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All right then, um I'll leave my video off just for the sake of it actually working. Um But as I go through just anyone messaging the chat, any questions. Um So we're doing gastro set over two sessions. Um These are the core conditions for this session and then we've got another four or five tomorrow um in terms of overfeeding and faltering growth. Um There's, I've not put too much detail in terms of a co condition. Um I looked through my notes from last year and I've just put things about um like weaning advice and like feeding advice for babies, which I think is probably the most relevant. Um And then, um I'll show you what else we've done later on um core presentations. Um They're gonna be covered like over today and tomorrow. Um Yeah, I basically um put a few SBA questions together and then um got a page on most of the core, well, all of the core conditions um and a few questions um about other presentations as well. So, and those are the learning outcomes we've covered. Um Just to remind everyone before we get started, we've got a um competition for members. So if you fill out the feedback form at the end, um that will be an entry into the competition. And also, um we, you'll get a certificate of attendance if you fill in the feedback form at the end as well. So if everyone's happy, we'll get started. So case 16 year old boy presents with abdominal pain, bloating and infrequent bowel movements over the past two weeks, denies any nausea or vomiting, but reports loss of appetite on examination, his abdomen is distended. He has palpable fecal masses in the left iliac fossa. Um If everyone can just give me an idea of what you think is going on, I mean, it's a very basic question. But yeah, just yeah. So this is just constipation, um which is quite common in Children. Um So constipation in Children. Um So it's defined by less than three times a week um or difficulty passing stool. Um Some Children will go every day or every other day but have real difficulty passing the stool. Um I'd still count this as constipation and it still needs treating because obviously, there's things that can, you know, be caused by having like difficulty passing stool on a frequent basis. Um Presentations pretty simple. But remember that overflow diarrhea is um also um related to constipation. So having watery diarrhea doesn't completely exclude the fact that it might be constipation that's um going on. Um Normally it's just dietary causes. But um there are some secondary causes, um, that it would be important that, you know, a bit about, um, Hirschprung's disease and cystic fibrosis, I'd say are the more important ones and then o other things there as well. Um, in terms of Hirsch sprs disease, I've not put any specific notes on here, but I would recommend, um, know a few basic things about that. It will come up again a bit more tomorrow when we talk about, um, bowel obstruction as well. And the same with cystic fibrosis that comes more into it more when we talk about bowel obstruction, especially neonatal bowel obstruction. Um, it's usually just a clinical diagnosis. You don't really need to do any investigations unless there's any worrying features. Um, I think we've got another question here. Um, so I'll give you a minute or so to think about what medication you think would be first line for fecal impaction and, um, pop it in the chat. Yeah, I'm seeing a good fiance for mo. That's right. It's, um, important that you treat with like a disimpaction regime if you've got like an acute, well, an acute constipation, that's, you know, they're not passing stool for a long time and even if they're, um, got more like chronic and they're still passing stool, but less frequently you still start off with more mov put. No, hear about laxatives. Um, because they do sometimes ask like things first about stimulant versus osmotic laxatives, um, osmotic laxatives are usually first line. Um, and stimulants usually used if kind of, we've got, um, more difficult to treat, um, constipation. So that's it for constipation. Um, move on to a question about vomiting. I'll let you guys read through the question and proper, um, message in the chat when you've go on. That's great. I'm seeing a couple of answers for go, which is the most likely diagnosis here. Um, so the, the key thing here is the fact that it's recurrent vomiting and also the, the cough um is quite a common feature of um gord as well. Um And pre premature babies are more likely to suffer with gord. Um because their esophageal sphincters are even more um undeveloped, which is the cause of gord in babies. Most babies have some element of reflux, but um it becomes pathogenic when um it's interfering with feeding and causing symptoms basically. Um So this is the, the typical symptoms. Um But yeah, like I said, most babies have some element of reflux. Um But yeah, it's, it's more um severe in some than others. Um And I've got a second question a bit more about um vomiting again. And um yeah, so again. Ok. Ok. Yeah, brilliant. So