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This session will be on common respiratory illnesses and their management in pediatrics led by Dr Karen Rahim. Um Just before we start off, I'd like to tell everybody that um any questions that you do have, you're more than welcome to put it throughout the chat, but they won't be answered until the end of the session. Um And as for certificates, just make sure that you fill in the feedback form and you to attend at least 33 sessions in order to get a certificate. Um I've put all the links in the chat, at least I will in just a moment, I'll hand over to Karen. She's asd six in pediatrics and great. Thank you so much. So, thank you. Um Everyone for joining. Um I'm afraid it doesn't get any better. Once you qualify, you still have to give feedback before you get your certificate. So do do give feedback. Um I'm just gonna share my screen and then I will get started with like introducing myself and stuff. I'm also a dinosaur. So bear with me. Uh I believe it's this one. Yes, from the beginning. Um So can you see the screen just can you let me know if that's a yes because I now. Ok, perfect. Ok. So today for the next sort of half an hour to 45 minutes, I'm going to be covering common pediatric winter illnesses. Um, so disclaimer, um, I'm Karen, I'm a mom of three and I'm also a pediatric registrar. I've been doing pediatrics for about 10 years now. Why am I not a consultant? Because II train less than full time. Um and we'll get onto that in a minute. So today we will be, I will be telling you a little bit about myself and then we'll be covering common pediatric illnesses, what to look out for, what are sort of the salient points in your pediatric history. I won't be covering, you know, a pediatric history per se because I think you have a separate session on it. Um but also you can get that from books and stuff. Um and then what the management options for these illnesses are. And then finally, I will end with safety netting for respiratory illnesses. And this is for you to get an idea of how we work in pediatrics because it's very different to other specialties. Um We treat a lot of our patients at home, we have lots of ambulatory units, hospital at home kind of stuff. And that's why safety netting in pediatrics is key because Children um are looked after by other people and they can't necessarily always tell us what's going on and then we'll end with AQ and A and you can ask me anything about pediatrics, my life, whatever. So a little bit about me. So this is me. Um, and I, and I say I'm a mom of three and that's my full time job. And then my side hustle is that I'm a pediatrician. I have two boys and a little girl. I trained at Barts School of Medicine and dentistry. I qualified in 2011 and then I went on to do my F one at Broomfield Hospital. Um I did vascular surgery, stroke, um medicine and then renal medicine. And then I did the F two at the ho which is in London. And over there I did, what the hell did I do? I did cardiology and acute uh medicine. I did pediatrics and in Obs and Gynae, I had my baby, my first baby in F two towards the end of F two. So I finished and then I went on maternity leave for a year and then I was um and eyeing between pediatrics and Obs and Gynae. So I took a clinical fellow year in which I did my peds. And I think it's really important if you're thinking about peds to get some actual experience because working in a specialty is very, very different to being a medical student in specialty. And that's the case if you want to do acute medicine, whatever you want to do, you need to get some actual doctor exposure in it. Then I did my level one training. So in peds, that's sho years. I did ST one and ST two. I fast tracked my ST three because I'd met the common competencies. Went on mat leave two, came back and did my simulation and education fellowship. Um, so I, er, and that was again at the homa and then I went and had my third baby and then now I'm back in level three training. So I'm just finishing my ST six, I start my ST seven. So I've got about two years left full time, but I train less than full time because I have more to life than medicine. So let's get started. So today we're gonna talk about respiratory illnesses and the reason we're talking about respiratory illnesses is that they're really common. So 50% of all presentations to GP are related to respiratory illnesses under five years old. So this can be, you know, your coughs and colds, this can be your sore throats. Um, and actually it causes the N HSA significant burden. A third of presentations to ed are with respiratory illnesses between the ages of 5 to 10 years. And um they're, they're really, really, really common and so most Children before the age of two will get 8 to 12 respiratory illnesses a year. Now, they are mainly concentrated in the autumn and winter months. So if you think about it, they start around October ish and then they go through till February March. And if you think about 8 to 12 illnesses, that's roughly one illness every 2 to 3 weeks. So you need to know about them because you're gonna see kids, whatever you do. If you're a GP, you'll definitely be seeing them. If you go into pediatric medicine, um you'll be seeing them more than you care to and you can't escape them. So, respiratory illnesses, super, super common in the first couple of years of life, as Children grow older, they become less common. So in your preschool ages, so that's right, between roughly 2 to 5 years, you get about 5 to 6 respiratory illnesses a year. And then um as you grow older, so as you get into adolescence, you get about 3 to 4 respiratory illnesses a year. Now, most of them can be managed at home with appropriate safety netting and home measures. And I really, really emphasize this um because what we like to do in pediatrics is treat the child as a extension of their family and you want to try and get them at home where they're comfortable where they feel safe and where they know that people around them, the bulk of A&E presentations at the moment. So and that's the case every year is respiratory illness. Um pre panic. We used to have seasonal variations of things like flu and R SV surges. So for example, flu, we used to definitely have a surge in like October, November and R SV was di di annual. So we used to have a surge in March and then a surge in October November. We haven't had that since COVID and we're not really sure why. We're not sure if it's due to the isolation measures or if indeed these viruses are evolving. Um And they become more virulent because we're seeing, for example, R SV, we've seen every month this year and quite significant number of cases. So it's very interesting what's happening in the peds world. Asthma is the most common respiratory chronic illness in Children. So in the UK, one in 11 Children are diagnosed with asthma making it the most common chronic condition that we do. So why am I talking about respiratory illnesses in Children? Like I said, they're super common. But the reason you need to know about respiratory illnesses and why they happen so commonly in Children is basic anatomy. So Children are not many adults, they have their own physiology, they have their own anatomy. Now, the reason we talk about Children uh having different anatomy is because if you think of a baby, you think of a baby, you know that they have a small nasopharynx, they also have a massive tongue, they have a big old head that can occlude their airways. They also have lots of lymph tissue. So for example, your tonsils and your adenoids, they grow very, very rapidly in the first couple of years of life and then they begin to get small, little atrophy after the age of 12. Now, that's really important if you've got a child who's got a blocked nose and then has large adenoids because you have to think about compromising your airway and how they can