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I try over two. Yeah. Yeah, just like, yeah, that works. Ok. So um good evening everyone. Thank you so much for joining um our talk tonight. So um welcome everyone, whoever's joining still. So um we'll give it an extra two or three minutes if that's ok. Could just realize it's seven o'clock. Um And then we'll start and do introductions if that's ok. Ok. Hello? No, but I can, I can hear you through here. Yeah. Can everyone hear me? Can anyone put in the chart if they can hear me speaking? Yes. Ok. Fine, fine. Ok. So we're having a bit of technical issues with the audio on the video. So we're using two different computers. Exactly. All right. Ok. So, um I think that's probably all of us that we're waiting for. Um I'm Daniel, I'm president for a neuro this year. And um the events and education team have organized this very, very interesting talk that Mr Yan to who is a registrar, senior Registrar Aberdeen Royal Infirmary will be given to us and he'll be focusing on pediatric um neurosurgery. So I'll pass on the microphone to him. Thank you. Thank you, Dan. And Thank the society for this uh invitation today for this interesting, at least for me, interesting since I have uh interesting pediatric surgery. Anyway. So, uh, the reason when we discussed about this talk today, the reason I was thinking like, let's have a chat about the pediatric surgeries because usually it creates a lot of fear for every medical student. And to be honest with you, not just the medical students, but I think like generally physicians that they're not dealing with kids with Children, with babies, with neonates, approaching a child uh with regards to actually uh what do they have? What's, what's wrong, what do we do next? OK. My experience so far with kids is that they are the best patients. OK? They always tell you what they have, they always express what they have. OK? In a very simple and nice way, the most important and keep that in mind um for later on whatever I suspect um the majority of you might have an interest in neuro and neurosurgery neurology. But the most important thing is just observe the Children, see what they're doing and you're gonna realize a lot about what's going on with them. OK. So the other thing II was preparing this um talk today, I was thinking like to do it like more interactive. I do you know that we have you online? Uh So my question that some of the questions addressed to you. Yeah, you have the privilege here that you are, those that you are here to answer these questions most likely the remote, they can also give some answers. So let's focus on pediatric neurosurgery now. Ok. What do you think is important when you go and assess a child? What do you think it's important to think of when you go close to a child and start assessing a child and see some thought Alex build report with the child? Yeah. Exactly. Exactly. This is really important. Ok. Building report with the child is really important. The child needs, trust you trust you. Why? Because you need the child to be relaxed and start doing what usually does like playing. Ok. Otherwise it's an afraid child on the hug of mom or dad and doesn't go away from there. You're not gonna be able to see anything about this child. Ok. What else is important to understand about pediatrics? Are they gargle or non either? Yeah. Yes. Physiology, for example is different. Exactly. It's not pediatrics are not small adults. Ok. The physiology is quite different of pediatrics and this is important to understand because they have a unique characteristic. That's that uh, the Children like they have that they have a compliance to a disease, really good compliance. But rapidly they get unwell. Ok. They reach to a limit that they cannot hold anymore. They are really well and rapidly and well, keep that in mind with chi with Children. Ok, adults they gradually become unwell. Children are not like that. You'll see that one in the, I suspect might have rotator in pediatrics. You might have heard this one. Ok. Or you might have seen your physiology or from? Ok. We don't have pediatric ICU to rotate here. But, um, you might have done like some uh lectures with the consultants in pediatrics. They might have told you this one there, but the physiology is quite different. What's the normal weight of a full term baby burn? Uh like bone like today? Full term. What do you think is the normal weight? What do you think? Roughly? Let me test you from the lobe. Now, what do you think is a normal birth of a child? Mhm. Alex. All right. 3.5 kg. Ok. If a child is like um less than three you call it like low weight birth. Ok. If it is more than 3.5, more than four high. But if it is less than 1.5 it's extremely low. Ok. Is this significant? It is, it is really significant. Have you ever heard of the um um this pathology that is called like um germinal matrix hemorrhage, terminal matrix hemorrhoids like that. The neonates have e especially the preterm and the preterm is not just because they are preterm, it's because they are low birth and because they are preterm, they are like the system is less mature. Ok? And it's a hemorrhage that they develop and uh around the ventricles and this called hydrocephalus, et cetera, et cetera. Ok. So it is important, it is important to know what is the normal weight of a, of a, a full term baby? What is the normal height? Roughly Alex centimeters? You are very accurate. It is 50 centimeters. Ok. It is 50 centimeters. It is about 50 centimeters. Ok. It was of advice. Always, when you see these things, always look at the patterns. Ok? If parents of giants expect the side to be slightly bigger as well. Ok. What is the normal ofc? First of all, do we all know what OFC is? Mm. Head circumference, occipital frontal inference. OK. What is the normal OFC for a child? Guys? Roughly centimeters, roughly 35. Well done. You are very accurate, all of you. Ok. Well done, well done. That's very good. You are very accurate. Yeah, it's around 35. Ok. Can it be 38? Yes. Can it be 32? Yes. Now let's go to understand what is macrocephaly though? Ok. Who can tell me what macrocephaly might be you on the back? Yeah. What do you think macrocephaly? Mm. Take safe a big brain. OK. A big brain is the reason for