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Hello. Good morning, everyone. I'm Caroline Delahanty. I'm a consultant pediatrician. I wanted to follow on from last week where we looked at some common outpatient problems. So I want this, uh, teaching session to be as if we're in clinic. And so I'm going to stop and pause, appoints and ask you to give me your thoughts. About what? What are you going to do? But I'm happy to be interrupted and take questions at the end as well. Um, I think if you are a general pediatrician, one of the problems is that you cover a huge variety. But as always, the important thing is is to take history, do a detailed examination and pull on your knowledge and also a degree of common sense. Do you feel the child is unwell or not? But never be frightened of Children. Um, and Children medically, because I think there is actually a bit for fear in the community Sometimes that people don't want to deal with Children. They want to deal with adults, but they're fantastic. There's such fun. Anyway, we locally, actually, because of the volume of referrals, came coming in, actually had a look at what was coming through the door, and it was huge. What was being referred from primary care, and this will differ around the world, and your experiences may be slightly different. But we would have referrals on anything in this long list, from constipation to tick disorders. And you don't know what When you go to clinic, you don't know what you're unless it's a specialist clinic such as gastroenterology, you're not going to be sure what's going to come in for the outpatient consultation. So there is a wide eyed stare because that's what that list feels like. I appreciate some of you may have seen these slides already from last week. Again. I've got the slide coming up with the most common accepted referrals. Abdominal pain, which I'm going to do in a separate lecture in its own right headache, diarrhea, allergy, which appreciates being covered, then constipation, soiling, cough, wetting, murmur, lots of different problems. Let's go to our first patient. So our first patient is a referral of a 22 month old boy, and I think age is important who, uh, mom is concerned because he is limping on running and he's got an in toeing gate at times and can trip himself up, and she's concerned that there's pathology at times. He'll also walk around on his tiptoes, and he limps when running. As I've said, Does anybody want to put in the chat what their immediate thoughts are? So I'm going to have to see this chat, actually. Now. Okay, let's move on. Right. Oh, you have more fun things told to you in the history. He was a breech delivery, but he was screened for developmental dysplasia of the hip. So he did have his hip ultrasound. Well, when you you want to, when you get mom in the room, you're going to act as you ask. What was the screening? Was it a hip ultrasound? Or was it just a clinical examination? Because the most sensitive and specific is the hip ultrasound. It is not the clinical examination. Um, he looks well. The G P tells you are general Practitioner tells us he stood on both feet, didn't show any discomfort or pain. He wouldn't walk in the clinic, which is always the problem, isn't it? But when he walked with bare feet and no trousers on, you must undress the child. That's always rule number one always have the child strip down. He looked okay. He seemed to have normal range of movement. Sorry. Rom is range of movement of hips, knees and ankles. And the the general practitioner thought he would grow out of the limp but wanted to get a second opinion. Okay, so hang on. Right. Any thoughts people can shout out or type something in the chat? Do you think this is innocent, or do you think from what you've read, there is a true pathology here? Okay, we're going to go on to talk about a natural history of childhood gate, and then I'm going to go on to talk about how we how to approach Olympian Child's as our first case. So picture when the child comes into clinic, you've got them stripped off. And what you see is a child that is naturally into in and they always look because they're chubby and they've got a nappy in. Quite often, they may look a bit bow legged, but not the true bow legged of rickets. Um, but there is this natural sort of posture that Children that toddlers have. So we are all babies are born with their femoral joint antiverted by 40 degrees. An adult anti version rotation in is only 15 degrees and through childhood and in particular by the age of eight. That internal anti version, which brings the at the the feet pigeon feet almost we call it walking like a little pigeon, brings the toes in the into in naturally corrects itself through childhood, so it should self correct. By the age of eight. What you must demonstrate is a normal clinical examination. We are going to take you through. I am going to take you through that. We're going to talk about it, but you absolutely must demonstrate a normal, passive range of movements. What you don't want is any fixing at the heel fixing at the