um easily deteriorate. Children also are so babies, for example, are obligate nose breathers so they can't breathe through their mouth for the first couple of years of of their lives. Any respiratory illness under the age of six months is very, very significant because if their nose is block, they can't breathe and you need to find a way to unblock it or support their breathing. Other things that affect the uh affect Children um is that they have less, they have sorry floppier airways, they have floppier larynx. Um and therefore they are more likely to get sicker with respiratory illnesses. And as we grow, the cartilage becomes more functional, um the muscles become stronger and we are able to maintain our own airway um in a better way. So the most common pediatric respiratory illnesses are your t so your upper respiratory tract infections and these account for approximately 80% of all respiratory illnesses. So by I ti mean, you know, things that affect your ear, nose and throat and your sinuses, the most common it are common colds and Children get that several times a year followed by um pharyngitis or sore throat, acute otitis media is also very, very common occurs in all ages. Um and that is the majority of ti we see croup is also an ti that you need to be aware of. And I'm gonna go through some of these in a bit. And then finally, you have your te so your lower respiratory tract infections and when you're thinking about respiratory illnesses, you want to think about whether it's upper respiratory or lower respiratory and how to recognize them in Children. So common la include bronchiolitis, flu and pneumonia and across the board. So things that presents as te and lite is asthma. So asthma is a pediatric illness that can present either with upper airway or upper respiratory symptoms or lower respiratory tract um symptoms. That's why it doesn't come under either ti or ti so common causes in Children. So the vast majority of respiratory illnesses are caused by viruses. Um and that's very, very reassuring, but it also shapes how we manage our patients. So you don't want to rush in with things like antibiotics. Um So RSV is the most common viral illness of childhood. So I think the statistic is something like 98% of Children will have had an RSV illness. By the time they are two years old, then you've got your other common viruses that we see in the UK. So things like adenovirus, flu parainfluenza and I'm sorry, that should say enterovirus because those that is again a common cause for respiratory illnesses and then you have your bacterial illnesses, um which I'm afraid we never used to see as much, but because of the rise of sort of anti vaccine vaccine, um sentiments and mistrust and dis misinformation is dis and disinformation. We've seen a huge rise in bacterial illnesses. So things like pertussis, Hemophilus, influenza and strep pneumonia are far more common now than they used to be maybe 10 years ago. And then finally, you've got group A beta hemolytic strep, which is one of the most common causes of sore throats in Children. Um and you may have heard about sort of the strep outbreaks that we had last year this time, last year and we have it usually every couple of years. So take home message viruses cause 90% of all illnesses, but you need to have bacterias at the back of your mind. Other things that affect Children getting respiratory illnesses are things like socioeconomic status. So we know Children that are born into poverty, into um a domestic abuse or things like that are more likely to uh get illness, uh Children that have a parent smoking, but particularly mum who smokes are more likely to get respiratory illnesses. If you are a little boy, if you are premature or if you required um ventilation after birth, or if you develop chronic lung disease, if you've got any abnormalities of the heart and lungs, and that makes sense because if your heart and lungs aren't working very well, you're gonna get sick and your age is a very, very important factor. So always bear that in mind when you're taking your history. So like I said, the younger you are, the more likely you are to get respiratory illnesses. And then finally, if you've got siblings, so unfortunately, any siblings in school or nursery will bring home lots and lots of viruses. And this is really important when we see babies. Um and how we speak to parents because you can't stop them going. But you need to have good respiratory and hand hygiene measures at home to help manage respiratory illness. Oh, ok. So we're gonna talk about croup. So, croup, like I said is an so it's an upper respiratory tract illness. It's normally caused by the para influenza and adenovirus. Um So, oh, I don't know what's right. It's most common between the ages of one and three. and some Children can get it multiple times in their life. So it's not a case of you've get croup once and you can never get it. And actually there are Children who are serial croup. So they'll get croup every winter and multiple times in the winter, essentially, croup is swelling to the larynx, trachea and lungs. Um and its symptoms are that you get this characteristic seal like harsh barking cough and this happens because you get swelling and inflammation of the vocal cords, um which is known as your larynx and then they produce the characteristic sound that you're hearing. Croup. You also get a Stridor er, which is heard when the child reads in. And this is because as you get inflammation, the windpipe and the voice box becomes very, very floppy, almost like it is in sort of infancy. And then you can hear it quite well. Croup is one of these illnesses that once you hear, you'll, you'll never forget what it sounds like. Other symptoms of Croup's will will be like your upper respiratory symptoms. So things like Coryza, otherwise known as runny nose, Children might complain of a sore throat or like a pre preceding viral illness with cold like symptoms. However, Croup can just start quite, quite um suddenly. So one of your differentials in any child with Stridor is to rule out a foreign body. Um And usually you can tell because Children with Stridor and Croup look very unwell. Whereas Children with Stridor and foreign body inhalation, they're usually running around your department with this classic like In and Out Stridor. I have a video here. Hope it plays. So I do a lot of youtube education for parents and also on my Instagram. Um and I try and share videos for them to see to like come in to see us if they um hello, I'm not gonna go through it, but I will play you the sounds of Croup. So you can check this out in your own time. Um but I will be sharing other videos in the next couple of months so do check it out. It sounds like in real Children. Oh uh oh oh uh oh hi come come up. Ok. Ok. So couple I mm yeah and moving and no my and my and my one. Ok. Thank you. Ok, so I'm gonna stop it there. So these are my lovely patients who have given me um their videos. Well, they, they've given me their videos and I've extracted the audio. So that's what Croup sounds like and honestly go back and listen to it and if you can watch it um watch this whole, it's a five minute video. I go through what the common cymp omss are, what the ages are and what the management is. Um But Croup is a very, very common illness in winter in, in peds and we see it all the time and this is an X ray showing what happens if you don't treat it, you can see it's completely narrowed and we've almost lost our way there. Not ideal. Oh, no. Right. Let me see if that works. Ok. So the next most common illness is bronchiolitis and as is um said before, um we see a lot of it. So this is a lower respiratory tract infection and this is the most common respiratory infection of infancy. Now, bronchiolitis normally occurs between um the less than age of one so 12 months or under, but it's more common in babies that are six months