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um right. Hold on. I'm waiting for that message to go. So when I was chatting, teaching on Tuesday around faltering growth, I asked your the students that were in attendance for ideas of topics. And I was asked, Could I take you through common outpatient problems? Which is obviously a huge topic. So we're going to do it slightly. Alternatives Day. These are real Patient's a real clinic that have pulled together. Obviously, we're going to be jumping around topics, but I think that could be quite fun as well. And there's a huge variety of what we can see in outpatients. A lot of the pathology is a topic in its own right that is, for example, being covered throughout the curriculum that we're trying to deliver. But this morning we're just gonna jump about, and I've probably chosen slightly uh, maybe more unusual cases, but still very common problems. But here, let's go. But we won't Don't get overwhelmed by the variety that we can potentially see. And I think it could vary around the world as well. So what we see in the UK because this is based on an audit, and obviously I'm working in Scotland. What I see here may be different to what my colleagues are seeing around different parts of the country, but the themes are probably similar. So there's a huge list of when we did an audit. These are the topics that came up of what was being referred in, and you can see it's varying from constipation and abdominal pain through headache, diarrhea, vomiting, baby colic, faltering growth, poor feed in urinary tract infection all the way through to tick disorders. So there's a huge variety of what comes in to what I'm going to label as general pediatrics. Um, remember, some of this will be filtered off into specialist clinics where they will be seen my specialist tertiary consultants. But there's a huge list of what comes into a hospital for outpatients. So this was our experience when we looked at it. So, uh, staring eyes here because you're a bit overwhelmed when you see all that list. How on earth are we going to possibly learn all of this? Remember, every day you spend as a student, and every day you spend in training post qualification, you are requiring experience, that experience that you acquire throughout all of the specialties can be extrapolated, and the physiological and assessment communication principles come down into pediatrics. People tend to be frightened of Children, but don't be. Children are amazing. It's a real privilege to work with them. So the most common referrals, because we what I've just shown you is what we found from an audit, actually. So abdominal pain, headaches, diarrhea, allergy. And then you get this plethora of constipation and soiling cough, uh, rhesus wetting, murmurs and lots of rather strange little things that sometimes you don't know what they are. But if you see no pathology when you examine the child, you can be quite reassuring, and you just have to follow your instincts. So some of the topics that I have pulled together are the list that we've seen that we see here. Growth faltering. We've already covered. In a previous lecture. I'm aware that my colleague is one of my colleagues, has covered microscopic hematuria. So I pull that out, but otherwise I'm going to have a go going down through some. I will take abdominal pain in a later lecture. Not today, because it's too big a topic, and equally headaches is too big a topic, but we are going to see a case as we go through our clinic today, right? So the first patient walks in through the door is a third. Thank you. The letter from the G P. The referral is Thank you for seeing this 13 year old girl who has started displaying Tick. Actually, I can't see all my slide tick behavior several months ago. These occur every day and take the form of I really can't see my slide. Actually, I'm going to have to minimize this. I'm afraid, Right? Excellent ticks so started displaying ticks nine months ago. These occur every day and take the form of head shaking. Banging vocal sounds are movements Tencent up to her mouth, and she adopts the fetal position, and the episodes can last up to 45 minutes. There's anxiety and panic Attacks have been raised as problems in the past, and it's also worth noting that Rebecca's sister display similar behavior and her brother has autism, so there may be patterns of stereotypical movements in an autistic child as well. Things are getting worse, and they're keen for her to be seen. What are tips? So I'm not talking about animal ticks here. I'm talking about the recurrent sudden nonrhythmic twitches. Now the reason This is not epilepsy and there is a talk today on epilepsy I saw is that epilepsy as a general rule, has a rhythmicity to it. This is non rhythmic can affect more than one muscle group, but it can also be more complex that it's a semi purposeful movement and the