwise. Well, I think it's totally reasonable to give reassurance and to offer to maybe see them, you know, again in a week's time and you can give them some advice. So actually the, the answer I would give in this situation is reassurance, but equally, I, I'm quite happy to speak to GPS over the phone. If they're worried, it's something more than colic and see the child. Um, yeah, I think if they had, um, uh, vomiting like persistent vomiting or bilious, vomiting or something like that, um, an abdominal x-ray might be useful. Um, and if I thought sort of there was some signs more of pyloric stenosis, the blood or blood gas might be useful. Um, and if they had delayed passage of the con him or something and they're opening bowels really infrequently, I think, refer to surgeons would be reasonable. But often breastfed babies only open their bowels, you know, three or four days is, is quite a normal amount. OK. Where am I up to? Oh, yeah. Uh In fact, I think this is my next talk. So I'm going to, sorry before I let you go on to that one, I'm gonna go back to the powerpoint. Um So that was abdo pain and linking on to abdo pain. The recap here go. That's what I've talked about. I think, yeah, my approach, which I would say, you know, my, my uh consultant colleagues have always think, you know, no one said to me, I've got a, a bad approach and they always quite happy with what I come up with. And I think a lot of them I've learned from to go down the age based approach. Um And again, like I said, chronic abdominal pain over 12 months is unlikely to be due to serious underlying pathology. Uh My little asterisk for primary care and education point is celiac disease is actually quite common in Children. About 1% roughly of abdominal pain in Children is down to celiac disease. So if they have got chronic abdominal pain, I probably would recommend a celiac test. OK. So the next one is feeding problems on in the newborn. We talked a little bit about colic. So it's a really common reason for consultation with um general practitioners. And it's a common reason that we get referrals as pediatrician. It causes an awful lot of anxiety. Um, and sadly, a lot of newborn babies often get over medicalized. Um, so this goes back to mental me. Sorry, I'm jumping about a little bit, but it's because I want to not just be me talking, talking, talking and a bit of engagement. So my first question is you need to know what normal is. And I think a lot of people don't necessarily know what normal is. So, ah, they go, oh, we've got a scale. Yeah. So, go on. What do you think? How big is a newborn baby's stomach when they're first born in Mills? And I've given you a, a scale. Ok. We got a big spread. No. Ok. So, pardon me? I'd probably say the biggest is around about, I'd say most people are going for around about 50 mils. Um, and II tricked you a little bit with this because my scale, I did 0 to 100. Um, but oops, you know, we're on a bit. There we go. Actually. Um, a newborn baby's stomach when they are first born is absolutely tiny in their first day. Um, and it's the size of a cherry. It's really, really tiny and it's only about 5 to 7 males when they're first born. Um, and the whole point of this slide is babies vomit a lot. Um, and it's cos they've got really little stomachs to begin with and it stretches as they get older. And they, you know, they drink more milk. Um, but pussing and vomiting is very common. It doesn't necessarily mean that it's pathology. They just have little stomachs and a really common reason for presentations is b over fed. Um, and as you can see it do, it does get bigger quite rapidly. Um, so af after a week it will get up to about 50 meals, it will be the size of an apricot, but actually it doesn't get up to the size of an egg, um, till they're almost a month old. So the whole point of this is that babies are very often over fed and their stomachs are very small to begin with and then they do expand. Obviously, the more babies are fed, the quicker it expands. But that's a sort of law of averages. Yeah. Ok. Red flags. Uh, the protector, vomiting is what you classically hear. Pyloric stenosis. Um, it does run in families a little bit. Um, it's the little, um, you know, like a, a grape in their abdomen that you can feel when they're feeding. Um, generally true. Pillar stenosis. They really do a V and it goes over your shoulder and it hits something. There is a spectrum sometimes. Um, it can be, uh, less obvious, but if they do have ploo, it does tend to get worse, it doesn't tend to get better. Um, there's a lot of vomiting, there's a spectrum. Um, sometimes it's really hard to tee out. What's what with vomiting babies? And sometimes they have more than one problem at the same time. This is where um things like your birth history are really important. Um So were they a, a preterm baby? Are they more likely to have um feeding