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Ok, good evening everyone. Thank you very much for joining us. Uh My name is Doctor James mcintosh. I'm the pediatrics lead at mind the bleep and it is my absolute pleasure to introduce two of our pediatric registrars. Doctor Bex Evans and Doctor Sophie Pitt Fitzpatrick, er, who will be giving us a whistle stop tour of all things that a new F one or F two doctor moving into pediatrics needs to know. Um I will hand you over to them in just a second. Um, but before I do so, I just want to highlight that over on the right hand side of your screen. Um, there is a chat for those that haven't been to one of these webinars before. Um, we're doing a Q and A se session at the end. Um So if you have any questions you would like to ask, um, we will go through everything at the end. However, as we're going through the presentation, if you feel you have a question about something that we're talking through, that you feel is particularly relevant if you pop it in the chat, um, we should be able to see it or I can stop, um, stop the presentation and then we can kind of go through it and address it while we're presenting. Ok. So over to Doctor Evans and Doctor Fitzpatrick. Um, so I'm Bex, I am a pediatric registrar. I'm currently working in a um district General Hospital uh in the Northwest in Preston Hospital. Um, and I'm also the pediatric editor for Mind the Bleep and I'm Sophie, I'm also a pediatric registrar in the Northwest. I'm currently at the Children's hospital also on ter replacements having done DGH placements, um, earlier this year. Um, so as James said, this is an intro, a whistle stop tour of an introduction to Peds, um, sort of aimed at like, um, new F ones and F two s who haven't done Peds before, but it'd be relevant to lots of other junior doctors as well. So the main objectives of the session, um, I'm going to talk through understanding your roles and responsibilities as a junior doctor in Peds when I say junior doctor, I mean, um, generally, like I said, like a new F one or F two or junior sho. Um, and I'll also go over things that you shouldn't be expected to do and sort of when to escalate concerns for senior. Um, we're gonna talk about understanding the differences with prescribing in Children as it is, uh, very different to prescribing in adults and that includes, um, fluids and blood products. Um, also gonna talk about, uh, key questions to include in your pediatric history again, how it differs from adult medicine. Um and also gonna go over um a brief um tour of like exam and how to examine a child. Um We're gonna talk about um some pediatric clinical skills although um this is difficult from a webinar and the best way to get experience with this is to do it in practice and, and watch people. Uh And we're also gonna talk about uh the most common pediatric problems that you'll see day to day. Um At the end, we're just gonna talk about um why Peds is the best and everyone specialize in Peds. Um So this is just a list of things you might be expected to do as a junior doctor who's new to Peds. This isn't an exhaustive list. So there are lots of other things that you'd be able to do and um and you also won't be expected to do all of these things on your first day. Um It's all a big learning process for everyone. Peds is very senior led and it's very well supported. So never feel scared to ask for help or raise any concerns that you have. Um But the main things that would be expected to do are to document on ward round. Um, a nice performer that most people use, whether it's handwritten or typing on an electronic system is starting with the date. Um The consultant who's leading the ward round a list of problems. So you can split that up into current issues and background problems as in like past medical history and then putting their EWS score, um their examination findings and any discussion and then the plan at the bottom of the ward round. Um and then it's always important to sign your uh entry in the notes so that people know who's written it and who to come and find. If they've got questions about the plan, you'll be expected to prescribe. So we'll go over prescribing in a little bit and how it's different for peds. Um, the B NFC will be your best friend. So if you've got the adult BNF in the top right hand corner of the app, there's a little arrow and you can change it to the B NFC. So that's the BNF for Children. Um, and, uh, just never be afraid to look up every drug. Basically. Um, you'll be expected to request investigations normally just x-rays and ultrasounds. Um, generally CT S and MRI S need to be requested by a registrar in most places I've worked. Um, you'll be expected to escalate as, as much as, um, as much as is necessary, basically. Um, like I said, never be afraid to escalate to a senior. No, no one's ever gonna tell you off asking questions or escalating concerns. Um, you will be expected to Clark and examine Children. It's an RCP guideline. And, uh, so in every hospital that any child seen on a pediatric assessment unit or a pediatric ward has to have a senior review by registrar or consultant before they can be discharged. So, even if it's your first day, don't be afraid to get stuck in and clerk and see Children because they'll have to be seen by a senior before they go home. Um, and it's important to just enjoy your placement or your job and ask lots of questions, learn, get stuck in. So, um things you shouldn't be expected to do and it's important to say no, because it might just be like a, a junior nurse who's just started and doesn't know what the role of like a sh would be compared to a registrar or it might be that someone from A&E is inappropriately escalating to a junior. You shouldn't be expected to see sick patients on your own. So, like I said, whether that's a inappropriately escalating to like an F one or an F two or it's a nurse coming to you about a sick patient that they're worried about, always ask for help if you feel out of your depth. Um You shouldn't be expected to just take safeguarding referrals that should always, always be the registrar at the very least, if not the consultant. If it's in the daytime and there's a consultant around, you shouldn't be expected to cannulate babies. Although if you want to and you're interested in peds, no one's gonna um, deter you, but just, um, know that if you're asked to do that on your first day again, that's not particularly appropriate. And you should always like, go and watch a few cannulation, um, and ask for tips first before you start doing it on your own. And then if you start, um, to feel more comfortable cannulated, then always ask for someone to come and help and observe you as well. Um, you shouldn't be expected to go to deliveries on your own. So this would be applicable to people in a, um, in a pediatric unit where they're covering like a tier two neonatal unit and you might be holding the delivery bleep if you've not done your NLS or it's your first p job. Um, you'll never be expected to go to a delivery on your own. You should always be near a registrar or an A NP or someone more experienced who should come with you until you feel comfortable enough to go on your own. Most places they have a rule where it's 10, you go to 10 deliveries, it's just a random number that's plucked out of the air, I think. But you go to 10 deliveries with someone else before they can, like, sign you off as competent as going on your own. Um, you shouldn't be expected to give advice to whether that's GPS bleeping you or A&E ringing for advice. Um, they shouldn't be expecting an F one or an F two or a junior sh to be giving advice out over the phone and that's well above your pay grade. So, um if someone's calling, you always tell them to call the registrar, the consultant on call and you also shouldn't be expected to have difficult conversations with parents. So whether this is um regarding like unhappy parents who want to talk about disagreements with care or um difficult conversations regarding end of life care or anything like this, that should also be always be escalated to the registrar or the consultant on call. Um So then moving on to why peds is different to adult medicine and Children are not just small adults, they have different anatomy and physiology, which makes it a completely different specialty and sort of affects everything that we do and how we treat Children. So these are some of the main differences between Children and adults. And like I said, this impacts the way that Children present and also how we treat them. Um So Children have a larger body surface area and this particularly applies to babies. It means that they have higher and sensible losses. So they lose fluid a lot more quickly, particularly when they're feb. Um and this means that they can have higher fluid requirements or need more fluid boluses when they're unwell. Um