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Okay, So good evening, everyone on. Welcome to the third episode in our pediatric Siris. Uh, tonight's webinar will be all about vomiting in babies. Is my absolute pleasure to introduce Doctor Nietzsche ago. Who is a clinical teaching fellow? That stuff. Man of the hospital. She spends half her time teaching undergraduate medical students and the other half working clinically in both pediatrics on neonatology. Um, she did her foundation years in the West Midlands. Um, and then, like, she will be joining us for a webinar before I hand over to for, um I just want to quickly mention our sponsor, Uh, which is CPD me. Um, so through minor bleed, um, we've got you a 50% discount. So if you just ate pounds for your year and you get the full access to hundreds and hundreds of different webinars ulcer ppd accredited. So for you, if one's f twos that need non core learning for your portfolios, there's the entire variety of things you could go out and get on. You get certificates, and it's a lot. They're ready. Future kind of you at your leisure. Um, So now, um, I'll hand over to doctor goal thank you so much dot So, hi, everybody. Em as dreams that my name's nature on. But I am really excited to talk to you today about formative and babies. And so obviously I can't see any of you. And I don't know what pediatric experience you've had. If you have pediatrics before, I'm sure you would have seen plenty of vomiting, baby. And if you haven't, it can be something which is a bit scary in about a known on by think. It's quite a common symptom, and it can be difficult to think about all the things that can cause it. So I'm hoping to just use a few case based examples today from my experience. They go through a few common cause is, if you've got any questions, then feel free to pop. Um, the chapter on then James, if you could just let me know that would be great on. Hopefully I'm hoping to do is ask you questions through. This is well, so it would be great if you guys could just answer. And if you feel comfortable, that would be great. Yeah, absolutely. I'll be monitoring the chat throughout, um, passing on any comments or questions effect. So the first thing that I really wanted to cover Waas what is vomiting? I think it's really easy to just think of vomiting as what we know in adult world. But mom, it in babies can be or vomiting and babies, as the parents will tell you, could be a lot of different things. So in theory, it's the expulsion of gastric contents do to increase intraabdominal pressure. But I would say that probably about 50% off the time when it parents actually tell me that the baby's vomiting is actually vomiting and a lot of babies just possible it which and it's just small amounts off milk or stomach contents being it's expels, but it's not often not forceful. It's more just like a dribble, that is, you can see from that picture that looks a bit like flemmy. And so it may even be that babies who are quite snotty can bring up quite a lot of phlegm, just that they're solid from their stomach so often, it's not always actually vomiting and quantities could be really hard to work out, so we will cover this in a sense off. What questions you want to ask parents in in terms of the vomiting history. But quantities are really difficult, so parents say they're vomiting the whole feed. It's really difficult to work out there, actually vomiting 60 mills of milk. It could look quite a lot on a little Muslim cloth on, but it spreads out onto a blanket. It can look like quite a lot, so that is something to just be aware off. So in the history, bearing in mind that we're concentrating on babies in this webinar, think I can any of you suggest what you might want to know from the history? Say the parent can't see you've got a team, um told his coming with vomiting, Just give it a minute or so for people to reply, because there is a slight delay. But when I did some of my training and GP the things to always ask, I was told they're eating and sleeping on on. What's in there now is, um and actually we're getting some good questions coming in now. Eso Olivia is saying feeding habits, fever cry infections get the color of the vomits. Two different people. It's just suggested that, um, how long it's going on four is getting worse. Perfect. There are really, really good suggestions. So absolutely So let's start with what you want to know about the bomb. It you want to do when it started. You want to know how much, See if you can gauge how much it is. You want to know the nature of the moment. So you want to do the color you want to know. Is it Is it stomach content? If it blood, is it bile? You want to know the the force that the vomits coming up house and that may may be able to help you decide for it if it is actually vomit. So is it just a dribbling? Is it when they're lying down? Is it when you set them up just after the feet and they just hurt and is it productive? I'm on the go straight across the room with your meter away and you want to see if it's getting any worse? Absolutely. On feeding habits is crucial. So with babies and you want them to be having 150 million Pitino per day of feed. So with a baby you on based on their weight. You want to calculate that on That's Humpty should be having, and parents will often to walk out seven mils. So one ounce of formula is approximately about for two melons milk. So that's just a he's e way to interpretive. If some parents say that three ounces every three hours, it