difficulties because just being premature or have they got, um, had, you know, a, a brain issue due to being um born prematurely? Um, you know, have they ever an IV H because they're a premature baby. Is there a family history of, of vomiting reflux babies? Um So the antenatal history and also sometimes they're dopplers. So, um babies with abnormal antenatal dopplers are more at risk of developing neck or having feeding intolerance. And you need to ask, are they breast or bottle fed babies? Generally. Um Breastfeeding is a protective mechanism for um feeding problems because you have um it creates more of a healthy microbiome for the, the baby and also asking about antibiotics in the initial period cos that changes your gut flora. Um And then one of the most important things I always say to my um uh juniors is check their red book and their growth and their growth velocity. And I'm generally a lot less worried about babies that are growing normally, even if they vomit a lot because that's more likely to be due to overfeeding than actually structural or a metabolic problem if they are growing a normal growth velocity. Um So I'd say that's one of the really important things to get as a trend. And if you see them in your GP practice to plot them and to put it in the red book and whoever comes after, you can see what's happening so you can see the trend. So trend is really important. Um Oh yeah, and this is a bit about regurgitation. There you go. And generally just a really good history growth looking at the baby reassurance. Um It's really tempting just to jump to tests and investigations and that often reassures parents and sometimes you as a practitioner, but it's not necessarily always the best thing to do sometimes doing nothing is is the the best option. Um So this is a little extract from nice's advice on reflux. Um And I think what, what is the extent of the problem are parents worried and they just want some reassurance. Are they really at, at the end of their tether? And they really need something and actually they might need some signposting to some support or if you think it's really an extreme end of things that there might be harm coming to the baby, you might even need to, sadly liaise with social services and they might need extra help because it is hard and you're sleep deprived and sometimes people do have moments of madness. Um So the nice initial guidelines are quite convoluted. I'll let you look at them, but these are some of the suggestions, generally, they suggest uh Gaviscon or a feed thickener such as Caravel. The Gaviscon often makes babies constipated. Um And the feed thickener, babies don't love for some babies. It helps. Um Generally, I tend to just give positional advice and reassurance. Often by the time they see me, they, they've seen their general practitioner, they've tried GS and they've tried a feed thickener. Um And generally most babies just tend to grow out of reflux. Um, and it, but it is distressing to parents and to tell them that it will get better with time. Um If you think it's more a cow's milk protein allergy, I would probably refer them to a dietician. But if there's a very clear history, you can try a dietary elimination or a hydrolyzed formula. Um If you're gonna do dietary elimination, you need to make sure you give advice to mum about uh alternative um uh sources of uh nutrition in her diet and she might need some supplementation because actually to do it properly is quite hard. Um And I generally don't go down that route unless I really think it's very strongly a cow's milk protein allergy. You can also use omeprazole. But I would generally advise only to be started by a pediatrician because it does come with side effects in, in young babies. And I generally don't start it unless they are having um, uh weight loss um, or poor weight gain or it is having a really, really significant impact on parents quality of life and they're constantly, you know, bringing the child to hospital, but generally, I would do it more on. Um actually, is the child not thriving due to reflux. So my bar is generally quite high and I think generally most of my colleagues don't tend to start PPI S in babies unless they, you know, they have really significant reflux and then you start thinking about other medical causes of reflux. Ok. So, yeah, things not to miss when you're approaching a baby or a vomiting baby with reflux. Is, is it an anatomical problem? Do they actually have a co anal atresia? Do they have um, a cleft palate of some degree? Is it a central cause um from uh you know, an absent neurological structure or a congenital problem or a neuromuscular issue is infection? Do they actually have early onset sepsis? And that's why they're vomiting? Do they have a uti often babies vomit because they have a uti are they vomiting because they are jaundiced? Um Are they vomiting because they have a, a