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On leave. Yeah. Ok, so good evening, everyone. Um And welcome to the final part of our neonatal themed week. Apologies for the slight delay in us getting started. Um I am joined this evening by Doctor Connor o'neill from the Royal Manchester Children's Hospital who will be taking us all through neonatal sepsis. Uh Over to you, Dr Neil. Thanks James. Um our doctor mcintosh, uh apologies on the delay as well. That was entirely my fault. Uh my per technical skills. Um So hello to uh whoever is listening um as uh James said, I'm Connor. I'm one of uh I'm a pediatric, truly sorry in the Northwest. Um And uh today I'm here to talk to you about neonatal sepsis. I think that a few of you have had may have been listening to some of the other talks this week. So hopefully today's will be of interest to you. Um So to start with um what is neonatal sepsis? Um does I was planning to this interactively? But I think this may be difficult if, if there is people in the chart. So, um well, I'll go through the first slide at least and then see if there is any takers for next question. So um the first bit neonatal sepsis click on is refers to an infection in the bloodstream in a baby, less than 28 days old. So important to differentiate um just because yeah, less than 28 days old, but obviously, um it's divided into early and late onset forms and and this differs by the mode of acquisition and therefore the time of onset. So um what we will, we'll see both of them quite frequently in practice, clinical practice. Um But the one that will see almost uh on the postnatal ward particularly, and the one that you'll see more of will be suspected early onset sepsis. Um So, the theoretical on the physiological basis of that is um is vertical bacterial transmission from the mother during the perinatal period. Um So, and definitely the bacteria can reach via from the vagina into the uterus or through the blood into the center. Um That is off, it's good to sort of keep that physiology and anatomy even in mind just whenever you're trying to think, well, we'll talk about more about this in the future in the next few slides, but in terms of the risks for potential infection, um and why we treat and how we treat. Um but, and then late onset sepsis, um by contrast tends to be a result from postnatal environmental exposure to bacteria. Um So some places I've worked, I mean, both in the literature and in clinical practice, um it'll differ based on where people, where people will count things is early onset sepsis in late onset sepsis. And the differentiation for this. And I'll just touched on this briefly, will not go too far into it. But differentiation for this mostly lies in the fact that it can be different practice within what clinical setting urine. So for example, if your baby that's been in the neonatal ICU for, if you've been, if you're a preterm baby, that's been there for say two weeks and then you pick up an infection at that point and then that will be deemed um late onset sepsis similarly, uh will be treated with certain types of antibiotics. On the other hand, if you're a baby that comes in at four days old, um to any having been discharged at six hours of life, um then you will almost certainly be treated uh for uh well query sepsis in almost all cases, no matter what the cause is in clinical practice, but you then will um the different antibiotic types may be used. Um So it can defer even based on different, I work in different units that they'll change. Will the types of antibiotics. Also, the timing's so don't get too bogged down and I'll just be aware that there's a difference in the antibiotics used are different. So it's important to be aware of that. Um So next slide, please. Um So um the associate pathogens, as I said, two. Again, that's one of the other things who, and, and the reason why we give you antibiotics, obviously, we should probable to think about the reason why we give different uh antibiotics is because different pathogens are more likely to be uh uh the calls. So there are, there are obviously similarities here, but the main things we think about with early onset sepsis are the top two, some G group B strep gps more colloquially known or equally. So, they are the two that we see a lot of um in in clinical practice when you do see um positive blood cultures, um you can, you know, going further down the early onset sepsis side and they're the ones that you see probably less regularly. But you may see the all time if you worked in NICU a fair bit and then on the right hand side is the right answer, septus, um pathogens. So, um as I said, there are a bit different um and tend to be more related to, for example, stuff, staph aureus, um enterococcus car Oculus negative staff, they can be often do too late on to Texas can they can be often due to, for example, in babies that have been in NICU for a prolonged period. Um things like line infections, things like things that are more common um in that type of nature. Um And then the, yeah, so that, that's the main differentiation to get your head around. Obviously, um we'll keep this very basic today, but um just to be aware that there's a difference there. So next slide, please. So why is neonatal sepsis