macrocephaly. Ok. Big brain doesn't mean cleverness though. Ok. Good. Might be other pathology. OK. Macrocephaly is, let's say a big head. Ok. However, it macrocephaly 40 is macrocephaly 50 is microcephaly 39. Macrocephaly is considered to be every, um, ofc above two standard deviation from the normal one. Ok. Crossing like the 97 centile and above. Ok. Equally. Or this microcephaly very small, less than two standard deviations. Ok. Um Good. Why it is important to know that one? Why it's important to know about the, um, if a child is macrocephalic or not because it might be underlying condition. Ok. And the child and the baby that the newborn has on with uh um macrocephaly, OK. Or microcephaly. OK. I'm more focusing on the macrocephaly because most likely neuro center will be called on microcephaly cases rather than microcephaly cases. Ok. So microcephaly, let's say who can give me a reason for macrocephaly for a big head. A child was born, for example, um yesterday full term have micro microcephaly who's gonna gonna give me a reason why? Here again. Ok. Mary, think of your medicine, it's not something that it is completely outside like could be. All right. So, hydrocephalus is one region. OK. As we call it. Ok. The ventricles have blown up. This has pushed the um calvaria, the bones, the big, the head is bigger. Ok. What else? Hemorrhoids, hemorrhoids can cause this one. Ok. Metabolic reasons, syndromic many, many, many, many different reasons, maternal reasons, infections which all have caused some kind of deformities in the brain. And the, the uh baby is born, the neonate is born with macrocephaly equally for uh microcephaly. OK. We're not gonna go in details, this one because we need to discuss other things. Ok. So let's go slightly deep up pediatric history and examination. Ok. This is actually the topic of a discussion today and what we should focus. Ok. As I told you, the most important thing with pediatrics is observation, observation, see how the child is playing. Ok. And another let's say advice is always ask mother and father, parents ask, what do they think if the child is normal? Ok, always ask their opinion. Is the normal child. It is the child, you know? Ok, they also know very well to tell you what is normal and what is abnormal. So he sort of presenting complaint. We, we don't do something different than we do in adults in approaching. Ok. Again, it's gonna be present uh presenting complaint, history of presenting complaint, examination. It's exactly the same thing. OK. However, we have different areas that we focus and we highlight, ok, onset duration pattern, modifying factors associated with symptoms and the localization. Ok. This is a story that uh this is these elements you get them most likely from the parents. OK? A child though which is eight years old, nine years old, five years old, they're also able to tell you, they will tell you all these things with simple words. OK? They're not gonna the difference with the adults. That's why I prefer Children is adults will try also to help you with the their diagnosis. Still do not do that one. They just going to finish with this one. Go, go back playing, go away from you. So they will be really straightforward and really clear with you what's wrong. They will say short head. Ok. Uh, they will say something else like my hand or whatever. Ok. Prior baseline function, it's really important. Ok. It's really important. I will see a bit of later why it is so important because a child that has um um fully trained toilet, let's say. And now incontinent something different. OK. A child that's um was able to, let's say make sentences many with many words and now cannot, it's regression. OK. So this says something about the child about what might going on. OK. And if there is underlying inherited disease like X links and many other things that you might find from um from the history there. And metabolic disorder don't forget Children about metabolic disorders because there are a lot of there that we can discuss about uh what else might be under it. OK. Yeah. Uh that concern us. No, for us. No, we don't see many. OK. That has to do with the neurosurg metabolic disorders. Usually you see most likely uh syndromic features in syndromic patients that have syndromic. We don't see many of metabolic OK. Some polysaccharose that they might have also of course of features and everything. But generally we don't see them much usually because they don't, they will not need surgical intervention for these things. Ok. So we don't see them. Usually, usually they might see a neurologist but not neurosurgeon. Ok. Uh, equally important birth history. Ok. A good physician that deals with Children with neonate s needs to have a very good birth history. Ok. We make, when I did my fellowship in Bristol, one of the first meetings that we had with the morning meetings, handover meetings. He was a consultant and he, I was, I had a referral for a neonate and he asked me, OK, what was the after score? And I said, come on after score. Honestly, a score. It's really important. OK. But let's start with this one and the natal course. OK. What's wrong with mom? It's equally important to the stance. Like what do you expect his mom? Like taking drugs, alcohol? Ok. Did she have infection? Did she have preeclampsia? Did he had any hemorrhages during the? Uh uh so it's important to understand the antenatal course. It, it did the um you know, as a fetus did have ultrasound have all the checks that should be done. OK. So it is important to understand the antenatal course because many, many things may be related to um birth with problems. Ok. Um Imagine that um spina beef down is something that we can speak a we can speak about a bit later uh or like um all this kind of um holoprosencephaly. I'm not sure if you are aware of these things like um some kind maldevelopment of the brain. Ok. Either migration problem or uh on the development of the brain have come because for example, first trimester um was having hot tubs, OK. 10 minutes in hot tub increases the risk like of having spina bifida bite 10% I think. Yeah, overall risk of or like they didn't have folate but they need to have been folate all these things. It's really important to understand what to expect from