And it also means that they absorb toxins quicker. Children have rapidly dividing cells which makes them more prone to mutation from radiation. This means that we're a lot more stingy with um x-rays and CTS and we think very hard before requesting even like a chest x-ray for a child and particularly a CT or a CT brain. Whereas in an adult or an elderly patient, you'd be a lot quicker to just get a CT. Um Children have high respiratory and heart rates which affects the way they break down drugs. Uh uh again means that they have higher in sensible losses and it means that they're more prone to respiratory illnesses. Um They have an immature blood brain barrier which affects quite a few things. Um It affects medication doses. It means that um Children, particularly babies are more prone to meningitis and this is something we should be aware of when seeing AAA baby or a child with a fever and looking for signs of meningitis. And it also means that um babies with jaundice are more prone to uh brain damage from the jaundice which um Sophia touched on in a bit. Um They have a more immature immune system, particularly young babies that haven't been immunized yet and babies uh that aren't breastfed. Um This means that they're more prone to infections and they're more prone to serious infections and getting more unwell from common infections such as RSV. Um and they have a high metabolic rate which affects um how they break down toxins and, and how they present after ingesting toxins and also affects how we prescribe medicines. Um, so going on to history taking, um, it's quite different from history taking in an adult, particularly as you've got two people there that you're going to be taking history from. You've got the parents and then you've got the child, if the child's old enough to talk and, um, old enough to sort of explain their own instances to you, which I'd say would be for four and above. Although it just depends on the child, and then you should always include them in your history taking as well, make them feel involved, ask them about their own symptoms. Um, and particularly older kids, when you're asking things about like bowel habits going to the toilet. Obviously, parents aren't going to be aware of those things. It's important to involve the child and not just talk to the parents. So this is like a whistle stop to of a pediatric history. But obviously, there's lots more things that we include, but these are just like the, the headlines. So you start with your presenting complaint and your history presenting complaint as you would as an adult. Um, so whether that's, um, they're presenting with a cough, respiratory distress, et cetera, we'll dive into that. How long have they been unwell for? Then we'll go into their past medical history, which in some Children will be nothing they'll be fit and well or it'll just be like recurrent tonsillitis in some Children. It'll be a bit more complex then how it differs from an adult history is you go into your birth history, particularly um in a teenager who's fit and well, it's not that important, but when you're seeing a, a young child, a toddler or a baby, it's quite pertinent to um your management and sort of how illnesses may affect them. So you want to ask about their gestation. So I always just say, were they born on time? If they weren't born on time? How early were they born? Because often parents will say, oh, they were born early, but they just mean they were born at 37 weeks and not like 40. And that's fine. And so ask, how early were they born? Did they need to go to the neonatal unit if they went to the neonatal unit? How long were they there for? If they're really preterm? Were they intubated? How long were they intubated for? You can go into a lot of depth for this. I wouldn't expect you to um, as a junior who's new to peds, but there's lots of things. Um Uring preterm, it'd be good to like read up on. So, um, preterm babies are prone to brain hemorrhages and they have brain scans. So that might be important to ask about in your history. Um And then also in preterm babies, did they have problems with their lungs? Did they get you home on oxygen? Um, and then leading on from this, you'll ask about their growth and development. So, are they growing? Ok. Do you have any concerns about their growth? Are they just following the line on their um growth chart or have they dropped off? And generally parents will know this because they have a growth chart in their red book that the health visitor will be plotting them on. Um Lots of parents who come in with a baby or a toddler will also bring their red book in with them. So you can ask to see this. Um And then ask about their development. So any concerns with their development or are they meeting their developmental milestones on time? Um If it's a young baby or a toddler, you can ask about pregnancy history. Um So you can ask, uh was the pregnancy? Ok. Were there any concerns on the scans? If there were concerns on the scans, what were they, um was mum taking any medicines? She's smoking, drinking alcohol during the pregnancy? Again, this is more pertinent in like um newborn babies, but it's still important important in um the history of older Children and then medication history on any meds. Um, an important thing to note here is that because Children take oral suspensions of things. So liquids most of their prescriptions and what parents know about their prescriptions will, they'll tell you in Mills. So if they've got the bottles with them, just have a look at what the milligram dose is because that's what you want to be prescribing it in to avoid any drug errors. Um You want to ask about immunizations, which is really important and it's quite useful for you to look up the immunization schedule in the UK and know what this is and what um when Children receive certain immunizations, um, you want to ask about their allergies if they do have any allergies delve more into this and ask what the allergy is. So I'd say, I don't know, like 20% of the kids, I see the parents say they're allergic to penicillin, but it, it doesn't sound like a true allergy. It'll just be a rash. So it's important to know whether they've had an anaphylactic reaction before or if they've just come out in hives, ask about a family history. Um, and then ask about your social history and you can include in your social or family history. Are the parents consanguineous? This is. So, are they related in any way except by marriage? And this will be more important depending on what the presentation is sometimes. Um And then you also ask about who's at home. You want to draw out a little family tree if you're doing handwritten notes to make it simple to see who's living at home, are the parents separated? Other stepparents involved? And then always, always ask is, uh, are you known for social care or do you have a social worker when you first start doing pediatric histories. This feels like a really awkward question to ask. But as you get used to it, it just becomes a part of your history. And I always just say, do you have a social worker? I have to ask everyone and parents, I don't think I've ever had like um parents getting angry with me for asking that everyone understands. Um So then moving on to your pediatric examination again, it can be a bit difficult to describe. So just bear with me. Um if a child looks unwell, the same as in an adult, always just do your a two week assessment. So starting with airway, you're listening for any stridor or like a harsh barking cough and looking for any drooling, an older child who's got an obstructed airway or inflammation in their airway, maybe try pudding. So that's where they put both arms forward on the bed and then stick their neck out like this and that's them trying to keep their own airway open. Then moving on to be you're listening to their chest, obviously with the stethoscope and looking for signs of increased lack of breathing and you also want the reservation. So the respiratory rate and their um oxygen sats um when you're listening to the chest, you're listening for equal air entry bilaterally and you're also listening for crepitations or wheeze um or reduced air entry anywhere. And then in terms of your signs of increased work of breathing, um you're looking for recession. So that's where the child's drawing in underneath their ribs and in between their ribs. So that's subcostal and intercostal recession. The tracheal tug and that's where they're just tugging in at the um at the trachea just here. Um And you're also listening out for um well, you're listen, looking for tachypnea. So if they're breathing fast and then you're also listening for grunting, um which I can never recreate. But if you look up videos of babies grunting on youtube, there's lots of good examples and some of those signs are more serious than others. So I'd always be more worried about