rare underlying metabolic problem? Although they should pick up some of the common things on the gut or it doesn't pick up everything. Um And then the other thing you need to also think about, sadly that people often don't think about is it child protection? Um Are they vomiting because they've been shaken and they have raised intracranial pressure? Um Yeah, people often don't think about that element of persistent vomiting if you're thinking nothing quite adds up. Oh. Oops, we are on to the next thing. Let's just check. I haven't got a mentee quickly. How am I time for 20? I, ok, for time. Which is good. Yeah. Newborn stomach. Nope. That is my last little bit. Ok. So, 12, number three. So third topic I got asked to talk about is eye problems. Another common reason. So the big issue um that you need to make sure you you know about in uh primary care from pediatric is is it periorbital or preorbital cellulitis or orbital cellulitis? And you essentially need to try and figure out which ones which, so is it in front of the orbital septum or is it behind the orbital septum? So, infections in front of the orbital septal. So, preorbital uh or preseptal cellulitis um are low risk and they're just superficial infections and they're not so much of a problem and they cause a little bit of uh superficial eyelid, upper or lower um inflammation and redness. But then orbital cellulitis or postseptal cellulitis can cause a lot of problems. Um and it can extend posteriorly and you can get meningitis, abscesses, cavernous, sinus, thrombosis and Children can be critically unwell and die. So it's a real big differentiator. Um So the, the, the preceptor, as I said is around the eyelids and the surrounding skin, it's commonly from trauma or a sinusitis. Um, and the most common organisms that, that cause precept citti are staph aureus, strep, uh, pneumonia and strep py genes. Um, ok. So what do you or I should, so I should have done this augmenting if you want to put on the chat function or two new messages if you want to put on the chat function, what are you gonna do in your assessment of? Do you think it is preseptal? Do you think it is postseptal if you've got a, a child in front of you? And, um, their parent is concerned that they've got, uh, an eye infection and you want to help differentiate? Ok. How aggressively or not aggressively do I need to treat this? What are your, what's your assessment points? Mhm. No. Is it not working with the, the chat? Don't worry. Sorry, I'll skip on. So, essentially you want to check, um, their, their eye movements, you want to see if they've got painful eye movements or not? You want to see if they've got, um, proptosis? Um, these are some of the, the key bits. Um, so I found this very good, um, lightning learning on, uh, em three. that's got a nice, um, good OV on it. Um, so as I said, a bit about proptosis, ophthalmoplegia. So that's the painful movement if they've got a relative afferent, um, pupillary defect, if they're systemically un, if they're actually toxic with it. Um, if they've got, um, a ptosis as well. Sometimes that's quite worrying and if they have any altered visual acuity or blurring. Um And if you think it's an orbital cellulitis, you generally need to manage it quite aggressively and they need IV antibiotics, they'll need to be admitted. Sometimes you need further imaging, you need to speak to your ent team. Sometimes they'll end up doing a CT head. Um That's, that's um generally the approach and generally, um different places use different age cut offs. But um certainly uh under three months, you should be very worried about um eye problems and treat it very aggressively unless it looks very mild. Um Different places say different age groups. Some places have two years, some places have four years, it's a bit gray, it's to do with your orbital septum. Um And as you age, it becomes thicker and it becomes a better um barrier for bacterial translocation. So, younger Children are at higher risk of a preceptor cellulitis spreading posteriorly. So that's why we tend to treat younger Children more aggressively um than older Children where it might be totally reasonable to try some oral antibiotics in the first instance. Uh So this is my slide um to remind you and to remind me um the orbital cellulitis or precep cellulitis either is, is very uncommon in Children under three months. Um And what you need to re remind yourself not to miss is do they have um uh a chlamydia or eye disease or gonorrhea, eye disease. Um, and generally, that'll be from, um, mum picking up an sti late in pregnancy that she might not be aware of and it'll be go to the baby. It tends to present reasonably early. It generally is in the first month of life and often in the first couple of weeks. Um, but, um, sometimes it can present a little bit later. Um, and the important message is you need specific PCR swab. So not just