a, from a, from a neonate or a baby? Ok. Labor delivery. Why it is important. Why do you think it's important to know about labor delivery, public presentation order? Mhm Exactly. Instruments, instruments. It's very common to call you and say, oh the we have a neonate in the unit was born three days earlier and his head has become big and you go and treat the child and most likely has cephalata. Ok? You ask why? And you realize that four section might have been used or whatever they use. Ok. So it is important for this reason, it is important to know C section, why the patient had C section. It's not the most common thing. Usually they try with vaginal delivery but this uh child was born with C section wasn't was any asphyxia, any kind of. So you need to know the, so what to expect. OK. Yes. And postnatal course like sepsis, I bilirubin. OK. Can make the might be implicated with uh post uh na so starting with, you see the, you see the baby, you see mom, OK? You see them both, how do they behave? OK. And you take, you go through this history, OK, before touching, before going close to the child. OK. It's really important to establish that one. I'm not saying on a 15 years old, which is or a 14 years old, which still considered to be in pediatric spectrum. You need to go back and check the sco OK? But usually on the age of 1415, you don't see them because of something congenital. Ok? You see them for something acquired, OK? Because you would have seen them before. It's, it's, if it's new diagnosis, usually it's not con it's a trauma, it is something else. OK? Developmental history. You don't see developmental history in adults. OK? Because you don't need to see development of mi in adults in adults. Either you have this gentleman, this lady or whatever has learning difficulties, learning disabilities. That's it. It's a fact. OK. Inter is different because they haven't yet developed all their skills and all the abilities. So you need to check developmental milestones. So every eight has its own developmental milestones. Can you see a child at um a baby at one year old? Ok. Usually not. OK. One word, two words, maximum. OK. Can you see um um a child, three years old just scrolling. No, I should have started walking by the by this age. Ok. Are they playing with other Children? At six years old? They should OK. They should socialize like that if they don't, there's another problem there. Ok. So the development of milestone, we see them as these three elements. OK. Cross motor. How are they doing with their hands? Handedness? Like usually at the age of one, between one and two, they have also pick hands. OK. Which hand they prefer, usually if you give them something with the hand, they prefer they can take it with both hands. OK? But after the age of 12 years old, they start actually be OK, vision and uh fine motor skills that they start developing after the age of two and three years old and social emotional behavior after this after the age of three years old. So it's important to say that I have a one years old that doesn't grow. I have a one years old that cannot sit on the bump. It's important to know that one. OK? Because you see, so what's might, that might mean that might say that has some weakness has hypotonia. So there might be a tumor. OK. Slow growing tumor might be something like that. OK. Yeah. OK. The delays, we classify them as mild, moderate and severe. And as I told you earlier, it's important to understand if there is a regression of the skills, OK? If there was something acquired and slowly lose this function, lose this kind of skill. Ok. Usually you see, that's when the spina bifida with toilet, as I told you, it's very common because not all the spinal bis are obvious. Ok. They might have Teor syndrome. We don't see anything on the skin, don't see anything outside, but they go at the age of five and six and they start wetting their beds again and you say like, what? And then mom, they retire to psychologist but maybe they have the third course. Ok. Mhm. Past medical and surgical history as in everyone, if they had an operations, if and what else they had family and social history. Ok. Again, and you need to see what's going on around. Ok. Why a child? Um why we might have Children with different like let's sa let's say some Children like um babies or Children or toddlers, they start speaking earlier, some later. It's about this one has to do with the social and family history as well. Ok. And also family history of disease, for example, let's play a guess again, let's say my brother has spina bifida. What is my chances? That's a younger brother to have spina bifida. Alex. 50% done. No, it's not, it's usually sporadic. But if I have, if my brother passed my chances is 6%. Ok. If we both thought and you are the third child, it's 10%. Ok. So that's what I'm saying. Like in order to what to expect. Nice let's go to the examination now. Ok. This morphology, something that you don't usually see in adults. Ok. You see it but you don't care because this has been sorted out. You know, the diagnosis in Children, you need to make the diagnosis. Ok. What do you think? This? Very nice toddler husband sounds, sounds ok. So my things down. Yeah, the eyes, the ears. Exactly. Exactly. That's the, that's the multiple things that you say like where is the ears? Ok. The level of the ears, the low up, OK. Where is the level of the ears? The eye is like the um um the eyelids? Ok. Something you can understand that the child has um dysmorphology in uh neurosurgery in pediatrics. We don't know many of the syndromes that pediatrics have. However, do you know what we do as he did we say? Ok, has dysmorphic features. So I'm heading towards genetics. So I'm heading towards diagnosis that has to do with some inherited or some kind chromosoma. So I need to ask from pediatrics to have a look on genetics for this child. OK. What is wrong there? Alex. What do you see this style has morphology, it morphology. But what exactly you think? OK. Just describe what you, you what you see. Mhm Maybe. Mhm Exactly. Exactly. Exactly. This is the best way to describe. OK. Despite that you don't know what the baby has, you understand that there is this morphology there? OK. OK. What this baby has, it's called PFER