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Hello, everyone. Uh apologies for the slight delay. We should have thought about our timing a little bit better. We don't like starting things late. Um But I know that Andrew has lots and lots to tell you you can actually get, I will be uploading his previous event onto the platform probably tomorrow. So if you want to catch up with that on, catch up, you can as well as this one and his slides will be there too. So without any further ado I'm gonna hand you over to Andrew if you want. If you have questions, please pop them in the chat on the right hand side. All right. Thank you. Thanks, Andre. Thanks very much. Um So I'm sure many of you have just jumped over to this link from my previous talk that I was just given about uh outcomes of prematurity. Um but there may well be some of you er, that um I'll just listen to this talk. Um, so, er, to introduce myself again. So I'm Andrew, I'm a consultant neonatologist at the Evelina er Children's Hospital in London. Um and um for the next half an hour or so, we're gonna be thinking about the crying baby. Um Please do put your questions in and if I can't get to them this evening, I will er respond to all of them um after the event uh as much as possible. So the crying baby. So, um what I'm hoping to, to cover by the end of this session is to give you a little bit of information about how we might differentiate normal and excessive crying. Um Think about the differentials of, of when we're worried about crying being excessive. Um a and highlight a few parental resources for you. Um So we got to think about what's normal, what's not normal and the differential diagnosis and support to parents um has just alluded to. So I think the kind of headline thing that you probably will know and it's probably worth highlighting at the start is that crying is very much a a normal part of being a baby and that is what they do, that's how they communicate. And when you look, um you know, evolutionary speaking, it is a very ancient thing and many animals cry or do similar and all primates babies cry as well. There's different theories as to how it evolved and why it evolved. Certainly communication is a key thing. It was an interesting theory that um the reason babies cry so much is because that will get them to feed. And we know that breastfeeding limits the reproductive capacity of the mum until they've stopped breastfeeding. So there might be a, a AAA selfish advantage for the baby to maintain breastfeeding as long as possible. Um to stop any pesky siblings coming along. I don't know how much evidence there is to that theory, but I quite enjoyed reading about it. And we also know from psychological studies that us as adults have very specific responses to when we hear a baby cry. Obviously, if you're on an airplane, that response is usually frustration, but we do have a kind of innate reaction to it. We are inbuilt to respond to a baby crying. So it goes both ways. Um So what is normal? So we know babies cry a lot and we, we know that they cry most during the first few months of life and there's a general peak around kind of 6 to 8 weeks of life. What's interesting is there does seem to be a difference between babies in different countries. Um So the babies that cry the most are in Britain, which is good for all of our parents, um Canada and Italy. And it seems that babies in Japan, Denmark and Germany cry the least. What's also interesting is that if you um assess and look at the cries of babies from, from parents that speak different languages, there is variation dependent on the language that the baby is exposed to. So Macri does have a slightly different cadence and slightly different pitch depending on the population that the baby comes from. And in the UK, the average amount of crying is around 2 to 3 hours a day, which I guess is a small minority of the day, but it is still a fair amount of listening to a baby cry. So what does crying usually signify? This is not ground baking medicine. It's pretty simple stuff, but usually it's to signify that they're hungry. They might have a dirty nappy or they're tired. They might just want some affection. We all want a cuddle now and again, and they might have some wind or indigestion. They might be too hot or too cold, they might be bored or they actually might be overstimulated. There might be too much going on in the room and actually they need to calm down a little bit. So the kind of basic principle if you've got a growing baby is to tackle the big three things. So offer them a feed, change their nappy or change their environment, whether that's changing room, changing their position or supporting them to get to sleep. And those of that kind of triad will solve things nine times out of 10, you may have heard of this concept of purple crying. Um Now this is a kind of, I mean, the Purple Crying initiative is a formalized education program from the US that was kind of borne out of initiative to try and reduce shaken baby