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Hey, guys, I can see a few of you have already joined. We're just gonna wait for a few more um people to join. We'll probably start about five past. Um If that's OK. Hey, so those of you that have just joined, we're gonna start at five past. Um We're just waiting for a few more people to join, hopefully. OK. So I think in the interest of time we'll start. Um So my name is Georgia. I'm gonna be leading the session today. Um I'm one of the final year medical students um for those of you that don't know me. Um And today's session is gonna be about basically growing up so focused around peds. Um And um for those of you that haven't come to our, any of our sessions before, uh we teaching things basically, we um we offer weekly tutorials which is open to every one of all year groups. Um This is focused on like high yield content mostly um and specifically like core presentations um and teaching diagnostic technique. Um It's all taught by medical students. Um and our slides are reviewed by doctors to ensure that they're accurate. Um And yeah, So, if you like this session, please come back to more of ours, um That would be great. Um And hopefully these will be useful for you. Um So today I'm gonna cover um development and developmental delay to start with and then we'll look at um im immunizations um including like an OS station and then um we'll move on to puberty and precocious puberty. Um So, OK, so, um obviously we're gonna start with development. Um OK. So what are the four areas of development? I'm sure you all know this, I'm not going to bore you with it too much. Um But the four main domains are gross motor. So things like um rolling from front to back or back to front, um sitting, walking, running, um We'll go through these in more detail in a second. Um fine motor and vision, which is things like um palm grasp, um pincer grip. So like picking up things um drawing um things like that speech and hearing um which is obviously talking um like sentences, questions, colors um and like hearing, you know, like following commands, um things like that and then social behavior and play. Um So this is obviously just like how Children interact with each other, but also um like their facial expressions, how they dress themselves, how they feed themselves. Um Yeah. OK. So we're gonna start with some um kind of quick fire questions just to get you all hopefully interacting. I know it's difficult because you can't turn on your mics. But if you, if we could try and use the chat as much as possible, that'd be great. Um So if we start with the first one, so at what age do you guys think a child should be able to respond to their own name? Uh If anyone can just put it in the chat, um or if not, I can reveal, but I'm sure I'm sure a lot of, you know, that anyone brave enough to use the chat. No. Oh, um, ok, so pre put six months. Um, so it's actually, um, 9 to 12 months roughly. But every, um, so basically every kind of, um, you know, like the M RPC website is one place where they have a table of milestones but also, um, on like past medical, but they all kind of vary and the M CPC ones tend to be slightly younger. Um, but the range is like 9 to 12 months. Um, normally I think past me says 12 months. Um, ok. Number two, does anyone know when Children would start to like, talk in short sentences? If not, I would just go through these because II don't wanna spend ages on this really? Um, so in terms of which one we should follow for exams, I would use the table, um, on passed. Um, those are the ones that the questions are like most likely to be based off, but to be honest, they don't vary hugely. Um Three years. Yeah, that's correct. Yeah. So two point like 2.5 to 3 years is roughly the range. Um But yeah, three years is from past me. Um OK. And drawing a circle. It is also three years. Um And in a second, we'll talk about like ways to remember this. Um and other masters um sitting without support with back straight. Yeah, so 7 to 8 months. Um but again, we'll go, we'll go through like when you'd actually be concerned if they can't sit without support because that's important. Um ok, and smiling, smiling. So smiling, six weeks, um that doesn't really tend to vary between um different guidelines, um and walking unsupported. So walking unsupported is 12 to 15 months. Um at 18 months, you'd start to kind of get a bit concerned. Um But again, we'll discuss that we'll discuss red flags. Um And finally combining two words. Yeah, two years. Correct. Thank you, Amelia. Ok. So we're going to move on to some tips and tricks for actually learning the milestones. So if I'm honest, milestones can be a really annoying thing to have to learn. Um But you will have questions on your AKT on them pretty like pretty much guaranteed. They're also very likely to come up in an A station. Um which again we'll go through. Um So these are like, I find a really useful tips and tricks for learning them. Um social behavior and play, I don't really have any tricks. So if anyone does feel free to put them in the chat, um, but these are the ones that I've learned. Um, I was especially, I was taught a lot of them on like P BSC, which I did. Um, so, yeah, I'll go through some of them now. So, speech and language I find a good way is basically the number of months or years you use that as like to work out the number of letters or number of words that they should know. So at three months, they should be able to like co like make sounds um which obviously co three letter word. Um six months make six like they should be able to babble, which is a six letter word. Um At nine months, they should be able to form like longer words. Um Sorry. Yeah. Um sorry, not longer wise, they should be able to like imitate. Um So yeah, imitation nine letters. Um And then one, these are the ones I find the most useful is just like one year, one word, 18 months, 18 words. Like I feel like that's so e such an easy thing to remember and that will help you so much. Like even if that's the only one of these tricks you learn, I'd say that's probably the most important one. So yeah, one year, one word, 18 months, 18 words. Um and then at two years, they should be able to start combining two words. Um And at three years, like combining three words also following multiple step commands. Um And then four years like short sentences. Um also um at four years asking like questions, why when and how um and at three years is when they start to ask like what and who questions and also learning colors. Um And counting to 10. Um I didn't write them all on here. I don't really want to go through all of them because there are plenty of tables out there for you guys. Um But I'd recommend looking at the M RPC website as well because that is really useful. Um But yeah, a few more speech and language ones to go over just some key ones at three months. Um They'll as well as like co they'll start to um quiet into parent voices, turn towards sound and like squeal make other noises. Um And a nine months of child will, will start to understand. No, hopefully. Um And at 12 months, um they'll start to basically know their own name and respond to their own name. Um ok. So gross motor this trick I find really useful. Um It's basically like going from head to toe. Um So you start from the head and