a grunting baby and a baby with a tracheal tug. Um Babies can also have head bobbing, um, and uh and nasal flaring, which is where the nostrils are flaring out. Those are the main signs of respiratory distress and then moving on to c so cardiovascular, you want to listen to your heart sounds all the normal places that you listen in an adult and you're listening for any murmurs. It's more common for Children to have what we call flow murmurs or innocent murmurs, which you might have heard of before. They tend to vary depending on the child's position and it usually is at the upper left sternal edge and like a grade two or grade three out of six. And if you ask the parent, they'll often say, oh, they've never um had a murmur before and they'll be like a five year old that's normally fit and well. Um but always ask if you think you've heard a murmur, always ask a senior to have a listen. You want to check their central and their peripheral cap refill. So a central cap refill in a child, you just press on the sternum for five seconds and then release and count it. You want it to be less than two and then peripheral, just press on their hand or their foot uh and do the same, press down for five seconds. Release and count how long it takes for the um cap refill. And then you want to feel for the peripheral pulses and also feel for the femoral pulses in a baby. Um And I'll go on to how to feel for the fem on the next screen because it's a bit of a skill. Um and then moving on to DC disability, assess their D CS a quicker way of doing this in an unwell child is called an AV who and this is what you have on your Ews charts. So an au it stands for alert. So are they alert? Um in general, are they awake? Are they talking to you? V is alert just to voice? So are they sitting there with their eyes closed? They're responding to you if you're, if you're talking p is, are they only alert to pain? So if you um do like a sternal rub or something like that are they vocalizing but otherwise not. And then you is unresponsive. So, just not responding at all. You want to examine for their tone or do they have increased tone or do they have reduced tone and they're floppy and unresponsive? Um In a baby, you also want to look at their posture. So, um a young baby will have a nice flexed posture where they hold their arms in and they have their knees and their hips flexed. And then you also want to feel their Fontanelle in a baby less than one. And so the e um anterior Fontanelle and you're feeling for if it's bulging or if it's sunken, which would mean that they're dehydrated. If it's bulging, that could mean that either there's a bleed on the brain or um meningitis or other causes of raised intracranial pressure. Don't ever forget glucose. This is really, really important in peds. Um You, it's quite handy that most pediatric nurses are um, incredibly adapt and really good at triaging. And normally I would say 99% of the time if they're, if um, they should, they will do it like a glucose on triage and you'll have it when you need it. Um, but never be afraid to ask for blood sugar on a child. So, whether they've been vomiting, um and have diarrhea or have reduced oral intake and you're worried that they might have dropped, dropped their blood sugar or in a baby who's not feeding. Well, it's always important to check a blood glucose. Um And again, in an older child with respiratory distress or with other signs of DK A, that's important to check your blood sugar as well to make sure that um they're not diabetic then moving on to e exposure. So look for rashes um in younger kids and even in older kids with a fever, um it is important to strip them off and look everywhere for a rash because even if the parents say they haven't noticed one, they might not have noticed uh like a non laning rash that starts on the sole of the foot, for example, and it started to spread. Um So make sure you look and then document that you're fully exposed and you've looked everywhere for a rash. Um We've had a question about um chaperons and consulting with parents present in an older child. Um If you're doing that kind of examination and you're exposing them fully to look for rashes, that would be the point at which you probably want a chaperone with you, but it's quite variable. Um And I think it depends on personal preference as well, but definitely an older child or a teenager. If you're doing that kind of body map, you'd want um a chaperone with you. Um and then feel the abdomen. So you're feeling for a pup or liver or a spleen um and feeling for any tenderness and then ent is so important in peds. It's so common that you'll get referred a child with a fever of unknown source from a GP or urgent care or A&E and they've got whopping great tonsils with pus on them because no one's properly examined the ent or a uh a titus media or they've got a really runny nose and it's really obvious where the source of infection is. So ent uh examination is always your best friend even though the child will not thank you for it. Um, and always do your ent examination last because you will upset the child. Um, these are sort of some top tips for examining, um, a baby or a child if they seem a bit apprehensive about you examining them and they've got a teddy with them, examine their teddy first. They put your stethoscope on their teddy or their parents if they've got a parent with you just to make them feel more comfortable and show them that it's ok. It's not a scary thing. Um, or sometimes I'll start by putting the stethoscope on the child's foot and go up their leg gently until I reach their chest or an older child. I, sometimes I ask, oh, do you know where this could go? Can you put it on for me? Um, and it just like, gets them a bit more engaged in the examination shows and that it's not a scary process when you're doing an ent examination. Have a parent holding them. So this is how the the picture at the bottom, right of the screen is how I'd get a parent to hold for an ear exam. So have them have one hand on the head, but obviously leaving enough space for you to look in the ear and then one arm covering the body and the arms and then have them flip around to look in the other ear. Um I couldn't get a good picture of um examining a child's throat online. It was all incredibly compliant Children who didn't need holding, which is unusual to say the leaves, that's the 1% the majority need holding still. So then in that case, you have the child sit them facing you on their lap with one arm across both their arms and their body and one hand on their head. And then uh in I say 90% of cases you need to use a tongue depressor to have a good look in the back of the throat. Don't be afraid to do that because it means it will make your examination a hell of a lot quicker. You'll have a quick look and then you're done rather than spending 10 minutes trying to coax the child to open their mouth wide enough for you to have a proper look. Um And then what you're looking for obviously is um enlarged tonsils or pus on the tonsils and you want to make sure there's no kissing tonsils there or sort of obstruction of the airway um, in a crying baby who obviously you can't talk around to being settled for your examination. You can, um, if you've got gloves on, put your little finger in their mouth and more often than not, they'll, um, suck on your finger and settle immediately. Um, and that enables you to have a quick listen of their chest while they're settled. The only thing you can do is use sucrose, which is like a um a sugary water solution. It's incredibly safe and it's just like a natural pain reliever for babies. There've been lots of studies that show that it activates the same areas as painkillers. Um And that again and more often than not stops the baby from crying and settles them straight away. And then at the bottom left is just a picture of someone feeling femoral pulses on a baby. So, like I said, it's a bit of a skill getting used to how to position a baby to feel the femoral pulses to begin with. But this is the easiest way that I was taught to do to straighten out both the legs and put your fingers like like over the femoral pulses. Um If you're trying to do it um with the hips flexed, it's a bit more difficult to have a good feel. Um And if you have both hands on the hips and straighten them out that way, it's the easiest way to straighten the legs. And so moving on to IV fluid prescribing, this is very, very different to adults. You don't just whack up a bag and push through a liter. That is terrifying to think of impedes. Um So uh starting off with the type of fluids that we use again, different to adults and it depends what hospital you're working in everywhere, has different fluids available in different guidelines, but generally it'll be plasma light and 5% xrays or not 0.9% of 5% xrays. And this is the same guideline for prescribing