syndrome and reduce the stress for parents and educate parents about what is normal. So there's the link to the website there which you might like to have a look at. Um but essentially trying to normal, sorry, trying to normalize the fact that babies can cry a lot doing. And as kind of I said at the start, it generally peaks uh around the two month mark and it can be unexpected, it can resist those things that II talked about and it can, what's I think most concerning to parents is often that the baby looks like they're in pain and they have a really kind of um scrunched up face that you red in the face. They really look like they're in a lot of discomfort even though there does not seem to be any reason for that. Um And actually it's important to be aware of these things. It is important that despite doing what I said on the previous slide, sometimes babies can be a little bit unconsoled and they just need a little bit of time to, to settle themselves out. And there's probably, you know, some babies will cry more than others. But there's a a as with all things, there's a spectrum a a and there's not necessarily something pathological underlying it. So even if crying seems excessive, it is important to go back to those basics. I know it seems really simple. But do don't neglect thinking about the basic things first because there's often something easily fixable if there is anything to fix at all. So in terms of hunger do take a feeling, history and think about whether there's any associated issues with feeling. And I'm going to come on to think about what some of those might be in later. Have a look at the weight gain. You know, if the weight gain, you know, a growing baby is generally a sign of a healthy baby. So have a look at the growth charts. Is the baby gaining weight appropriately. How's the the breast milk supply? And interestingly, if you know, interestingly and importantly, if the family of formula feeding are just double checking, are they mixing the formula appropriately? There are reports in particularly in low income areas of um you know, families kind of half diluting or or not putting as much formula in to make it go further and obviously that will have an impact on on the baby's hunger and nutrition. Nappies have a little think about the normality of the the the bowel motions. Um How frequently are they going? Is the poo they doing normal or is it very loose or are they very constipated? And do they need exploration of that to try and improve um matters and have a look in the nappy? Is there a really nasty nappy rash that could explain discomfort and tiredness? As I said, babies can kind of get overstimulated and overexcited. And um you know, it's important just to highlight that babies don't have a circadian rhythm, day night means nothing to them. Is kind of famous because parents don't get any sleep. But it's important to, you know, acknowledge, you know, and query whether the baby does have good sleep still, they have a regular pattern. Are they going down between feeds? And are they achieving suitable amounts and exploring kind of the safe sleeping advice and making sure the baby's having optimal sleep is an important component. I was obviously not going to be able to go through a talk on a crying baby without mentioning colic. Although it's a really difficult thing to talk about because it's one of those areas, despite seemingly being so common, we really know very little about. I've copied and pasted in. Um Well, I screenshot, I'm not sure how well that displays from the nice clinical knowledge summary about kind of how we would define colic in this day and age. As you can see, it's very clunky and the opposite of succinct. Um You may be more familiar with the kind of old vessels criteria which was the rule of three, which was baby crying for more than three hours a day, for more than three days a week, for more than a couple of weeks. That's kind of less popular. Now, that is kind of going out of fashion, although it's still obviously in various older research studies. Um but the room for criteria are generally are what regarded to now in relation to colic. So it has to be a young baby under five months, they have to have recurrent and prolonged periods even from crying, fussing or irritability reported by the caregivers without obvious cause and cannot be prevented or resolved by the caregivers. Um And importantly, there's no other kind of signs of illness or failure to thrive. Um There remains a lot of uncertainty about what colic is. Um kind of feeling is it's probably related to indigestion and kind of increased gastrointestinal gas. Um Some would argue it is just part of the kind of normal spectrum and and probably a lot of what is kind of that purple crying overlaps with colic. Um What we do know is there's very little or no evidence for most of the commonly used remedies. So things like simeticone brand name is Infec or lactase co leaf gripe water, you'll see lots of people use and omeprazole is often prescribed, but