forefoot. You must be able to get these the whole foot and remember the 4 ft into neutral with passive movements because your differential, obviously if you've got a really fixed foot, is club foot. But that should have been identified at birth or even on antenatal scanning. So at birth, certainly in the UK, we do a routine examination of the newborn, and we will look at the feet and we will naturally expect there to be some internal flexion. But we can always bring them into neutral with passive stretches or even by stroke in the outside of the foot that quite often just tickling the outside of the foot actually causes the foot to correct itself. It responds by the the metatarsal abductor muscles coming out. Okay, so I want to discuss Intoeing tipper walking, development and confidence. Children are learning to walk. Okay, they don't hit. Walking with perfect posture, perfect strength of muscles they are learning. It's a developed developmental line, a developmental curve. So but also because Vinto and because the natural femoral head anti version, they will walk with their toes pointing in. And then as they run, they will trip. They stumble and they trip. Children often walk on tiptoes at the beginning. You need to encourage them to bring the foot down if that happens. But you need to check that the Achilles tendon is not tight or and that they don't have abnormal tone or a neuro muscular problem. So the clinical examination is hugely important, and there are slides coming up on that, so make sure if they're a tiptoe walker they're not fixed in tiptoe Walker, and we call them the ballerina Children that they do come down to normal walk in and that they just intermittently go up on their tiptoes. Children that have been put in these walkers where they're suspended in a sitting position and they're mobilising before they're ready to walk. Those walkers are not for physio. Physiotherapists do not like those walkers because they take the Children up onto their toes and we need to bring them down. If you've got a fixed toe, tiptoe walker in a neurologically normal examination child. A lot of people would go to MRI of the spine, but we don't all do it. You would actually think about cereal plaster cast in to bring them down. And sometimes we even use Botox Elin botulinum toxin to relax that the vasculature those calf muscles to bring them into neutral neutral So we may give them botulin toxin, Botox therapy, and we may do cereal plaster casting. But remember the whole gait development. It's all about that toddler becoming stronger, becoming confident, and it's developmental. There are leaflets available that some services because it's such a common problem that parents will be concerned or they're stumbling. They're not walking right there to should they not now, have a good gate. Nappies interfere with the gate as well. So quite often there are leaflets that your health board may have or your pediatric service may have. I wanted to go on to I'm going to take that away. I mean, it actually. So abnormal. Eight red flags. Does anybody want to put anything in the chat? About what? Things would worry you. Because although this child has come in and I've said this is normal and I will be reassuring this family. There are lots of times you got to think of your differentials. What are you wanting to a waddling gait? Okay. A waddling gait is a description. Skin color? Yep. Absolutely. So I'm going to take the first point. A waddling gait is actually a description of the gate, which may be newer, muscular, absolutely. So it may represent weakness, but equally, a waddling gait may be normal. So it's all down to that muscle power, Skin color, erythema. Yes. You'd be thinking about infection. Well, I don't know about I color. I'm not sure what your thought processes. There Okay, let's move on. Every time I get read chat, I seem to get stuck. Don't go right, Okay, So there's gonna be a couple of slides on what I'm going to call Abnormal gait. Red flags. This slide doesn't quite make sense, but never mind. You need to think about the age and stage of the child and whether there's a loss of skill or whether it's just a developmental. So I'm much less worried about child just learning to walk with an abnormal gait than what I would be with a 10 year old with an abnormal gate, because a 10 year old should not have an abnormal gait. Okay, so age of child is important. Is it a new problem? And is it out with the developmental stages of walking pain? Pain worries you, particularly if you can localize it. You may start thinking about trauma. You may start thinking about septic arthritis. History of trauma is important. Should you be X raying? Could there be a fracture? Is there a viral infection? Is this a transient sign of itis of the hip or just general not walk in? Because their joints have become inflamed as part of a viral infection. Always remember child protection concerns and check your history and your case records. You need to watch the gate. Unfortunate Children aren't always the most cooperative, particularly if they're under