could just be a bit confusing, but and it's about one ounce is about 30 mill. And so the age of the child. I mean, obviously this bourbon are is about babies. But knowing the age of the topics, master difference as to what your list of potential is going to pay. When did it start being mentioned? How much? So it's good to get gage and idea, but I definitely take it with a pinch of salt and ask further questions if you're really not sure how often. So is this with every feed? Is this not related feeds at all? Is it uh, you know, every 10 minutes? Is it just once a day really good to get an idea? And that will give you an idea If you think this child is dehydrated as well, which is a really important question, she'll come on two. Is there any triggers? That was it when they fed. Is it when they lie down? Is it? Um, it could be lots of things. Is it when they see a bright light or something like that? Thinking into renal cause relieving factors, so does it help if she gives a bit? Mom gives a little bit last feed. Does that help if she gives some Kalpoe because that much fever related, what's the color that includes bile or blood or coffee, ground and stool? You want to know that it in their bowels? What color? If there's any color change of the bottles, I just remember other bits. So birth history medications. He's really important. Children don't get if they're old enough to have any vaccinations. Didn't get to ask about that. Ask about home life. So you want to do things at home. Has anybody else had home? Take that might give you an idea. It's to the coals, a swell. So the next bit that you do will be examination. So I've got this picture of this baby here. It was quite a nice way to share examining the anterior frontal. So the way that I always examine my babies, and you don't necessarily do this for older Children is just there and head to toe. It's the easiest way to make sure that you've not missed anything, actually, easiest way to just systemically go through and look at the baby. So obviously you'll start by looking at them, and you've got a lot from just looking at them. You'll be able to see if they're active. You'll be able to see if they're alert. Even if they're sleeping, they should be responding appropriately to you. So if you, you know, hold the hand, they should still grip. And if you just start to move their arms, he should respond with a little bit. So you build Steve warm. Think well. If you use things like that from was feel, start feeling the anterior front in El. So, um, the things that you want to look out for when you're feeling the anterior frontal is if it's soft on, if it's normal tenses. So if it's bulging, you may be thinking about something, which is increasing the intracranial pressure, so it's always worth me in the anterior frontal male aimed babies with vomiting as well it's worth measuring your executive front will and the conference. Do you want to do their heads? The conference. Hopefully, if parents are prepared, they will have the red Book with them, and that will have their other heads of countries. It's on. It's worth noting. Seeing what symptoms are growing along. Um, I saw a baby recently. Who? It didn't have any other signs other than the fact that their head circumference, the hard jumped to sent aisles. They weren't vomiting, but they had massive hydro capitalists. So it's really worth remembering to measure the head. Circumference is it can tell you quite a lot. Hydration status. So a lot of you, I think, may have more adult experience and peed. So just think about what you look for an adult. So it's similar in the 70. Want to look for some couldn't eyes dry mucous membranes. So still look for things like that in Children and in babies, and fixing and following is just example that I've put off sort of developmental progress. So fixing pulling at the six weeks check, they should be excellent followings. They just check that they're vision looks okay and ask Mom if she feel warm or dad? If they feel like that and it's watching them and me following things around the room, it's a really good indication of vision. Work of breathing. It's worse just having a look at, because if they're vomiting, just want to make sure that they know aspirated. Or if they're vomiting because they got a chest infection or violin, just squeeze, and then you want to examine that tummy, so you want to tear. Look at the tummy to see if you can see anything on the new one. Take sound in the tummy as well on. Then you could have a look everywhere else if it burning rashes, feel the femoral things like that. There was a question from a partner. She asks up to what age can you feel the anterior fontanel, so it's normally open until about nine months, and it may get it will get smaller and smaller, but until nine months you should be able to feel it. Thank you. So can anybody suggest what we've gone over? Sort of what you'd ask. But what red flags are that in the history or the examination that may turn the warning light on in your brain of what might be causing the vomiting. Okay, let's see if you have any suggestions. So abdominal mass on palpations Okay? Yeah. Yeah, I think that's Yeah. That would be definitely something that's like something or brain. Yeah. Yeah. Stiff neck is another suggestion that is looking kind of meningitis. Yeah. Good summer also suggested intussusception. Okay, so what? We'll go on to that, but yes, that's certainly something. Which is there a serious cause Obama take, But just more thinking about ready