there's really no evidence that any of those things reduce things, reduce the symptoms in the meta analyses. There has been some data coming out in recent years about probiotics. Uh and in particular, um Lactobacillus Ruteri DSM 17938, which is a very catchy name um um which has been shown to potentially have some benefit in breast fed babies, not formula fed babies. Um And that's yet to kind of filter down into the nice guidelines. It's not routinely or widely recommended as yet. But you know, science moves, it changes views and we might see that that kind of comes into practice in coming years. If the evidence remains strong, it is worth bearing in mind that not all probiotics are the same. And we know this across all studies, we use probiotics in preterm infants as well. And it's what is clear is there are differences between different strains. So not all probiotics are created equal. And so if you know parents are moving towards or asking you about probiotics, it has to be lactobacillus Ruteri, which is the one that's shown to have any potential benefit. Um There's lots of stuff you can read about colic. The, the nice clinical knowledge summary is a reasonable read and there's also linked here, a couple of recent review articles and, and meta analyses that look over the, the um information I talked about. The other kind of big feed related thing is cm protein allergy. Um This again, it's very difficult to generate accurate um statistics for um for a variety of reasons most commonly because it's there's varying definitions, it's difficult to kind of definitively prove clinically. Um lots of parents might just treat it without seeking help. So there's quite a wide range of prevalence values anywhere from kind of 0.5 to 7.5% of infants. Um As you might be aware, there's kind of two main forms of C MPA and non IgE and IgE mediated that non ig a cell mediated response. It typically gives more kind of delayed symptoms. Um These are babies that have kind of grumbling intestinal symptoms, diarrhea, or constipation, they get eczema, they might have faltering growth. They generally a bit uncomfortable with the at the severe end of the spectrum. There's these conditions that you may have heard of called F PS or F pip. So, food protein induced enterocolitis syndrome or food protein induced procto colitis. And these are kind of more significant end of the spectrum. The FPs in particular babies can become quite unwell with, they can become shocked and have marked gastrointestinal symptoms. And um nepro colitis is a cause of kind of frank rectal bleeding in a baby. So certainly babies is presenting with that you would need to consider AC MPA. Um Then you've got I GE mediated which um as you might expect is it has a faster onset after exposure and and this is kind of more your kind of classic allergy type symptoms because of the I GE um action. Um So you get kind of more quicker onsets of rashes. Um you might get rhinitis and wheeze um other types of you can get eczema but other types of rashes as well, but it is much rarer than the non IgE mediated form. Um This is taken from the nice guidelines. It gives a bit of an overview of the kind of categorization of the symptoms that you might see, ii won't dwell on it and you can review that in your own time. Um Some of them are obviously fairly nonspecific, but you know, it's helpful just to kind of frame them in your head. The diagnosis is primarily clinical and usually typified by a dietary exclusion of cow's milk protein. Um have a low threshold to refer to your local dietetic service as well as your local allergy team. Um There's no specific test for the non IgE mediated form. Um so that you do have to exclude. But part of that um diagnostic process is to rechallenge and the vast majority of babies will outgrow. Um So well, rechallenging has to roles one partly to see if the symptoms come back and that kind of confirms your diagnosis, but equally the vast majority of babies do outgrow their, their allergies. So it's important to rechallenge at later thresholds as well to see if they've outgrown it. The IgE is, is um generally managed in secondary care. So, if you are worried about an IgE mediated form, um then have a very low threshold to refer to your local allergy service. Um There are tests that you can do for IG ES, you can do skin prick testing or serum specific IgE. But as with all kind of allergy testing, it's a bit of a minefield and can be difficult to interpret. So it is generally led by the allergy team. Um dietary exclusions, I mentioned um for breastfed babies, that will mean maternal exclusion of dairy uh or you can use an extensively hydrolyzed formula occasionally in severe forms. Um We occasionally need to prescribe an amino acid formula, but generally, that should be managed by secondary care if you're getting to that uh stage. Um non I GE as I said, can be rechallenged. I GE mediated. They us usually because they're more quicker onset and more severe um allergic type responses, um generally