or below 2 to 3% of all babies admitted to the hospital in the UK in any winter period are admitted due to bronchiolitis. Most cases occur between the ages of 6 to 9 months. So, like I said, think of infants and your babies, the smaller they are, the more likely they are to get Bron and the more likely to they are to get sick with it. Right. And as I said before, um so Bronch is most commonly caused, caused by R SV and R SV infects 98% of Children by two years. So until proven otherwise, Bronch is almost exclusively caused by the R SV virus. And this is why um Children and we talk about RS VA lot in, in peds. We talk about hand hygiene and respiratory hygiene, particularly in the winter months, um especially around newborn babies and letting other people near newborn babies because R SV in adults doesn't cause any symptoms. For the vast majority of us. We probably just carry it in our nasal tracks. Um but Children who go to school and nursery, they may just have like a cold or may, they may be just sneezing a lot and most of them will be colonized with R SV all the time and they'll pass it on to little ones who then get it and then get very sick. We used to have surgeries between March and November, but post pandemic, we're not seeing that. So this year, for example, we've had R SV, pretty much all year. We, we have definitely more cases in the winter months, but that's just a byproduct of people being indoors and, and spreading viruses. So, what happens in, uh, in bronch is that you get swelling and narrowing of the bronchioles, which as you know, are lower down in your uh in your lungs, they essentially become wet. And what I mean by that is they produce excess mucus, which makes your lungs very, very, very wet and then that causes the child to work harder to breathe because the alveoli can no longer do gaseous exchange as well as it could. So what that looks like in Children is that they, they have increased work of breathing. Generally, it's a 10 to 14 day illness. It sucks if you have it as a kid because Children get really very unwell with it and it gets worse before it gets better. So it starts off with like symptoms and then you get into the peak of it around day four, day five and then eventually improves day seven onwards. Um And you have to tell parents that the cough can last 3 to 4 weeks because what happens is once you get bronchiolitis, um your airways become hyper reactive and then they react to everything dust, they react to allergens, you know, pollen, whatever and or even other viruses that they wouldn't normally react to. I am gonna be sharing, I think tomorrow my video on Bron goes out um and that's got all the signs that you can look out for. So, symptoms of bronchiolitis include cold like symptoms. So Kisa sneezing and coughing, you get a characteristic like hacking cough, which parents will describe as initially very dry and then it sounds like a very wet sounding cough. You may or may not have fever with it. Um You get fast and noisy breathing. Now, increased work of breathing in babies. Remember bronch is usually a illness under the age of 12 months looks like things like head bobbing. Now, head bobbing is something that I'll show in the video that I share tomorrow. But it's essentially when babies are using their entire head to try and move air in the. Now you get recessions, you get intercostal, subcostal recessions, you get abdominal breathing, you get a tachypnea, you may have like noisy breathing. So you might actually hear some wheeze in, in very little ones. And then in Children in babies, you have to think about trouble with feeding. Now in the very small babies. So those that are three months and less bronchiolitis can actually just cause apneas. And what they do is they'll take a breath, they'll stop breathing for about 5 to 10 seconds and then they'll take another breath again and, and that's not a terminal sign, it just happens. So you have to really know what you're looking for in Bron because it is so, so common. Um And we see it blocked. So the management of Bronch is largely supportive. So, remember I said um earlier that the anatomy of like babies in particular is that they are obliger mouth, uh sorry, obliger nose breathers, so they can't breathe from their mouth. So in bronch, one of the early symptoms is right. So you get a runny nose, it gets blocked and then they can't breathe when you try and feed them and they can't breathe, they're just not gonna feed. So the most of the supportive management that we do is feeding support and parenting support to telling them how to feed their baby so little and often to use nasal saline drops at home, they can humidify the air in the home if they want. And then that's how we manage the vast majority of cases. So, although it affects 98% of Children, by the time they're two vast majority of Bronch can be managed very, very safely at home. And remember we only see 2 to 3% of Children who then require admission with Bronch. You need to ask about red flags and you need to treat red flags. So, um, so red flags are things like, um, if they're feeding less, if they're lethargic, if they're irritable, if they have a very increased work of breathing and then you, the final management for Bronch is that you give them breathing support. So they might need supplement, supplemental oxygenation. And that's if they're tiring, if they have apneas or if they have severe work of breathing or if their oxygenation saturations are less than 90 to 92%. There's no real cut off with Bronch. Every hospital has its own guidelines. But generally speaking, we say 92% in slightly older Children and less than 90% in babies. So the way um bronchitis is managing managed, if they do need breathing support, you may start off with just some nasal cannula oxygen and then you will move on to high flow nasal cannula. So these are things like Vapo the and optic flow and then if they're having um apneas, you might need CPAP and if they're getting really, really bad, then you tube them. And actually, I would say we, we try not to chew babies as as much as possible. And most of them are managed usually with high flow nasal cannula. So the way respiratory management works with bronchiolitis is that you look at the severity of the child in front of you and then there are no absolute thresholds. So for example, asthma in UK has very strict guidelines, but bronchiolitis will, it has varying guidelines depending on who you are where you were and the child before you. So high flow nasal oxygen is used for a variety of um pediatric respiratory conditions. So it's used very, very commonly in bronch. You might also use it in like asthma. You can also use it in pneumonia and essentially what it is. It's a device that heats and humidifies the oxygen. And what that does is it purges your airway. So we all have dead space when we're breathing in and out normally. And what that does is that it replaces the, the dead space which is like carbon dioxide rich um with oxygen rich gas. So the baby has a lot more oxygen which is then humidified and heated and it makes it easier for them to breathe in and out. You're essentially taking away their work of breathing. It also avoids oxygen and dilution. So when you give them just regular nasal cannula, there's a lot of air in there and there's a lot of other things that go in. Whereas with high flow, it is literally just oxygen. It also prevents the drying of your nasal passageway and your and it promotes ciliary function because the cilia in our nose, sorry in our um upper airways likes to be quite moist. It thrives on it. So we humidify it and that's what helps Children breathe. If you wanna look at um respiratory management in bronch and how it works, you can look at these trials of Paris Tremont and the first ABC. And what they've all found is that actually high flow nasal cannula oxygen and these devices are known as