syndrome. Ok. There's only one in Scotland. It's quite rare or 21 or two in Scotland and the whole, um, in Scotland. I'm not sure how many there might be in the UK. But pfizer Pfeiffer syndrome. Ok. This is not a child. This is from the, this, uh, picture. Ok. Uh, but they have like, um, why we know about these syndromes, like, uh, has surgery because they have synostosis in these cases. Ok. They might have hydrocephalus cases. Um but mainly they have synostosis and usually they might have some kind of instability in the uh in scoliosis. OK. What else we see dysmorphology? OK. Then stigmata. What is that? What do you think it is? Mhm OK. OK. Uh No clue. Done. Cafe sports, well done. Do you know any of your mother? Give it a go. I heard of the, exactly. It's the most important thing as medical students to start with. It's very good. This is spots. OK. This is cafe sports. There are the Aleve sports. Generally when you examine a child, you look for this one, you look how the skin is. If it is like hyperpigmentation, if it is more white. OK. Look for stigmata always, that's why I'm saying like it's really important regardless why you have been called for a child. OK. We always undress the child and we examine everything, especially when we call the neonates. OK. Then say that the child is hydrocephalic. Yes, we'll see the head but we start and see everything. Ok. All right. Here it says what it is. But it's just to point out that when we examine a child and, um, in a neonate or a baby, usually a baby because the child they, they have seen already these things we try to find if there is any of these things there also. Ok. This is a bath of hair. Ok. This is lipoma and this is hemangioma. Might be altogether, might be one of these might be none of these but might be to get it as well. Ok. Why it is important because this one always shows underlying condition. Does anyone have a clue why, why is with CNS problems go back to limb? Mhm. Exactly. Exactly. Skin and CNS that are coming from the same uh OK. From the, from the E OK. That's why we have, um, that's, that's why um, cafe sports. Which condition do you know it's related to cafe sports? Sure. For the, I'm not sure if the uh has a spot but it might have, it might have, but I don't know it, which more common and if one, yeah. And if one uh has this kind of, it's actually one of the landmarks like the, the, one of the cardinal features that, and one of the criteria also for diagnosis. OK. Is the, but not one of the criteria um for NF one. OK. NF one is not that uncommon. Ok. NF one is one up to 3000 cases. It's not that uncommon. Um, let's go to this one here. That's more interesting. The dimple, the dim, the dim my is actually communication all the way down to the spine. Ok. You see on the skin, it doesn't look like very suspicious, but this goes all the way into the spinal canal usually. Ok. It can be in this area, it can be elsewhere. What is the common you haven't seen for a chil, for a child? For a baby. Usually if a baby comes like with Ricard meningitis, look for might be in the hair. Usually it's in the middle line. It can be everywhere in the middle line. Ok? But look in the hair, it might be somewhere in the hair. You don't cannot see it. That's why they have meningitis. I remember a case when I was in Greece. It was actually in the pharynx. It had this dimple there. Ok. So regarded meningitis, they couldn't find it and they didn't go to find this one. So they found it there. That's why they get meningitis. It's very common for meningitis. Last one. Keep in mind if you heard the story about like a child that has meningitis without any obvious vision, this is the vision most likely. Ok? Head size and shape, ok. The number one thing that we think in the they call us, it's the most common thing that they're gonna call for neurosurgeons, head side and shape. What do you see one check? Obviously? Tell me what else you see? All right, I see a lot of superficial, superficial vascular. What is that? Exactly. Exactly. Permanent veins. Mhm. A big head and eyes. Why the eyes are like that? No one is like that. Mm. Her, what is the sign? How is the sign is called? I would say. Mm. He has a name. How's the sign called? Mm. No, it's 1200. That one Alex graduate college. No, no. Have you ever heard of the I'll I'll tell you how you might have heard it as a sunsetting. I All right. Sounds very familiar. Sunsetting eyes. The official name is Syndrome. Ok. The official is called Syndrome. Ok. It's down, it's up ga palsy. Ok. However, on top of the up gaze palsy, they have also what's called col sign. Have you heard the collar sign? Collar sign is the retraction of the eyelids back? Ok. So that's why they look like that. It's because the leads are also retracted back and they have a palsy, they cannot turn the, the air and this is from the compression of the brace, the mass DS more specifically on the MN from the tech and forget why, forget it's not for now. But what is the fact that the because we discuss about that the the there are two more elements since we discuss about it. It it the uh later back. What is the other one? Light dissociation? All right, you cast, you put a, a light here, they have very, they don't have response to the light, but when you bring it close, the pupil retract, OK. This has to do with, with part of the uh ML is compressed and the last one is what I'm gonna say it and you're gonna forget it. It's called convergence. OK. By the time you bring something here, the eye to this one, OK? For these are the four, but I put that one just to see once in your life. If you don't work in, in the pit, what is the Sunsetting ice? Sunsetting ice is very obvious. OK. It's not something that now it doesn't do later if a child has on setting eyes is this one? You don't need to have this Hydrocephalus to do to have sunsetting eyes. OK? But let's go back to yes, big head. Usually we don't see that much, but this is a big head and prominent vessels. Yes, you're right. You, you will see prominent scalp vessels OK? From the compression there. Look at um on the top, you can see my mouth now that this works. No. What is that there? This is where the fontanel is OK? The anterior fontanel, OK? Actually, the anterior fontanel is this bump here. OK. So it's