important? Um So the next bit will say that in 2015, um a study identified neonatal sepsis as the third most common cause of newborn mortality. Um And the 16th greatest contributor, two years of lost life across all age groups. Uh the sepsis case rate for case fatality rate is 2% 20% in term infants, 20% in premature and 30% in those with associated the meningitis. Um It's important to say that that's for people or that's for babies and infants that have been had proven true sepsis. Um So in clinical practice, you'll hear a lot. If you ever do work in NICU or even in pediatrics, you'll hear a lot of quote unquote suspected sepsis. And so you'll see a lot of babies are treated for sepsis, but these cases just not terrify use. These cases are about babies that have been shown to have proven sepsis. Um So it's probably equivalent, I mean, I can't be, I'm not sure if the Abbott figures, but you know, if, if I don't have shown to be truly septic, then I guess, imagine the fatality rates may be in the same ballpark. And, and the other thing I would just say to keep in mind is the needle sepsis can be associated with multiple forms of develop developmental delays. We've all heard about that, you know, kids with MS meningitis and whatnot. Um And so obviously, if there has been uh an insult to the brain through infection, then you would expect there then to be, especially whenever the brains in such a an immature form, there would be, you can often be um associated neurological delay. And so, and that's a note for going into the future. So if a child does have, even with that few, even if there is no neurological sequelae when they're an infant or sorry, a baby in the neonatal unit and they've had proven blood culture positive sepsis. Um and have there a few weeks of IV antibiotics, then they will need follow up from uh a new nail consultant will follow up in clinic just to see how they're getting on developmentally. So, next slide how or why is it missed, missed. So, um this is uh being of every neonatologist, uh wife and pediatrician. Um And anyone that works with Children and babies ever really. Um So um what we even whenever I started with in pediatrics, I must be on, I'll be completely honest and say that this is the one thing that I found really difficult um neonatal medicines extremely different to adult medicine. So the way I always sort of whenever I speak to anyone that's doing NICU and finding it difficult, particularly the start, I always say is it's a real gear shift in your mentality in terms of how you think about things. So a lot of the time in adults, we're trained to try to exclude things and then treat accordingly and treat rationally um using clinical skills, which obviously makes sense. But with NICU, it can often feel like you're doing the opposite. And the reason for that is because um they don't present in the same way. And so as with babies, they'll um their initial. So the signs of potential sepsis maybe are very variable and can be extremely subtle. Um So the risk factors, of course, the correlated risk factors can be extremely weak as well. So around set sepsis looks often like uh the normal postnatal transitioned from uh yeah into the extrauterine environment. So, um for example, it's extremely common to see um if any of you will do an echo placement, then you will see baby's born with some increased work of breathing. It's extremely common to see some recessions. They'll often, especially if they've been post resection. There's a common condition called transient. Technically, technically, if the newborn um that you may have been spoken to about in one of these other sessions and it's can be extremely difficult to differentiate between that and potential sepsis in the, in the initial uh a few hours. Um Again, certain places will do that differently. Um in terms of how we will treat that, some places will go full hog to get at the get go and just start antibiotics immediately and other places will sort of hold off a bit until there's a bit more of a clinical suspicion. Um But again, the fact that we do that is, it means that there is a fair bit of variation across the country and across the water leaving, um, conditions rely on cereal observation. So, and risk factors as a result to try to uh to treat things. So instead of, you know, speaking to an adult patient and ask, asking how they've been and asking their symptoms and their signs and the usual typical history that we ask to go through things in terms of identifying diagnosing and managing with neon. It's obviously, we don't really do that and the history sort of comes a lot more from things like risk factors. Um So as I said here, the study um in a study of 240 newborns with first factors for sepsis, only two of the 12 patient's with true blood culture positive, presented with signs and symptoms of sepsis where the remaining 10 were asymptomatic, highlighting the challenge of identifying infected new units. Um So which sounds again terrifying, but it's not in the sense that remember that those 10 will have been picked up by risk factors alone. And I guess that study is just highlighting that the why we take the approach in uh new nail medicine that we do in terms of screening and treating babies. Um, again, I think a lot of