five. Sometimes you get a lot of it by watching the gate, I would always say, particularly if it's a gait problem. Go out and collect the child and parent from the waiting room yourself, so you have an opportunity to naturally watch them walking in. And I would normally say, Ask the parents to take their shoes off and let them walk in and bare feet. Um, so watch the gate and look at the neurology and the musk, the muscle definition for abnormal tone Because although I said some tiptoe Children, it's normal. Remember cerebral palsy in a spastic diplegia? Because of that increased tone, they're likely to be on their toes if there's pain considering inflammatory conditions. We can't forget leukemia. Remember, it can develop. It can present the bone pain. We mustn't ever miss septic arthritis because that will destroy the joint and the child may become sector asemic and die, So I'm being a bit dramatic. Don't forget trauma and examine the whole child, even though it's a gait problem. And you think, Well, I'm just going to look at the legs. Always think about bruising lethargy, pallor, lymph nodes. Is there hepatomegaly because that would then take you more down a leukemia route or a systemic illness such as J. Juvenile Idiopathic arthritis? Okay, some more red flags. Although a lot of this is repetition, I just pulled the talk to ways pain. Waking the child at night may indicate malignancy. Certainly that's what the textbooks tell you. I think that's a little bit vague because I think you can get pain at night with a transient sign of itis. You can get pain at night with a septic arthritis redness in your chat. Someone put skin color absolutely. Redness, swelling, stiffness of the joint. You're looking at infection or inflammatory joint disease. Um, obviously, if there's bruising, you're looking at trauma, weight loss, anorexia fever, night sweats or fatigue. Again, you're thinking about malignancy. You're thinking about infection, including TB, and you're thinking about inflammation. Juvenile idiopathic arthritis in Children under five is very often a systemic problem, so they get the temperature, they get the rash, it it can be systemic. It's not necessarily localized. Monoarticular unexplained rash or bruising may indicate hematological inflammatory. Systemic Lupus will present with a rash. J. I A. If it's systemic, can give you a rash, Um, or don't forget. If you see bruising it, don't forget your child mild treatment and your child protection issues. We're always taught that a child with arthritis is usually worse in the morning limp and stiffness is worse in the morning, Unable to wait more or painful limitation may indicate trauma, infection, etcetera. And obviously, if you can feel a mass elsewhere in the body, you're thinking about malignancy with bony involvement. So how are you going to approach this? It always comes down to history, isn't it? If you're stuck and you don't know where this is going to take the history, you start with history. Ask about the duration and progression of the limp. Ask about trauma. I've already said about child protection. Check the medical notes. But if the history Children are often falling, isn't it? And particularly the limping, they may be falling more than ever, so it's always difficult to say. Well, was it a fall? I caused it, but just see if you think they're consistent. If there's not a really good history of trauma, I'd be concerned to label it as traumatic. I would be thinking of non traumatic causes. Think about your viral infections. Has there been any precipitating causes? Has there been a recent streptococcal infection? Could this be a post streptococcal reactive arthritis or reactive inflammation in the joint? Think about pain. Pain is really important. Nature. Local location, severity. Is it worse at night? Is it worse in the day? Is it worse in the morning with that early morning stiffness and discomfort? Pain, the we usually say, represent a fracture, malignancy, osteomyelitis or a septic arthritis, but it can be transient. Sign of itis. I think I think that's a difficult one. I put this next bit in bold. I didn't learn about this, believe it or not, until I was a consultant and I saw a case. Children babies are susceptible to get an inflammation of their discs and a disc itis. Quite often it's haemophilus, but it can be viral, Um, but if the parents say it seems to be changing the nappy that is particularly difficult or put in the child in a seat, for example, a car seat or a, uh, high chair. That flexion is often representing of back flexion. And it may be that there's an inflamed disc, and it's quite difficult sometimes think, Oh, is the pain the hip or is it the back? But if it's very much that if you lie on flat and move the hip, it's not a problem. But if you bend their back, it's a problem if you bring them in to curve that spine by bringing the legs up to change a nappy that's quite often a disc itis and they they need six weeks of antibiotics. They need neuro imaging, and six weeks of antibiotics actually have a look if you think it's the muscles that