child they try to mask this movement by saying it's an ache or an itch, and that's why they keep doing it. You see bizarre gates. You can have vocal tics. You can have motor ticks. It can be sensory ticks. It can be everything so vocal can be sniffing, grunting, shouting, squeaking, clearing throat and cough. Sometimes you think of these as just regular daily habits that you can't. You can't stop yourself doing unless you actively distract yourself from doing it. And actually sort of ticks are part of a spectrum of that. The face is very often involves a blinking, remisin, neck twisting shoulder shrugs, but you need to think about how epilepsy would be different. So you haven't got the jerkin of epilepsy. You haven't got the slow athetoid Korea for movements of epilepsy extend to be situational, so stress can make them worse. They're often when the child is in its own world, they're not actively running about. They're not actively playing a game. They are in their own zone. But I think what's important is you should be able to distract a child from a tick. And they are suppressible. You can stop them doing it. You can't stop the epilepsy, Um, although it can be all consuming and it causes anxiety. And if you become anxious, then you then have a, you know, increase in frequency. So ticks wax and wane. That's the other important thing about them, and sometimes the child knows they're about to do it, but they just have to keep doing it. They can't help it, so they have a pre pre monetary feeling. We're coming in, boys. It's a family history that came out in our letter, and they wax and wane over time and they can change style. Normally they get better after puberty. Puberty helps us. I'm going to go into Tourette's because the parents are often and this is because of the media and because of films out there say, Is this going to turn into Tourettes? Tourettes is it's all part of the spectrum. So tics at one end of the spectrum. Tourette's is the other end of the spectrum. Tourette's have a poorer prognosis, so it's more of an inherited neuropsychiatric condition. You, by definition you get motor and vocal ticks, and they need to be present, released a year, and they're frequent. There. Daily is the Tourette's is chronic and daily and is both motor and vocal. We often see echolalia that they'll repeat phrases so they have a pattern of vocalization. And the thing that hits the media is this phrase called coprolalia, which is swearing or abusive language. Most people with threats do not have that. They're only seen in the minority Tourettes associated with Huntington's um, rare brain conditions, and sometimes you can get self harm in motor takes very difficult treat. There's no evidence based medical treatment available, although dealing with the anxiety through cognitive behavior therapy, through psychology or even through medication can actually help the British national formulary and the Internet will tell you. Sometimes you try haliperodol, one of the anti psychotic drugs, but it's not something we jump to very early. We try to use anxiety and just treat any co morbidities that may be present, such as obsessive compulsive disorder or a D H d. So we look for comorbid pathology. So strange things. We see this quite a lot in in Clinic, actually, certainly in young boys prepubertal. The next thing that comes through the door is an abnormal shape test pectus abnormal pectus chest. So it's caving in and the family are showing, saying she's got marked pectus excavatum presence in his birth. Uh, Dad has the same sort of family history. They then throw other things into the letter. Her growth has dropped to the ninth center. She's a fussy eater. Exactly. Medical examination is normal. So what do we do for pectus, excavatum or abnormal chest chains? You need to think it would be a syndrome here. Could she have Marfan's? Because if they've got Marfan's, but she'd be very tall, more common in boys. Um, this is the girls were unlikely, But rib chest wall abnormality is a common but usually minor and not associated with any intrathoracic defect, which is what you need to reassure the parents if It's very bad. You may want to consider UM, chest Wall service, referring for surgery but very few people, but they would only want to do that. Post puberty. After all, the growth has taken place, and it's for cosmetic reasons only very rarely taken. Okay, so I'll tell you, this is a random thought. Hop around topics which we're probably not going to pick up elsewhere. Tongue tie. Very controversial. Should you treat it or not, the midwifery team often actually in some countries, And they may do so. You in Ukraine, cause I said, you know they do in Germany, they just snip it at birth and then put the baby straight on the breast. But there is actually very minimal evidence base that it causes difficulty. Feeding is often a comfort factor, with the latching