different names depending on where you work. But generally the most too common that you may hear are things like Vapo the and opti flow. They work as good as CPAP and you start patients on them depending on their weight. So you can see here in this. Um So if you've got a baby under the age of 12 kg, so that's roughly one year. This is two years, three years and this is how you would start it. So if you've got a baby who weighs 10 kg, you will start them on 20 L. Um and then you will pick a flow rate. So, so you, then you would also pick up oxygen. So if they're needing oxygen, you can start them in 24% 25% up to 40% oxygen. And then if that fails, you have an option. So, failure of um high flow oxygen is defined as severe respiratory distress. So, if the Children are getting worse, if they're getting more acidotic, if they start having apneas or they're not tolerating the nasal cannula, so the nasal cannula are quite bulky. They sit underneath your, er, er, so just into your nose and some kids just really do not like them particularly are toddlers. So then you've got options of things like CPAP, bipap or I or intubation and manual manual ventilation. I'm not gonna cover BIPAP and I MV, because that's getting on to things like HD U and PICU and most of us, pediatric, uh although we do manage some of these things, we wouldn't routinely manage them in AD GH. Whereas um uh high flow and CPAP, we see all the time, particularly in winter, you'll see on all the respiratory water. It's really familiar, you know what they do and like what they look like. So CPAP, now people often get confused as to what CPAP is. So CPAP is essentially a breathing device that offers a single level of continuous pressure, right? And that pressure is usually positive. Now, the easiest way I can describe how CPAP works is if you think about a balloon and when you inflate the balloon, you need a lot of pressure to initially make it bigger. And then once it's slightly big, it inflates really nicely. And that's exactly how your alveoli work when um when they, and when you're unwell, that inflation pressure that you initially require gets harder and harder and harder. So what CPAP does is that it maintains the alveoli or the balloon in a state of inflation. So you instead of using the same hard pressure in the beginning, you just have to use gentle pressures to make your balloon bigger. Or in this case, you just have to use gentle pressures to keep your alveoli functioning. So instead of having them collapse at the end of every breath, they stay there and then they just keep on doing your gaseous exchange. So that's what what you mean by positive pressure. Um CPAP is very good so there's no leak, it's an occlusive fit and each hospital has a different way of doing it. Most of them have like a occlusive device over the nose. But you can also get head CPAP. You can also get head and neck CPAP, you can get a face mask, there's lots of CPAP devices just go and find the one that works in your hospital. Now, generally speaking, the guidance is that you start at 7 to 8 centimeters of water, but that's quite hard and it's very poorly tolerated. So we start at lower pressures 5 to 6. But actually, according to most manufacturers, they're not that great. Um And this is why we don't, we don't often use CPAP as our first, as our first protocol. And if we go back to here, this is why I said we will start with high flow nasal cannula. And if that doesn't work, we'll start on CPAP. Now, the reason CPAP fails is not because it doesn't work effectively on Children. It's because Children don't like it and Children aren't gonna do anything. They don't like, they're very, they're very, very strong will and, and so you have to negotiate what you're going to do. And so, although CPAP may seem like the better therapy, um we will start with high flow oxygen. And if you look at some of the trials, actually, CPAP has shown to be of no better benefit than things like h high flow nasal cannula and that's due to patient compliance and if that fails, we need to go to intubation and ventilation. So, thinking about respiratory illnesses. So we've talked about bronchiolitis. I want you to think about the age. Remember when we talked about in the beginning and I said age is a really important factor as to how you see illnesses in, in Children. So in the first year of life, it's usually gonna be bronch, right? If they're gonna come in unwell, it's usually usually gonna be bronch, then we get to your preschool year. So if they're a toddler, they're usually gonna get viral. Wheeze. And as you get older into your school age Children, then you get into the asthma brackets and these three so colitis viral wheeze or viral induced wheeze and asthma are the three most common pediatric respiratory illnesses that we see. And the way you differentiate between them is in your history is in the way that they present age will be a significant factor into which ones you consider. And then you will always have these like overlapping years. So if they're 12 months or 14 months, 15 months, they may have bronch, they may have wheeze similarly here, if they're four or five years old, they may have wheeze or they may have asthma. And this is why you need to be able to recognize and know your respiratory illnesses. So, viral induced wheeze is essentially any illness that presents with wheezing on a background of respiratory symptoms. So, wheeze associated with cough, coryza fever, blocked nose, the shebang. So wheeze can be inspiratory or expiratory. Um And you don't, you, you often, you will often hear pediatricians describe it as for example, an end expiratory wheeze or an end in spirit wheeze or prolonged expiratory phase. And we're talking about the phases of inspiration and expiration. It's usually diagnosed under the age of two years. Um And after 2 to 3 years, we start thinking about is this pre asthma or is this child atopic? Are they gonna develop asthma? Uh Again, Children can get multiple occasions of um wheeze in a winter month. So, you know, our serial offenders can come in several times in the winter months. So every month, some of them come in every other week and they are really influenced by things like smoke. So you will find that Children that come from families that smoke. Um and whether that's first hand or passive, whether they smoke outside and come home with smoke, smelling clothes, they're all coming, they all come in wheezing and it can be caused by any respiratory virus. So we often don't diagnose or we often don't test for viruses in Children because honestly, it would be like looking for a needle in a haystack. There's so many it could be we and we don't care because the management is just the same asthma. On the other hand, happens in older Children and the history is gonna be your key differentiation. So when you take a history for asthma, you obviously wanna know about the cough, the cold, the fevers. But actually the most common history bits are things like whether their child wakes up at night, coughing more likely in asthma than it is in bronch or viral induced. Wheeze. Do they have a history of ATP? So does the child have eczema allergies, whether that's food or drug allergies? Um Have they had an episode of wheeziness or bronch in the past? Is there a family history of ATP? So any hay fever, any allergies or asthma or eczema in the immediate family? Some parents and siblings? And do they wheeze without cold symptoms? Now, this is really important. So in asthma, Children can wheeze at several um things. So they might wheeze after running, they might wheeze, for example, if they've been swimming, they might wheeze um if the weather changes. So for example, if they're laughing or so, if it's very cold outside, they might wheeze at the end of pee. And do they have a dry cough? Now, the dry cough um is not similar to viral induced wheeze because in the viral