you think like start from when they're at the youngest. So three months you start with the head, they start to gain head control. Um So basically at three months they'll no longer have a head lag and be able to stabilize their neck better. Um, and then six months we start to move down from head to toe. So towards the trunk. So at six months, um, baby should be able to lie on their front and extend and like lift their chest off the ground. Um And they should also be able to pull, to sit, um, and roll front to back as well at six months. Um, and 7 to 8 months is when, um, sorry. Uh, so, yeah, 7 to 8 months is when you should be able to sit without support. Um, so you'd start to get concerned about 12 months when a child can't do this. But 7 to 8 months is kind of the average when they'd start to. Um, ok, and then moving further down, we've got obviously knees so crawling, most babies will crawl at nine months. There are a lot of different variations of this. Like bottom shuffling, come on, like bottom shuffling where they kind of push off using their hands and just like shuffle along the bum, um, commando crawling where they'll kind of like have their arms in like a plant position and like, um, shuffle like that. And a lot of parents can be quite worried about this, but they should be reassured because, um, these are completely normal variants. Um, and sometimes they can be genetic. I can just run in families. Um, yeah, and then 12 to 15 months, as we said is when you start walking, um, running kind of towards two years. Um And then two years jumping, I kind of remember that as like two years, 2 ft, um jumping with 2 ft, three years tricycle, like tricycles, tri three. Um and then four years hop don't really know how that's just, you always have to learn that one, I'm afraid. Um ok, and then fine motor of vision, the blocks. Um I'm sure some of you already know this trick, but you basically like you have to remember just that 15 months is a tower of 2, 18 months is a tower of three. And then when you're two times it by three, you can make a tower of six when you're three times it by three, you can make a tower of nine. Um And then shapes, I find these quite useful. So a line has two points like a two year old should be able to draw a line. A circle has 360 degrees. A three year old should be able to draw a circle and AFA point has a cross has four points. So a four year old should be able to draw a cross. Um And then five s like square and triangle again a bit harder. Um But um yeah, I mean, I'm sure there's something you can probably remember without tricks, but it can be a bit lengthy to that. I know. Um Oh, ok. Pri said something in the chart so she said something we got taught was to imagine a child at their 1st, 2nd and 3rd birthday and what they would be doing at that birthday as a way of remembering the general milestones. Ok, that's actually, yeah, that is actually quite useful. Yeah. Ok. So yeah, think of their birthdays and what they might be doing to celebrate their birthday. Um Thank you. That's very useful. Um, ok. Oh, fine motor vision. I was going to go over a few more key ones. So three months, um, babies will start reaching for things, um, might hold like a rattle. Um And they're quite visually alert and they'll fix and follow. So if you put your finger, like if the baby's like lying down and you put your finger there, they will follow it with their eyes. They should start to do that in three months. Um And six months they should be able to have a palm grasp. Um And at nine months they'll start to develop, they're like pincer grip, but it won't be very good. 12 months they'll have like a, they should have a strong pincer grip. Um Yeah, and also at 12 months they'll start like, um banging stuff together since my son has that just called banging or casting, which is when they like throw stuff um or mouthing as well, which is where they just like put random objects in their mouth as a way of exploring the world. Um OK, so we're gonna move on. So social behavior and play because I didn't have any tips and tricks. I just did a separate slide on this. Um Again, like these tables are on past me, but like, I mean, I'm not gonna waste time going through all of it now. Um But key things smiling six weeks um will come on to this, but there's a red flag involved with that. So that's an important one to remember. Um Like Children will often enjoy being handled until they're about like nine months and then they can be a bit shy um and start to develop like stranger anxiety. Um This is just the way their brain develops. Like initially, they don't see like have a sense of danger and then as their brain develops more, they develop like a sense of a sense of attachment to like people they know, but then also more of like a stranger danger kind of um fear of people they don't know and that's completely normal and should happen. Um Feeding, yeah, I'm not gonna go through those but you can see them there um dressing same thing um and playing. So peekaboo babies will like respond to at nine months before that they'll probably be scared because of the whole like stranger anxiety thing. Um But yeah, nine months, they should like be able to play Peekaboo um kind of respond to it and then mostly they'll play like, by themselves but alongside other Children. But when they're four, like four, when they start school, it's, they should really be playing with other Children. Like that's, that's kind of normal. Um, sometimes Children but do long before that, it just kind of varies. But, yeah, I suppose you would kind of consider maybe like autism, um, or various other, um, neurodevelopmental issues if a child isn't playing with other Children at all. When therefore, um, ok, we'll move on. Um, if anyone has any questions at any point, just put them in the chat. Um, I'm more than happy to try and answer them. Um, and that would be great to just get some more engagement. I don't want to send you all to sleep. Um, so this is like, what should you look out for in exams? Um, because obviously, like I said, they do come up quite a lot and I'm sure at some point you will be tested on them. Um, so in Osk, um, it's, yeah, quite likely to come up. Um, and we had a station actually the, the other day, um, in like one of our mock Hokies. Um, and it's like watching a video, this is probably the most likely way it would come up. So they basically will play you a video of a child. Um, you have to watch it, identify what the child can do and then what they can't do. Um, and like describe ways that you would kind of assess a child's like um social behavior or things like that. Um Like using toys. Um for example, um and I don't know, it was quite a lot to do in the time. I think we, we got to watch the video twice. So if you have this, um I would recommend watching it once at the start then trying, they often give you like a worksheet to fill out with like gross motor skills. The child can do like fine motor and vision skills, the child can do and like, I'd recommend watching it once filling it out and then watching it again and seeing what else you can add to that um that you've already filled in. But if you, if, if you watch it twice in one go, I just find that sometimes you're actually not looking at it properly and it just kind of will go over your head. That's what I