week, because that may be a neuro muscular disease problem. Now, if it's a congenital, neuro muscular disease, the child probably won't have come up to walk in OK or they really struggling if they've got weak muscles and power. If you've got them playing on the floor or they're struggling to stand or they're climbing up something to stand, even they may even be climbing up their legs. Remember Gowers sign the same in adults where they put their hands on their leg and they climb up their body to stand or they have to climb. That suggests they're weak. Okay, so remember neuromuscular disease. Always take your birth in developmental history. So we're spending quite a long time on limp. But I think we're here. We're in clinic. We've got limp. Let's just do it. Remember, you walk in history. Is there delay or regression? Okay. In a child, your risk factors for developmental dysplasia Does anybody want to put in the chat the risk factors for developmental dysplasia, which is a complete separate topic, But someone want to put out one or two OK, breech delivery and positive family history are probably the big too. So if you've got a family history or breech delivery, okay, so delay in motor milestones have already said would suggest a neuro muscular or an abnormal tone problem. Okay, so if you've got abnormal brain and cerebral palsy, you're going to be delayed. If you've got weakness, you're going to be delayed. Whereas regression loss of skill suggests an acquired disease such as inflammatory arthritis. But equally it may be an a an acquired neuro muscular problem that is suddenly presenting family history of neuromuscular or rheumatological problems is important to sort of demonstrate it on the slide. Because I've opened that chat, I always get problem. Okay, you always go on to examine a child. Are they pyrexia? Are they tachycardic? Which would suggest if they got a septic joint in there? Pallor, irritability, lethargy can be sexist or systemic disease. Rash or bruising will take you down that hematological inflammatory or child abuse line. And always look at the growth of the child. Because if they're chronically unwell with a systemic and I guess I'm thinking about TB and things here, they're not going to grow okay or if they've lost weight, that can be malignancy. Anorexia, TB, anorexia. So think about the growth of the child, right? This is always a bit sort of worries people, doesn't it? But actually, it's very similar to examining joints in adults. You just have to be a little bit more opportunistic. Look at the gate and assess mobility. Try to have them stripped off, remember and do the gate and mobility for age and stage of a child. So a seven year old I would expect to be able to hop, okay? And I'd expect them to do star jumps, and they love it if you start hopping and start jumping with them, but otherwise just run with them. Get them to run to you. Throw a ball, ask them to go and get it. Use toys. Look for your erythema, your tenderness, your swelling. Inspect the back. Obviously, with spina bifida and spina bifida A culture, you may see signs of the spinal disc. Destress is, um I can't say that word with a tuft of hair or abnormal skin pigmentation. Look at your muscle definition. Do you have poor city of muscles? Particularly? Look around the calves. Uh, look, look everywhere. Look at the thighs, but definitely look at those calves. Um, do you have paucity of deaf muscle definition? Examine the joints above and below. You never just examine one joint, so don't just think. Oh, it's the foot. Always examine the knee and always examine the hips. Think about the power. Think about how much you can get them to move it. Ask them to do the splits if they can, or how much can they do? Always look for leg length because if you've got a femur problem a hip problem such as developmental dysplasia of the hip, the legs going to be shorter. So look at leg length and always do a neurological examination. You have to assess tone and reflexes and planters Remember, planters are up going in the first year of life but become down going after the first year of life. So in cerebral palsy they will stay up going, OK, so always do your neurological examination. And even if you can't get the reflexes, you should be able to get plantar. Okay, I've got a slide of hard to check leg length. So the easy way to do it is to actually get them lying with the bum flat on a flat surface and then bend the knees have the feet down as this demonstrates, and look at the knees and you can see the discrepancy in the knees. Obviously, you can do measurements for the anterior superior iliac spine down to the medial aspect of the ankle. I've lost my words, but you know what I mean. The inner the inner ankle protruding rinse. Um, you can do that. Okay. Any questions about lymph before we move on, or I can absolutely take them at the end. Okay. Gonna move on? You've reassured this, Mum. We've talked about the differentials and you've sent her a way to say this is going to get better and not to worry. Okay, Your next patient comes into clinic beat, gain