again, this is the last one. Um The reason it's an alginate that you try is because she um we got a breast fed the baby. Um So the first line I think it's on the next page, but the first line management for, um, Gordon Breastfed Babies is trying Alginate. Um, whereas if they're bottle fed, um, you want to try sort of more, um, smaller meals more frequently and, um, of like basic advice um, before you go on to, um, alginates. So, and there's other formulas you can try. So sometimes a different formula, um, like a specific reflux formula, um, would be sufficient to sort out rather than trying, um, medication. But breast fed babies, obviously, that's not an option and then they feed slightly differently. Um So you need to try and alginate first line basically. Um And it's important to remember any red flags um for anything more serious um and other conditions that you might be worried about and again, um Gaviscon um and thickening your milk, um it can help as well. Um And A PPI is basically last line for Children. So that's how it differs from um adults kind of in terms of management. Um If everyone's happy for me to carry on going. Um Our third case is about diarrhea. Um If you have a read of this and let me know what you think is going on. Yeah, so we've got a vote for viral gastroenteritis. Does anyone have any um ideas about which of the two type, which of the types of gastroenteritis would be more common in a child? If not? That's all right. Um So the most common of forms of gastroenteritis, you're right is viral. Um, in sort of the normal population, the most common cause would be no norovirus, but Children and babies, the most common cause is rotaviruses. Um I'm not sure why it's different for small Children. Um But yeah, it's, it's more common. Um, and there's also bacterial causes. I've put E coli in bold here. Um because it's something you need to remember in terms of hemolytic uremic syndrome. Um I'm not sure if anyone's heard of it before. Um, but it's, it causes bloody diarrhea and also, um, uh, like kidney problems. Um, it's a specific strain of E coli and it's a good one not to miss and it definitely one that they could pop in there in exams as well. Um I'm sure everyone's quite happy with the presentation of gastroenteritis. But remember in Children, it can, and babies it can present slightly differently, obviously, still have vomiting and diarrhea but being floppy and um, just more tired and more difficult to settle. Um, slightly less specific symptoms. They obviously won't be able to tell you that their stomach hurts or anything like that. Um So it's just things to be aware of. Um, yeah. Um and again, it's normally a clinical diagnosis but a stool culture can be used, um, can be done if you're worried about the cause. Um, in terms of management, same as adults, it's generally supportive measures. But again, with small Children, you need to be really careful that they're not becoming dehydrated. Um, does anyone know what sort of thing you'd look out for in small babies in terms of their hydration levels? Um, like, what would you monitor? What would you tell parents to monitor even, um, in terms of looking for children's hydration levels? Yeah. Some can eyes even something less medical, something more just, yeah, urine output, I would say just for telling parents to monitor, um, urine output is a really good one. If they're having we still having wet nappies, um then you can kind of say that yeah, they probably are well hydrated enough. But if they're not having wet nappies, that's quite a big red flag. And you need to start thinking about um replacing fluid. And yeah, of course, all those other things are important as well. Cap refill is important. BP in babies isn't really BP in babies and Children even isn't as reliable as it is in adults. Um It's probably the last thing to go. If you to have a baby that's or a small child, that's BP is really low. That's a bad sign. Um So yeah, things basic things like urine output. Um And then all those other things that you've mentioned as well, it's really good. Um And then in terms of giving antibiotics, they're only really needed in like systemically unwell patients. So someone that's very dehydrated and very poorly, um and immunosuppressed Children, there's less of those like in terms of Children than adults. But, um, being careful about neonates and anyone that was premature, um, because their immune systems often not quite as good as everyone else is. Um, and just pop in the chat. Any causes that you think you can think of, of more chronic presentation of diarrhea in Children. I've come up with a few ideas but I'm sure you'll have some that I haven't thought of. Yeah, IBD. Celiac. That's good. HIV. It would be a very rare presentation in Children. But, yeah, of course. Um, it's always one to think about, especially with, um, vertical transmission. Mhm. Yeah. Cow's milk protein allergy and any, like, um, food sensitivities. Um, they're quite common in small Children. Cow's milk protein allergy will be