found myself. But I don't know, you, you guys might, everyone does it differently. Um You might ask to be then like you might then ask to be to estimate the age of the child as well, which if you know your masters, that should be kind of OK. I think some people find it hard when it's like, what can't they do? Um And this is also specific to the video itself, like you can't just say a random master that's not shown in the video, like they'll specifically ask the child can you jump? And if they don't jump, you can write that as like, well, they didn't jump and when they were asked kind of thing. Um Also, it's important to be specific. So don't just write when it says like what fine motor skills can they do? Don't just write Pinter grip, put like pin grip to pick up because it will show in the video like Pinter grip to eat or like, you know, something like that. Um Because it will show what, what they're doing in the video. Um uh What else did I have to say about that station? Yeah. Pre said Mr CPC H have videos on the website um where you can practice these a stations. That is true. And yeah, I've also, I've also said that on the side, um I found that really useful definitely do that. Um I would recommend that. Um Also I think I got caught out on that station because it's not just necessarily milestones. It's, it's often says skills. So you might think something's not a milestone, but it's just like a skill to say that I don't know they're putting an animal. Um So I don't know the one we had, it was like putting animals into these slots and if they put an animal into a slot that, that's like a skill, but it's not a, a specific mil milestone as such. So just read the question really carefully will, will also be my advice. Um, and in a KT it will most likely just be what age should a child? Obviously, I'll give you a brief and then it'll be like, what age should a child sit unsupported or what age should a child smile, things like that. Um, or they'll give you, um, vignette and they'll say like which domain is D is delayed in this child. Um, but yeah, we'll go through some AKT questions anyway. Um And OK, this is really important. So red flags, you know, learn this. Yeah, like really, really well um this will come up. So the main red flags that come up a lot are not walking by 18 months. So if in GP you see a child not walking and they're 18 months, you should urgently refer them to pediatrics. Um ideally to have a developmental assessment. Um Also, if a child's not speaking by 18 months, that's also a red flag. Um And another one that comes up all the time in AKT is hand preference. So before 12 months, a child shouldn't have a hand preference. They should still be exploring like using both hands. Um and the part of like their brain that would decide the hand preference just hasn't developed yet. They should be trying to use both. Um Yeah. And if, if like it can be a sign of cerebral palsy, for example, um if there is a hand preference because if there's like brain damage to one side of the brain. Um Often the dominant hemisphere that usually controls the hand dominance will um be affected and then that will kind of switch. So that'll just only be using one hand more than the other. Um because one side of their brain is just not working properly, um not smelling by 10 weeks is also like socially a big, a big red flag. Um for example, things like autism, um you wouldn't necessarily diagnose it in a child this young, but picking up early signs is really important like for early intervention which improves outcomes a lot. Um And not being able to sit unsupported by 12 months is also a really common one, but all of these are important. So learn all of these if you can. Um OK, and prematurity, we should talk about this quickly. So basically, you um when the milestones are normally met by like a child that was born at a normal um gestational age um born at town, basically, um you add on the number of weeks premature that they are to when the milestone should be met. Um And you do this up until they're two like two years old. Um So that's important to remember if they, they might try and check you out with like a premature baby in an AKC. Just remember to add this on. Um Does that make sense? I mean, you don't have to say yes, but if it doesn't make sense. Please stay in the chat. OK. So developmental delay. Um So the definition of developmental delay is basically a lag in a child's development um in one or multiple domains relative to established milestones. Um Global developmental delay, there has to be delay in at least two domains of development. Um And it's in a child under the age of five, developmental arrest is when like a child normally has like has normal development initially and then suddenly they'll halt and they just won't gain any further skills. So they'll like, be able to walk and then they just won't learn to run at all, uh, or they'll be able to crawl and they just won't learn to walk. Um, this is one of the red flags when you should prefer developmental regression. Um, is when a child like loses previous milestones that they've had. So if they could sit unsupported and then they start to just fall over all the time and they can't sit unsupported, that would be a, a red flag. Um, developmental delay can also be quite like parents can be really worried about it and it can be quite mild. Um, I think, I mean, it's, it's too detailed for any of us to know, but there, I have seen like classifications of different scoring systems you can use to classify it. But basically, it's like if they're, if, if they're walking at 16 months, if they start to walk, that's not a red flag. So you wouldn't really prefer them or worry about that too much because there is, there can be a big variation in when Children achieve different milestones um depending on like their environment, genetics, all sorts. So I think it is important to reassure parents, but also just stick to those red flags. Um But if developmental delay is mild, it can be managed in general practice, which we'll talk about in a second. Ok. So these are the main types of developmental delay. So each um like domain and global and the causes and their risk factors. Um A lot of these are similar, have similar causes and risk factors. So I won't necessarily go through all of them but um for global, so these that it can be caused by things like down syndrome, fragile X syndrome, um like metabolic disorders. Um and risk factors are like prematurity. Um Obviously, we account for that when we um correct the gestational age for the milestones, but it's still a a risk factor. Um and they can like even when you correct it, they can still be delayed. Um um Being small for gestational age, um being male, not quite sure why this is. But um yeah, males, it's more common in males, um multiple pregnancies and minority ethnic groups. Um and then gross motor, this is really important. So like cerebral palsy is the biggest cause of gross motor impairment. So most likely if they have a delay in that domain that would be the most likely cause. Um and cerebral palsy is like a disorder of movement and posture um caused by um a nonprogressive lesion of the motor pathways in the developing brain. And it has to happen before the age of two. Um and the most, yeah, like I said, it's the most common cause of major