to relax in the history examination? We will. It's inception of something. You to come to, um, someone else's suggested foul smelling urine. Yes. I'm racking my own brains now as well. Um, what's, um, what's come of blood in vomit fever? Changing urine output change in bowel habits? There's any sort of focal neurology from my head. Yeah, absolutely. So they're really good. And I think a lot of the ones that people were coming up with definitely related to neurological causes and on d things like fevers. I wouldn't mess. Oh, let's so necessarily say on its own. It's a red flag. Think about things like if it's frequent and forceful vomiting. So I'm not going to say what each of these red flags made indicate what we'll go through all of them, hopefully, most of them frequent and forceful. Vomiting, bile stained vomit Hematemesis is blood in the stool, abdominal distention or tenderness? So talking about some paralytic tenderness, chronic diarrhea and any old responsiveness our building from to now Let me. So I sort of put a few of the causes into different category. So and the main one, the main two, I would say, are gastrointestinal causes on central causes. So your gastrointestinal causes contained from reflux, too. Bowel obstruction. It can have a really big range of having a very well baby toe about very sick. Lately, you can also have been set pilots neck pole. It's stenosis and or infected and plumpy and causes such a Z e T. I. A gastroenteritis. And I think that some people mentioned foul smelling urine and which is a definite course. You charged definite cause heartburn. Bomb it in babies, allergies, intolerance. So think about babies who are on milk on. Also, when they start to wean a swell, it's important to think about that about six months and your central causes have mentioned how to cath list meningitis. Always think about poisonous. Well, this could be accidental nonaccidental injury as well. So just think about that on but her metabolic say there are Children with complex metabolic disorders. They are screened for six of them at the new Barbie heel prick test. But obviously this There's thousands of metabolic disorders. So any child who comes in with vomiting and they are really unwell and possibly with low blood sugars. It may be worth thinking about metabolic causes, but that's something which you will exclude far down the line. I wouldn't say that's your number one cause, but it's just something to consider. So I want to think about case study now. So and they're Let's take this four week or baby who has milk. Yvonne. It's after every feed Mom stating that. Sorry, I didn't If you could see that cause of my face is mom States, it's projectile half of the feet. Volumes coming up. They're hungry. After the bomb, it they tried to give her some stashed actually toe one day, which got from the GP and the babies have normal wet map these normal day to Happy's is putting on weight really nicely and has had a normal blood. Dallas. So this is based on a baby that I saw in my foundation year to year, So we'll work through this. So hopefully reading that you may have a bit of an idea about what we're thinking about or is what difference was you got. So sorry. So the difference was, I thought off just for timing. I just am was through them. But, um Gastrin Gold. I thought it could be gold. I thought it could be cause milk, protein allergy. I also had in the back of my head that it could be biologics to know. So it's particularly as Mom and called it protect oil on. And this is why we did the gas said the cost was miserable. So just to talk about about board and baby, thank you, you have dribbling after it's thank you. So gastroesophageal reflux is quite common in Children, so I sleep. The statistics think that about 50% of North three month old infants have an element of reflux, and it normally happens around 3 to 4 months of age, and but it resolves by one year. So a lot of parents will come in and say after a feeding. I like him flat on the really They cry. They aren't from their back have seen. I was on people at the pediatric decision you today and I saw two babies and possible reflux. So it's really common. And they all just said they're just so uncomfortable lying flat when I picked him up there so much better. Sometimes you might feel like they don't want to have anymore feed because it's getting really uncomfortable on this is when you might notice the positing as opposed to actual vomiting. So it's literally the milk refluxing up. So I be a Cuba in the street. It's a very clinical diagnosis reflux, and you wouldn't necessarily do a lot of investigations. It I don't land. There is things like a soft your pH, monitoring the evening in my time in a huddle. So I don't think I saw anybody with reflux who had that. It was very much about the textbook, then a. There is sort of a similar thing that you could do for Children and babies, but it's really only if you feel like they're having the most consequences from that. So they had aspiration pneumonia after having after years. And if you feel like that, are suffocates is getting very inflamed or they're having any don't erosion. And if they're having any bile stained vomit or dysphagia, then you can think about contrast of the But this will mean that you're referring to Attention Center because you're worried about something quite sinister. So I would say for the most part, reflux is a very critical Um, the management of reflux is a lot more conservative than I think is actually practiced. I'm