as every uh like everywhere in the UK has this guideline. You have 100 mils per kilo for the 1st 10 kg. Then after that 50 mils per kilo for the next 10 kg. And then after that 20 mils per kilo for every kilo after um and then uh that's for your daily rate and then you divide by 24 to get your hourly weight and that's how you prescribe. We'll do an example in a second and then fluid boluses again, incredibly different to adults. Uh It used to be 20 mils per kilo, but we've gone down now to adequate of 10 mils per kilo because often one single bolus of 10 mils per kilo is sufficient and Children are very easy to overload with fluids. We use plasma light or 0.9%. Saline plasma light is preferable if you have it in your um unit or your hospital because it's um more physiologically similar to plasma. So we generally give Aliko of 10 mils per kilo up to 40 mils per kilo. And then after you've given 40 mils per kilo, you'd start to be thinking about inotropes and involving P IC or your regional transfer transport network. Um You would never be expected as a junior, I think even to make a decision to give a single bolus, but I think it's just useful to know if someone asked you to prescribe a bolus, what to prescribe. Um indications for a bonus would be um Tachycardia, a prolonged cap refill, hypotension or a raise lactate or a septic child. Uh The list is more extensive than that, but those are the main things. Um And it's important to know that after every 10 mil per kilo bolus. So after every um sort of intervention that you've made for that unwell child, you reassess. So if you've done it for tachycardia, you reassess the heart rate and the BP. Um And if you're getting multiple fluid boluses, you also want to be feeling the liver to make sure you're not fluid, overloading them to make sure the liver is not enlarged in between bonuses. And then we thought we'd quickly mention wet flag. Um This is a tool that I think is used in most pediatric units and in A&E s and it's really, really useful tool for the unwell child. So wet flag is an acronym. Say if you're called down to A&E for a red phone, you've got expected coming in or if you've got an unwell child on the ward that collapses and goes off, someone will write out the wet flag but that someone might be you. And that might be a really useful thing for like an F one or an F two to do in a recess scenario. Um So uh in a child whose weight you don't know, you start with the weight and kilos. This is a quick formula for working out the weight of a child. So age plus four times by two. But also in most a, there'll be charts with estimated weight for Children based on their age and gender. Um then everything else is based on this weight. So your energy, this is um if they're in a shock rhythm and cardiac arrest, it's four dos per kilo uh tube. So that's your endo endotracheal tube, which is your age divided by four plus four and that's your diameter of millimeters of the tube fluids. So, like we said, that's 10 mils per kilo LORazepam. This is in case uh a child is seizing, which is one of the most common like emergency pediatric emergencies that you can see and that's 0.1 mg per kilo IV and then adrenaline. Um So this is in case of a cardiac arrest, not anaphylaxis. The dose is different in anaphylaxis and the dose for cardiac arrest is different one mils per kilo of one in 10,000 and then glucose, this is in case of hypoglycemia. So, as we said, in a newborn baby, that would be a sugar of less than 22.6 or three and then an older child, that's a sugar of less than three or 3.5. And that's two mils per kilo of 10% dextrose. So just an example of prescribing IV fluids. Um You've got a five year old girl presenting to A&E you can't get a weight because she's unwell. Uh And you just want to get on and treat her, she's tachycardia and she's got a prolonged cap refill and you want to give a fluid bolus and start maintenance fluids. So uh going back to our wet flag, her weight, uh estimated weight should be the eight plus four times two, which would make her 18 kg. So your fluid bolus would be 100 and 80 mils and that would be either plasma lights or 0.9% saline. And then starting maintenance fluids would be 58 mils an hour. That's calculated from your 1st 10 kg of her weight uh times 100 which gives you uh 1000 mils and then the next 10 kg or in this case, it's only eight kg times 50 then your uh the total fluid divide by 24 gives you 58 miles an hour again after your fluid bolus, you go back and reassess her heart rate and capillary, refill time and see if she needs further boluses. Uh I've not gone further into prescribing meds and things like that because everything's in the B NFC. I've worked in P for five years and I still check the BNF for paracetamol and ibuprofen doses and literally everything. I think the only thing I remember off the top of my head is cefTRIAXone because we prescribe it about five times a day every day. Um But everything else just always check the BNF, never be embarrassed to go. I'm just gonna check the dose of that in the BNF, even if a nurse is telling you because at the end of the day, it's your G and C number, your, um your, your responsibility for prescribing correctly and then quickly moving on to blood products. So, um I wouldn't expect a junior doctor to either a, make the decision to prescribe any blood products or prescribe blood products. But it's just important for you to know that um, it's a different prescription to adults. So in adults, you just whack up a unit or two units. Um, in Children, there's formulas for, um, for figuring out how much to give. Um And we're a lot more considered about deciding that you're gonna have, give a blood transfusion, so impacted red cells. If it's a neonate in a neonatal unit, generally you give 15 mils per kilo, you can also give 10 mils per kilo. Um And in a child, you do the desired hemoglobin minus the actual hemoglobin. So say you want the hemoglobin to be 100 which would normally be our target. And the actual hemoglobin is 50 that would be 50 times four divided by 10 and that gives you the amount in mils. Um, platelets will be 10 to 20 mils per kilo. Um and FFP will be 15 to 20 mils per kilo. And there's a really handy app to know about called blood components, which should recommend everyone download. It's really, um, it's an NHS app and, um, you can see there's in infants and Children and a neonatal section and it just tells you, it gives you the, there's formulas for prescribing blood and it also tells you different requirements for prescribing blood, for example, in a neonate, they need CMV, negative blood and it gives you that information in this app. So it's really, really useful again, never be embarrassed to look up um, a formula or how to prescribe. I still do it now, like I said, after five years in Peds. Um, and it's better to, um, check and get it right than not check and get it wrong, uh then moving on to Feeds for babies. Um, this is a general rule, obviously, it differs for preterm babies or babies with heart defects, other congenital defects or babies that are on, um, the babies that are being breastfed. But if you have a formula fed baby or a baby being admitted on IV fluids, this is a fluid requirement. So day one would be 60 mils per kilo per day. Generally in a uh, formula fed baby, you'll then divide this by 12 to give you a two hourly feed amount or by eight to give you a three hourly feed amount. You wouldn't stretch under three hourly feeds in a, in a one year baby. Um, and then you want your, uh, pre feed BMS to be above 22 is an acceptable blood sugar technically for a one day old baby. But if their blood sugar is persistently two, you need to be slightly concerned. Um, but you would accept the blood sugar above two, then day two, it goes up to 90 miles per kilo per day. And again, pre PBM above two is acceptable. You would want it to be higher, higher than two. And, um, I'd be slightly concerned if a baby's blood sugar was persistently just two and not reaching above two. Then day three, it goes up to 1 20 mils per kilo per day. And you want the pre feed BM to be above 2.6 and then day 41 50 mils per kilo per day. And you want the pre feed BM to be above three. And then following on from this, it's 1 50 mils per kilo per day until they're a month, a couple of months old and then generally, I mean, parents aren't going home with this formula in their mind and increasing the feeds based on how much the baby weighs. Um, they just give the baby how much formula they take they'll take. But it's important to have these sort of figures in your mind. So that when you have a newborn baby coming into the, um, assessment, you know, who's not feeding, well, you know how much they should be taking. So I'm just gonna hand over to Sophie now. Cool. So just to go through sort of a few more specific areas of heed um thing. And so just to talk again about