important when you see the head. A part of it is big. OK? You palpate the Fontanel. How many Fontanels do we have? Alex? Yeah, continue, continue. We gotta have three. So we have the anterior which is the last to close, almost the last to close up to 18 months. Ok. Usually between 1218 months. Ok. We have the posterior the first to close. Ok. Usually three months, six months, it's closing and then we have uh with you in the area and to the on the above the mastoid, OK, that they close about 12 months, 1213 months. But for us, we are so happy when the child has Fontanel. Open Fontanel because we can see everything we can see the hydrocephalus from there. Ok. Also the child is protected to it to an extent means that still there is area that decompresses a bit hydrocephalus. OK. We can use the Fontanel for ultrasound the best way it's like looking at the CT scan. It's very good. Ok, especially this Fontanel here, which is gonna be huge. Honestly, you can uh you can tap CSF from there. You can use it for uh yeah, ultrasound. It's really good that they have open fontanels by that at a specific age. It's OK because you can deal with cephalus by far easier. Ok. Who's gonna tell me what we see there? Is it a normal one some more, it's more elongated. Exactly. It's more elongated. Why do you think it's elongated that to birth? No, it's quite older than this one. It's not a neonate that one. This is a baby d what do you think? Physicians? It, it position now it pressures, right? So your child, yeah. But you see, it's very symmetrical to be positioned on that one. It's elongated. OK. It's elongated. How does anyone know how this, this is called scaphocephaly? Ok. So it's a type of synostosis? Ok. Um What type of synostosis? It's the sagittal sinus. It's the most common synostosis. Ok. Um And why it is that? OK. Because the theory says when the child has open like sutures and the um the um growing of the skull is happening perpendicular, let's say to the sutures in every way. OK. So that's why you have a normalcy when this one is fused. The there is where the uh um prematurely fused. OK. Because this is prematurely fused. So the growing of the skull is happening back and forth. OK. So that's why it takes the same. What is that? What do you think it is? It's a manifestation of, is it the frontal fine once without his sticks? No, that's his sticks actually. What do you see exactly? What is that? What is that? Do we have a suture? Here? We have one, it's called metopic and it's prematurely closed. It's the one that closed. So it creates this kind of trig because it's the same triangle. OK. The three things. What is that done previous, obviously? Yeah. OK. My name is mm I see. So what you see, just tell me what you see. So you can see the change so you can see in the eyes. So it feels like when you there is a way there is a reason we look at the pictures like that. This is how we check the childs as well. Exactly like that. We put them like that and we look at them. OK? So tell me just describe what you see. What is this forehead? Does? What is this one? What the do, what the back of the head does? Oh It's not let side of what they would do. Yeah, I, so this one or this one, this one, this one. Yeah. Mhm So what is the normal, what, what is the abnormal? You think? What is the abnormality? It's very difficult, it's the most difficult synostosis. OK. I will give that to you. It's the most difficult synostosis or one of the most difficult synostosis. So this is pleiocephalus is called OK. Ple means lateral. OK. Pleiocephalus. What is the problem? Yeah. So what we said they don't, they don't extend perpendicular to the suture that is fused. OK. So this has gone extended here, extended here, but the extension has stop on this side in a way. OK. So this creates a safe and we'll have a paper here. Mhm This creates a say not parallel gram as it is on the other types of positional, for example, plate. OK. So what you need to see because this is the most important thing that the most commonly parents bring your Children with flattening this one as it is here. And they ask you, is it kind of synostosis or is it because I have the baby in the bed sleeping on this side all the time? So what you, what you need to see is where the ears are and the frontal buring is. And actually what say you use this one. This is a trapez, let's say, OK, when it is positional, a normal one, just because the child is sleeping on this side only is parallel. So you're gonna see a shape like that and the ears is going anteriorly. You do see many pictures of the time this one it comes the faces exams and people still making wrong for this 10 It's really difficult but you need to see a lot of things in order to understand it better. This is for fusion of the lambda in suture. OK? Not very common, but it it does. And what is the last one? What is that? Sorry? I feel like you can see more of the lower half of the face forehead, you can say like that, but this diameter is big. OK? This is the opposite of that one and this is from corona suture, synostosis. OK. This is called brachycephaly. OK? We have, we use the cephalic index which is a number. It's actually if you divide this to the occipital, frontal, frontal occipital uh dia diameters and multiply by 100. It gives you a number. The normal values is between 74 and 83. This is above 83 it's 84 and above, this is below 73. It's a cephalic index as we call it. OK. What it is important to not to have car nostos. Why did they come to us these cases? What is the problem? Why do we care about the bone have been fused early prematurely? Why do we care that thing exactly for the brain? OK. For the brain to develop? Ok. First of all, second of all, they might be related with, OK. OK. Um Up on a lot of cases with kind of nostos also, they might be related with anomalies in the eyes. OK? Because by the time that it's not that this one is uh um has been used, the problem is that even the eye gets different shape, they get screened, they get other problems. Ok. So all these apart from the cosmetic, because in some cases, you might do just for the cosmetic, for the co for cosmesis because they might be a normal child and they might bring you this child after being like already two years old, which means