sorry. Let me just need this. So sorry. So parents will get very, very worried about reflux, and they may also think it's colic, which it could be. And but often parents will come to you and say, I think they're a bit reflux. A on I think it's really important to reassure parents. It could be really distressing for them. If their baby is crying and they're not sleeping on, this baby won't settle on. I think it's really important to acknowledge that and the breast fed babies breastfeeding support team could be an absolute godsend. Breastfeeding is we were as healthcare professionals. We want to encourage breastfeeding on if there's anything it Babies are reflux. See it can really discourage months from breastfeeding. But having the breastfeeding support team could help to continue hoping to continue with it. For formula fed babies, you can try smaller and more frequent feeds on. But so, as I mentioned, for example, if we had a baby, he was on 150. If they're 150 milk a kilo per day Waas say 90 mail every three hours you make say Okay, why don't we try 45 mil every 1.5 hours or 60 mil every two hours? And it will reduce the volume in this in baby stomach, and it will reduce the chance of reflux on there. That's a really good conservative option. And, he asked, telling Mom's Keep a be upright for 30 minutes. Post speed will just produce that distracts an invitation, if therefore will affect. You can also get feed thickness and which could be added, which is a good option. It's a good non medical, non solve drug option. If that doesn't work, then eat news Gaviscon. So infant Gaviscon is good and but then if you're doing that, you would want to stop that. They conform, you know, and go for the Gaviscon. Now this gown is constipating, so it's not something that could just be used, really, nearly without any consequences is very constipating. So you do have to think about one parents about that, because it may be that their baby then gets irritated because that screening and they can't do him you can. Also. You can also do the Gaviscon for breast fed babies, but they just need to give it with a better board for the feed. The use off things like, um, Apostol. A minute to Dean. Um, I'm not used very often. Have you used omeprazole seen? A map result is quite a lot compared to how it's recommended by Nice to be used so normally, they would say Nice. Has a four week trial off that resolved foreign it Dean. If there's unexplained feeding difficulties, so so I'm not sure why it's God, but they're really struggling with feeding fall from growth or distress behavior. And if you would stop the Gaviscon, then if you're going on to a map result that and that can have its own side effects as well. So I think the key thing about me flux is reducing medical intervention on doing a lot of feeding support with parents. The other thing that was running through my mind when I saw this patient just to go back to that case, remember, Mom had only tried Gaviscon sashes for one day so that I would say that's absolutely not enough time to you have ruled out Refluxes, of course, for this vomiting and cow's milk protein allergy was the other thing that was running through. My mind wants to my mind when I see babies vomiting. So it happened in about 2 to 3% of babies who are formula fed on. It only happens in about no point. 5% of babies are exclusively breast fed, and it's normally before they're one year of age. There are two ways that Cosmopolitan allergy can presentable can happen in the body, so it could be I d related on on IgE mediated reactions on the main difference between this is the symptoms of the time. They're I g e. Think of your classic allergies. You're thinking urticarial, Russia, thinking, itching or thinking acute vomiting, loose stools, swollen lips. Think about and going along, you're on. It'll access symptoms type, pathway. Um, your non idea is often what subtle on but that can present with X Merced really dry skin, blood or mucus in the school, in the stool. Food aversion faltering grows generally quite mawr, insidious onset symptoms, and that may not be picked up easily because they're not, as obviously, a allergic reaction there. Maybe family history is low, so I am in the history alongside everything else that we asked before. We want to think about we want to ask about these symptoms specifically, take them. Had a family history. You want to maybe ask a little bit more about thesis willing of the legs that itching the mucus in the stool. I'm think about the timing in relation to the milk exposure to get an idea. If you're thinking I g e on on i d. The reproducibility of symptoms is really important because it may be that parents have already tried a different milk or they just started something new, particularly weaned. Is this because they introduce new foods at when did the symptoms start? Do you want to really link it to the cause. And if there's any other topic conditions in the baby or their family, this picture here is getting prick. Testing on that is generally what it's used to diagnose allergies and Children. So it's where you put a small bit of the allergen on the skin on. Then prick the skin on dezso. Be and carry a reaction that happens. One important thing that is good to know is the fact that the signs of the earth carry a little reaction that you get does not predict the severity of the allergic reaction that the patient will have is just a more likely that the patient is allergic to that allergen. So you're unable to predict severity