on and milk spilling, but in the majority of babies, that baby can move its tongue enough to facilitate latching and suction. But this is a baby that comes in a bottle fed, so actually there's no evidence in a bottle fed baby. It's only in breast fed babies. There is a debate amongst the world moderate amount of milk trickling from the mouth. Mom's changed teeth's for no benefit. The baby is still losing milk but feeding good volumes. And she's put the baby on too high fat milk, which we don't actually recommend. And the baby is taking less volumes. Get fuller quicker but gaining weight and thriving. That's what you want to see. No health concerns, no aspiration. Gaining weight and thriving. But Mom wants the tongue tie fix often because they've read on the Internet. It's going to interfere with speech as a picture of a tongue tie. So basically it's this, you know, to get my cursor up. It's this lowest lower fibrous band, so it's a bit like a bottom frenulum, if that makes sense, um, so it's a thick fibrous band, not particularly vascular, but can bleed, but you can snip it if you catch it very early. Very simply, he looked at the tongue movements, so if the tongue looks more been 50 and can't protrude beyond the lower lip, we would be a little bit more concerned if it's a posterior tongue tie right at the back of the tongue. More difficult to detect but really shouldn't give any problems. But infant feeding teams sometimes want to snip it for a breast fed mum. Otherwise, it's only on the recommendation of a speech and language therapist that you'd get your surgical team involved if there is significant speech problems, linguistic problems, very rare. Okay? Or I am jumping rather quickly. The next thing that comes through the door is play geo carefully again, a bit controversial. Three month old baby parents very concerned with the shape of the head. I will be showing you some pictures. It's distorted, and the baby seems to struggle to turn the head to the right head. Circumference. 45 centimeters that jumps out at me has been quite big, otherwise well and starting at three months to hold up head independently. So meeting neuro developmental milestones. You see him four weeks later, clinical examination is normal. Out with this exit, it'll frontal head circumference on the 99th center aisle. So what you're seeing is a baby with good tone power, normal anterior fontanel they are. It's not bulging. Despite the large head and the sutures are normal, they are not separated in hydro Careful ISS. I would expect to see the sutures being separated, but we do have the classic flattening, which is what play geo carefully is. It's normally on the side or the back because all to do with the positioning of the baby on small bones, all odd soft bones. Sorry. Always look at the neck to make sure there's no, uh, mass tightening of sternocleidomastoid muscle, which is causing restriction of movement. This is the head circumference, although I can't see my second. So this baby starts off down here on the second sent Island has now gone up to a red dot on the 99th sen tile, which we've said about not sure that showing on the screen, actually. So what are we going to do a bit that worries me in that history, Believe it or not, is that head circumference? It's not actually the shape of the head. I'm not worried about the shape of the head, but if you've got a slight restriction and neck movement, our physiotherapist will see that baby once and give advice. Or sometimes they'll just send our belief lit. And it's basically very much encouraging the baby through play and your visual facial stimulation to look to the other side. We would because the fontanelle is open. Do an ultrasound to make sure, just because it's easier to image at this stage, although it's a less specific and sensitive image. But you've gone from the second to the 99th. I would probably put a probe on that head to look for dilated ventricles to make sure that we don't have hydro. Careful is developing, Uh, as of the parents head circumference. I'm more concerned about the microcephaly here, and I would want to monitor this baby's head circumference so I wouldn't bring back a pleasure. Carefully. I would discharge them with advice, but because of the big head, I'm going to monitor this baby's development. The ultrasound was normal. Both parents have got big heads, so this is likely to be family based. Let's go back. We've seen the baby. Now we're nine months in baby juice in its hands. More. It's got hand mouth regard. Nine months. I would expect some, uh, transfer to be taken place from hand to hand. I would expect babies to bring the hands up to the mouth babies role in that comes in at seven months and nine months. They should roll back to front and sit in briefly. Unsupported. Um, should sit with supported. Eight months sitting unsupported is 10 months, so that's okay, So