more cautious about rechallenging those. So again, should generally be managed by your secondary care colleagues. And as I said, the majority of babies grow out of C MPA, um most by five years and actually a non IgE mediated, which is the majority, the majority have grown out by kind of two years of age. Um There are a couple of articles including the, the nice guideline as well. Reflux, again, are commonly diagnosed things in babies, but it's really important to remember obviously that positing and bringing milk up is a normal part of being a baby. They have a exclusively liquid diet. They spend most of their life on their back. So, you know, it's really common for them to bring up milk after they feed. Um If you are worried that it's causing symptomatic impact, so either making the baby refuse feeds and having an impact on their weight or they are seemingly in a lot of discomfort in and around feeds and it's not unreasonable to start some treatment, but you need to be clear with the parents and yourselves about what that treatment is aiming to achieve. Gaviscon. Um So Gaviscon infant does have a mild thickening action and can obviously um reduce some of the discomfort. The key thing is that omeprazole does not stop vomiting. You know, I see a lot of families that hope for a magic cure and omeprazole can obviously reduce the acid and may reduce some of the discomfort, but it is not going to stop the positing, it's not going to reduce the laundry bill. So it's just important to think about what medications you are prescribing and what you're aiming to achieve with that. You can, what's not listed here is there are kind of for formula fed babies. There are kind of antireflux formulas that have kind of a thickening agent in them, which are an option as well. But generally, my general thing is if there's, if you're concerned by the amount that's coming up, then Gascon is a good option. If you're really worried about the kind of discomfort and then potentially omeprazole is the better choice. But what I would say if it doesn't have an impact, stop them again because you don't want babies taking things unnecessarily. Uh and nothing is without risk. And Gaviscon can cause constipation and omeprazole can increase the risks of infection. So you just need to, to balance the risks uh as with any medication lactose intolerance is another thing you might be asked about. Um, uh, it features a lot on blogs and things, but actually, true, lactose intolerance is very rare in babies. Um, some Children will have a secondary lactose intolerance. Uh, in particular, if they've in older Children, typically, if they've had a severe gastroenteritis in the kind of younger baby population, if they have got C MPA, that could, um, er, um, you know, cause inflammation in the gut and lead to a secondary lactose intolerance. Um or if um you know, they're post weaning and um have celiac disease again causing that inflammation. It typically causes a very frothy kind of um um very large volumes and kind of, I mean, it's not a very nice term, is it a frothy kind of bubbly diarrhea? Um and it is often associated with a very severe nappy rash. So, in those situations, you could consider a lactose free diet, but usually, again, like C MPA, it's usually just a transient period. So you can then rechallenge other things to think about. So, um there was a study relatively old now from 2009. Um but of all the babies brought to ed with a kind of diagnosis of excess, excessive crying, around 5% of them had an underlying condition. Um that was diagnosed and, and UTI was the most common thing diagnosed in that cohort. So it is important to think about serious illness. So, you know, your your standard things. Is there any other red flag um symptoms for that baby? Do they have a fever? Are they feeding poorly? They got reduced to an output. And as the character of the cry changed, parents will obviously be very in tune with what the normal cry for their baby is. So if they're saying that the character has changed or the baby seems more irritable, then that's obviously notable. We need to check the abdomen and the groin. Um So obviously an acute abdomen, in particular, um volvulus, um can obviously cause discomfort. You'd expect some abdominal abdominal signs interception can be a little bit more subtle in terms of the clinical features of the abdomen. Um but there is um obviously the classic kind of red currant jelly and, and generally, the, you know, the baby would have other signs of discomfort that make tachycardic and and look unwell, um incarcerated hernias to check the groin. As I said, certainly in preterm babies as well. Hernias are not uncommon and unfortunately, babies can suffer testicle torsion as well. So you do need to examine the groin and testicles even for a young baby. You've probably heard of the concept of a hair tourniquet. There's a picture here but little kind of stray hairs can cause mischief and wrap themselves around, dealing with the digits. You can get a genital