a generic eye swab to pick it up. So any baby's under three months, even if uh you just need to send it really because the consequences of missing it are super high, you know, you can have neonatal death and blindness and they can be really unwell. Um So that is that one and then my next bit is I'm moving on to uh eczema. So it is really, really common in Children and a common reason. So again, it's all about taking a good history. Um And you need to take a good allergy focused history and atopic history, both for the child. Um and their family members and think are there any specific triggers? Are they an alternative diagnosis? Is it more of a contact dermatitis? Do they have another condition? Um So this is the diagnostic criteria. Um And some of the guidelines from bad, so British Association of Dermatology. Um And again, you know, it is itchy um if it isn't itchy it's probably not eczema. Um And these are some of the, the conditions that are suggested. Um And I just put this slide on of um a baby with darker skin because often eczema is underdiagnosed and undertreated in nonwhite skins and it looks slightly different. So often in darker skins, you uh often get lichenification, which is a thickening of the skin which you're seeing here. Um And sadly, uh people with darker skins often have worse eczema because it's sort of under recognize and undertreated. Um The Royal London do a really good project on this called Skin Deep, which has got photos of uh common skin condition in, in non-white skin, which is a useful resource for healthcare professionals. Uh Just check in. Oh yeah, sorry, someone's on it. Um So on once you think you um they have eczema, um then you need to, you need to assess it. You need to say, you know, is this mild eczema? Is it moderate eczema? Is it severe eczema? Um And actually, what effect is it having on their quality of life? Um And sometimes the severity of the eczema doesn't necessarily relate to the impact it's having on their quality of life. Um So this is from nice that I've stolen on here, the Holistic assessment. It's, it's some of the um categorization of what they would say, a mild, moderate and severe uh and the impact on quality of life and psychosocial wellbeing. But more evidence based, which is what I would say to go to if you're working in primary care is you can use different tools so you can use poem um which is uh a questionnaire that parents can fill out and it says how um severe the eczema is and also their effect on their quality of life. Um And there's also, it's not so catchy the qid, which is sort of pictographic, which I think is really nice for younger Children. And it's a visual thing that they can complete with their parents. Um And then ideally you should come up with um an eczema plan over what, what you know, together you're gonna do about it. Um So avoiding triggers, um there's no point giving loads of therapeutic treatment if you're not gonna try and address some of the triggers. Um So here, I've got a nice slide here from um one of the uh guidelines at, at the Whittington again, um about avoiding um potential triggers saying about soaps and detergents, irritant clothing. Um and the scratching and sometimes in younger Children, if it's applicable, sometimes mittens, it's not sometimes always practical. Um And really the mainstay of the treatment of eczema is um is emollients and it is um keeping the skin nice and moist and generally, amongst many factors. Often the reason Children have really badly, well, really aggressive eczema is because they're just not getting emmolient regularly enough. And it is actually really hard work and to explain to parents that, you know, it is hard and you will have to apply the emmolient really regularly. Um, at least three or four times a day. Um, and also to ask about how they're applying it. So, um, they should have their own separate pot and they should have a, um, if they're gonna put it on with their hands, they have, should have a utensil that c stays clean that they can plop onto their hands. So they shouldn't put their bare hands into the tub and back because then you sort of uh it all becomes infected with their skin floor and then you get bacteria that grows in their pot. Um And often Children with eczema tend to get chronic um infestations of, of staph and sometimes PBL staph. And then when you get a skin breakdown, you get more increased risk of infections and it becomes a real nightmare to manage. Um So the mainstay of treatment is emollients and if needed, topical corticosteroids, um bandages don't really get used very much nowadays. Sometimes dermatology will use them. Um And the urine inhibitors are generally gonna be started by dermatology and the systemic therapy such as the light therapy. Again. Um Sort of UVB therapy will be started by dermatology. OK. Oh Whoops. Uh Yes. So that is my eczema, the, my home