we've had that we have F two has come through our level three unit where I've just worked and I think some people sometimes can think, why are we doing all this? I mean, clearly these babies are fine but actually, you know, thinking, making sure people are sign posted towards these types of studies important. So we do understand even a medical student level or an F one F two level that um it is different medicine. It's not your sort of you're trying to find infections rather than waiting for them to come to you and treating. Um So even though 95% are diagnosed in the 1st 48 hours after birth, sepsis can still be missed. Um On the other hand, over treatment is now being seen in some areas. And actually, you know, if anything, I know I've sort of given this big defense of treating, treating, treating, but actually I'm definitely more on the Hawkish end and try. Uh and yeah, you'll, you'll need a, if you ever go into pediatric, you made a huge range of um you know, otologist and some people. Some yeah, and some units are and I working units that are extremely well screen screening, treated at very low levels and somewhat will be much more uh liberal, but we'll get onto that a second. So next slide, please. So what should I be looking for? So, these are the main types of things you look for. Again, they're really dissimilar to what you'd be usually expecting levels. And, and again, the difficulty with neonatal is is that none of these things are extremely specific. Um So again, a lot of these types of signs can be found, both are normal findings within the extra to write if in the transition into the extra around environment. So after birth, um so it's extremely common for babies to have mild tech be a mild nasal flaring a bit of grunt thing. Um They, you may or may not know physiology but you know, when babies come out after having, if they've been a C section, for example, um they haven't had the chance to push the fluid out of their lungs have been, that's been in there since birth. So, um or sorry, that's been in there during the, in the, in the room throughout pregnancy. Um And so if they haven't had the chance to go through the canal to push that fluid out, then what can often they're just yanked out. And so that's why that TTN can be really, is really common. But again, it can be really difficult to tell between what's a congenital pneumonia and what's not. But so yeah, just close observation, other things, tachycardia, hypertension mean tachycardia is very common again, just but mild. Again, these things are within, you know, it's all about relativity. So if it's, you know, very high, then obviously be a bit more concerned and persistent or if it's high whenever they're not crying. And that's a big, that would be a more worrying sign, delayed cap refill. Again, you'd be a bit more, can you probably keep an eye on it? More and diminished pulses would be a bit stranger. Um And you'd be thinking more along the cardiac lines you call if that was me. But again, these things are all just any babies can present with um and can be within the range of normal. So we decreased feeding. All babies in the 1st 24 hours of life have ups and downs with the feeding and it can be very difficult and that also can depend on mom and how moms getting on with how able she is. Um things like irritability and temperature instability, bulging fontanel, they're all really important to look out for obviously apneas, you'd be a bit more concerned about. Um John this again, this is some of the risk factors that are well come on to this in a minute. But part of the national guidelines and then things like new onset rash, physicals, erythema, swelling around joints, model skin. So I know on paper, all of those. Look, I get you, you think of course, you know, of course, I'll be worried. But actually in reality, when you do go into Nick, you quite a lot of those actually would say the majority of those can even be within the range of a normal big babies transition. Um So all, almost all babies will get some degree of jaundice in the first few days of life, even rashes, there's a rash called everything the toxic. Um that is extremely common and I advised looking it up because it looks terrifying the first time you see it, but actually is completely normal. And so just to keep an eye on and keep your mind on those types of things, but um just to be aware that it can be, it's a really gray area when you're first starting out just clinical more experiences when you sort of get your head around it. So um next slide, uh I never go to red flag for his clinical indicators. Um So this is the stuff I was talking about just recently. So I sort of was talking about the potential uh things that we worry new from a clinical perspective, from a clinical features perspective. Um I've taken this directly from the nice guidance. Um And so the way nice works nice, I assure, assume you will, although, but is the National Institute for Clinical Excellence. Um but they have a national guideline where they are, they treat for early onset sepsis in particular. So, um the vast majority of units will use that as their sort of Bible. Um And they work on the basis of red flags or not. Um So if it's a, if there is a red flag, you screen so you start