that they have developed, they're fine. Ok? Not necessarily all side will be syndromic and delayed or whatever. OK. You might do for, for cosmesis, that one. But if they bring it early and usually the uh the um suggestion is for operation between six and 99 months. OK. Why between six and nine months? Why not earlier? What does circulate in blood for a child? How much blood circulates in the child? About three months old? Roughly let's say how, how, how many kilos is a child? Three years old? Mm might be 9 kg, say 89 kg. So how much circulating volume they might have? Roughly how much is it like per kilo in adults in adults? It's between 70 mg per uh per kilo. OK, I say it right. Yes, I said it right about 70 in neonates and in two in the babies is about 8090. OK? And the infants are just born might be 100. OK? But let's say it's about 80. So is about 700 ml of blood circulating blood and there are these operations are quite bleeding operations. OK? So you cannot put like in this kind of high risk of complications. OK? It's hard. They say that's why we say 6 to 9 or a year. OK? And you would say also 6 to 9 because we want to prevent from having problems in the future. OK? That's why we need to allow the brain to expand normally good coma scale. This is where the party starts. OK? For everyone, for everyone. This one. OK. That's I want to be fair. Even for neuro centers, we revise this one. Before we state. What is the, the uh G CS for a child? Ok. It's not easy. It's not easy. And if we want to be more like, let's say, um more accurate, it's quite different for neonates or less than uh or babies, less than one years old and different for one years old and above. Ok. But here for simplicity, we have put them together. OK. Ice, how did you break it down? I, we haven't done a gcs in the first year yet. I can tell you OK. Eyes. Yes. Mhm Still pain. Say you, you, you squeeze someone to open the eyes again. No response. OK. Eyes is exactly as it is in adults. OK. Motor score. What do you think? Is it the same? It's exactly the same, the different. That's why we say normal spontaneous in adults. You're not gonna observe the adult, you're gonna ask to do movements. OK? However, if you observe that, that spontaneous movement, you are again happy. OK? Or colitis, the pain flexion with withdrawal or abnormal fraction, abnormal extension extension. Actually, it's not abnormal and our response and now we're the big, big difference. He is the response. OK? That's the only big difference. They have alert, bubble goose speech, the usual ability. OK? So that's whatever is usually done like um at this age as mom says, OK, we uh before is when the child cries but it can settle down. OK? And otherwise fine then cries the pain, not easily controllable. And in appropriate words, if they have also gained ability to speak mon to pain, crs, agitated, incomprehensible sounds, usually they're very unwell. You see them, even with the painful stimulated, they don't, they might not even cry. Ok. Which is very abnormal for a child. Very abnormal for a baby, not even to cry and none. Ok. No response. That's the only difference. So it's not very big deal compared to the adults as if you know, if you be are able to remember that this one that's um the five is a normal reaction for the eight. OK. Bubble goes I would say for the babies uh or I say mama tada or before it cries but you can set, it can settle down. OK? Then cries, not set down and then not even crying. OK? Make sounds but doesn't cry. OK? And um and for intubated child, OK. Yeah, we are what else we examine in child in Children, in babies, usually in to and toddlers. OK? But usually in babies, primitive reflexes. I just put like for example, OK. Of Primitive model asymmetric to do you know any of these? Mhm Good. So why it is important to know that one? Because all these primitive reflexes are the words that primitive and they should regress. OK? Because the our nervous system is getting mature throughout after birth and takes actually months in order to get the adult, let's say uh mature myelinated nervous system. Ok. So that's why they have primitive reflexes because there is no maturity yet yet on the uh nervous system. That's why when everything goes nicely and everything goes smoothly, all of these needs to disappear at some point. Ok. Uh Palmar grasp reflex. Where did you see this one in adults? Actually, you can see um the ring as well in adults. You can see uh and some others that I haven't mentioned there. Where do you see them in adults? This reflexes? Mm. No, no, because Planar and uh uh Planar and a grasp reflex is you put your finger like in the child's uh palm and they squeeze it. Ok? Or like on the sole of the foot and they, yeah, flex their toes. So where do you see that in adults? Do you see it in others you think? Mm. Not going very well. Yeah. You see them, they, they are reflexes that come on when they have significant brain injury. You see them in elderly that. Ok. And um usually it's a when you examine the frontal lobe and you wanna make sure that everything is fine and you have done a perfect examination of the frontal lobe, you examine from reflexes because they will, they might come back on the surface if there is abnormality. Ok. So that's why you have heard, oh my dad before he died, he was squeezing my fingers. He was holding my hand. No, your dad actually had primitive reflexes. But you cannot say this one. Ok. Your dad's squeezing your finger but your dad had all right. Yeah. Slightly cruel. But, ok. Can your nerves, can you examine, can nerves in Children in babies? Mm. Yes and no. Is the answer? Ok. The answer is yes and no, not all of them. Try to examine olfactory. No way. No way. You cannot, you cannot, they're not gonna stay with you unless they're 89, 10 years old. And they are very familiar with you and they can closure and you can ask them. Oh, what's that? It's bubble gum. OK. All right. But generally it's very difficult to examine cranial nerves. OK? You can examine pupils, OK? They might let you do fundoscopy if they know you well. And if you have proven to them you have played with the uh that's the most important thing, especially when you start the examination play, play, you need to play with the, with the child