taught more in, um, a later session. But, um, it's a very common presentation. So, the ideas I've come up with, you've basically come up with them all. Remember IBS does, does happen in Children, less, more babies but small Children, um, they get anxious too, um, and have manifestations of irritable bowel syndrome as well. Um, so sometimes it's not something that you can kind of diagnose as easily. Um, but since celiac disease is one of your core conditions, um, I've got a few more, I've got another question here, which is about chronic diarrhea and then we'll talk about Celiac disease afterwards as well. And if anyone's got any questions at any point, please feel free to put them in the chat and I will do my best to answer them. Yeah, there will be, um, a feedback form at the end and we'll give you the slides, um, for this at the end as well. Yeah, I've got a few thoughts of celiac disease. Um, that's, that's the right answer. Um, the specific things that I picked that you'd want to pick out in this question. Two years, two years old is quite young for a presentation of celiac disease. I mean, lots of Children would have it from a young age, but two is quite, quite early to pick it up. Um But yeah, it sort of, it's, it's sort of fallen out of favor but like a failure to thrive pattern, which you've got here cause she's growing slowly. Um And specifically the pale and smelly stools um is a pretty um common feature of celiac. Um Yeah, and she's on the 25th percentile. We'd want to compare this to sort of uh what percentile she was on um six months ago and see if that's changed. Um because that's how we measure sort of weight loss and things in Children. Um Some notes on celiac disease. Um It's, the presentation is quite easy to remember, II think, but, and the stair, so the fatty stool is quite a late sign um or a sign of severe disease. So it's not something that you'll necessarily see very often in real life. But in exam questions, they've always called it pretty much. Um, so investigations I've put on the blood test here. But, um, does anyone know what the gold standard investigation is for celiac disease? Yeah. So a duodenal biopsy. Um, and, um, in terms of the bloods, anti T TG is the test that will pretty much diagnose it in most people. Um, but you need to do the total IGA level alongside it. This is because if you have a global IGA deficiency, then your anti T TG will be falsely normal. So if you were to do someone's to anti T TG and their total IG um and their total IGA was low, then you'd need to then go on and do the anti A um as well um to make sure um to confirm or deny the diagnosis and you do this, do it as well. If there's um the anti TTG is weakly positive as well as sort of a second investigation. Um in terms of management, it's pretty simple. A long gluten free diet. Um uh There is the odd case that doesn't uh respond to gluten-free diet, but that's not really something you need to know about, to be honest. Um I didn't put it on here. Um But there's a rare presentation of um celiac disease which you can get um called gluten ataxia. It's sort of a neurological kind of presentation of celiac disease. It's not something you necessarily need to know about for exams, but it's probably one to have just in the back of your mind. Um in case you get a presentation of someone with a funny um gait alongside the symptoms of celiac disease. Um in terms of complications, there's a lot of malabsorption in patients with celiac disease. So, anemia, an osteoporosis related to Vitamin D deficiency, um and also some hypersplenism. So there may be slightly more immuno um compromised than you sort of your normal patient. And the severe um side effect that you need to be aware of is the T cell lymphoma. Um And that's basically related to how much gluten you continue to eat despite the gluten-free diet or even how long you went undiagnosed kind of thing. Um So yeah, just something to be aware of that, that is a complication. Um I haven't got any questions about obesity because to be honest, I don't remember us getting any questions about it in third year. It's not to say they definitely won't, but it would be quite difficult. But the things I think it's important to remember is using the BMI percentile charts, make sure you know how to use those. Um It's possible that they could come off him risky. Um I'm not sure if they're on the stationary, I think they are. Um But it would be a reasonable question for them to get you to calculate someone's um whether they're like their BMI percentile kind of thing. Um, epidemiology of childhood obesity, I've put this in for interest and just for general um information that it is on the rise, um II guess it is in all um ages, but especially in Children. Um and then remembering when, when you intervene as well. So the BMI at 21st centile or above is when you, you make a plan with parents and you know, um actually make a treatment plan. Um and the 98th centile is when you start testing for comorbidities because you know, there are other things other