antibiotics no matter what. So as I've said, these can be fairly obvious. So for example, things like apneas seizures need for CPR um signs of shock, of course, you're gonna start antibiotics uh because it's sepsis until proven otherwise, in many cases. Um the other things though, however, are not red flags and that's because as I've said, they can be part of the normal transition. Um And so again, just so you're aware of all of these. So John Doe's within 24 hours of birth, feeding, difficulties, reduced muscle tone or altered muscle tone, um persistent pulmonary hypertension, unexplained, excessive bleeding, uh signs of respiratory distress, etcetera, etcetera will not go through them all again. But just so you're aware and that actually none of those things alone make up a red flag. But if there are two or more, then you do screen. So oftentimes your, you'll be caught out or not caught out, but you'll be um some of the things you'll be looking for is, you know, if there's a baby that isn't feeding too well. And um and has had a bit of mild uh as a, a bit of a mild increased work of breathing when they've come out again, you're sort of, it depends what consultant you have on or what reg and stuff uh in terms of who would screening, who wouldn't someone try to get away with sort of holding the baby for a few hours or, you know, keep an eye closer for a few hours where someone screen straight away. Um because yeah, you're really within the realm of clinical suspicion. They're um so next slide, please. Um and then it's not the red flag risk factors um until I said to you got the clinical indicators and then you've got risk factors and the risk factors are the things that within the nice guidance, talk about uh that they can answer if you've got one red flag, no matter what you screen. But if you've got uh one, if you've got a risk factor, if you've got a non red flag, more than one, then you screen as well. So for example, if there is a preterm baby with, uh so a baby that was born at 36 even if they're born at 36 plus six, they still count. It's preterm, technically who's temperature has gone down a bit low. And then you're sort of, again, you're in the realm of having to think about screening. Okay. Um You can sort of match these two tables up when you've got the sides of the end. But um in terms of just having an idea when you're thinking, but these are the sort of risk factors that we're thinking about from, uh and when you're going to deliveries and stuff you sort of have in the back of your head with experience. And so things like if mom has been treated has been found to be group B strep positive in the past through vaginal hi vaginal swabs. Um if mom's had a fever. So this used to be uh interestingly used to be a red flag risk factor. So it meant that orwell fever is still a fairly high risk factor, but what you used to be was maternal sepsis. So, and uh traditionally, the threshold with an obstetric teams for treating maternal sepsis was extremely low. So it meant that we used to screen a lot more babies than we don't do. Um But the nice things is sort of changed to reflect that. So now it's based on fever rather than the mom having a temperature of 37 5 and a heart rate of 105 as it used to be very common. But yeah, these types of things pre like really labor, rupture of membranes, confirmed rupture of membranes for more than 18 hours for preterm birth. So those types of things are telling back to what I mentioned the very start, which is um f a baby. If you think if you're thinking about the anatomy of it and you're thinking about the physiology of that, how an infection may occur in the baby, um or it may come to a baby, then um what happens is is that, you know, if you've got a general canal that uh the sac is know if the, if the membranes have ruptured and there's no protection to the baby any longer. They can be exposed to the potential organisms within the general canal that can spread upwards. And that's fairly common actually, um, mechanism or uh neonatal sepsis. Um And then clinical diagnosis of chorioamnionitis, I'm munitis. I would ask if anyone knows what those are, but I don't think anyone's taking anything. So I'll just continue and say that usually, um, that would be things like that would be from the obstetric obstetricians. So they would tell you if they've got clinical suspicions. Um And from a pediatric side, it's actually just that it's very, very smelly. Um So if you've ever smelled chorioamnionitis, you will know you will not forget that smell. Um So moving on uh next slide, this is touching on what I would just say, which is about the management as per nice. And so as I said, every unit in the country should really be using this. There are exceptions that I can touch a little bit on what we've discussed this slide. Um But largely the vast units are using this, which is any red flag or two or more of the risk factor, red flag risk, non red flag risk factors or clinical indicators. You perform investigations and start antibiotics, do not wait for any test results. So you give antibiotics immediately. Um No red flags but one non red flag risk factor or clinical indicator, then you just use clinical judgment. Um So is it safe to withhold antibiotics, etcetera, just as you