from the size of those. It's just it's bigger than that, more likely to be allergic to you can do serum specific I D testing. So that's a blood sample. But the results don't come back from that four weeks on. It's generally a bit less available on on, so we prefer skin prick Testing don't really so management for breast fed babies. You would ask Mom to exclude or cow's milk for 2 to 4 weeks That's generally the advice. Make sure the East Bath of Publixes, a cow's milk protein allergy, makes respecify house smell, not lactose, and because a lot of parents think that's anonymous, but they're not. And if their formula fed, you could recommend hydrolyzed formulas or there's also a medium acids formulas, which probably don't taste is nice. But they're the options, which don't have cow's milk protein in them. It baby's still struggling with those. Then you can go on to and get the dieticians involved on. You would want to follow them up Analogy clinic If they have a full term growth to their reactions or severe atopic estimate. Nice has a massive list. I didn't include them all here, but if you've got any concerns about their development on, want to follow them up, then you can ask the consultants to hold my committal neck. The key thing about this is exclusion and re challenge. So we want mums or parents to exclude the capital protein for 2 to 4 weeks and then rechallenge, and that's the only way that will know if this is actually the cause. There are. It could be really difficult if the pair of the picked. If the baby is on a dairy free coverage free diet for no reason, I mean there's weaned, and then that can make them deficient nutrients that can play their bone age. So I think it's really important to rechallenge. So we're not misdiagnosing there and theme out with diagnosing cow's milk protein Allergy is going up, but if the incidence is not, is not necessarily going up. So we want to try and not have diagnosis by asking parents to be challenge. Well, not don't actually do it, because if they're babies better, they don't want to go back and make him being make them worse. But it's really important to strap that if you can. And a lot stenosis was the other thing that I have crossed my mind. So let me just hope we can steal the pictures. So this is something which medical schools, anything like mine. This was really drilled into us quite a lot of the medical student in my pediatrics block, and they said, Look out of the pilots know cess and I've seen it twice in for the Children I've been looking after, but it is really interesting, actually when you see a child, whether it's very textbook and it happens in about 2 to 3.5 per 1000 live births on, it's often when they're quite little, so 2 to 12 weeks old. Think about it then, and it's more common in males, so the ratio is about two to one's. It's twice as common in boys and girls on. It's more common. In effect point Child don't know why it is on a and so the clinically um, we can you can get a lot from the history on. 14% of cases have the classic triad. I'll go into that in the next slide of symptoms, and about 87 38 87% of cases will have a least one classic sign, and you can get a lot from the history of the sense of the project or vomiting. So obviously, I don't know. You know how much pediatric night you guys have got a bad batch. Pyloric stenosis is the hyper tree of the pill or isthmus a while and in the stomach. So if you can see in this diagram here, and the reason that you get a projectile vomiting is because of food literally can't get past the hyper church feels of the pylorus on. So it's to know this the gastric out outlet on it's projectile. So you get forceful expulsion of the time after that. And they typically say that projectile vomiting is you're starting a meter away and it will hit you. So So I've had parents say projectile military means it's just landed here, but I wouldn't call that protect. Oh, and in terms of what you could do to diagnose up in the history is you could do blood gas analysis, which will go on to that. Also sounds is a really good everything tool for diagnosing pyloric stenosis. So does anybody know what symptoms were the classic triad? Yeah. Oh, for the symptoms of low, it looks to the basis. Okay. I'll just give people, uh, few seconds. They want to jump the gun. Do you know them? Have you gotten in your head pains? What? Let's get plants. That I think I definitely don't have a three. Something gonna help me. Okay. Still waiting. So I think, uh, the projectile vomiting? Yeah. One. Yeah. Um, do you get a live shaped mass in the abdomen. Yeah, um, and I'm really in order myself for not know. The third one is the hardest. I think of three. So what? We've got one visible Paracelsus. Yeah, exactly. So protective hum attain the olive sign. So the olive side is literally the pylorus it and you can see in babies I've never seen. Actually, in the two pump status cases, I still don't have the nurse time and visible postop sensitive either. So in the statistic that said, 80% have one of the classic triad, I definitely think that is the project or vomiting part of all of them. But this is why, um, the examination. I said it's definitely worse just looking at the tummy. And you may also here pediatricians say we'll do a test feed on, but we have babies who came in with projectile vomiting on this case that we, um, watched mom fee to see if you could see it. See any of the visible Paracelsus. So it's worth doing if you got time and get the chance. So this blood gas, so a