safeguarding. So, safeguarding is a really important kind of role and responsibility within pediatrics. Like we said, it's absolutely not gonna be expected that you will be dealing with these Children yourself, accepting any of these referrals. But it is an important part of the job that we do. Any concerns that you have always fact to a senior and who escalate it further, but just some things to think about because like we said, part of your role will still be assessing Children and that might be impedes or if you're in an A&E job. And so when you take in your history, like we said, always ask about any involvement with social care. And as be has already said, just it feels awkward at the start, but just make it that routine part of your history. Taking the same way as asking about smoking, felt awkward with adults. Once upon a time, you get really used to it. And if they are known to social services, just dig a little bit more. Ask about why. And are they on a plan in terms of presentations for concern for you to be aware of any injury in a nonmobile infant? So these are the ones who can't walk, can't crawl. Um, should be a red flag for concern for a possible safeguarding incident. Um, spiral fractures can like more commonly be due to an nonaccidental injury and any unexplained bruise in unusual places or in an unusual pattern should raise concern. Um, if something doesn't feel right, just flag it to a senior that's always going to be your first step, speak to your registrar or consultant. Um, and don't, don't accept those referrals yourself or feel the need to escalate those yourself. Um, your main responsibility in this case is flagging it and clearly documenting any concerns that you have in case these go any further a tip for drawing your placement and find out who your safeguarding lead is. Every department will have a consultant who's responsible for this and also try and find out when your safeguarding meetings or peer reviews are taking place as these are really interesting opportunities to explore cases and learn more about it. And now just to talk through a few things that you might see or get involved in. So neonatal jaundice is a really common presentation that we see in the newborn period. Um Generally, you will see lots of babies presenting within the first two weeks of life. And this may be physiological or pathological. So for some babies, this is a normal part of adaptation. They have loads of red blood cells when they're in Mu's tongue, which then start to break down quite quickly and the liver is immature so can't cope with it that fast. And this is more common in breastfed, babies generally comes on after 24 hours, typically kind of 2 to 5 days. Some babies will have a pathological process going on and this might be differences in blood groups with mum. So more commonly a bs incompatibility, it may be due to sepsis. Some babies who get a bit bruised at delivery from sort of instrumental deliveries or underlying um inherited disorders. Some of these babies will manage to clear this themselves. But the reason we worry is that if the bilirubin level that that's the causing the jaundice goes really high, then it can cross the blood brain barrier. Like we said, the mature blood brain barrier and can cause NICUs, which ultimately can cause long term disability or even death. But we treat these babies with phototherapy after 2 to 3 weeks. So two weeks in a term baby or um three weeks in a preterm baby less than 36 weeks. Um these babies, the blood brain barrier is robust enough that we don't need to protect it by treating the phototherapy. But this is an abnormal process and requires further investigation and treatment as needed baby who percent in the 1st 24 hours. Um It's more likely to pathological if your job involves neonatal units or postnatal wards, just something to be aware of. And when you're assessing these babies in your history, you want the gestational age and the time of birth, which will be important to determine how to manage them. Any risk factors for neonatal sepsis, which we'll touch on in a moment, um What their feeding history is like. So whether they're breastfed, um and also to be aware that babies who are less hydrated, much struggle with managing the jaundice themselves. Mum's blood group if we know it, um any family history of babies needing treatment for jaundice. Um and also the color of the stool and the urine if the stools are pale and the urine is dark. This is more worrying when you're examining these babies. It's your general top to toe examinations. We've already touched on checking for a palpable liver because this could be a sign of something more underline and examining the genitalia to manage these babies. At the very least you're gonna do a bilirubin level. And then you also should also check for a full blood count to see if that hemoglobin is falling and check the baby's blood group and AD ct or a direct cos test sometimes called the D 80 that's gonna look for if there's any immune reaction taking place between them and baby's blood groups for babies who aren't feeding. Well, they might need support with a bit more of a detailed feeding plan. And then you're gonna plot your belly on the jaundice chart, which will help you to decide about phototherapy, the jaw discharge because they are something a bit different that you first see in peds look like this. If you get us to look for one, literally typing Google, the nice neonatal jaw discharge and it will give you a link to an Excel sheet that looks like this and you will fill in the demographic details. Um and this little drop down here will allow you to select the baby's gestation, babies who are more preterm will have a lower threshold and the graph will update accordingly for the first lower line. That's would be your threshold to start phototherapy. And then the second line is the threshold for an exchange transfusion. In cases where the bilirubin level is really high and needs to be rapidly brought down. Rarely, an exchange transfusion is needed. In a lot of these cases, you'll put loads of phototherapy lights on top of them. But if you're getting calls about babies whose levels are this high, you need to escalate that to a senior as soon as possible. So just an example of one that we filled in. So say you get a phone call from a community midwife who's gone to see baby Jones who looks a bit yellow this morning. They are, they were born on the 11th at four o'clock. So you've included all this information. Conveniently, someone's checked, there's no difference in the blood groups and your DT is negative and the baby was born at 40 weeks. You've, it's important that you note that your time zero is the baby's date and time of birth. Um And so that every 24 hour period is plotted accordingly on from there, particularly in this first couple of days when the threshold increases that they can tolerate. So our baby Jones had their blood done at 10 a.m. Um, and it was 320. So you've plotted it if the four o'clock, the, the 10 is gonna be just before and it plotted above the line, you inform your CIA and we'll arrange for that baby to come in and get some phototherapy. I know that's very, very whistles stop. It's just to give you a little bit more familiarity with these things because I remember finding it all quite different when I started. Um, conveniently now there's this app called the bi app. So if you're on the go and don't have quick access to those charts and you're getting a phone call about a bilirubin level. It, this does that job for you. You will still need a chart in the notes, but you can pop all that same information in here and it will give you your answer as to where the bilirubin level sitting in relation to the treatment line and what you and what you should be doing about it. Once the baby's um on treatment, you need to monitor that quite regularly and in particular, early on to get a trend for how quickly it's going up or whether it's slowing down just to touch on sepsis. So we've split sepsis into neonatal sepsis and or ge more general pediatric sepsis. So, neonatal sepsis covers the period up to three months of age cause these babies are particularly at risk of infections. One of the key take homes of the talk today should be that any baby less than three months old with a recorded temperature of more than 38 recorded fever should at the very least be screened for sepsis. If not treated with antibiotics, any baby, less than 28 days of age will automatic get antibiotics. If they've had a proven temperature, more than 38 even if they look very well, when you're assessing these babies ask about feeds sometimes with or without a temperature. This might be the first thing that parents have noticed and been worried about and that they're not feeding as well as they normally do and then ask about risk factors for sepsis. So the main ones you need to ask about are any