can imagine. So you continue to monitor and what you'll usually here. So if monitoring continue for at least 12 hours, so most units will have their own guidance on this. So for example, if a mom is um a mom had group B, it was found to have a positive group B strep swab in pregnancy then, but they've, you know, there's been no babies come out, it's completely fine. There's no concerns. There's no other risk factors whatsoever. And then they will observe for at least 12 hours. Um, some places will observe for 20 for some will observe for just 12, but they'll do, they'll do observations every 2 to 4 hours and if there is any concern, then we'll go see the baby. Um, and then, yeah, otherwise no concerns. Um, so, yeah, that's the sort of fairly straightforward from a treatment perspective or from a management perspective and then next slide. So types of investigations. Um, so yeah, the types of things that we investigate that we were looking for is the main three, our FBC, um, which you'd be looking for any signs of particularly high neutrophils. Um, again, it's not the most sensitive, well, it is fairly sensitive but it can be, um, difficult to ascertain. I mean, the first few days of life, um, the true readings and CRP that's vastly ready of units. That's the primary way to sort of look at, um, whether we should be treated or not pro cancer told him I know is coming in in a few places. But I think it's still prefer in the new nail period because it's still not the most sensitive. I mean, CRP is not either, but we've been using CRP for years. So I think people know what they're doing with it. Um, and I get, but however, again, so what we'll often happen is the CRP is used as a measure to decide length of antibiotic course. So once you started some antibiotics, um CRPS, you'll end up doing things like called interval CRPS. So that's just seeing the trend over the next few days, obviously, sometimes as I'm sure most of, you know, CRPS have a lag and that's the same with babies. Um But actually, you'll often see it go up initially because if there has been an insult to the baby, particularly around the delivery period, what you imagine is when your screen them initially say straight after delivery and then you do the lot, the CRP inter interval at 18 to 24 hours after that, that's whenever you actually should expect to see if there has been a true insult or not. So that's why you often will see babies if there have been treated for suspected sepsis with not really any clinical indications or even just mild clinical indications. Then if the CRP stays below a certain level and the consultants are often have happy to stop again. That level is very intimate. It depends on the unit. I've worked in a unit where if it was above 10, the baby's guaranteed five days of IV antibiotics. I've worked in the unit where if it's uh less than 20 even if it's 21 22 some consultants are happy to stop after 36 hours as long as the baby is otherwise fine and then blood culture obviously is of course the most important blood culture, night blood culture, positive. Any baby with blood culture, positive with true blood culture positive. I should say contaminants are quite common. But if it's true blood culture positive and that's sort of different catfish and then you're going into a different realm of a work up in terms of future thinking. And I touched on that earlier in terms of potential developmental and um and also just other things, you know, try to rule out meningitis and whatnot and that touches on lumber puncture. So um the indications for lumber puncture from the nice guidance and from sort of any unit I've ever worked in is um if there's blood cultures positive. Um a lot of the times however, baby's been on by the time the blood culture comes back as positive, it's been about 24 48 hours. And so if it has come back a true positive, you will definitely do it if it's true positive. And but if its potential contaminant or if the baby's been all of IV S for a few days, the clinical significance of a long puncture isn't going to be protected early high because there have been on IV S and so it may be a false negative. However, you would usually do them street quite quickly. If there's a strong suspicion of bacterial sepsis, felt suspicion wrong in our apologies. And, and then that would be things like if the baby looks really unwell or if the initial CRPS come back is quite high or if the other one is trending upwards. So again, every unit is different in the CRP. They want to treat on where they want to sorry, do it on a puncture on like one, you know, I've worked in the lumbar puncture above CRP 15, 1 unit was, they don't care how high it is. It just depends on the baby's clinical commission and how you stronger suspicions are, which I would argue is probably better practice. But I have not been in this for many, many years. You're seeing babies that have been missed. So, you know, who am I to judge? Um Otherwise, of course, things like not improving with antibiotics or any neuro signs, you know, the obvious things should be thinking about with lumber puncture. Um So of course, if there are any neuro signs, and then you'd also be thinking about doing some imaging of the head before cracking on with lumber puncture just