stretch. We're gonna go to uh my rashes. Am I crazy? So this is a guess the rash. So we're gonna go through some common rashes. Um And essentially the, the dermatological emergency you want to not miss is eczema herpeticum. Um But then I thought I'd go through some rashes that are often known as mimics or look a lot like it. So, amongst them, we will have one Eczema herpeticum. Um But I throw in some of the other things look maybe a little bit like, ok, got one response so far. So this one, I think the way I've set it up, you have to look on your phone. So sorry. OK, so you're right. It is impetigo. So it's that crusting and it's classics off and around the face and the nose of Children. And then what about this one? So I'm not sure this is the best quality picture. Yeah, is indeed molluscum contagiosum. Um But I sort of can see a little bit where you're going with scabies because it's coming in a little row or line. Um But I think you often get the sort of um the, the sort of um yeah, the, the bulbous nature and the molluscum and the chicken pox sometimes can look a little bit like molluscum contagious when it initially starts and then when the pox has become more evident. Um It, it does look more like chicken pox but to be fair sometimes molluscum and chicken pox can in the initial phase look a bit similar. This one is a bit harder. I just shingles. No So this one's a bit hard. This is just um what, what we would classify as um uh an erythematous exanthem. So it's sort of nonspecific um viral type rash that you get with a lot of viral infections that uh is very red and like that. So it's not any specific condition, but it can be caused by lots of viral infections. There's more description than per S ea rash and then the last one. Yeah. So yeah, so this is Eczema herpeticum in this case. Um And what you can see in the picture is it the classical appearance of eczema herpeticum is it looks like punched out lesions and they're very um red and they often come together. Um And yeah, that is, but it is sometimes quite difficult to figure out the the differentiation between them. Um So some of the things that more favor eczema herpeticum are, they should hurt, they should be painful. Um The lesions themselves are very similar in size. So they don't vary massively in size and they have that classical punched out um lesion and it's in areas where you have existing atopic dermatitis. So it's often where the skin breakdown occurs. So in older Children, cos that was a baby, it's in the cheeks, but in older Children, you'll often see it in the um flexural surfaces. Um And unlike herpes also, it doesn't respect dermatomal boundaries. Um And Eczema bacin is one of the dermatological emergencies. Um and it, it generally needs, um, IV Acyclovir if they are an otherwise very well looking child. Um, and they are very sensible parents that you're happy that they will then represent. It can sometimes be reasonable to treat them an issue with high dose, um, oral acyclovir to see if they respond to it. But I think you need to be following up very closely if you're going to go down that, um, route. So generally it's IV unless they look very well. Um Yeah, so that's Eczema herpeticum, which is the one of the main dermatological emergencies along with probably um Steven Johnson syndromes and sort of toxic epidermal necrolysis. Um So that was a whistle shop store of um some of the common um primary care pediatric type presentations. So we covered um abdominal pain in Children, um feeding difficulties, colic reflux a bit about preseptal and orbital cellulitis a little bit about eczema and eczema herpeticum. So I hope you enjoyed the talk. It was a whistle stop talk through some very big topics. Um And I hope that it was, you know, reasonably interactive. These are some of the references I used. Um I'm happy to be contacted if you got any more specific questions um about things I don't think I've added on what I was meant to, about feedback. Um I will go back to the home screen and hand back over to you. Sure thing. Yeah. Yeah, I Yes. Ok. Oh, what's this? Or is this what I meant to open? Uh oh, there you go. Do I still do I need to still share, share a screen or should I stop? No, no, that's all right. Don't worry, I just sent the link for the feedback form in, in the chat there. So that will be very useful for everyone who can fill out the feedback form and that will also give you access to the recordings and the slides. Thank you very, very much John for that brilliant talk. Very, very informative. I think you covered. Yeah. Bang on time. Exactly. Perfect. Thank you very much for giving up your Friday evening for this. Very, very appreciate it. And you're actually our last session for um the pediatric part of this series. So thank you very, very much. Well, I hope you enjoyed it and have a nice evening and a weekend. All right. Thank you. You too. Bye.