the development is all reassuring. I'm gonna mention the hedge. I'm actually climbing further away from that 99th percentile. So you tend to and I think the over investigating the UK in a otherwise normal child. I think it would be okay to not go to Imogen. But this case, my colleague, decided to take this child to Imogen, which is fine as well. You're greater than 99 Cent Island. We have easy access. What we're seeing is that, reassuringly that this MRI is reassuring. Um, trying to get the cursor down the white rim. Right? Hang on, I've got my cursor. This is just showing that you've got some fluid in the extra axial space. So that is not hydro. Careful is this is all very reassuring and that we're seeing the pleasure carefully. The flattening of the skull shape here, but nothing of concern. The microcephaly you're thinking about is could you have hydro peta lists and remember that you may not have raised pressure. You can have normal pressure hydrocephalus, and we would actually not necessarily do anything about that. You're looking for a cerebral abnormality causing a large brain something called Poly Micro Gyri. When you have too many folds in the brain, all you need to think about is you're looking for a brain abnormality. So you're looking for extra fluid you're looking to see Is the brain abnormal? But you'd expect to see some developmental problems coming in at this stage. But polymicrobial very may just present with epilepsy later on. You're looking for bleeding. Has there been a subdural or any bleeding or you make majority of familial and are innocent? So remember the head can be innocent and flying. That's the big message in a normal child. Here's two m. R. S, a theology here. So we have one here where we're showing dilated ventricles. So we've got some hydro careful ists. We've got one here where we're actually showing there's been blood in the space so that China well has had subdural, so it's probably been shaken and we've had nonaccidental injury, and we've also got some blood in the ventricles, which is why they are looking white comparing to our black here. So this is a hemorrhage. So subject Dural and intraventricular hemorrhage. This baby has had an insult. Join your pictures of heads here looking on. So when you're looking at the child, don't just look at the face. Look down on to the head and there's a huge variety of normal. These are all normal. I'm going to show you some abnormal ones, but here's a baby with a flattened head, and that's going to happen because they lie because we don't like to put them on their bellies because the risk of cot death, we keep them on their back. We're actually creating, flattening. If they lie slightly to the side, you'll see that the head shape flattens that side. The bones are soft and you will see distortion of the ears now distortion in the ears. When I look down in this plane, I'm not worried. But if I've got asymmetrical ears when I look at them in a vertical plane, I would be more worried. So if I'm looking at the face of the child and I see the ears are symmetrical, that one is higher or lower than the other. I'm worried here. They're just pushed forward with the bones and that's obviously a normal head shape. So it's positional skull bones, molds. They're soft. You may have a coexisting torticollis, a tight sternocleidal muster mastoid muscle, and you have to sort of deal with that. But what you're really wanting to reassure yourself is that you don't have abnormal fusion of the sutures and bones with a condition called craniosynostosis ISS. Okay, so for plays your carefully, we do nothing. We don't put them into helmets. I think it may vary around the world because the baby is gonna naturally correct itself. And if you put a helmet on a baby even though it's like it may be light, you can stop, Stop. The baby's learning to move its head. Naturally, it's got a bit of extra weight to to to lift up so we don't We don't offer it in our service. It's only done privately. We do encourage the baby to be put on tummy time or to be carried in a sling and carrier so they're not lying on their back. But when you put them to sleep, you still put them on their back. You don't put them on the front because the risk of pop deaf. Okay, so this is what we encourage. Lots of skin time. I'm gonna move very quickly on senates totus because of time, I'm showing you an abnormal head shape here. Actually, you can see that the ears are lifted. One is higher than the other. And you will have region of your sutures and reduced head growth. The head tends to grow more conical as opposed to more round. There will be there may be developmental concerns. Not always, actually. And you would want to refer that one for neuro imaging and to see the surgical team. So the parents can be counseled if they want to do it, something they don't all get broken open. And the sutures, um, opened up because