history of mum being known to have group B strep in pregnancy or any siblings that have previously been known to have group B strep. Group B strep is really nasty. B that can cause problems with neonates make them really sick. Ask about prolonged rupture of membranes which is more than 24 hours from mum's waters breaking until um the baby being born. And also ask if mum myself was suspected to have sepsis at the time of infection. Even though this all happens around the, the period of being born, it's still relevant up to three months of age. Ask about the gestation babies who are preterm or more at risk of infection and then ask about any, any features that might suggest what's going on cough eye, particularly in winter. And then like we said, these babies are at high risk of meningitis. So asking about irritability and this is you, you'll get used to the field for this in pediatrics. It's more than them just being a little bit aggie and a bit unsettled. It's sort of neurological irritability. They're crying, they're really inconsolable. I just don't know what to do. And you're examining these babies, like you said, it's gonna be your a reassessment checking for perfusion. Do you need any fluid support, checking for any rashes checking that Fontanelle? Is it, is it depressed or is it bulging? Um and the posture and the tone, are they floppy or are they, you know, hypertonic and both would be worrying to manage these babies you're gonna put in, they're gonna get a cannula, they're gonna get blood cast culture. The, the same sort of sepsis stuff that we're familiar with with babies. Catching a clean catch urine is really important. This can commonly be a source of infection that it's hard for us to pick up on. Um and subsequently down the line. These babies may get a lumbar puncture to check for meningitis. Um But this will be a senior decision and if they're gonna get the antibiotics treat as per your local guidelines, will be brought that cover um and then pediatric sepsis. So a little bit of a different approach, you're bound to see loads of kids with temperatures, especially if you're doing peed or A&E in winter. Um and the what you're looking for when you see these kids is what's causing the temperature, the focus of the fever and any worrying signs of a serious illness. Loads of these kids, as we've said, will have a tonsillitis, a virus, something something quite common and quite easy to manage, but some will be something more worrying. So when you take in the history, like we said, they get dehydrated fast check what the oral intake has been like and whether they'll need any support with this check for the timeline of the illness and how things seem to be developing any localizing signs. So coughs sore throats diarrhea, vomiting. Um And again, that irritability change in behavior is still important. Have they been just not the usual selves? Do they seem confused and things like that? Um, when you're examining them again, perfusion, do they need any fluid resource rashes and particularly these nonblanching rashes, which we'll talk about in just a moment if they're less than one check that Fontanelle and again, behavior and tone, are they just a bit clingy to mum? But as you'd expect a poorly child to be, or is there really no getting close to them or the other side, are they just not waking up and not behaving like you'd expect any respiratory distress. Sometimes, viral illnesses can progress into something more and always that ent examination, like we say, more often than not, there's some big old tonsils hiding down there which chances what's going on from a management point of view. As always, if you, if you're worried it's gonna be a sepsis. Six and nurses triage know quite adept at picking this up. If you've been able to identify a focus with your um with your history and examination, then treat with a appropriate focused antibiotics um as per your local guidelines. But if there's no focus and you're worried about them, then it's best practiced to give something broad spectrum, good broad cover, which typically for us is cere, but we always check locally when we talk about nonblanching rashes, these nasty looking ones. Essentially, it's the glass test that you'll hear people talk about, you press on it and it doesn't go away for, if you're looking at the picture, it demonstrates two types for it. Petechiae, sort of small, more pin prick ones and papo, these sort of big and nasty looking ones. Either of those, they won't press them when you go away and either are worrying, always escalate nonblanching rash to your registrar who will assess and investigate and treat as necessary. And then like we said, finding those worrying signs can be what challenging in pediatrics and what a lot of us worry about when we start. I has another lovely guideline called Fever under five, which includes this traffic light system. The red highrisk ones are those kids that you need to be more worried about Amber. You're still gonna escalate it, but maybe you'll watch it, you'll do some tests, you'll see how it goes and the green ones are a little bit more reassuring, but always get support with this and then just to quickly touch on some clinical s like we said, this is much better explored in real life practice. But I know some tips and tricks are always a good way to start. Um One most common ways we get blood from babies and small Children is he prick bloods in some bigger Children. It might be finger prick bloods and most, most of the time nurses and midwives will be able to do these but it's still a useful skill to learn. A nurse. Took me to one side on day one and was like, come on, I'm gonna show you how to do it. Um, and it's useful either if you need something doing kind of fasting or your nurse is tied up or if you're in a resource and you just wanna, it's handy you that you can do a quick blood gap. Um, top tips, make sure you've got a warm foot, warm finger. Um get just a, you know, blue blo full of warm water just to warm that up to improve the circulation. Um Some places you'll be able to apply Vaseline, which just helps to come out in nice blocks rather than spreading everywhere and use for the lancets. There's typically different sizes available, use as big a one as is appropriate for your child. The technique is demonstrated in the pictures. You're gonna get a good hold. Um You're gonna press on with your lancet and do the click, make sure you dispose these sharps and then the blood will come out in a spot which you can drop into, collect in whatever way you need to and then just pressure afterwards, like I say, have a go have a go at this one. Once you've started, cannulation is a different skill impedes compared to what it is in adults. And the first thing to know is make sure you've got enough people with you and try to reduce the distress to the child as much as possible. Always make sure you've got some help. Whether that's gonna be to help stabilize an arm or a foot or so, just pass your things if appropriate to have parents with them for holding and cuddling and again, ways to make them as comfy as possible. So, Emla or AOP is essentially numbing cream that you can put on about 40 minutes if you've got that time before your cannula. If you haven't got that time, some, sometimes you can use cold spray. It feels pretty strange but it takes away the pinch of the needle and in the smaller ones, the sucrose works, as we've said before, hands and feet are best, but you may need to have a little look around and essentially, rather than in adults where it's always what you can see rather than what you can fe what you can feel, rather than what you can see. It's typically what you can see and you can usually insert them fairly superficially into a visible vein. Um, you'll advance your cannula and typically, if we are inserting a cannula and we need bloods at the same time, we'll do those both in the same trick. But the cannula we use and the veins that we using won't typically tolerate a syringe and then drawing back on it. So you'll collect them. But watch somebody do all of this and it will make a lot more sense. And then once you've got your cannula in, stick it down, especially in the little ones for it. Like, um, these are gel codes which are the cannulas that lots of us love. But I had not come across one before starting in pediatrics. Um, so if any of you seen are asking for a gel coat, it looks like this. They have a little hub, they typically aren't safety, which isn't popular with various management teams, but they are a lot easier to use. And a lot of us have you learn how to use with them. Um But so just so you're familiar with a slightly different type of cannula that you're likely to come across. Um And from and so, yeah, and also again, this is kind of the whole that you would do for a little baby, it's all about getting good stability. Um And in bigger Children, like