motor impairment. Um and there's different, like the main symptoms you'd see is like abnormal tone um in young Children, motor delay, but also like got some global delay as well, potentially um an abnormal gait. Um so often have like a scissor gait. Um And I don't know if you guys have seen this but if you haven't maybe watched a video um and feeling difficult, sorry, feeling difficulties as well. Um OK. And then social and emotional again, like the main one is autism. So I'm guessing, ii assume some, a lot of people know, but autism is a neurodevelopmental disorder. Um And it's basically like impairment in social interaction um and communication and there's often like repetitive stereotype behaviors and like rituals um that Children will stick to and they might have like specific interests um that they're kind of quite like fixated on. Um And in terms of like um social behavior and play, they might not really interact with other Children that much, not go much eye contact, not want to be picked up um Things like that. Um OK. Let's move on. Um, so in terms of investigations and management, um, of, um, developmental delay. So first you'd want to do a developmental assessment. Um, so this can just take place in GP. Um, or if they're really a gps really worried they might refer to Peds if there's red flags and this might happen in Peds. Um, so this will include a history. It's really important that it includes a thorough birth history and family history, um examining the child and also like, I guess testing their hearing. Um It really like, that's really important because the most common cause of a um if delay in like speech and hearing is like hearing impairment and also just in general, like other like global delay, also, it's really important to check hearing. Um Just remember that's always a really important thing with, with delay because it can cause all sorts of different delays. Um In a when you're doing a developmental assessment, you can use like pens and toys and things. I don't think you'll ever have to do this in an ay. So I wouldn't worry about it too much. Um Then obviously it's important to determine the cause. Um And then if there's any red flags an urgent review by PS um but like I said, if there's only mild delay and it's in one domain and there's no red flags, it can be monitored in general practice. But it's, yeah, it's, it's quite common for this you know, these issues to be referred to pediatrics. Um and it's unlikely unless, yeah, especially if there's red flag, it's unlikely you'll be peeing. Nice for saying like I would refer to Peds. Um ok, and if there's a sudden like cognitive delay, they might need like a neuro review um or imaging like brain imaging, MRI CT. Um and they might need a specialist referral if there's like a specific cause that's identified uh in terms of management. So you'll get this a lot with like autism and other neuro developmental disorders. And they will say like how is it managed? It's usually an MDT approach. So with developmental delay, you'd want initially a pediatrician and then depending on the delay, you might want speech and language therapy, occupational therapy, um like physio, especially for motor impairment, also fine motor um support school like um I don't know, they might need like ta support and things like that. Um Psychologists and psychiatrists for um social behavior and play um social workers and audiologists, which again is really important for speech and hearing and also just in general. Um Yeah, so for example, like the treatments are very specific to the causes. So I'm not going to go through all of them, but for cerebral palsy, some of the main like treatments can, obviously, it's an MD approach, but family support and counseling is really important. Um and muscle relaxants and surgery can be kind of other things if they're having like contractures and pain. Um And like I said, early improvement, early intervention always improves outcomes. So it's important to pick up developmental delay, early and refer um early. So this is our first SBA. Um So I'm gonna open the pole so I I'm gonna open a pole and it should pop up on your screen. Um Tell me if it doesn't and you should be able to answer this SBA. So I'll give you a second to just read it and to respond. Mhm OK. OK. Cause it was quite a few, few of you have responded. So I'm gonna stop the pill now and it looks like. Um So let's say you did really well. So 80% of you got the correct answer, which is when he started picking up food and toys with his right hand. Um So like I said, this can indicate cerebral palsy um and a lesion to the brain um which can, depending on the side can control like determine which hand the baby is more like the child is more likely to use. Um So, yeah, you guys got that right. This is a really common AKT question. So that's good. Um OK. Next question away from the pole. OK. So I'm gonna stop because you guys have all answered it and all of you got it correct. So that's great. Um So the answer is normal development. Um Yeah, so I mean a lot you will get this a lot in real life and in a KT questions, um, that the parents worried about the child falling behind. Um, I mean, the, it's a nine month old child, he sits without support, which is great. That should be achieved by 7 to 8 months. Um, doesn't move around the room much, but I mean, nine months, they'd probably be expected to start to crawl. But up until kind of a year or even some Children might not even crawl by a year and that's completely fine. Um, he has a pincer grip, which is great. Not a great one, but that's completely normal and he shy developed strange anxiety which is completely normal in a nine month old. So, yeah, perfect. Um, ok. Next one. Oh, sorry, I not. Ok. We've got a bit of a split in this one. it's only five responses, but I will. Ok. There's seven now. Perfect. Um, ok. So, mm, I'm sorry, I was just ok. So there was a bit of a split with this one, so I'll go through it. So the correct answer was the child enjoys playing alongside other Children. Um, so I think, II think I briefly might have touched on this, but when a child's about two, they might start to play alongside other Children, but until they're about four, they won't necessarily engage with other Children specifically. Um, but I mean, a lot of, um, Children between the ages of two and four will play with other Children. Um, but in terms of like, actually, um, like trying to work out this SBA, um, I think complex group games, I mean, automatically the word complex, like in a 2.5 year old, then that complex group games wouldn't really be until a child's like about six or seven. Um, preferring to play with adults rather than peers. Again, Children of like two year olds would prefer to play with other peers just because they see them as alike to themselves. Um, a uh imaginary play with imaginary friends again. That wouldn't be till older until Children that have started school. Um And competitive games wouldn't be till much older, maybe like eight or nine. So, yeah, just remember two will play alongside other Children and when they're four, start to play with other Children, um, well done. Uh and the next one I will open, I think this might be the last one for, for development. Um, ok. Ok. So only one person's responded, but I'll give you a few more seconds. Ok. So