some Well, actually, if provided you've got some head growth and the head is continuing to grow and the child is developing normally, you would actually say, Well, you've got an abnormal head shape, But maybe surgery is not in the in the best interest. So it's a discussion to be had. Okay, I'm going to move on to headache. I appreciate this is a topic in its own right, but this is your next case that comes in through the door. You have a 12 year old with the three month headache history of daily headache, borrowing, common referral. We see a lot of headaches. So three months, daily headaches and sickness. She's lost weight, and there was no obvious trigger for the headaches you want to ask in your history. Where is the headache? It's by temporal. It's severe, it's jabbing, and it can be associated with dizziness. She can sometimes need to lie down, sometimes takes paracetamol last after two hours, but she can then complain on and off. Throughout the day, she's been checked by the opticians. We always like them to go and get their eyes checked. Also, they're very good at for endoscopy, and they usually take rational photographs as well. And she was being sick with meals or traveling on the bus, so she's very susceptible to nausea. Must examine, and I've put up BP in black. Please always do a child's BP, and although she's lost weight, she's almost in proportion to her height. You must do a full neurological exam examination. You're going to do a fundoscopy because you're looking for benign intracranial hypertension which will present with popular edema. Or you're looking for evidence of an interest cerebral pathology, and you want to make sure she's not got papilledema with an interest. Cerebral pathology. There's normally a squid. There's normally something else going on. There's normally a loss of skill, but benign intracranial hypertension will probably only that your clinical finding will be your BP and your fundoscopy, and the BP is not always elevated. So you've had a look at her. You review her, you give a on the first consultation. You'll probably just say, Well, should we just wait and see it? Depending on how bad things are, make sure she's not over using analgesia. She's no better, she's know, needing painkillers every day. If you're going past three times a week, we don't tend to like it, not vomiting so much. But she's not going out. She's taken on your advice about reducing screen time, TV time, phone time, and you've asked her to establish a good sleep pattern. But it's not great. So your plan is you want, although you want to reassure her because she's neurologically normal, sometimes just telling the parents there isn't a brain tumor is enough to reduce that anxiety and things settle. But it's starting to sound very like migraine, isn't it? It's chronic. It's associated with nausea and vomiting, so you'll have a discussion about prophylaxis. And I've listed some drugs there that we offer all the side effects. Um, propanolol, your beta-blocking. You wouldn't give it to a child with asthma. If they're very sporty, you may impede their exercise. Step up. Positive fan Can Cause weight Gain A lot of the teenage girls don't like it, too. Pyramid. It is very well tolerated, but only licensed in the teenagers. I think it's over the age of 14. There is some concern about a little bit of memory loss or a little bit memory impairment, but most seem to tolerate it incredibly well. It's a very good drug, so she starts on start even she's fine and you send her to psychology for coping. Strategy is a one off session, and you discharge her back to her GP or general practitioner. If you represent a year later, this is a really case, actually, and I'm going to go on to talk a little bit about headaches. Continued headache now is changed. It's got severe occipital pain radiating down into the neck, and it's occurring multiple times a day. That worries me, particularly in a child. In an adult. You may be looking at this and saying, Oh, if they not got neck arthritis and is this not osteoarthritis and tension headache. Children don't tend to get this. They they're not going to get osteoarthritis at the age of 12. So actually you you think, Is there a pathology here? Actually, because acceptable pain again is not migraine. Um, you can get a very rare a typical migraine, but it's not classical but pain radiating down the neck. And it's a continuous headache. You would go to MRI. Her MRI was absolutely fascinating because I'm going to see right? Okay, okay, What you're seeing is here. I'm not a radiologist, but what we're seeing is that she's herniated her cerebella tonsils down, and she's got what we call an R. And she's developed a sphinx. The syringomyelia. She's got an Arnold Chiari malformation. So you find a pathology reported by your neuro radiologists. Um, so she therefore needs to go to surgery to have her former Magnum