I say, you might have mum or dad giving them a big hug and then one of your nursing colleagues holding the round, but make sure stability is the main thing that you're gonna need that is going to help you to succeed with this skill, watch, watch it and get a feel for it. Um If you're with your registrar, they might ask you to help with sticking down again, it's just a little bit different. Um, particularly if the Cannula don't have wings, which a lot of the smaller ones don't. We often use this over under sticking. So you get one of your sort of horizontal stickers and you're gonna put sticky side up underneath your cannula and cross them over and then over the top of that, you'll put your small Tegaderm. Um, you have Ted on, if you're lucky, you got the teddy and often with smaller Children if, where you want extra security, I often stick another teddy bear stick sort of after 90 degrees to that. Um But yeah, just if, if you're with somebody just follow what we say. Yeah, there's been a couple of questions. So if a child has DNV, um leading to hyperkalemia, when would you pick for blood to determine supplementation management? So, um, it's a good question. We're a bit stingy with bloods and cannulas in kids. Generally, if someone, if a child presents with DMV, we try to manage as hands off as possible. We give what's called a fluid management, which your nurses will normally do from triage, which is where you give them a pot of diuretic or apple juice with a syringe and the parent gives them five mils every five minutes. And you see if they can keep it down, if they are looking relatively well and aren't hypoglycemic and manage their fluid challenge. You wouldn't do bloods and you certainly wouldn't cannulate them and start them on IV fluids. Uh, the caveat to that is if a child presented looking unwell or was hypoglycemic, then you would want to get IV access straight away. If you're a bit on the fence, I find what's really helpful is a blood gas because it gives you a lactate. It gives you a PH, it gives you a bicarb and it gives you a glucose and it gives you a potassium all the information that like you would need for a child with DMV. And if your blood gas is fine, then you can be fairly reassured that you're gonna manage. Ok, with a fluid challenge and be ok. Yeah, I think like we said, getting a probably getting a blood sugar in that instance is gonna be your first protocol cause more likely to drop their blood sugar than the potassium. Um, and if they are able to tolerate oral fluids, even if the potassium was sort of a little bit borderline, it will generally correct if they're able to tolerate. Like you said, if they're looking, well, you're gonna check your gas, which will give you those sort of results anyway. Um, should be have a question before the fun stuff. Yeah. The other question is, what are the critical neonatal risks in babies born to IV? Drug abusers when on infected endocarditis treatment? I assume that means is there a risk of infective endocarditis to the baby? I've never seen a baby born to an IV drug abuser on treatment for infective endocarditis. The main risk of babies born to IV drug abusers is withdrawal syndrome or neonatal abstinence syndrome. Um, baby born to IV drug abusers, it's generally already known as like a red flag in the notes that they IV drug abusers. There'll be a plan for the baby when it's born. They'll about extra scans to make sure that the baby is ok and the baby is then put on what we call neonatal abstinence observations. And the midwifery team or the nursing team are constantly doing observations and if they're severely withdrawing, then they need to go to the neonatal unit. Um I don't think there's a particularly high risk of infective endocarditis transferring from mom to baby. And particularly if the mums already on treatment, I would say that the risk is very low. The risk would probably be if mum had infective endocarditis and wasn't being treated and it wasn't known about. But generally, if they're already in hospital giving birth, it would be known if they were unwell with fevers. And in that case, that's a risk factor of sepsis for the baby. And they'd normally be screened for sepsis anyway on treatment. And beck said typically the typically these families and these mums will be known to services. And if there is, if there was anything like this known, relevant drug teams, infectious diseases teams are all involved. And so yeah, it would be unlikely to be something that you picked up first. But like we said CCC in your part and then they'll get the relevant specialist involved good question. Very neat. So why kids is the best and why should all come and join us? It is good fun. I think there's something really sweet about having to be a bit lighthearted in what you're doing. Um, and it does get you through some quite challenging times. Cuddling and keep babies is really fun as well. Um, you get to be creative, you have to think of it naturally sometimes. Um, because like I said, um, kids aren't just small adults. It's a completely different specialty and lots of medicine was designed for white adult males and sometimes you have to think of it outside of the box. Um, even if it's just how to hold a child to do a blood test or how to get an autistic child to comply with treatment. It's fun to have to think of it naturally, isn't it? And not have to stick to a specific guideline have always found that everyone is really friendly and even the surgeons. Yeah, we like and your seniors typically, um, will be approachable. We know what, everyone knows what it's like to remembers what it's like to start all this for the first time. Um, but yeah, it's, it's a lot of work. A lot of really, really good teams over the last few years and kids don't want to be in hospital, um, as opposed to adults that show up to A&E with an overnight bag and a cold, um, Children. Um, you know, they don't want to be there and as soon as they're better, they're bouncing off the walls and raring to go home, which is quite nice and you see them improve very quickly in like a, a normally well child, it's nice to see them improve that quickly and then see them want to go home. Yeah, it's, there's a lot of variety in peds. Obviously, it's kind of, you're covering your, your general peds. Josh will be covering all of the different specialties. Anything can come in some things you'll get to see and a lot of, and things will still come in and surprise you quite a lot. Equally, the more you explore with people, there's obviously some specialty areas like the job I'm in at the moment. Um, so you can either see a lot of keep seeing a lot of everything or you can narrow things down to things you're more interested in as well and there's lots of clinical skills to learn. So, um, every ps trainee rotates through neonates and you get to do intubations and lines and that's really fun and exciting. Um, and you get to go to deliveries and then, um, you also get to do lines and Cannulas on babies and older Children. Um, you get to do Lumbar puc's very frequently if you're a fan of lumbar punctures, um, and other things like love gasses and, um, yeah, there's no, there's so much to learn and it it, it's, it is challenging and it is interesting, like I say, things will come in and really surprise you and really get you thinking. Um, there's a lot of good puzzles and, you know, I really enjoy the challenge. A lot of people kind of are put off by kind of managing the parents as much as the Children. But I find that a really enjoyable part of the role and working with the family as a whole is something that I really enjoy the job I really like. Yeah, I think on that note if you find that struggling with an, an like a or let's say an angry parent and you're struggling to sort of get on their level and build a good report. Just remember that they're worried about their sick child. And quite often if you just empathize for a couple of minutes and be like, oh it must be really hard to see your baby. So well, you must be really, really worried. But I see this all the time and I'm not worried and this is what we're going to do to make sure that they're safe, et cetera often that will help you to build a rapport and help, help you to get on their level. See, we've had a question which is how, how involved can F ones be in? Oh yeah, it's OK. Question how, how involved can F ones be in the rotations with regards to practical skills? Are we limited because we're f ones I say if you're interested, absolutely not. I've worked with F ones who are interested in ps or just, yeah, interested in practical skills and having a go at stuff and if you are interested, just tell people and they will absolutely get you involved. Um, I know some places have the F one role as kind of almost been a bit supernumerary. I think some juniors do feel like they end up falling back into doing lots of