induced wheeze, you get a usually a very wet sounding cough because they have acute illness. Whereas when asthma, their dry cough is persistent, it happens throughout the week it's worse at night. And finally do Children complain of pain in their chest in the morning? And that's usually a sign that they've had bronchoconstriction overnight and they've been struggling to breathe. So if you ask parents to ask their child or ask to charge yourself, if they're old enough when they wake up in the morning, do they hear a noise or does it feel like they're, they're struggling to breathe? And if they've got asthma, most of them will say yes, because untreated asthma has sort of prolonged bronchoconstriction and that's what happens. So whether you've got viral induced asthma or wheeze the management is very, very similar in the initial stages. So I'm just gonna briefly go through it. So your hallmark of any respiratory illness management is your ABC assessment. So your ABCD E assessment and you really wanna get familiar with this because this is what we do. And as a pediatrician, I probably do an A to E assessment about 20 times a day. So your airway, your breathing, your circulation. So you wanna know um are if any of them are compromised. Um And if they're not, then you go into whether it is mild or moderate and if it is compromised, you start thinking, ok, this is a really, really sick child. I need to consult my pediatric ICU I may need to prepare for intubation and early early on when you look at your baby and you're doing your a to c assessment, you decide whether this is a mild or moderate presentation or this is a severe presentation because their management is slightly different. So mild to moderate wheeze or asthma. Um your child is usually talking. So they might be telling their parents they want to go home, they sat up, they're not agitated, they're not drowsy. They might have some slight tachypnea. They may or may not use some um muscles of um, accessory muscles of breathing. So, for example, they might show some intercostal subcostal recession. They may have a tracheal tug or they may not, but generally speaking, they look well, they may or may not have a tachycardia and they generally are saturating fine er, in air. We tend not to do peak expiratory flow in the acute phase, but this is just if you have it at hand, do get them to do it, but most of them don't come in with um with their peak flow meters and we definitely don't do them in undiagnosed, asthma, in undiagnosed Children. Now, severe wheeze or asthma is a child who is not really talking or only saying one word answers. Um, and usually they look really poorly so they might be hunched forward. They're very irritable, they're trying to fight off your mask, they're not letting you listen to them, they're very, very tachypneic. They use it all of those accessory muscles. So your stenoclada mastoids, your tracheal tons, you've got your, you've got you've got your diaphragmatic breathing, abdominal breathing. They're very tachycardic usually. And usually they, um, are saturating in their eighties actually. So you decide very early on, is this a mild to moderate case or is this a severe case because your, then your treatment differs and if you can go to, go, like, introduce yourself to a peds reg and ask them, can I see the wheezes because you'll get very, very good at recognizing what a sick child looks like. Mm. Right. So then if you've got your mild to moderate, so if you've decided, actually this kid looks ok, what you tend to do with wheeze or asthma is you give them your salbutamol. Now you give them in inhaler form if they're, if they're not requiring oxygen or you give them in your nebulized form, if they have an oxygen requirement and the amount you give is dependent on their age. So, in any child under the age of, er, six, we tend to give, er, six puffs and in a child over Children over the age of six, we tend to give 10 puffs. But all you need to know is that we give them salbutamol, either an inhaler or a nebulizer. Now, in pediatrics, we do something called burst therapy. So burst therapy means that we give them back to back. So every 20 minutes they either get an inhaler or a nebulizer depending on the oxygen requirement. And we usually do add an Atrovent. So this is ipratropium and we might consider an oral cor corticosteroid, something like oral DEX. Now, in your serial offenders, they'll definitely get their DEX if it's their first presentation and wheeze, we won't give them the steroids because that's the nice guidance. And then you assess and you see what's going on. If you have a severe viral induced wheeze or asthmatic, you still give the burst therapy, you still add the IV. Um the um Atrovent, you give them oxygen, whether they've got poor saturations or not because oxygenation helps. And then you usually consider oral IV corticosteroids. Now, usually at this point, if they're severe, we've already got a lining. If we haven't got a line in, we've put an IO in and we're considering things like IV hydrocortisone, IV magnesium sulfate. We're gonna think about Aminophylline and we're gonna think about IV salbutamol early. Now, the problem with all of these things that, that they have side effects. So salbutamol in Children drives a lactic acidosis. It also drives the tachycardia and Aminophylline drives tachypnea and it drives their um sympathetic drive, so they breathe faster, um which is not ideal because what you want them to do is slow down. So you have to balance it, you have to check their levels very, very regularly and you have to see how they respond to the treatment. Usually we give this, we give this salbutamol, we give the Atrovent and we, if we're gonna give IV, we usually start with IV magnesium. It's a really, really amazing drug. It works within sort of like five minutes and it will either rescue them or it won't. And if it's not gonna rescue them, these are gonna be your sick kids. Right. So we give birth therapy and then that depends on how it happens. So if they respond, then we might give, we'll complete the burst therapy. So that will be a nebulizer or an inhaler every 20 to 30 minutes. And then we will think about doing things like a chest X ray blood gasses, we may consider an IV magnesium if they don't, if they don't get better. Um And then escalate it down here. If they do respond, then we admit them to the ward for stretching. So you'll hear the word stretching a lot on the pediatric ward. We're not literally stretching our Children, we're stretching the amount of time that they need their inhalers or nebulizers. So, nebulizers if they're in oxygen inhalers, if they're not in oxygen. And so what happens is you give your initial burst therapy and then you review them one hour after the last one. If they still have wheeze, if they still have work of breathing, then you'll give them the second, you'll give them a repeat inhaler dose of either 6 to 10 puffs or a nebulizer. And then you come, you keep reviewing them. So you review them one hour post nebulizer or inhaler. And if they haven't got a wheeze, you'll stretch them to two hourly, which means that they'll get their inhalers or nebulizers every two hours and you review them every two hours and if they are fine then you'll, then you'll stretch it to three hours and then you stretch it to four hours. So, the cut off for most hospitals is that most Children need to be able to make it to four hourly, it four hourly inhalers before they're allowed to go home. Um And usually they go home with a wheeze plan. So a wheeze plan tells the parents how to give the inhalers and it's usually every four hours for the first day at home, then it's every six hours the next day, then it's every eight hours and eventually by day four, they don't, they don't give any inhalers and you also arrange for a regular follow up. So they need an asthma nurse follow up or a GP