obesity. I do appreciate things that it could be different around the world, but we get a lot of referrals about weight gain. But quite often, what's tricky about this one is the behavioral aspect of it. Which is why you're not going to just divert it to a dietician. So the referral letter is dear Doctor, I would appreciate your review of X fit and, well concerns re eaten for 13 year old way in 14 stone, which has occurred gradually over the last few years. So that gradual is reassuring. Rapid weight gain would suggest potential pathology. Gradual. Uh, you know it. It's more reassuring as put. That's what I'm thinking. When I'm really reading this. He denies any purging of eating, but does hide a wrap it rappers, you know I can't see all of this. He's hiding rappers, okay, and has secret eating behaviors. He is managing school well with no other concerns. The G p, the general practitioners, done blood's for us to really rule out causes of weight gain. However, Mom is keen for a referral to pediatrics. With help from the dietician, I've listed what I would put as my primary screen. So when I would look at what has the GP done, we always tend to do a full blood count. It's not particularly related to obesity. I agree. Use Annie's comes along with our liver function. Tests are LFTs. The reason you want a liver function test is you're looking for fatty infiltration of the liver, causing a transom in Isis. So you want to see how much fat deposition is going on in the organs, because then you would be counseling the parents look, the liver's laying down flat fat that is going to cause inflammation and eventually may go on to scarring and even cirrhosis. In America, the one of their biggest causes now of cirrhosis of the liver, believe it or not, is obesity and not alcohol. By 2030 in the UK, we expect obesity to take over alcohol as the leading cause of cirrhosis is absolutely scary. You do want to do a glucose because you're looking for type two diabetes, rare in Children, becoming more common in the obese because of the rising levels of childhood obesity. You tend to do your cholesterol and triglyceride. So hopefully these bloods been done fasting first thing in the morning. That would be my primary screen, but I'm good. But then told he lives at home in the referral letter with his mom and three siblings, and he has regular contact with his dad. So we do have parental separation here. Mom has become concerned because he's stealing money and he's been in trouble at school, being over physical with his peers. Mom's raised concern with the school, but they do not feel there are significant concerns about his behavior. Sleeps well, no concerns about depression. He's had a previous child and adolescent mental health assessment for a D. H D attention deficit hyperactivity disorder. Um, um feels that his inattention behavior of deteriorated and she's finding him increasingly difficult. So really, one of the reasons he comes into clinic is because of the other factors as well. You're going to want to assess. So I want to suggest have a chat about medical causes for obesity. So I thought this was going to come in intermittently. They're rare. There are genetic causes. Remember Prada Willi syndrome? Uh, normally, I'd expect the obesity to present around about the age of five with Prada Willie. But some do if they've been very well controlled, uh, with eating behaviors not present quite so young. But to come in at age 13 would be unusual. Underactive thyroid can happen. Um, and actually, a common time is that presentation around puberty. But I would expect the weight gain to become rapid and look at height and then a hypothyroid child. It will affect linear growth as well as obesity, so they're usually short and overweight and not overweight with height cushions. I've honestly never seen one, um, but it will be the classic features of looking for high BP, looking for the buffalo hump, looking for that moon face and signs of excess steroids. So the stree, a unfortunately stree A can go with rapid weight gain and, um, the thinning of the skin, But it's very rare. Excessive eating will be a feature in all of these, unfortunately, family's always want a medical explanation. They always want you to fix the problem, but we need to make sure there's no co morbidities. Think about Type two diabetes, particularly if there's a family history. The child is more at risk and you are counseling this family. So when you're talking you you really need to point out all the problems with being overweight. And actually, I got into the practice of writing to them. So they've got the consultation in black and white so that they're very aware that this is really significant. Think about the orthopedic problems of obesity slipped up. Ephemeral epiphany sees more common in obese boys. Think about obstructive sleep apnea. If they're snoring excessively, it does go with depression. Um, learning if you know the behavioral aspects, I think we need to tackle clinical psychology. Input is required here. Strict boundaries. How his mom approaching this