jobs. But if you are interested and want to do stuff, tell you, tell your registrars and they will absolutely get you involved. Yeah. If someone shows that they're interested to me, er, it's almost a mistake because then I'll take them every time that I do. And then, um, yeah, I, I, uh, and with our last bout of F ones I had, um, my F one doing Cannulas and, um, coming to help catch CSF with Lumbar punctures and stuff. If she'd been there longer, I would have had her doing LPS. And I don't think it's out of the question to have F ones doing Lumbar punctures because we do them so frequently. If you've seen enough and you feel comfortable, just ask and I'm sure people will be more than happy to let you have a go. Yeah. But you'll equally always be appropriately supervised on your own. So, just in and so then some useful resources that are good for extra reading. Um and also for health stuff, you don't know what to do in work. So, spotting the sick child is a really cool website um which I use a lot in my F two PS rotation. And it's literally got videos of what it's, I think it's R PC Commission and it's got videos of what all these things look like. So we've talked about recession, we've talked about Strider and this has just got loads of examples of it and bits for you to work through as well just to get and don't forget the bubbles is a really, really good resource. It's a website that's constantly updated by um mainly pediatric emergency medicine specialities and it has a lot of articles and tips and advice on pediatric emergencies and how to manage them. And it also does quite often reviews of like the latest evidence for peds. They also have a, a sister website called Don't Forget the Bubbles Skin Deep and it's got pictures of all the different rashes that you see and PS and what to think about when you see that kind of rash. But it's also got different rashes on different skin types and different um skin colors, which is really, really important because quite often when you try to look up a rash, it'll be on a white child and obviously it looks different in um Children of different skin colors from a safeguarding perspective. RC PC H has a just have a toolkit on their website if it's something that you're interested in. But again, some of those where we talked about injuries and things that would be more high risk that can be useful if you for, for further reading to support things that you've seen in practice. And the nice fever under five guidelines, which we just showed you the traffic light system from is a really useful resource of how to manage um a child presenting with a fever because that is the most common thing that you'll see in peds. Yeah. And the nice jaundice chart as well. Literally typing into Google look for the Excel sheet. That is what you need and then you have your regional pick co transport guidelines. So every um sort of deanery or like operational network area in the UK has its own regional peu transport and they will have their own guidelines which are really easy to find online normally. So we work in the Northwest. So we have new, which is the Northwest Northwest Transport system. Um And they have um really helpful, really useful guidelines on their website which are really useful to find. I know that South term's retrieval service which is stars also have one online. And I think every other regional PICO to find out what your region piu transport system is called and have a quick look on their website for guidelines because it might be that in a recess scenario if you're the junior there. It would be a useful job for you to get up that guideline for your registrar just as a prompt for them. And it might be that someone asked you to get that up for them. And then a PLS. So I know a lot of people have to do a LS as part of one of two, but a PLS is the Peds equivalent. And so it's something that you're interested in. Obviously they have the, the algorithms the same as A LS has their algorithms. Um So that can be useful for you to have a little look at or if you're interested, obviously looking at the courses, which should be Yeah. And your study budget always if you're an F one or an F two, use up your study budget because otherwise it goes nowhere, it just goes back into the pot. So make sure you use it. And a PLS or NLS is a good way to use your study budget. And NLS that we said first is essentially the neonatal algorithm for life support there as well. So if you're doing a, a job that will cover neonates or posts, even if you're not going to do the full cost, familiar with that. And then questions I've had a couple of questions. Can I look for PS F one? Is that a good way to get experience? No P job. Sadly, um I guess it depends what's available around you. I think when you are, I guess all is if you're signing up for locum positions, I guess it's, it's hard to say. I think they, I don't know what, I don't know what the locals positions would expect, whether it's in your trust or anything like that. Um, I guess there's other ways to get to seeing kids, um, A&E jobs volunteer and say you want to see lots of kids and you'll almost get to do those initial Clarkin and things and then ask for the support there. Um And the other one is, is like GP placements and things. Um, because again, if you say you're interested in seeing Children, they will absolutely love you for it. Um Otherwise, obviously, f three gaps are becoming more and more common now. And so when it's sort of getting about halfway through your F two year, have a little look for what's around if pi is something that you're interested in. And the other thing is taste a week. So you can apply for taste a weeks during your foundation as well. You can apply for taste a week. It might be better in your F two because you might get to do a bit more than you would as an F one just because, um, you're fully registered, um, with the GMC. I, I don't think I'd recommend opening in as in Peds if you've never done it before as an F one. but like I said, there's loads of different ways that you can get experience. And yeah, ask for a taste a week. Definitely. Um any useful tips on getting a pediatric clinical attachment for international medical graduates interested in the specialty? Um II I don't know much on this. I would say email around different um hospitals. If you have a particular area of the UK that you want to work in, find out where their pediatric units are or like their biggest pediatric center. So like in Manchester, we have the Manchester Children's Hospital and email their sort of general pediatric lead, which you should be able to find online easily enough and ask them about um experience. Otherwise each pediatric unit should have an educational lead. Again, you should be able to find that information online for most hospitals and it should have a list of like pediatric consultants with their email addresses. So it's fairly easy to find who's contact information and a lot of centers. Again, some working in Big Manchester Center and I know they have lots of international medical graduates coming for post and the regular advertising for those and they'll have contact details in. So if it's just the attachment you want, that might still be a place to start. Any other questions. Seems like it's it. Ok. Wow, thank you very much guys. I, I can't believe how much stuff you managed to crown. Um That was very impressive and um really informative. Um So as you probably noticed I have popped a link to the feedback form in the chat. Um Really do appreciate it if you can take a few minutes um to fill that out. Um And you know, put, put suggestions, what we can do better, um What things worked really well. Um It's good evidence for our portfolios helps us improve the webinars for yourselves. Um Also, as many, as many of you will know, um we will all as doctors do lots of teaching throughout our careers. So any feedback that can help us improve um or keep us doing the good things and there are plenty of good things throughout the hour, like I said, um it's really helpful when we do read it. So please do take a little bit of time to fill that out. Um And Tony, I've already uploaded the slides to medal. Um So you should be able to see those in the catch up content. Great. And then I just popped my email address at the end. If you have any more questions that you didn't want to ask in the webinar, you uh want to ask for webinars on different topics. Obviously, there's so much that we weren't able to cover because it was a short period of time and we just wanted to cover like the basics or if you want to write a pediatric article for mind the bleep, just email uh pediatrics editor, mind the beep dot com. Ok. Well, thank you very much. I'll let everyone get on with the evenings. Um, please do fill out the feedback, um, and we will hopefully see you in the not too distant future. Great. Thank you so much. Sure.