about half you respond. Um So you've all got it right? Um It is referral to audiology for um, auto emissions testing. So this is, um, like I said, um, a delay in like, and this is an isolated delay in speech and hearing, um, like not using words. He's 18 months old. So that's a red flag. Um Otherwise he's growing well, um there's no like he's, he can walk, he can hold objects, there's no signs of other like delay in other domains. Um So this is specifically speech and hearing. Um And yeah, most common cause is hearing impairment. So always check that first. Great. It seems that you guys know that anyway. Um OK. And we've got two case studies. So I'll just give you a second to read the first one and then if any of you want to put in the chart, how old do you think this child is? Um So this is like estimating the age of the child? OK. So if any, if you think, you know, um pop your guesses in the chat. OK. Yeah. So um what on the media? You're right. So, um this child is roughly um age three. They can follow two step commands, um three or four word sentences, um a vocabulary of 200 words. You could expect this from a two year old and above. Really? Um She can't count to 10 yet, which you would normally expect from a three year old, but that's fine. That's one tiny element of one domain. So that wouldn't be classed as like having delayed. Um 00, that's for a question too. Oh, ahead of the game. Um OK. And yeah, she can draw circles 360 degrees. Three years. Um She can't hop though, um which is a, a four year old would usually be able to hop. So again, that's consistent with three years. Um ok, so number two, I mean, Amelia's already put her answering the chat, but if anyone else wants to make a guess, go ahead. Ok, so I'm gonna go through this one. So this one is 3 to 6 months. Um So yeah, basically they can raise their head to 45 degrees, um, which is expected of like a three month old. Um, but they can't sit, which a three month old would usually be able to sit with like a curved back with support. Um, but it's not abnormal for them not to be able to sit at three months. Um, fixing and following should be able to do it three months which they can track objects. This child can do. Um having developed a palm grasp, that's six months, um can smile and laugh, laughing is three months is three months, smiling is six weeks. Um And the Moro reflex. Um I don't know if you guys know this reflex. I can, I'll, I'll go through it quickly. Um But there's, there's quite a lot of, there's quite a few primitive reflexes. Um Most of them are lost by six months old. Um This is another good thing to look at. We don't really have time to go through all of them now. Um But a classic one that might come up in an EKG is the Moro reflex. This is basically where you hold the baby. And you like, drop them like very slightly lower them and then re catch them again. Um, this can be really scary to do if you haven't done it before. I remember the first time I was on award round I did. It is actually quite scary and the moms are like, oh God, but it's fine. Um, so yeah, just make sure you recap them, but basically they'll kind of extend and flex their arms. Um And that's a normal reflex. Um And that's usually lost by about six months, but that's basically that should be there. Um Up until six months. Yeah. So fun fact. Um OK, we're going to move on to immunizations. I know we're a bit short on time, but I think these sections are shorter, so it should be fine. Um So here is the beautiful childhood immunization schedule, which I'm sure you all love. Um Again, this is another thing that you kind of just have to learn that aren't really, I don't really have any tricks and tips to actually learn it. I'd say the key ones that come up a lot in AKT are two months, three months and four months and I always get them mixed up. So try and learn these as best you can. Um like men B is two months and four months. Um The six and one is given out 23 and four months and remember which vaccines come under the six and one. So diphtheria tetanus whooping cough, polio, Hemophilus influenza B and HEP B. Um And then another one that's tested a lot is the Mmr which is given at 12 to 13 months and then again as a preschool booster um when the child is 3 to 4 years old. Um Yeah, another key thing now is that the HPV HPV vaccine is now given to both males like boys and girls, which initially it was only given to girls. Um So that's also important to remember. Um And then the AC yw is often given like uh a boost is often given when people start uni so like 1819. Um OK, so we've got an S PA here. Um I will open the po mm OK. Mada OK. So about half of your photos. So um we have got a mixed, mixed uh responses for this one. OK. Cool. Most of you voted now. Um OK. I'll close the poll. Um So. Mhm mhm So the answers to this one is Meningococcal conjugate vaccine. So this is because like Children with sickle cell disease are more at an increased risk of more severe infections um including like meningococcal disease. Um And so they're given this vaccine, I don't think you'll be tested on like how often but um in case you are, um it's given as like a two dose series um eight weeks apart um for Children that are two years or older. Um And then a boost is given after three years and then like every five years. But I think there's a very niche, like that's, that's very niche. I don't think you'll be expected to know that. Um, so I think this question in itself is a difficult question and is already quite a niche. Um, but yeah, I just remember Children with sickle cell. Um, yeah, they should also, like, they should receive this vaccine in addition to the, um, routine schedule. Ok. Another sp ok. So only one of you has responded. So I'll just wait another minute or so. Oh, now five you have. Ok. Interesting. Ok. Ok. So um 80% of you have put severe egg allergy, which is interesting. Um and you can challenge my knowledge if you like but um the Mmr vaccine doesn't contain egg. So that shouldn't be a problem if a child has a severe egg allergy, they can still have the mmr um the answer was acute lymphoblastic leukemia which I think one or two of you got, which is good. Um So this is because Children with immunosuppression um shouldn't have live attenuated vaccines and mmr is a live vaccine. Um So this is another I put this question in because this is another important thing that you might be tested on is which vaccines are live. Um There's a not, I mean, I think you're, that's the most important type of vaccine to learn. There's all sorts of different types like conjugate. Um I don't think you'll be tested on those. It's mostly live, are like the really important ones to learn. Um, so, um, yeah, obviously if they've got acute lymphoblastic leukemia, they're likely to be immunosuppressed and at an increased risk of severe infections. Um, so it's, yeah, they shouldn't have the, a live vaccine. Um, because obviously a live vaccine is like a weakened version of the pathogen which is gonna, um, stimulate an immune response, which this child wouldn't be able to cope with. Um So it's important to know which vaccines are live, like I said, so um some examples are the BCG um Mmr the flu vaccine, rotavirus, polio um and Typhoid. Um Yeah. Ok, cool. So now on to the, so this is a classic like brief you might be given, this