hair tourniquet as well. So it's just important to take the gloves, knit socks off and actually have a good look at the feet and the hands to make sure there's not any evidence for hair tourniquet, although it's never nice to consider. Um you do have to think about um non accidental injury. Um I have in my own career, seen a child present with the diagnosis of excessive crying and was found to have a leg fracture from N I. So, you know, it's not nice to think about that. these things do happen. It's our duty as healthcare professionals to kind of just always have this in the back of our minds. So I do have a good look over them, make sure there's no bruising or deformities of anywhere and making sure it's not a cry for help for something else. And you can also consider corneal abrasion, obviously not the easiest thing to assess for in a baby. But if there are a watery eye, red eye or something concerning there, then you probably worth having a chat with the ophthalmologist if you don't feel confident looking yourself. And it's really important to acknowledge the impact on parents of excessive crying. It you know, it is stressful and exhausting and we know that um babies that are big criers that is linked with postnatal depression. So it's important to, to ask the parents about that. We also know that babies that have are at the higher end of the crying spectrum are at increased risk of child abuse and and the kind of so called shaken baby syndrome. So it's important to pick up if the parents are struggling. Um, as kind of, I alluded to at the start education of what's normal is important. Um, and, um, there's, there's kind of a concept that you can't leave your baby crying, but actually we know that it's, it's ok to do that. You can leave them for a short period, get some fresh air, make a cup of tea and then go back and try and settle them again and just kind of authorizing the parents that allowance can be, can be very useful. There's two very good resources I want to flag the best is crisis, which is one of the best named websites I think I've ever seen. Um, but Cry si S crisis.org dot UK is a, is a helpline. Um not quite 24 7, but um certainly during the majority of the day, daylight hours and into the evening that parents can call and they can kind of talk through concerns with their baby. And there's lots of good information and resources on that website that you might want to look at yourselves. But certainly if you've got a parent that's struggling referring to that is beneficial. Um, safe sleeping is really important and being advocates of safe sleeping advice. And if I'm sure you've heard of the Lullaby Trust, but it's an excellent website again with lots of resources on. Um, but, you know, it's very easy for parents that have a very cry baby to kind of start to renegade on some of this advice and you know, holding them, falling asleep with them in bed, falling asleep on the sofa, resorting to alcohol and smoking and swaddling in unsafe ways and things, these kind of habits creep in. So just always being a champion of safe sleeping advice is important too. So, um just about half past now. So just to summarize, obviously, crying is normal, it is how babies communicate. Um But acknowledging that a baby that does cry a lot can be very stressful for themselves. And for the parents really do focus, don't neglect the simple interventions. I know you probably don't need a lecture to tell you that. But you know, a lot can be talked and thought about in relation to the simple things before thinking of the weird and wonderful. But you always have those other key differentials in the back your head and if there are red flags or the parents keep coming back and you're not sure or you're just worried that there's something else going on, you know, refer it to us and we can check the baby over and give it some thought as well and remembering those resources that I said that about supporting the parents. So thanks very much. Um I hope you got a little of something from that. Um uh I will share the kind of quick cheats reference list. There for you to have a look at. Um I have a quick, I saw some questions coming in. Yeah. Are you happy to have them? Yeah. Yeah. Look through them. I never actually thought I would put Claire's question up as a question. I never, I never thought in my life I would be asking what is normal. Um Is there any good resources for what is a normal? I have not got a good resource off the top of my head. In terms of that, I think I've asked, been asked similar before and um maybe I should create an encyclopedia who I can make some money. Um I don't, the, the, the, the difficulty with that is, is there's a huge variation of what is normal and similarly with adults, babies all have their own patterns and um what's normal for them. So what I would, what I generally focus on is if there's been a change from what the parents feel is normal for them, um You know, one baby might be going once every three days and that'd be perfectly normal