colors, lights play. It's a game for the Children. OK? Otherwise you don't go close if you don't start playing with them. OK. So in order to examine like pupils, you will examine, they might tolerate some fundoscopy if, if they are you have, if they, they trust you that you're not gonna hurt them. OK? Definitely not visual fields that you cannot examine your vision child, but you cannot communicate. Yes, because by the time you do this one, they do this one and they do that one, they do that, that's the, the same thing. OK. It's very difficult to examine. Uh this one. He has visual acuity there. Specific charts. OK. There's not a chart for P for Children that they have the boats, they have the symbol system of letters. OK? And 3rd, 4th and 6th, in order to examine in Children just play and usually what they like a lot is either like very bright colors or sounds OK? Because by the time you start cleaning your keys, for example, and they tend the head means that the 78 complex works. OK? Also the ran and start working. They're not gonna say I have diplopia, but you're gonna see movement in the eyes, you're gonna see like some symmetrical movement in the eyes. OK? Also, uh five, in order to examine five, again, you see grimacing, you can Yeah. So, uh some pressure, see if they take the hand away from, from their face means that they have this 17. OK? And as I told you, sounds do some sounds, they turn their head around to listen to where this is coming from. God reflex 910, you have it there. OK? And the hypoglossal if it is neonate, just stick your finger, they start playing with the, with, with the tongue around you. So you can appreciate movement of the tongue there. If they're older, they find like they do Cres find faces. So it's the most accurate thing because all the funny faces come with out left, right or whatever. Ok. This is how you examine nerves. Yes, infection not, but all the others you might get very good information. Ok. Motor examination again, it's a game you play with your child. You see, you try to pass toys from hand to hand. See if they're both hands, like if a child is one years old or two years old and you see that one hand is done, you give toys and always do that one. Look for this hand specifically what's going on. They don't move this hand. OK? See them how they stand up from the floor, how they run around. OK? If they can run around, see for hypotonia in neonates, it's even nicer because in neonates because they cannot move away from you. So there you see, actually you test the tone, OK? You squeeze them, you drag them, they pull the, the legs back. It's really nice to understand like what is normal tone? What is hypotonia? What is hypertonia there and uh how they move the uh sensual examination. This is the most difficult examination in Children. OK. So you're not gonna get any feedback if there is reduced or not reduced. OK? Because painful stimulate, what are you gonna do in a child? You're gonna pinch the child. No, you're not gonna do it easily. Yes, you pinch once, then it's gonna come to you again. For the second one, ok? If you go with a pin, they're not gonna come again next to you to check the other, the other side or the next side. So it's very, very difficult and this is where you need to build to uh with the report with the child before you do anything. It's the most difficult but you need to use, you touch them, you see their face if they understand if they feel, ok, especially with the non verbal, with the verbal, they might tell you a few things. But the out of every other examination, this is the most difficult examination, the century. Ok. You know, before we close, I just brought in one case. What do you see you? What is it? Good stuff. Is it uh x rays? Uh I think, I mean, it could be an X ray. It's not, it's a CT CT. Ok. It is a CT scan of a, how do I know what to do? Child? How old is the child? How do I know that it is a child, child? What is a neonate? S is not exactly you see this uh I that this sutures? Ok. Haven't been fused. OK. It's not the best because we have lights on. But can you see anything weird there, done? Thank you. Ok. Yeah. Yeah. Yeah. Good thing. This one and ideas, the only thing that stands out to me is that sort of sort of white or gray? Bit at the back and there's a slight gray speck in the top. Right. But that's all, I mean, right here. Yeah. This is the left side of the head. Ok. Yeah. Top. Right, as you said. Yeah. Yeah. No, no, you are totally right. You're totally right. Ok. What is it? What do you think it is? What's the speck of brightness outside the brain outside? This is outside the brain. Yeah. No, it's hemorrhage in, in old heaven. This is a on a child. How can a child have chronic s the only reason I brought this one is to discuss about what is that? Alex broke femur, broken femur. Is this a baby? An adult? It's a, it's a baby how a baby has a broken femur? Oh, usually abuse like if it is, if it, if that child has not been extricated from a significant heart crash, something is wrong there. Ok? Because this child is not skating, he's not doing any skating, he's not doing skiing, he's not walking and he has a broken femur. Ok. Yes, it is important. It is really important. One of the things that they always call us for us is for trauma. Ok? It is important to understand that Children are abuse. Ok? And you don't get based on the parents look fine. The parents looks well, the family is nice. Ok? There's no such a thing. If you have concerns that something is wrong, you need to report OK. Chronic in Children, no way there is abuse there. It's multiple times that this child has bleed microbleeds the brain and usually it's baby syndrome, we call it, ok. They save the baby some rupture of the bridge veins, small, bleed, small, bleed color, subur ok. Other signs that your child might suggest that there is a problem. One is the one, ok? They call us or for us it's not that one because usually in order this one come for a scan, usually the time might be drowsy. Ok? And be in, in A&E or in the they get a committee to be investigated. They don't find anything because the scan, they find this one. Ok? Because there is no history of trauma. No one will report history of trauma unless there are other features. But