decompressed, and she ends up trying to have, uh, string go hydromyelia decompressed and and sorted. I'm gonna dump on to talk a little bit about migraine. Okay, then. Headaches do actually need a topic talking their own right, actually, but let's briefly touch on this so migraine without aura, because this child didn't describe an aura. It's almost easier if they've got that aura. And if they've got the flashing lights and photophobia and much more of the adult history, Children don't seem to get it. Maybe they don't recognize it, I don't know, but they don't tend to get it. So it's a bit tricky. In Children, at least five attacks were looking for full fulfilling. My criteria be two D you want. You want it to last 1 to 72 hours and you want it to be unilateral. Or in our case, it was bilateral frontotemporal. But originally it wasn't acceptable, which is why I accept that primary diagnosis. Um, it's normally pulse. It'll is normally moderate or worse pain, and it's aggravated by exercise. And usually you need to get one of nausea and or vomiting photophobia and phonophobia, um, sensitivity to noise. So that's the krait. That's the diagnostic classification of migraine without aura, which we described here, and it's not attributed to another disorder, which is a bit of a strange statement, isn't it? But you can't find anything else on clinical examination that makes you think you should go to neuro imaging so we don't neuro image are migraines. Remember, you can have lots of type migraine. You can have it with aura. You can have it that they get hemiplegic seizure, which shouldn't last more than 24 hours. And you can have it that they have a confusional state. We always say, to exclude a medication overuse headache no more than three days per week and having days off before we would go on to our treatment. Very. This talk is taking longer than I hoped. Okay, so red flags and headaches would be abnormal. Neurology seizures, balance coordination problems, severe headache, which is new in onset and has changed a changing type of headache. Excessive vomiting. I don't like double vision. It tends to suggest that you can't move your cranial nerves, so ask about the history of it and think about an abnormal head position. So if they go into head tilt and developed or tickle is it's usually because they're correct in a visual defect. So a young child, a two year old, doesn't tell you they've got abnormal vision. But what they do is they tilt their head because if they don't realize I'm doing it to my vision, but they they develop torticollis. So they developed abnormal head position in so head smart dot org Sort of list these These what I've just said, Uh, and this is available on the Internet for parents to look at. I'm actually going to go. So what? We tend to know I'll stick with it. I think that screen time at the top at the bottom is probably the most useful and general dietary advice. We don't actually go down. Avoid Citrus chocolate unless you really think it's a trigger. I think excess caffeine can be a trigger. So these high energy caffeine drinks that are available around the U. K. A bad news. Um, but screen time and caffeine are probably the two Big East. Hey, one thing I want to bring up here before we go on is trip tons. So we briefly mentioned your prophylaxis, your propanolol you're positive on a really bad migraine because of the vomiting coming in very quickly and the very debilitating headache you get. Gastroparesis paracetamol, if it works, is great. You have to get it in early, get it in straight away. But sometimes we would use the trip. Tam's the sumatriptan and the beauty of the Sumatriptan group is that there is an intranasal preparation. So if they're vomiting and they can't take anything into the stomach, you squirt it into the nose and that gives them analgetic relief. It can be life changing. So migraine sumatriptan for acute management. If they're not vomiting, we would always start with paracetamol and proofing. Um, but yeah, we would think about sumatriptan and right next case. You know, I'm I think I'm gonna skip that, and I'm going to go on to incur prices and constipation because we're running out of time. Okay. Constipation, silent 12 year old Huge problem in the western world. Um, it's a nightmare, actually. So child comes in previously Noma Chronic constipation is not unusual for them to bounce back. He was seen by psychology team in the past, but he said coming in now with overflow, diarrhea and has lost control of his bowels. When they felt it is abdomen, he had palpable stools. So there was a degree of fecal dis impaction went back onto his dis impaction regime. We're going to talk about it, but wasn't having success. Okay, Came to clinic. I'm entitled the Inca Priestess because that's what the diagnosis is here because he is soil him soiling. So if you've got soil in, uh and constipation, you've