for them. Equally a baby that was going more often and then is suddenly going once every three days. And when they are going, it's really firm and they're really struggling and they're in a lot of discomfort, they're very different. Despite the same frequency. Similarly, you know, a breastfed baby, it's not unusual for them to be going 56 times a day. But if they were a formula fed baby and they were going once a day and then suddenly start going sick. So, change is very notable to me. Um Color less, I play slightly less relevance to unless obviously there's um pale stores for conjugated jaundice. If there's stuff mixed in with the stools, in particular blood, you can sometimes get mucus, which is notable but not always pathological. Um But yeah, so the short answer is no, I don't have a resource but do dwell in delve into what's normal for that baby and if there's been a sudden change or if there's anything particularly um uh concerning in it. Um I, I'm clicking on the next question. So I presume that's how it's best to go through probiotics in bottle fed. Um No, the evidence does show some benefit for breastfed, but so far not in bottle fed babies. Um That was a that there's a few comments that it's less clear what that was in relation to in isolation. But I think some of you have been sharing resources as well, which is helpful. Um um And there was someone asking about it's their local guidelines that all babies under 12 months have to be referred to secondary care for omeprazole. Um that I'm not too sure, but you may have been talking about that. Um Do you wake wake babies? Sorry. Do you wake up babies to feed them if they are well and feeding? Well, but sleeping six hours without feeding, um, that sweat Lana depends a little bit on the age of the baby. Certainly young baby. Um, they do need to be woken up overnight. Um, um, uh, I wouldn't let them generally go kind of beyond four hours when they're, you know, in the first couple of months of life as they get bigger and older, they will start spanning night and, um, will start developing a bit more of a kind of day, night cycle. Um So some of those babies, certainly, once they're kind of approaching 56 months might start sleeping through a bit more. Um But certainly younger babies, they sometimes need a little bit of a prompt to, to wake up overnight. Um I think there was a couple of comments about Kabel being used for reflux. Um That is not something I've ever used or seen in my practice for reflux. We would generally use Kabel for babies that are deemed to have kind of an unsafe swallow. Um It's a thickener agent so it can make it easier to swallow. Um I guess in principle, it has similar benefits in terms of thickening and reducing the the likelihood of reflux. But it's not certainly in my experience, it's not something I've ever seen used for reflux. Um How does omeprazole increase the risk of infection? It primarily just relates to the, the acid in the stomach as the first line of defense for a lot of, um, bugs. Um, and actually if you reduce, um, the, um, acidic environment, it can reduce that immune protection. Um, and we, we can increase the risk of gastroenteritis. We also think it probably increases the rates of necrotizing enterocolitis when we use it in preterm babies. Um, how do you inquire about whether parents have thought about being close to or actually shaking their baby? Is this part of your routine history taking in these babies? Um, yeah, I mean, any safeguarding question is always a difficult one to broach and you kind of have to find your own kind of phrases and ways to doing it. Um Well, I just work on neonatal intensive care units nowadays. So I don't generally have to take these kind of histories in, at two in the morning anymore. But, um, you know, it's ok to ask the parents how they're coping and that's probably a nice way into it. Um, how they're coping and are they struggling? And, um, you know, do they have any thoughts, um, um, related to what's causing the crying? And, and actually, I think as with most things in medicine, we're often more scared of asking the question than the parents are of hearing it. Um And you, you know, you do sometimes have to ask difficult questions about something and, you know, asking have they had any thoughts, you know, concerning thoughts about the baby and things if you're worried, you know, sometimes you just have to ask, ask those kind of questions. Mhm. Um How common is formula milk dilution by the parents? I don't have a specific statistic in relation to how common it is. But it is a thing that is known that some parents will do if money is tight. So it's worth asking about um uh is it safe for the baby to sleep in a bouncer or rocking chair? Um It's not really safe for a young baby. The the, you know, the the safe the back to sleep campaign, the safe sleeping advice um is very clear that if they're sleeping, they should be on their back to sleep in a nice clear um uh you know, safe sleeping environment, bouncers, rocking