lot of you probably will be able to use feel off what the blood gases in pyloric stenosis, so you would normally get a hypo perimeter High poke, anemic matter. Bolic alkalosis So So There are lots of different biochemical ways that the body creates this picture but effective legal vomiting. Your forecast said you lose your chloride irons and the body, then this is very complex physicality that I'm trying to understand my felt. But you the body then loses bicarbonate, so it's been able to compensate for the our closest. So then you get the hypochloremia metabolic closest, and that's the first thing that you'll get. You also get a You also get a low blood volume. So then you get access aldosterone, which basically expels potassium. So then you lose your potassium on. You also get the body favoring, uh, absorbing hydrogen irons in favor of potassium ions. Then you lose potassium eyes to that as well, because the body is trying to compensate your are close this so you'll. Because your potassium hypokalemia is actually a later on effect. With this, all the body adjusting to everything you may not see no potassium straightway. But you're more likely to see hypochloremia. So local ride. Uh, so it's a high, potent, really like I'll close this. And the management of pyloric stenosis first and foremost, particularly in a district General hospital is too. Tell the surgeons at the turn she sent her and correct their child's electrolyte abnormalities. They may be quite dehydrated because that one ain't been unable to keep anything down, so just make sure you're giving them IV fluids on according Teo. What they need to give put in potassium if they need potassium on an N G tube may be helpful. But to be honest, if they got the stenosis, then it may not be helpful cause you know it. But if you put any cheaper and you will be able to still get anything through the hypertrophied pylorus, and once you've been referred to a church presented, I'll do pyloromyotomy. But they won't take them unless of electrolytes are normal. So they'll ask you for most recent, and they basically just why didn't there and cirrhosis cap on? Then Children will come back with a scar but will be much better, say question about the management there, as they don't know whether it was an F one. F two was your Pedes job. Would you be likely to be cannulated a baby or inserting and YouTube. Is that something that you got to do? It would feel confident doing, So I would definitely say that. So this is enough to, um, I was very keen to get stuck in with skills s so I did do blood and cannulas, and it's not something that you're expected to do, but I think it's very you're very much encourage to try and and each each I've never put on any G tube down a child. It's more the nurses who who do that on. I would say that it can be quite tricky. So if you're doing it for the first time, I definitely go watch your nurse cause they're they want to do it. But I run a key. Sometimes if they can't do it there. Welcome to you on, I would say to them, but because I've done it before, I don't know why you're going to May, but it's great experience to watch any of these girls being done on. I think Cannulated tiki babies is really great experience because toddlers hard for their Wrigley and strong, but babies, you can see they're Bates really nicely in the hands on go Interesting if actually easier than one might think. Okay, Cool. Thank you. That's that's very interesting. Yeah. Yep. The chemotherapy nurses of the same on my hematology Would they are far better at lines and stuff, and I am. But if two of them can't do it, they asked me to do Is any chance likely? It's strange. Didn't know and perfect. So just going back to the case. I'm not sure if you'll be able to remember the case from before, but they we discharge that baby home because we said to Mom. But we felt like it was more reflux. She only had the baby had a Gaviscon pull. One day we said, Give it a time. Um and it should settle down, then re presented only two days later, but had lost weight. And we'd wait baby on the same scales and had an abnormal gas. Which was the gas I showed you on a few went nappies. Then we thought Okay, we think this baby is a pyloric stenosis him? We didn't ultrasound. This isn't the ultrasound, but we did a ultrasound which showed have had a terrific pilots to no cyst so wear them referred to potentially center to the surgeons. Pyloromyotomy. So the reason why I told you about it's about cases, because I think it's really important to start simple. I think it would be unreasonable to a seem that that child and with projectile vomiting, which I know that put in diabetic comments. But it wasn't productive her when they first came in with a normal gas, he'd only tried Gaviscon for deck, and it was very reasonable to actually not jumped pyloric stenosis. And when they read present with an abnormal grass weight loss within two days, and if you wet map ease, that's the time the time to think about things. And on also just think about safety netting. They think about what things are, red flags in our brains. I think about that. You want to tell the same advice to parents. And just in the sense of the fact that that baby had back nappies, this is just a bit of a idea. Off signs of dehydration Children. So just things to look out for. It's similar to adults in the sense of dry mucous membranes, some kind of I've got corporate freely. Check the cap refill, and they may just be a bit listless and lack of tears when crying might make