so that you're not causing any other problems. Um Cool. Um And the next slide is further management. So that would be things like um antibiotic choice. Um So I sort of touched this, the beginning. Um antibiotic choice will depend on local sensitivities and unit um if suspicion of sepsis, but no clinical findings um can be where I've worked in most places is I'd be kept taxing. So kept taxing is usually the first one to give the reason for that. It's broad spectrum unless be given twice a day. Um And uh there is a good reason as to why we don't give kept track zone, which is obvious uh sibling, but I can't. Well, I usually ask if anyone knows why, but I'll just leave it. Um If the reason why we don't give that is because of things like the risk of any biliary duct involvement in the medial period that can be very important. Um if admitted to NICU. Um So say, for example, your baby on the postnatal ward, you were screened and treated, but more just for not for actual signs, but more and you're not actually worried about maybe then they can stay on kept taxing on Postmates. If they're admitted, then they started Ben, Ben and Gent and that's who you are properly covering right across the spectrum. Um There's in many units, there's this and I think nationally they try to push this gold and other things. So some places are a bit heavier on it than others that have worked. But, um, it's talking about within an hour off, Cannula off deciding you need to give the antibiotic. And so usually that's like if you know the baby needs to, to start, then you need to just get cannula and crack on. Um, and again, most places have work, to be honest, the S H O on the reg whoever's doing the Cannula, um, they're giving antibiotics as well. So we'll have little skits that you do the Cannula drop attacks. Um, and just give it um, within, yeah, straight away. If there's someone that's just been screened, if they're coming to the unit, then we'll just give them the unit and the nurses will do, of course, but just to sort of expedite things and then for later onset. So that's the sort of stuff I was talking about previously. So that's one's usually do with potential line infections. So that would be often a combination of narrow spectrum antibiotics. So things like I be flu clocks and gent is the first time where I previously was working. Um, but there are different concoctions out there based on different units. So I just went on what I've come across most commonly. But yeah, my main advice would always be just have a look, if you ever do working nephew or impedes, then you'll have this sort of drilled into you in your induction. I mean, there's always guidelines at any unit, wherever you work, duration of treatment just varies in the microbe identified. So if you do have blood culture positive sepsis, um certain sepsis is you need to, certain microbes require um several weeks of antibiotics. And so that means that maybe babies may need longer term access or central access or um yeah, even just pick lines. Um yes, with things like peripheral central access. Um in order to sort of give antibiotics for a prolonged period because obviously it can be quite difficult to cannulate babies at this age. But yeah, just the consideration. Good. And then that is my final slide. Do we have any questions? I just really have sort of just spoken at you for half an hour. Um, I don't know, I don't know if anyone is even out there. Um, if not just being whispered into the wilderness, into the, yeah, please do pop any questions that you have in the chat, that's normally a few seconds delay. Thank you. That was both very interesting and slightly terrifying, uh, impede surgery and visit the uh, Nick you probably every day but not have the same level of involvement thinking about pretty much every single uh baby that I must have walked past but have had quite a few of those risk factors or potential to be. Um, I mean, it's always just say that neck you is sort of sort of just a, it's a mind of its own type of place, you know, it's, it's a, it's a world of its own almost. I mean, because it's so different, even just pediatric, pediatrics is different to the rest of medicine. But then Nikki is just that its own sort of fitting because the way we practice medicine in the way that we do medicine, it's just entirely different from the I said, oh, was that question? I just saw a 10 Thank you. Very informative. Thank you. All right. Well, thank you very much. A question with the investigations. Any role for kind of source identification as we would do in regular pedes or even adult medicine source. Yeah. So kind of, you know, working as it urinary chest sepsis or actually, do you want a probe? Yeah. So I didn't go too far into that mainly because they don't want to muddy the waters and that I've sort of been touching on muddying the waters a lot during this, uh which is that it's very easy to give a talk in the unit, the sepsis, but in the real world and clinical practice a lot of times you obviously as with any, whether it's new dates or adults or pizza, whatever you're thinking of the wide spectrum of stuff. And, and so from an investigations point of view, if you've got a baby, I mean, it just depends what they do present with. So while they may