chairs, car seats and things are not designed for, for sleeping. And so parents have to be careful about that. Um um There's a question about gripe water that I have no experience that there's no evidence for gripe water. So um I've never used it or seen any colleague prescribe it. Um How are useful to try and change formula feed for excessively growing infants? Um It's a good question like anecdotally, you know, you do hear that babies prefer one formula to the other. I'm not sure that it's ever been studied and I'm not sure how much kind of theory behind it there is if you know, we know certainly formula fed babies, they are at more risk of kind of constipation and things. So it might be that they prefer one over the other if it is causing a bit of, kind of gastrointestinal disturbance. But I don't think they've, there's probably ever been a study looking at different formula on it, but maybe an interesting thing to look into. But, um, as with most things, if it's not going to cause any harm, it's probably not, you know, if the parents wanted to try another one to see if that helped, it's not going to do any harm, is it, but might not equally do much good. Um Can probiotics contribute to constipation? Um Not as far as I'm aware. Um How long do you try PPI S for babies? Um So I would, you know, um give it, give it 2 to 3 weeks or so a month at most and, and ask them to kind of keep a symptom diary and see if there has been um uh any benefit and if not, then then stop. If there's been a partial benefit, there's quite a wide range of dosing range for kind of omeprazole from kind of 0.7 makes per kig up to kind of three M per kig. So there's quite a wide dosing range. So if there's been a little bit of benefit, you could potentially like double the dose and give it another couple of weeks and see and then stop it if, if um no benefit. And uh it's a interesting question from Steven a about in practice, I've found that a lot of baby vomits are due to being over fed. Um, and often people are being told to keep feeding the baby if they're crying. Yeah, it's a very good point, Steven, it is true that sometimes babies are getting far more than they need. Um, and typically kind of 150 to 180 mils per kilo per day should suffice for an otherwise healthy baby. So yeah, you do sometimes see babies getting kind of in excess of 200 mils per kilo. Um It's a very good point. Um The the the key thing is um the babies are some are not very good self regulators a bit like me in in the amount of food that they need and and if you offer it to them, they, they kind of will just take it and then that can obviously cause vomit some reflux and discomfort in its own way. So trying to encourage parents giving them a ballpark figure of how much their baby should be taking is useful and also encouraging them to kind of pace the feed. So um um just having little breaks within the feed to see if the baby is still going for more and then offering a bit more but not always keeping the um bottle in their mouth if some babies like the tea and they'll get very upset if you take the teeth out, but in those situations, you can kind of um, put it on its side slightly or roll the baby slightly. So the milk comes out of the tea um and seeing if the baby is still hungry and, and seeking more. But yeah, it's a really good point I didn't mention. But yeah, important that they're not getting too much as well. Um I think I probably answered that in terms of the question about what to give for colic. Um, I never recommend any of the agents to be honest because there's no evidence that they work again. Most of them, they're pretty safe, they're not going to do much harm. So I generally find parents have often gone through them all by the time they get to me anyway. Um, but maybe in primary care they're coming to you a bit earlier in the process. But, um, um, you know, all we can do is uh, based on decisions on the evidence there is and the big meta analyses have shown that, um, gripe Water infec and all of these things don't decrease symptoms. So, you know, you can only tell the parents that and then it's up to them anyway. I'm being told that's the end of the Q and A. So I think I've got through them all. Um, but I hope that's been some use to you. Perfect. That is absolutely brilliant. As I said, I will make sure that the, er, catch up hopefully for both of these events will be on tomorrow along with Andrew's slides and we will let you know about that. Your feedback form will be in your inbox and your attendance certificate will be on your profile after you've completed that. Um So thank you very much, Andrew. That was great. Lots and lots of information in a very short time, I think. Um So thank you very much. If there's any questions that haven't been answered, then we'll, I'll let, I'll let Andrew know and we can get them sorted. All right. So that's us. Goodnight everyone. Thank you very much for joining us and hopefully we'll see you at our next primary care event. Thank you. Thanks ever.