follow up in 48 hours in most pediatric units, we will do a telephone review or we will bring them back to like a pediatric ambulatory unit to assess them. Now, if they're known asthmatics, they absolutely, by the nice guidance need to have either an asthma nurse follow up or a 40 hour GP follow up in most cases that doesn't happen. So we bring them back to hospital to see us and then you need to think about their long term asthma plan, if you're diagnosing them with asthma. So, what is the aim of treatment in either of these things? So I know I went through that in a, in a very quick way. But the aim of treatment is essentially two things, whether in asthma or viral induced, wheeze. The first is to relieve your airflow obstruction. So you've got lots and lots of bronchoconstriction. So you want bronchodilators, so you want your salbutamol in very early, you want your anticholinergics and then you want your theophylline. So the first thing is to relieve the airway obstruction. The second is to improve lung function. Now, if you are a child that comes in all the time with wheeze, um and you get multiple triggers, it can be triggered by smoke dust, it can be triggered by pollen. Then you want to think about reducing the inflammation and allergic triggers and you do that by either giving them a steroid inhaler, a leukotriene modifier or a, a long acting Broncho dilator, a beta two agonist. Sorry. So you have to think about what you're gonna do and inhalers versus nebulizers at home as well. So some Children with asthma can have nebulizers at home, they also can have night CPAP and things like that. And that's the aim of treatment essentially to re relieve the acute obstruction, but also maintain long term healthy lung function. And we've already talked about high flow. He we defined um nasal cannula, you some Children in with viral induced wheezing asthma in the acute phases also may earn themselves vapor, theal optic flow CPAP. I have put intubation and ventilation there. We tend not to tube our asthmatics because they are a nightmare to bag. They are a nightmare to ventilate because they require such high pressures. They are so prone to things like pneumothoraces. So in your asthmatic, you want to try and get the ivs in early to try and prevent you going down this intubation and ventilation route because they are really, really awful, particularly your asthmatics that come in every winter that we have had required multiple PICU admissions and stuff. So early treatment, uh it's good and this is why history is important. So, in respiratory illness, you can see, I've talked about four or five respiratory illnesses and they all sound the bloody same, don't s don't they? Like they all have fever, they all have cough, they all have runny nose. And this is why your pediatric history is important. So when you talk about symptoms, you want to know which came first? And what did the parent notice? So was it the cough? Was it the wheeze, was it the Stridor? And when did it start? You, you want to definitely know that about each of your symptoms. So I wanna know, did the cough come if the cough came? How long have they had it? So, is it 2 to 3 a history of cough? Was that preceded by cold like symptoms? Did they have any additional noises? Have the parents made any videos? So you wanna know the onset and duration of illness? You also wanna know about previous admissions? How often have they come in? Do they get respiratory illnesses every winter? Um Have they had any previous IV therapies? Have they had any interval symptoms? So, the things that I talked about, you know, do they get, um symptoms even when they're well, do they have nighttime symptoms? How often they're off sick from school? And then you want to talk about your relevant family history. So your at P your housing, your siblings and your social history. So things like smoking molds, damp, overcrowding, these all affect respiratory illnesses. Uh I think I have about five minutes left. So I'm gonna, I've got two more slides and then it will be question. So, pneumonia, uh otherwise known as your lower respiratory tract infection. We see it all the time in kids. Um It's very, very common. According to the World Health Organization, it can kills more Children worldwide than any other illnesses. And that's things like Malaria Aids TB combined. Uh One in five child deaths globally. And in the UK, I think we see about 200,000 cases per year of hospitalized pneumonias. It's essentially an invasion of the lower respiratory tract below the larynx by pathogens. Most of these pathogens are viruses and they're spread by fomite or droplet spread or um bacteria which causes nasal colonization. And whether you've got a virus or bacteria doesn't really matter. Both of them cause injury, uh, of the epithelia and alveoli migration. It causes a localized inflammatory rea uh reaction at the site of infection which then spreads and it spreads because of this exudative process. And that in turn impairs oxygenation leading to either um acidemia or hypoxia. So usually we have barriers to infections. We have our nasal hair, we've got our turbinas, we've got Piloti and our cilia, we also have our humeral and cellular immunity. But these viruses and these pathogens are very, very clever, they manage to get through somehow. Um and bacteria particularly now because of anti vaccination and a decrease in vaccination. And once they breach, essentially, you get inflammation and injury to your epithelium, right. So the way again it works is age, everything in pediatrics comes down to age. So your babies are gonna be colonized or they're gonna get things that are passed in the vagina or tract. So your group B strep your E coli and your listeria are the commonest things that you see in neonates. So, neonates is a baby under one month in your infant, it's gonna be respiratory viruses. So it's usually your R SV your parainfluenza. We are now starting to see more cases of strep and Hemophilus B and whooping cough in Children that aren't immunized. And as they get older, you, you get your strep pneumonia, you get your group A strep, which is also your beta uh hemolytic strep. And then in your Children that are over the age of five and think about if they're mixing in like institutions. So in your schools, in your um universities, you tend to get the mycoplasma. So age is really important when it comes to your bacterias as well. So, clinical features are fever, cough, work of breathing lethargy, poor feeding, tachypnea and inspiratory cause crackles. Now, unlike adults, Children don't get the classic signs of pneumonia. So they won't, they won't have dull percussion. For example, they won't have reduced breath sound or bronchial breathing you might see in the teenagers. Um and if a teenager is coming in, they're more likely to, for example, to have a mycoplasma pneumonia. So they'll have an atypical presentation. But essentially your child with pneumonia is working a bit hard. They may or may not have a cough but they look unwell. So you want to think about blood, you want to look at CRP, your bacterial pneumonias will give you a really high CRP. Whereas your viral one will give you a lymphopenia. Your chest x-ray can be patchy if it's viral versus low or consolidation. If it's bacterial, you want to do a nasal pharyngeal aspirate to look for any viruses because then we don't have to give antibiotics necessarily. And usually if they are coming in, if they've got a oxygen requirement if they're poor feeding and they look unwell, you are gonna treat them with oral antibiotics. And that's usually your local hospital guidance base for the vast majority of kids is amoxicillin or Co amoxiclav. And finally, we're gonna talk about flu. So flu is a flipping endemic epidemic every bloody year and every bloody year we get kids that are dying of it and people just need to vaccinate and they don't. Um And