is a very typical ACU station. Um So I'm gonna, I'll read, I'll read this out quickly. So take a history and address the concerns of Jean Gardner, the mother of an 11 month old girl um try to help her come to a shared decision on what to do regarding her daughter's vaccinations. You're an F two and GP. Um You can see she has no past medical problems, no prescribed medication and no drug allergies. Um So like how should you tackle gestation? Um This is a very common station. Um like an anxious parent, they will be anxious. Um Some of them to vaccinate their Children, obviously, their Children, their babies might cry and be quite distressed. Um which as a parent isn't nice. Um But it's, there's actually a lot of studies have shown that is your role as like a healthcare professional or our roles is so important um in educating parents and they really do like listen it and it does like studies have shown it does increase uptake of vaccines. And obviously, it's really important because if you even accidentally give misinformation that trust can kind of be lost quite easily. So it's really important to just know we'll go through this, but some basic information about vaccines that you can accurately give to a parent. Um because at this stage it's it, it's quite likely to come up in an ay. Um OK. So yeah, you'll be expected to address their concerns. Like common concerns are kind of, oh, what if it overloads my child's immune system? Um What if the vaccines haven't been tested properly? Um Is it not gonna make my child ill? Like if you're giving them the the bug like the pathogen? Um and also worrying about pre prematurity. Um So this is like some key information for parents. Um I would just try and like know as much of this really as possible. So like in terms of them saying, oh, it might overload their immune system, um you can kind of respond with, well, Children are, by the way, I'm sorry, we can't make this more interactive. But um yeah, if any of you have any questions, please put them in the chat. Um. Ok. Um, I don't think there's any questions in the chart right now. I'm just gonna double check. No. Ok, cool. Um, so yeah, you can say Children are exposed to millions of bugs every day, like when they go to nursery and just like around with other like interacting with other Children. Um, so a few extra which are in these vaccines isn't going to harm them, more overload the immune system and the immune system is built to be able to deal with like all sorts of different um pathogens. Um Yeah, there's, there's also like studies have shown that there's no increase in bacteria or viral infections um in Children after receiving the mmr. So if they say they're worried about their child becoming ill that um like theoretically that shouldn't, that shouldn't happen or it will be very rare. Um The main one you'll get is that parents will be worried about the mmr um obviously, you've probably heard the negative publicity um kind of in the nineties surrounding the leg with autism and this was actually done, this trial was done on a very small sample of Children. I think it was literally like 20 or something. Um And don't quote me on that, but I think it was between 12 and 20 but I'm not 100% sure. Um And this has since been found to be very inaccurate. The doctor who actually did, the study has been struck off and um the number of Children that developed autism was actually just the same as like the infants in the general population. So the study is completely inaccurate. So you can really try and reassure parents on that. Um And then London has the lowest mmr coverage across the whole country. Like due to there being like a mobile population, frequent like house moves, not being people not being registered with GPS um access barriers and like a higher proportion of people from um minority and ethnic backgrounds um than other places in the UK. Um And yeah, I think with parents, like some of them might want their child to have the vaccine separately. Um but one, this isn't available in the NHS two. This is more distressing for the child. There's actually no research done on the vaccines being taken up individually and adherence tends to be an uptake tends to be poorer then because like parents would have one and then just not have the others. So it's, yeah, there's, there's a lot, a lot of reasons you can tell, tell parents why. That's not a good idea. The vaccine schedule was developed specifically following research so that vaccines are given in intervals um as to as to how like the immune system develops immunity. And you can explain this to parents like that's why, you know, at two months you have men and then at four months you have men because the immune system has to take some time to build up. Maybe, maybe don't use antibodies. It kind of depends. I don't know. They might, you might need to explain what antibody is to the parent that might, that might be fine, but just try and avoid too much like jargon. Um And yeah, so in terms of prematurity, these babies should have their vaccines at the same time. And you can say to parents that this is because they're actually they actually have weaker immune systems, so they're more vulnerable to infection. So if they're saying, well, then their immune system can't cope with it, it's like, but actually then if they get these infections because their immune system is weaker, they, they are much more likely to get seriously ill. Um ok, so yeah, there are some side effects and risks. Again, this is a difficult thing with parents because they can already be anxious. But you've got to remember you're still gonna be expected in a station to not only reassure them and it like kind of encourage them to have the vaccines, obviously not force them to which I'm sure now you will but just give them accurate information and try and encourage uptake. But you will also you can't lie and say, oh, you know, there's nothing bad about vaccines or there's no side effects. You will also be expected to tell them the like main risks and side effects which are mostly mild. So it shouldn't, you know, it shouldn't alarm them too much. Um, but yeah, you don't have to say like there is a risk of death. You can just say there are some rarer more serious risks. These can include like a severe allergic reaction, uh, infection or nerve injury. Um, very, very, very occasionally they can be fatal but reassure that there's many more fatalities from like measles, for example. Um and I think measles can also cause like deafness and things like that, you know, these can be really serious. Um And parents need to be like aware of that. If their child actually gets these illnesses, they can um be really sick. Yeah, general like side effects, mild cri symptoms, uh muscle aches, things like that. This is a smart scheme just for you guys reference, I'm not gonna go through this now. Ok, so puberty. Um sorry, we've hit seven o'clock now. Um I'm hoping this will probably take about another like 15 minutes. So if you guys are willing to stick around, that'd be great. Um Sorry, the those sections took a little bit longer than I anticipated. Um ok, let's get started. So puberty, I'm sure, you know, but is the development of primary and se and secondary sexual characteristics and accelerated growth. Um and this is due to the production of sex hormones or