than lifestyle that do cause obesity. Um in terms of management of it's different to adults. Um because Children are growing whenever normally aiming for weight loss, um it's usually a case of trying to maintain their weight whilst they grow so that as they're growing, their centile comes down without bringing their weight down and the key intervention in Children is getting a good amount of exercise. Children should be having 60 minutes of exercise a day. Um And telling parents that they'll, well sometimes click for some people why they aren't losing weight because they're not getting that amount of exercise. It doesn't have to be formal exercise. It can be running around in the garden or running around at school. Um But yeah, um and getting the parents involved is really important because at the end of the day, there are other people feeding their Children. Um So yeah, um in terms of secondary causes, um I've popped a few here, medications is one to think about. Um, if you've got Children on antidepressants or people with epilepsy on certain anticonvulsants, um, that can obviously cause weight gain. So it would be important to check the full that medication history. Um, and then some genetic, um, causes like Prader Willi. Um, and yeah, endocrine causes as well. Um, so, yeah, if they're hitting that 98 percentile, then you wanna be, um, checking for these as well. Um I've just popped an example. I know it's difficult to see. Um, but I've popped an example of the BMI chart they're done based off gender and age and basically you go along the bottom to find their age and draw a line up, um, to find the percentile they're in. Um, they aren't the most easy things to read. But, um, when you've got it in front of you on a full size, um, it's not too bad. Um, it would be a relatively nice risky question, I think, um, to get that but definitely have a look at them and practice plotting and checking what, what percent are they're in because then they take a, a little while to get your head around. Um, and I've, we've gone through this quite quickly today, so I'll give you a chance for any questions at the end. Um I think tomorrow might be a little bit longer. Um, but in terms of overfeeding and then there was the other core condition about psychosocial causes of faltering growth. Um This is the feeding guidance that I've, that I had in my notes um, and learned last year. Um So b over 12 months, you need to be careful about how much cow's milk they're having. Um Basically, if they're having too much, it can stop you from absorbing because it's low in iron cow's milk. Um And if they have, if they're filling up on 500 mils of cow's milk, they're not gonna be eating as much as well as also it prevents them from being able to absorb as much iron from other things. So, um I feel like that's a way that a lot of parents can end up overfeeding in terms of giving too much milk. Um Breastfed babies need vitamin supplementation after six months if they're still breastfed. Um Six months is about the point where you start doing um uh weaning as well. Um And there's some specific weaning guidance as well. Um I wouldn't say you need to learn that specifically, but learn that six months is about the point at which um you should start weaning. Um and do that slowly. Um And there's lists of certain foods they can and can't have um in terms of post birth weight loss. Um I've seen a few questions about this before. Um There's a 10% cut off basically in the first week of life. Um So, um if the baby is lost more than 10% at their one week check or whatever. Um, that's when you start, um, considering breastfeeding problems, um, there's a lot of problems associated with breastfeeding. Um, both for mother and baby. Um, it's important to have a look at those as well. I'd say. Um, because they can be what's causing, um, issues with feeding. Um, bottle fed babies can be more likely to be over fed. Um, because they can just, they'll take as much as you give them pretty much. Um So it's important that people know that under 12 months, they don't really need more than 600 mils of milk a day. Um And the um there's also special formulas or go into this mall and redo the pal protein energy teaching later in the series, but um different formulas for different things. Um There's a lot of formulas sold that like are specifically for over one year olds and things like that or like follow on milks and things the dietician that we saw last year that did some teaching for us that basically any like the the same formula is fine from birth onwards basically, but don't use the obviously the follow on milk for newborns. Um The only time that weaning starts earlier is in very severe go. Um You can actually start it from 17 weeks um under specific guidance if needs be with severe go. Um So um yeah, it's important to remember that that is um something that they can do it is a management option for sort of refractory gourd. Um, does anybody have any questions or anything that wasn't clear, um, any exam questions in general, um, as well.