behavior, she may have to start locking cupboards, but if you're stealing money, he's going to go and buy things in the shop. Has he got an underlying learning difficulty problem? Always think idiopathic intracranial hypertension. You must do a BP and part of your examination must include looking for popular Dema idiopathic intracranial hypertension. Although we've said it's into idiopathic, it's associated with obesity. You know I am going to go on and do one more case. Okay, I think obesity is really difficult to manage. The main feature is obviously healthy eating, and you have to change the whole family. You can't just change the child. What goes into the shopping trolley has to change. Think about portion sizes and having that healthy balanced plate salad, vegetables, fruit, snacks. You know it's hard and the dieticians have a real hard battle here. Think about exercise calories in calories out. So it's a lot of it. Is your generic public health promotion here? Are they exercising? Try to get them exercise in. Skipping rope is really cheap. They don't have to pay for outdoor exercise, get them to use a piece of rope and skip in their garden. They don't need a lot of space, and it's a real physical workout and just build up. Can they skip for 10 steps and then skip for later? After that? Okay, an ex child that comes in your room, so this really is what our patient's is like. If you're doing a general clinic, you'll see a variety. It's great is a cervical. Lymphadenopathy in a four year old mum is concerned because he's got persistent lymph nodes in the cervical area. He was seen a year ago, and it was felt to be reactive. But it's not got better. There's no other systemic symptoms, so there's no fever. What you're thinking about is fever cough. Could there be TB? You know, as he developed any other symptoms, such as chronic cough? Has he developed any anorexia? Any weight loss? You're going to be asking about all these factors. Red flags are obviously if you've developed a breathing difficulty due to a mass effect, which would suggest that that's those Vical glands are pressing on the key here. Or you may in fact, have mediastinal lymphadenopathy as well. Have you got power and bruising suggesting leukemia? Do you have night sweats or persistent fever? Sorry, I shouldn't have put patter splenomegaly because that's not a history red flag. That's a clinical examination. Okay, if you see the child, uh, you will ask, You will have asked. Has he ever had antibiotic treatment? But when you're looking at the child, if they look unwell, if the mass is tender or if there's history of fever, you're certainly going to want to give antibiotics. You're going to look to see if there's an abscess. If the child is unwell with acute lymphaden itis, there's no evidence. Be it based behind this. And it's always controversial, actually, but we tend to admit them and give them 48 hours of intravenous antibiotics. But I think it also gives us an opportunity to scan them as well. Um, and do an ultrasound of the neck, right? What's normal? I would say. Normal is if that gland is mobile. First of all, can you move it? So make sure it's not tethered to the skin. We like glands to be pea sized. We like them to be small, but the cat. But we will accept up to 20 millimeters anything above that. I'm thinking, Oh, it's a bit big. We like it to feel slightly rubbery and slightly soft. We don't like it to feel hard and like a rock, we don't want it, rock. We want it more rubber. Okay, We certainly don't want it. Craggy. Um sorry, that's not very good English word. We don't want it uneven. We want it to be almost as if your moving a bean or a P. We want normal overlying skin know tethering, no discoloration. We accept that it increases in size from time to time that it will fluctuate in size because every time you get a cough cold an upper respiratory infection, your lymph nodes are going to react an increase in size. But they should go back in size over the next 1 to 8 weeks. Are you going to manage it? It's very common referral, actually. So if it's 12 to 20 millimeters without red flags, I would reassure. But if it's got atypical features, that's when we need to see. So if the firm and hard if you can see other glands involved, so you're always going to feel the auxiliary notes, you're going to feel the inguinal notes. But obviously, if you've got dermatitis or localized infection, and if Mom has come back three times to you in primary care, send it to clinic. Um, what do we do? We we tend to ultrasound more than blood tests. Obviously, if we're concerned about leukemia or TB, we would ultra we would do blood tests and think about chest X ray. Think about Montu test. But actually the most useful examination is actually an ultrasound, particularly if we're looking for reassurance that this is still reactive lymphadenopathy and that there's not an underlying significant condition. If we are concerned, though, on our examination we would take the child to blood test And we would also consider TB screening actually as well. But I think you do