the increased production um which enables like reproduction. The average age to start is 12 in males, but there's a range from kind of age 9 to 14 and it is 11.5 in females. Uh Males tend to have their growth growth spurt like two years later than girls. So at 14 and girls at 12 and girls tend to end their growth spurt earlier. So men will continue to grow much longer than girls. Um And the woman's average age of menarche is 13. Um A menarche is like starting your periods. Um So behavioral changes are also important to note. So the way the brain develops, there's an increase in um certain like sensitivity to dopamine and pruning, which is where like the synapses between like neurons, basically. Um they become more selective and some of those um connections like the more important connections you'll keep and then the less important ones kind of disappear. And that's the process of pruning and that happens in the pre frontal cortex, which can lead to like an increase in these like risk taking behaviors. So when a lot of people say like, oh teenagers are just like dangerous and like moody and stuff, it's because all these changes are going on in their brain um which are kind of crazy. Well, I think it's kind of crazy. Um OK. And this is the um HPG axis. So the um hypothalamic pituitary axis um and it starts in the hypothalamus. So GNRH is released which then stimulates the anterior pituitary gland to produce LH and FSH. Um So then these will stimulate the gonads. So in females, the ovaries and in males, the testes to secrete um testosterone in men and estrogen and progesterone in women. These I find actually like are quite good, easy ways to remember it. So LH is produced by the Leydig cells of the testes. So L and lad like that, I don't know if that helps me. And then um the Lasix cells produce testosterone and then FS H um sitoli cells. So a the S in FSH and seo cells produce sperm. So, sss um and then in women, um LH the, the uh stimulates the fecal cells um in the ovaries to produce in the follicles to produce and um stone um which is an androgen and then this is converted to testosterone and progesterone but in smaller quantities than men. Um And then FS H produces uh sorry, stimulates granulosa cells in the follicles in the ovaries to produce estrogen. Um OK, we'll move on. So these are the 10 stages of puberty. Um So because we don't have loads of time, I'm not going to go over this hugely but learn. So there's a lot of rote learning today but try and learn this table. Um Yeah, I mean, there's no, I haven't seen many questions on it personally, but just roughly no, like when you know, peak height velocity, for example, men in town stage three will reach their peak height velocity and in women, they'll reach it in stage between stages two and three. So like, like I said, they have their growth but a bit earlier. Um But yeah, this is basically just like how to, how a clinician will actually assess where a child is at with their puberty. So for instance, like stage two, stage one, um neither sex should have any pubic hair, females will be pre pubertal and men will also be pre pubertal. Their voice won't have broken yet. Um And then, yeah, like in men, stage two, their test volume will increase. They'll have a slight deepening of the voice, then the penis starts to grow in length. Um And then stage five is kind of like fully um developed across like females and males. Um some keywords. So the is um breast development. Um and a men I already went through and then agin arch is like basically hormones. Um and the hair growth. Um So like spine, soft hair that starts to grow. Um OK, let's move on. Um So precious previously is when puberty begins before eight in girls and nine in boys. Um it's much more common in girls. It's actually really quite rare in boys. Um And if it is, if it does happen in boys, this is important to learn is that if they have small testes, it's usually an adrenal cause because it means that the testosterone isn't being produced by the um testes, it's being produced by the in excess by the adrenal glands. Um So the testes are small. If there's unilateral testicular enlargement, there'll be like a tumor in one testae that's producing a lot of testosterone. And if there's bilateral enlargements, they say that their testes are, are big, um it will likely be like gonadotrophin release from a, a an intracranial tumor like a brain tumor. Um But yeah, there's two main types of progressive puberty. So, um gonadotrophin dependent or central, this is also called or sometimes true and then peripheral or gonadotrophin independent um or false. Um So, basically in um central, the FSH LH will be raised. Um and the sex hormones then will also be raised. Um And in peripheral um you'll have excess sex hormones but the FSH LH will be low because there's a negative feedback loop. Um So if the, if there's excess sex hormones, this will um reduce the cause the FSH and LH to be low. Um But if in, but in essential, there's just excess FS and H and LH um released. So you don't get this um negative feedback or you do. But because it's being FS H and LH is being continuously released, um it overrides a negative feedback. So, yeah, this is the key difference. One has FS H LH that are raised and one has FS H and LH that are low. Um So definitely learn that um and then the main cause is so mostly um central pu like central pre puberty is idiopathic. So it can just be like if a child's mother start her periods young, the child will also start her young. But other causes are like structural brain damage, brain tumors. These are very rare. So I wouldn't worry too much about these. Um And then gonadotrophin independent um causes include like tumors of the gonads, like the ovaries and testes, adrenal causes um for example, congenital adrenal hyperplasia. Um and then genetic like MCU um upright syndrome and also like exogenous sex hormones. So, if someone's taking like testosterone, for example, um which is unlikely in a child but it can happen. Um ok. So how would you assess it? So you take a thorough history to get their rate of like puberty when the girl starts their periods. Um, parental height is important to predict their height and see if they're like massively over that. Um social history. You might include a heads drug history and examination, um which would include tennis aging. So using that table like examining the child, um looking at their breast blood development, um with ma with males, you would measure the um size of the testes. Um ok. And then we have like the investigations. So first line investigations um include measuring, like I said test exercise in males, um early morning ethiol and testosterone levels, um, adrenal androgens, LH and FSH and then a pelvic ultrasound to see if there's any like cysts like ovarian cysts, for example, in a female, um which could be causing the precocious puberty, like the release of hormones or um and also looking at x rays are used to basically assess the age of the bone. So if the bones are much more mature, um this could indicate precocious puberty and then GNRH stimulation test is a gold is the gold standard. So basically you take blood from a child, then you'd give GNRH hormone and then you'd um take blood like a few hours later and see how um like measure LH and FSH levels and see how dramatically