it's sad because flu costs the NHS about a billion quid every bloody winter. So, flu needs to be at the back of your mind in every child. You see who looks unwell. Now, generally the symptoms of flu are that they don't usually, um, they don't usually, um, come with like a prolonged prodromal illness. Most parents will say they went down very quickly. And usually the thing that starts with is the fever, get the fever, it's very, very high. So we're talking about, um, 39 forties and then they get a cough, they get intense myalgia. So they say the Children are really lethargic. They don't want to be touched. Most kids that can speak will tell you they get a headache. They don't usually get the prodromal illness. So they don't really, really get like the runny nose or the sneezing. Um, and they don't usually, uh, you know, they're not running around Children with flu look unwell. So you always need to keep it as a differential. It's very common under the Children of age of five. This is all it's commonly caused um by, sorry, let me come back. So think of any child who is unwell without many respiratory signs. So, but flu is considered a respiratory illness, but it doesn't present as a typical respiratory. The other thing with flu in Children is that you get a lot of gastro gastro symptoms. So things like vomiting, diarrhea, and stomach cramps. Uh usually it's flu A or B, there is a flu CC but we don't normally get it. Flu A is generally worse than flu B. Um, and you do it on a swab management again is supportive. So things like IV fluids, uh, paracetamol Ibuprofen for the Myalgia, you do give Tamiflu if you pick it up early. So for example, if a parent came in within the 1st 48 hours of symptoms developing, you can give Tamiflu, it doesn't necessarily always work. A lot of hospitals don't give it. And finally, we're gonna talk about safety netting. So most of these kids come in and they're fine and they may come in on day one of illness and you're gonna send them home because otherwise we'd, you know, we'd, we'd admit if we admitted every kid we'd have like 100 bed ward. So your safety net using green amber or red. So you say to your parents, your child looks fine and you, you can manage them at home with, you know, simple things like um, paracetamol, Ibuprofen little and often feeding, uh, hydrating, focus on hydration instead of eating. And then you say you net their respiratory symptoms. So you say to them, if their breathing gets worse, you need to come back in. If they change color, you need to come back in. If there's any additional noises, you need to come back in or if they look like they're not breathing regularly, you need to come back in because these are your red flags. So your red flag safety net first and you don't tell them to phone 999 or whatever you tell them to if they can't get an ambulance. Yes, then they phone 999. Otherwise it come straight to the A&E if they are, don't have any of those symptoms, but they might be feeding less or they're having less wet nappies or if they're worried. So, parental anxiety is a huge determination of whether they're gonna come in or not. If they're unwell or vomiting or if they have a temperature, then they need to see a medic and if they don't have any of these things, then they're fine. So safety netting is really, really important in pediatrics because how your safety net depends whether your parents will come back to you. And I always say to parents, they are the expert in their baby, not me and not anyone else because they are the person that sees their child in and out and you need to learn to teach parents to empower them, to know what to look out for. So I always say to them, I would much rather they came in 10 times and I saw them and sent them away than them not coming in at all. And it's very different to adults. I think where we are a little bit more liberal with what we say to them. So that was a whirlwind tour of what you see in pediatrics in winter. So if you have any questions, please do ask, you can ask me about anything about pediatrics. There's no such thing as a stupid question. I still don't know everything and we're generally very nice. Um And it doesn't have to be medical. You can answer me all about a career in peace. Um And I'll be more than happy to answer. Oh, I went a bit over. I'm sorry. That's OK. So thank you for that. Um I'll move on to some, there's a few questions already. So someone's asked if they will get the slide. Uh the session is recorded so you should be able to access it and if not, I'll make sure it's accessible afterwards. Um The next question is what degree of tachycardia is pathological in the iatrogenic context of TX with beta agonists? Yeah. So good question. There's no degree of tachycardia that we say is pathological in Children. Um So we know that salbutamol is gonna cause a tachycardia, it's more that we look at things in the whole picture. So if they've just got a tachycardia, that's ok. If they've got a tachycardia with a lactic acidosis, that's not ok. So, you know, we do, we don't do AES in Children, we do capillary blood gasses. Um and it also depends on their age. So obviously, as you know, with Children, the heart rates differ according to the age group. So there's no upper limit for us and Children can, they're, they're generally more tachycardic than adults, right? So it's not uncommon for me, for example, to tolerate a, a heart rate of 1 61 70 with a child that's on back to back nebs for example, because I know I'm expecting that 170 in a eight year old makes me worry a little bit more. Um So there's no defined like parameters as there are in adults. Unfortunately, you have to look at the gasses. Um and you have to look at the work of breathing. You have to look at the oxygen requirement. You have to look at things like how alert the child is if they're talking to you and that will help you decide if they're becoming toxic or if they're not. Thank you. Um Another question is how to differentiate between flu and cold. Ok. So cold commonly presents with upper respiratory symptoms. So Children with cold will often get like the runny nose, they will get um sneezing a lot. Um, and they don't typically get a very high fever so they might have a bit of a mild fever. Whereas with flu, Children get the fever usually is the first thing that they get. It's usually like in their forties and they complain of feeling like their body hurting or the babies if they get flu, they're very, very irritable. They don't like being touched, they don't like being handled. The, also, the other difference with flu is that Children can complain of like a headache or their eyes hurting um or not tolerating like they don't necessarily get um photophobia, but they don't like being in like noisy like well lit spaces. Um and generally speaking, flu comes on like that, whereas a cold is a bit of a prodromal illness. Ok. So the question after that is why are males more at risk for croup compared to females? So they're not more at risk of croup. Males generally are more at risk of getting respiratory illnesses than females. And that's just just something to do with their genetics. Generally speak a bit like how girls are more prone to getting autoimmune diseases. Men are just more prone to getting respiratory sicknesses. And then the next question is um what should we do in university if we want to become a pediatrician in the future? So I'm a bit of a, I guess I'm quite a lefty, enjoy yourself at uni um And the reason I say that is because do you remember when you were at school and you went into a levels? And then you realize everything you learnt at bloody um G CSE level was a bunch of crap and you didn't actually need it at a levels. And then you did your A levels and you got to uni you were like everything I learned at a level is no longer useful here, life is very much like that. As a doctor you qualify and then you