got anger. Praecis. They're very upset and tearful. It destroys families, it stops them going to school. They're embarrassed. He doesn't want to take the dis impaction regime because he's concerned he'll have more accidents, which he will, because he's probably got a bucket load of stool to get out of his, um, G I tract. But you put it, You say you have to disimpact even if you do it and you take time off school, you have to disimpact because if we don't empty the bowel, we're not going to get you back to a normal bowel habit. So let's talk about who there are videos on the web, which the younger Children like to talk about because it can be fun if it's in a game, and it gets the parents and the child on board. So the definitely sorry definition of constipation is not just hard, infrequent stools. It's when it's painful to pass. You may have blood because you've torn yourself and given yourself fishers. They have to strain. They may disappear and take a long time because they can't get the anal sphincter to relax and because they associate the whole situation with pain so they spend a long time on the toilet. These are the questions we ask. They have accidents, so you get soil in and the young ones in particular. And the Children 70 or 80 year olds you'll see them jigging about and retentive posturing is what we call it. They obviously show demonstrate withholding behavior and certainly the young dog room. What are the red flags? Because it's so common we don't even investigate the majority. If you've got gross abdominal distension, if you see a big, distended abdomen, I'd be concerned if you got Mega colon it in there. I may not necessarily X ray them on the first presentation, but if I can't get rid of that two standard abdomen by dis Impaction I would do an abdominal X ray. The radiologist don't like it. Don't tell them you're looking for constipation. Say you're looking for megacolon your measuring the size of the colon. Always look at the anus like fishers are okay, because you will tear as you can stretch out with a large size stool. But if you've got multiple fissures and they're particularly fleshy, I should have put the word fleshy in there. I would think about Crohn's disease presenting with constipation, particularly in a younger age group, and overflow diarrhea. Look at the anus for its position. Is it abnormal imposition and tone? Because that would say, you've got a neurological innovation problem or you may have Hirschprung's disease. A lot of the her springs have an abnormal anterior anus, and it's got abnormal tone. Always do the Children's reflexes. You have to do the knee and the ankle because you want to do S one s two look at their weight profile. Are they thriving and ask about the history as their Hirschprung's in the history. But majority, uh, soiling behavior, constipation and incur Praecis and they'll tell you. And this is a bit that always worries the parents. I'm aware it's caused, too, but I'm just going to keep going for a few minutes. They don't feel anything, and they're not fibbing. They don't feel anything, because if you can imagine if that stool has stretched the stretch receptors in your colon for so long, your brain starts ignoring the stimulation to defecate. It stops thinking, I want to go to the toilet because it's spent days, weeks, months being stretched. It's like going in to a It's like a purple ov in dog reaction. You switch off the no, I shouldn't have, said Pavlovian dog. It's like going into a room that has an offensive odor. You smell it at the beginning. After a while, you've stopped smelling it. Your brain switch switches off your receptors. They'll have episodes of cramping and the barrel us. Try to move things through, often after eating to affect their appetite. You will see should feel abdominal fecal masses and you should see losing. It can also cause bladder retention in that it stopped the bladder. Always look at the Sinuses, I've said, and always do the reflected to management. It's so common. We have a National Institute of Clinical excellence. Guideline. So the macro Jal's, the osmotic laxatives are the better ones, as opposed to the stimulant laxative. So we start with move a call or fiber jail, a gel based laxative which pulls in water and softens the stool. Access soap. Well, then, second stage. Add a stimulant to try and support them. We may give them Sennecot. We may give them picosulfate. You need to sometimes work parents over the timing of this impaction that you like sometimes to do over school holiday. You have to disimpact them. You may want to give them, um, a topical local anesthetic bell. Young Children respond well to reward charts stickers. I get an exercise, believe it or not specifically important that everyone put used to put them on too high fiber diets the diet, the history for it is not there, but we do encourage healthy eating. If we're