these have increased. And if, if these have increased massively in this off the scale, then that's like classic precocious puberty. Um you might also consider uh thyroid function tests. Um as thyroid like function being thrown off can mimic um precocious puberty. Um HCG you might also wanna check. Um And yeah, if you, if you're suspecting like an adrenal tumor, you would do some imaging maybe like an ultrasound. Um And then congenital adrenal hyperplasia, you would do uh an ACTH stimulation test. Um Yeah. Ok. So complications, um psychological impact is really important. Like Children going through puberty, really young is that's gonna affect them a lot mentally, obviously, they're gonna be very different from their peers. They might be bullied things to consider. Um Yeah, and premature fusion of growth plates um which can basically stone growth. Ok. And management. Um So first line is just evaluation and treatment of the cause. Um So if there's a, if there's a tumor might need surgery and then you would give a GNRH agonist. Um I used to get really confused as to how this actually works because it's, you're giving an agonist, not an antagonist. I was like, why wouldn't that just increase the LH and FS H but basically the mechanism behind it is that if you're giving, um if you're giving a GNRH agonist, um it's obviously gonna bind to the receptors um and stimulate GNRH release. Um over time, like a sustained, high concentration of this, of GNRH results in like down regulation um and suppression of LH and of the like whole um hypothalamic pituitary gonadal axis um which will then reduce the amount of LH and FSH um produced. So, initially, you might have like a spike of LH and FSH and then OV like over time it will long term use will actually suppress it. Um So, yeah, remember this, it's not antagonist, it's agonist. Um And you might consider growth hormone as well, which can also have some negative feedback and stop um reduce the risk, the release of election age. Um OK. Um mm So I've just lost the chart. I'm just having a look at the chart. There's no, there's no questions that's fine. Um OK. And then for gonadotrophin independent precocious puberty, the management depends on the underlying cause. Um So uh resection of tumors again, stopping exogenous androgens if like they are like taking um testosterone and things like that. Um Aromatase inhibitors can be used for mccune Albright syndrome. I wouldn't worry too much about this condition. It's a genetic condition. Um that can cause like cafe lat spots. Um I don't know if you've heard of them which are kind of these like browny, milky spots. Um It can also cause like bone deformities um and problems, but it's very rare. So I wouldn't like worry too much about it. Um And then Glucocorticoids for congenital adrenal hyperplasia um because they basically reduce the ACTH levels um and minimize like adrenal androgen production. Um Yeah, that's also by like ne by negative feedback, the cortisol will suppress ACTH um which will minimize that um ACTH causing an increase in like um testosterone production. Um If any of this doesn't make sense, please stay on the chat and I'll, I'll try to explain it again. OK. So we have some S pa s to finish and then we'll be done. So sorry. It's over a little bit. Mm. Mhm OK. I have opened the pole. OK. So none of you have responded but that's OK. You might still be reading. OK. Someone's responded. Thank you a few of you responded. OK. And we actually have a bit of a split. OK. I'm gonna go through this just because I don't wanna waste your guys' whole evening. Um So yeah, for this you don't be expected to refer to pediatrics. Um This isn't really dealt with like precocious puberty. Would you'd normally refer to pediatrics and not deal with it in GP. Um Obviously this child is seven years old and precocious puberty in females is younger than eight. and early intervention is key. Um and it won't like by giving the GH agonist, you're not gonna reverse changes that have already happened, but you will halt um puberty and then um the child can stop taking them. Um They can kind of, you kind of have a discussion um about when they stop taking them and then it will take a while for puberty to like resume. I think it's like six months or so after they stop taking the G Rh agonist to actually wait for puberty to resume. Um But yeah, always your first to pediatrics in this case. Um I think one of you put requests blood test to measure at it and fate, this is also a reasonable thing to say. But again, like in this case, you would just refer to peds. Um and they would do that obviously impedes. Um OK, this is the next one. OK. So um two of you respondents. So, and again, we've got a bit of a split response. So we'll go through this. So this is enlargement of the testes, more than four males and boys and development of the breasts in girls. Um So yeah, this is basically these are the first signs of puberty. So just learn this, this will come up. Um So yeah, the arch it might be called instead of breast development, but it means the same thing or yeah, enlargement of the testes um beyond four M in boys. Um ok. Oh, sorry. Let me just see what the the other one you have. Yeah. Development of pubic care. Yeah, that comes like a bit. Um Yeah, the first invoices, testes will typically grow before any pubic hair grows. Um OK. Next one, I think we only have two more. Oh No, I think this is the last one. Yeah, this is the last one. Thank you guys for sticking around and engaging. I appreciate it. Um And I'm hoping that you're getting something out with this. Mm I don't think I actually open this one. Hang on, sorry, sorry, I didn't even know that Paul I right now. OK. So let's go over this. So, yeah, this is idiopathic, central precocious puberty, well done. Um So yeah, like I said, more than 90% of central uh central precocious puberty um is idiopathic in nature. So genetic runs in families. Um Yeah, that is the main cause. Um OK, I think we're done. Um Oh no, I'm on, hang on. I'm sorry, I've literally just showed that one as well. That's my bad. OK. We'll quickly just go over this one together. So um you can read this quickly if you like. Ok. So the key point here is that small testes. So a size of 2.4 centimeters and it says that they're prepubertal small testes. Um Like I said, in males, the most likely cause is adrenal hyperplasia because the, if the testis is small, the the androgens are not being produced by the testes, most likely they'll be being produced by the adrenal glands. Um Yeah. All right. That makes sense. OK, cool. I think we're done. So thank you guys so much for watching. Um My name is Georgia Sprain is for the feedback form. Um I think Pria put the feedback form in the in the chart. Um So it'd be great if you guys could fill it out, I'd really appreciate it. Um And thank you so much for coming. I really hope you learned something. Um And yeah, hopefully you guys come back to like our other teaching thing session so that every week um every Thursday and there's year four and year 51. So whichever you find more useful. Um But yeah, uh it was nice to teach you guys. Um Thank you. Um I'm going to just double check that the links in the chat and then I'll end the session the OK. I'm just gonna put it in the chart again anyway. Right? Cool. OK. Um Thank you guys and bye.