realize that medical school gives you a very um narrow view of things. So you only know the physiology and things at a very basic level. Um and then you start working and you apply your knowledge and that's where the magic happens. And I say that because I love being a pediatrician. I've been a doctor, you know, for, for many, many years now. And I still love my job and the reason I love my job is because it teaches me new things every day and I'm still learning and I think that's fantastic, but I think uni you don't need to worry about it. And there are always gonna be people that say to you, you know, work on your portfolio, work on this, work on that. But I promise you, you will qualify and you will have a career that expands decades where you have to do all of that stuff and you won't get the time necessary to spend it with your friends and your families. You know, I'll give you an example yesterday, my daughter broke her arm. Um, and I was on call, I was at work and she came in and I had to see her in between seeing my patients and it really, like, it really annoyed me because I did. All I wanted was to hug her and, and medicine will take so much of your life that at uni, I just think you should focus on enjoying yourself. And if you really, really want to do it, if you really want to be that super person, that's great. You think about things like joining a pediatric society, you can do a pediatric uh rotation. So you know your, what are they called? I mean, you can tell I'm old when you do your students selected modules and you do your final year placements um where you go abroad and stuff, you can do that impedes, think about doing an audit or AQ I impedes. Um But do things because you want to generally make a difference in the lives of your patients. Not because of the tick box exercise because I swear you'll have all the time in the world to do that once you qualify. I better. I hope your daughter feels better soon. Yeah, she's, she's just ruptured her radius in her, in her true, true. I old fashion. Um So the next question is, are there major differences in medical pediatrics? And pharmaceutical pedia. Um can you clarify what you mean? Because generally speaking, a career in pharma medicine is very, very different to clinical medicine. Um You are ge generally working on the research side of things and the development side of things. So you might be working um developing a particular product. So a lot of pharma medicine is about product management, generally rather than clinical medicine. So clinical medicine is about seeing patients who, you know, you do patient centered work. Um you can do a bit of research so you can do something called academic um F one and F two where you get a dedicated amount to do research. But that isn't pharma pharma pediatrics is generally you qualify as a doctor and then you leave medicine, clinical medicine and you work in the pharma industry. I think it's possible that this one's in the context of maybe being a pharmacist uh specifically in pediatrics or I I'm not sure entirely. So pediatricians generally work very, very closely with pharmacists. Um And that's because everything we do and prescribe in pediatrics is weight based. So there's no set dose of anything. And if you said to me, you know what's the dose of paracetamol? I would give a five year old. The answer I would give you is, I don't know because I don't learn doses because it's all weight based. So I know, for example, it might be 15 mg per K, but it again, that varies age to age and disease to disease. So we don't learn doses and that's usually why the pharmacists keep us in check. Um And we prescribe like, you know, micrograms and nanograms and M GS a lot because obviously if we're dealing with babies, certain drugs are micrograms and certain drugs are migs and stuff, it's very different to adult medicine where there are set doses across the board. Um So I think I'm hoping that's answered the question. Um, is being a pediatrician, a family friendly career. Yeah, very, very family friendly. So, like I said, I've had, I'm a mom of three. My eldest is 10. Um, and that's just how long I've been a pediatrician. Um, and my youngest is two and I've had kids in my, in throughout my career and most of us pediatricians do that. Um, most of us don't wait until we're consultants to have our Children. And I think everyone's priorities are different. I've always wanted to be a mom and there's an element of biology in that. And so I was very fortunate that I met my partner at UNI and we got married and I had kids early because that's what I wanted. Um, and pediatrics is very, very family friendly. So most of us train less than full time. So what that means is that we train anywhere between 3 to 5 days a week. So I work 80% now, which means I work four days a week, which means that at least I get three days at home with my family and that does prolong your training. But it's very different when you're at med school. So when you're at med school, um, and I say this to someone who wanted to do pediatric surgery when I was at med school. And I like, you know, that was where I was going. And then I met my partner and my sort of career plans changed. But when I was at med school, all I could think about was being a consultant. And then you start working and you realize that the game is not the end goal, the game is to enjoy yourself in training, build yourself as a clinician, build yourself as a person and have the bloody best time doing that. And that's what less than full time training allows you to do. So, lots of pediatricians don't have kids. They train less than full time and they do their side hustles. They, you know, one of us is a yoga teacher, one of us runs some, several people run their own businesses on the side and do other things that bring them joy apart from medicine. So if you want to do that, if you want to have a like a portfolio career. So I do a lot of work. Um I do a lot of brand work. I work. Um So I work four days a week and then I also do my Instagram. Um I do a lot of child health health information sharing. I'm also as ambassador for Smile Trained UK, which is a Cleft charity. I am a board governor for my local um secondary academy. Um and I do the safeguarding policies so you can do what you want with medicine as long as you have the confidence um to justify it. And as long as you have the right guidance, so please do connect with me on Instagram or whatever. I'm more than happy to speak to you about your career path. And I feel like not enough of a say, enjoy your life. And a lot of this can become quite tunnel focused. And that tunnel focus is I need to be a GP or I need to be a surgeon or I need to be this. You will be a doctor for 5060 decades. Honestly enjoy it while you can. OK? Perfect. So if anyone else has any other questions, uh just pop them in the chat, I will also put, I've also put all of the links in the chat as well for the feedback form um for the next episode and also on Instagram. And I've also put in Karen's Instagram in as well. I really hope the link works. Um Yeah, if and nobody else has any other questions. Um Thank you very much Karen for that talk. It's very informative and the questions again very well answered in my opinion. Thank you so much. Ok. Can I just remember to check out the youtube because you can listen to the C Proot video and then tomorrow I'll be uploading my Bronch video and that's got very good Bronch signss and then I will be sharing lots of things. I already have lots of like a few videos on there, like things that you will see in. Um and if you're interested in career in peds, it's good to know about them. Yeah, perfect. Thank you very much that sorry, I'm sorry, I'm just struggling to get everything ready. But um again, thank you for that. Thank you for everyone for attending. Um and hopefully we'll see you at the next. Do. Great. Bye bye.