not, they'll present with sort of similar stuff. Right. Across the board is only like four or five ways much to present and stuff. But for example, if they've got processions and they're working hard with the breathing, you know, always chest X ray. Sometimes you pick up a congenital pneumonia. They're like, not that common, but I've seen a fair few. Um, those will be definitely, um something to keep an eye out for uh in the, you'll always, to be honest, if it's a baby that's been admitted to make you, uh, got any chest, uh, signs, then you'll definitely a chest X ray urinary stuff you wouldn't really touch on. To be honest, unless, and that's more than the late onset sepsis bracket. Um, so that would be if it's a baby that's had catheters or just a baby that's been on the unit for a while or a baby that's went home, gone home, sorry. And then has, um, come back into the police unit. Um, it depends any and then in that case you'll definitely, you're, you're right. And that sort of in that sort of impedes, we talk about that first three months. There's, um, if the baby is a fever, you'll sort of give IV S and screen straight away and give antibiotics. Urinary is almost always, was very often, sorry, I shouldn't say almost always, but it's very often. Um, the, the main thing you think you're thinking about you're worried about. Um, but in this sort of, I'm a baby that's just been born. And, uh, yeah, there's very, I've actually, I've, I've very rarely seen, um, sort of anyone chasing up urine because I guess, you know, the, the theory for that isn't, there isn't really any theoretical basis for that in terms of how you ta developed, the only ones would really be if there's babies with even then, like, you know, baby hasn't paid, for example, you know, it's not gonna, the system hasn't worked so much to speak. And so the potential for a micro for or for a, um, infective organism to work its way in his place and that sort of takes a bit of time. Um, and then you're thinking about it and then I thought if you do identify something you're thinking about, you'd be always thinking about things like, um, if there's any other structural anomaly so things like, uh, retrograde valves or P U J obstruction, pelvic who ureteric obstruction and things like that. But in the early ones, that's weird and wonderful as well. I've seen a few. Yeah. But in the early onset sepsis. Yeah, I guess it's what one real different thing from apples, which is, then you probably wouldn't really go into urine too much. And then, yeah, I'm trying to think what other things. But, yeah, otherwise, no, it's just more, it is mostly chest would be the thing that you'd be looking for. And then, like, because, yeah, the blood culture is the main thing like that's always that, that's the thing that's dropped into if you do a neck in place, a culture, blood culture culture, because you, you want to make sure that they're not blood culture positive, of course. Um And then I have another question, there's no one else. Um Any questions um with it might be a silly question but with a, like a very small neonate whose mother or father has a penicillin allergy, say how much stock or worry is put into that? Would you still go straight ahead with penicillin and just kind of manage issues come up as we do in small Children. Yeah, you just crack on. Yeah, I mean, you, you know, yourself, like I was gonna say, half, they're almost say the majority of penicil allergies or how true are they intolerances? Exactly. Exactly. Allergies to things that used to be in your penicillin. Yeah. Exactly. And so if a parent comes and say, you know, I am definitely allergic to everything that I touch and, uh, you know, I have this weird and wonderful syndrome where, you know, my, but you'll be doing that already. But a lot of times parents have hyper, anxious about, understandably anxious about those types already. So kind of, it's almost people screen themselves, not always, but, you know, you'll often find that like the things that should be looking out for or you're often about 10 other people have done it for you before that babies even delivered. Um, and then, but yeah, with things like a penicillin allergy because there's such a range there. It's not something we can be too concerned about. And then obviously if there's any clinical findings, the babies in the right place anyway. Yeah, treat. But I don't think I've ever seen a new little acute true anaphylaxis. Uh Long May that continue? Yes, please. God, now you've got me worried. Okay. Perfect. Well, thank you very much. Uh, that was very important give talk. Um, I will just pop the link to the feedback in the chat and it also go out to everyone that attended, um, and the talk. As always, we'll go up on youtube within a day or so. Um, please do take the time to provide us with some feedback. Um, as we always say, it's useful for our portfolios, but also as teachers and educators, we do want to get better and we want to give you guys the best possible experience. And the only way that we can improve on things is by you telling us what was really good or what you perhaps change if we were to do it again. Okay. I will let everyone enjoy the rest of their evenings. Thank you very much. All the best night. Here's right.