usually they don't report history of trauma. Can you see this one without history of trauma? All right. So what other features do you think he might be there? Conflict stories from the family? Ok. Someone this, this the history of what they say when they bring with an injury or not? Just necessarily this one? It's yesterday he was playing and he fell from, I don't know if in the chair or father says this morning this happened something is wrong there or they come from Doctor Grace. Different story. Doctor Grace, different story here. Not consistent. OK? One is this one, second one, uh fractures in an age. That's they don't walk or they haven't reached the developmental milestones to acquire these type of injuries. Ok. Or fractures of different age. Because one of the things that we do as a protocol when we have concerns is we do fundoscopy, retinal hemorrhages. Second, is it to retinal hemorrhage? And we do skeletal survey. So you see rib fractures, different age, rib fractures. OK? Or um bone fractures, you see bruises in non bone prominent areas and non mobile Children. How can I I know Children like to have a bruise here and not here. Ok. Here they can have. Ok. Here they have but right here. Ok? Or bruises in the pattern or in a uniform or be number one. Ok? 35% especially in genitalia, you can see that one, ok? Um or bench with a specific mark like lighters, ok? All these should raise suspicion to protect the child, ok? And they are like the specific safeguarding team that you raise your concerns and they do the whole investigation. Ok? And of course everything. So it's really important, really important when you see a child, especially with trauma or weird trauma um or multiple attendances with trauma, you need to raise concerns, ok? Regardless of um your level of training, regardless of what you think if you have consents, you need to speak with the pediatric consultant and report the safeguard. Ok. Questions sensitive Lexa Biscay sensitized. I got distracted for a second. I got distracted for a second. I didn't check the shot when they were participating. No more. No other questions to good, no questions. I mean, what was the hardest case for you, like, uh, safeguarding? Have you had to raise any Ari, uh, I'll tell you what, uh, I have worked like in Bristol and in, um, in Greece, in two big pediatric hospitals. Ok. Both cases. They are very, very, very, um, uh, good teams in A&E and they pick this up real easily. Ok. Nothing can escape from them. And there was never, there was even the slightest concern a nurse can have, this will be investigated. Ok. Uh, with this creation with everything. Ok. We don't accuse the family. Ok. Straightforward of what you abusing the child here but it's quickly and everything. And believe me, if the family has is the best family and they haven't done anything. They do understand it. They do respect that one. If you have consents, they will say yes, please do whatever you like because occasionally, maybe one neighbor doesn't know. Keep that in mind. Usually they both know. Usually the possible, maybe me family member occasionally doesn't know because they might have come for, sometimes you never know. Ok. Uh, usually they pick it up. So, but as a physician, if you get called for this one, you need to say something. Ok. But if you see this one, it's quite straightforward. It's quite put on your child. You don't even need to discuss it, it goes straight forward for investigation that, but it's good to ask every time they call me here and they say we have a child with a skull fracture or whatever. I always ask this question. Do you have safeguarding? Because I have seen the child in A&E here always, I always ask. OK. And it's good to, to ask because it's about the well being of the talent, whatever questions. What's the most common type of procedure that we do in pediatrics? The pediatric is the most common we we'll do here. We don't do many here because with uh there's no pediatric ICU. So since after 2014, the service for pediatrics, the elective service was uh in the tumors got stopped. So here we do trauma if you have acute cases and uh hyphal, whatever it is acute here, ok? If it needs to be treated like surgically here, but there's no time to be transfer, they will be out here. So you don't do much pediatric epilepsy than here. No, no epi epilepsy specifically is, is organized in a few centers uh throughout the country. OK? It just not in Scotland. They do like in um they have the service in Engram, ok. Mister one of the accident uh surgeons who does epilepsy and uh then there are only a few centers in uh in England. The one is in Bristol but the chance to be there or street. Yeah, it's really amazing what they do with epilepsy. It is really amazing if you have interest in epilepsy, it's really, really good field that you can subspecialise later on and very nice operations. Very nice anatomical operations. Yeah, I it's not nice to speak like that because the child has refractory epilepsy. But if you see technically, if you have interest in the surgery, they're real nice patients and demanding, quite demanding. A few of those are quite demanding. Anything else? Good. Thank you. Thank you, Dan. Thank you so much. Thank you for everyone organizing this. Um You got a good team chasing up the phone and getting this organized. So thank you all. Yeah, and um thank you Alex for the invitation and uh and yeah, we can organize something in the future as well like uh for a few months, a couple of months if you would like. And I mean, like we can because I know that for uh my other colleagues, I know that um Jamie Low has interesting uh hemorrhages and family hemorrhages like uh has interest in spine. We can do like a, a more extended session if you like, think of it. Yeah. Ok. We are available. We are not available here. All right, good. Thank you. Uh Thank you all for joining. I think there will be certificates that will be sending for the ones attending. Um, and you should be receiving those either. So just certificates. Ok. Uh Any questions before we leave from the chart. No. Mhm. Ok. So I think that'll probably be the end. Thank you for attending and um wishing you a lovely evening. Thank you for some of you guys like, yes, it's a bit of a niche question.