really struggling, we may have to involve our surgeons to consider Botox to the anus. If that anus has got into such a cycle of spasm to consider biopsy and to consider manometry. If we're really struggling to see where the colonic transit problem is there you're actually saying I can't get control here I have I am I missing a pathology, but that's what you're really after. We do in some of our chronic soil. Ear's actually believe it or not to get them to pass a rectal pump and empty them out at night, they flush it out. It's called a para seen pump rectal irrigation pump. They flush themselves out every night, and a lot of the teenage Children who have had chronic MPA process and just can't get out the bit will actually do it and feel it's life changing, actually. So that's something we do as well. I think I'm going to be told off, so I'm probably not be able to go any further. I think what I'll do is I'll pick this up next week. There's still a lot in this topic. Sorry, I'm just flicking through. We're going to pick it up next week. Don't worry, I'm just getting to the end side to conclude a little bit. But don't worry, right, so I think we'll split this into two talks because there's lots of interest in very common things still here. But in conclusion what I'm going to say, you will see a variety as a general clinician. Reassure yourself with history and examination and follow your instinct. Instinct is the child well or not? A lot of things are common, and you will know what to do If you're not sure. Follow your instincts. Are they well or not? And just offer them some follow up, actually, because sometimes the picture evolves. And if you just see them a few times, you'll either reassure yourselves or you may want a further opinion. So never be frightened to ask for a further opinion as well. And at that point, I'm going to stop. What I'll do is I'll cover the lecture, the rest of the lecture and some of the topics next time next week. Any questions? Thank you very much, Doctor Delahunty. There is a question in the chat. I'm not exactly sure it says, Why does caffeine withdrawal also be trigger factors? Uh, it can cause headaches if you have had. So I'm talking about a high caffeine intake. Actually, one of the problems we have is we seem to have a teenage group. We like to take the Red Bull and the sport drinks, and particularly if they've got illicit drinking going on as well. So you you must be thinking the UK has terrible social problems. If they've got illicit drinking going on, they will be mixing high caffeine drinks with alcohol. Um, to give them a buzz, it gives them an extra buzz. And if you come off high caffeine, even if you do it yourself, you will find you have a few days of headaches and you just have to go through that. It's the same with regular analgesia use, which is why we don't like them using it more than three times a week. If you're taking and analgesia every day, um, then you need to stop it. But you need to equally say to them, You may find things get a bit worse before they get better. Just drink plenty of clear fluids, drink plenty of water, so push hydration. Simple headaches, respond to hydration and screen time and also putting except check the eyes checked. They don't need glasses, but put an acceptance that to have a headache is normal. Everyone has headaches at points in their life, like headaches are a normal part. Unfortunately, of our our living, Um, so it's normal to have a headache, but try to take away anxiety. Try to take away stress, try to encourage fluids, um, and just take them through it. But no chronic caffeine can actually cause headaches and caffeine withdrawal from cause headaches. I don't see any other questions in the chat, but if anyone wants to ask something now, you can post in the chat. Um, and also please. Like I said, um, in the chat, do the feedback form. Um, right. Any comments? You have any other feedback you have? Um, in the chat. There's also a link to the new WhatsApp Group now of any updates about lectures. Um, and I will post the link for the zoom link for the next lecture. That's in an hour. Um, but yeah, if you have any more questions, now is your chance. Um, and then we'll What I'll do next week is I'll finish common pediatric problems if that makes sense, because I've got wheeze and limp and just all the funny things that come through the door wheezes very common honestly. So we've sort of jumped around topics, but sometimes it's good to think. What would it be like? Sit in the clinic. Um, there's no more questions coming through. So in that case, um, thank you very much. Doctor Delahunty, your lecture. Um, and hopefully everyone who's here can join the next time. Also. Otherwise, yes. Just please do the feedback. Um, in the last few remaining minutes, um and then I'll pose the certificate in the chat. Thank you, everyone. Thank you. Keep safe. Thank you.