have to take into consideration. What else is around was prevalent in your pinnacle area. I'm actually going to stop here because I've done 45 minutes. The next case was we's, But we could actually do a session, Uh, next week, just purely on wheeze, actually, um, or abdominal pain. So they're sessions that will cover as we go as we proceed through to December. I think to conclude I'm going to I'm going to This is the reeds talk. Don't worry, right? Hang on to conclude, I'm going to say that you're going to see a variety to answer the question to cover common pediatric problems. It's huge. Always go history and examination and follow your instincts. Are they well or not? I think the danger is often that you can over investigate, actually, and you start off at the beginning of your career over investigating. But as you become more confident, you tend to investigate, probably less, as you gain more experience and confidence. And I think that's a natural progression of admonition. Always answer for help. If you're not sure, I am going to come back in to the chat and Paul's Sharon any questions? Some words about physiological jaundice, Right? Okay, there is a recorded, uh, topic on physiological jaundice, actually, uh, which was probably the very first talk. I did, uh, physio, right? I think what's important about physiological jaundice is that it's normal. Um, it's all down to the fact when a baby is newborn, they have a very high hematocrit. It coupled with a very immature liver system of the glue corona dill, your Odil transferees enzymes, which are responsible for conjugating the jaundice. And also they have immature gut bacteria responsible for clearing jaundice from the gut. It naturally presents Day 3 to 5 and the teach the treatment is obviously phototherapy. If it goes above a certain level, and there are charts that where you plot to a certain level, and if it's above a certain level, you give treatment to clear it. Because bilirubin, although in the majority of cases is not toxic when it gets above a certain level, can cause sensorineural deafness and obviously can in extreme cases, cause encephalopathy and, uh, basal ganglia staying in, which can then go on to to lead to a few toys. Cerebral palsy. But so when you you should be worried about physiological drawn, this is when it gets above a certain level and that you need to treat them with phototherapy. If and then it should naturally come down if it doesn't actually come down. It's not physiological jaundice, and you need to think about your differentials such as recess disease. Could you have a hemolytic picture? And could you have a problem and obstructive jaundice developing, such as biliary atresia? Could you have in utero infection driving the jaundice? Could you have ex utero infection? So you the answer to the chat. When should you be worried? You should be worried when it goes above a simple goes above a level that does not respond to phototherapy and naturally, the level dropping down um, clinic. The clinical signs of a child that is becoming increasingly jaundice is that they will become sleepy. They're lethargic, and they may develop poor feeding. So clinically. What you're looking at is, is the child feeding is the child's sleeping, but you can't wake them for feeds. I would always ask about the color of the stool to make sure that as you come out of that meconium, the stool doesn't become pale. But remember, they can be yellow. Still, they can still be some pigment. Ask for the color to make sure you haven't got an obstructive jaundice and ask about the color of the urine to make sure it's not excessively dark. But I think these things are difficult for new parents when they don't know what's normal, and they've seen that thick meconium. So you should be worried if a baby is too sleepy and not feed in, and you should be worried if it doesn't if it goes above a certain level and doesn't respond, but always go back on your history. What was Mom's blood group? Make sure you you haven't Mr Reese's, because then I would always do bloods if they need treatment, We usually do a full blood count and a, uh, blood group and a Coombs test. Actually, there you go. There is a talk on jaundice. The very first talk I did so November. It should be recorded. It will be, um, I posted the link on the chat on medal. So if you go on this link, you'll see all the recorded lectures, but it's a fascinating subject. There you go. Thank you for your comments. It's really helpful to get feedback that I'm pitching it correctly, right? So case based scenarios make it easier to understand. Excellent. Okay. We will always do case based scenarios, then. Thank you very much, Doctor. I just like to remind everyone, um, like I pushed in the chat. Please do the feedback. It's very important for us to continue. Um, any additional feedback and comments you can write in the chat. Um, so we've got a few minutes left, so if you could please do the feedback now, um, confirmed that you've done it in the chat and then I'll send through the certificate. Um, I will pause the recording now