make you think that they're dehydrated. But you said for quite Happy's this is from nice guidelines as well about and site different eating between 10 ago. Dehydration in clinical shock. So maybe make you think about whether you're giving and GI fluids or whether you're giving IV flow is a Molitor's, or whether you have peaches to do an oral fluid challenge. That's also an option for dehydrated Children. So I just have another case where to think about So sorry and so think about this. It's not as long as the other one, but it's just we're thinking about So six month old baby presents with abdominal pain for the past four weeks. It happens on and off, so parents are telling you, you know it's not all the time. It's just every now and again. They've had some diarrhea recently, but it's turned red and sticky recently on. Babies also been vomiting on, but that's just recently changed color. So this is not an actual case, but I've seen, but I think it just displayed some red flags quite nicely. So on examination, you see, go you see and you feel in abdominal mass in the right side of babies. Tell me, and they also have a dominant abdominal extent distention and gardens there really reluctant for you to to upset me. So hopefully running through your brain is thinking that they're peritonitis. Your I would be a bit worried if I felt tell me that was guarding undistended on the fact that the to the fact that the stool is red and sticky on the form that has changed color, they're my red flags six months old and on in terms of the vomit changing color. Mom showed your picture, and it looks like this, not that volume from a six month old baby. But it's this color, so hopefully you will think of this as file stained from it. Looking lovely in green on, I just wanted to show you some preventive exception. So, um, the interception is problem in babies left by the, uh often it's the proper approximate part of the bowel invaginated into the distal part of the about barrel on. You get this sort of telescoping effect. Um, on it's most common in the island sequel region. So you often get the Eylea going into the cecum and the reason you get it that way around, it's just about themselves. So you just think of the way of going and it just goes through. Um, so this is a this, but can you see my mouth's Yeah, and this. But here is the Ileocecal junction, and 77% of cases are there. So this is where, in the sense of this case, when he had MM right side of the tummy. And that's where your your secret region is. So the things that should have hopefully maybe think about reception in this child would have been the red sticky diarrhea. So it this child is having colicky pain, which is what I meant by being on and off on the fact that they're loose stool has turned red and sticky is telling me that there has been some ischemia happening to the bowel which is causing the meet New Coast work about to slough off. So through the invagination, there must be some blockage of the blood supply on, but it gets me close. It's sloughing off and causing the red current jelly stool as you're typically hear it for interception. Also, it seems like this turns obstructed. So, as you can see from this picture and the you've got complete obstruction off the barrel here on, it is likely that just more on the constrictive blood supply. So it's likely that more and more bowel has come into meth. Um, and that's what's completely occluded it for having the bastard in vomit and the parrot Knittig. So what would you do? Any suggestions about what you might do in this baby? I put a clue on the picture on this on their slide. Again, I give people a little bit of time to think about that. You find, um, I think in the first line investigation would be an ultrasound low for? Yeah, definitely. So the reason we're on X ray on there is because I hard a child who has protein it IC. I might think about X ray just for preparation, and but definitely an older something to Susceptive is great on. Do you know what sign you might see on ultrasound? I think it's a well pull sign. Yes, so there's lots of different names for it. I think you can call it a whirlpool. Sign this target sign, donut Sign a different things. It's basically when you I can see you still get a cross sectional view Almost of the interstim alone and me consult. See as a circle with them. The dark circle in the middle on that's what to it's a bottle. And okay, you're not No one has jumped him with any suggestions yet. Fine. Um, not nothing that I mean, I would probably ask for help from someone more. So for start. Yeah, absolutely. I would just be asking for senior help with the space station as well. They are sick, and other imaging options is actually in here is an abdominal X rays. James and I was just guessing so. And if you're worried about bile perforation, I've got parasitic child. I think I've done my expert X ray is reasonable. The what you can see here is the dilated bowel, and you can see the bowel invaginated into the other bowel with the arrows assuring really nicely. So rodeo pedia is actually a really good resource for any imaging. So have a look on there. If you guys want to say I would definitely give this child IV fluids on an N G tube. So in a similar way to adults, if any of you have done general surgery, you will have no about a good suck. You want to decompress the abdomen. Then, if you think they're obstructed with the MG each evening, you want to give him fluids to rehydrate them and abdominal X rays, he mentioned. And ultrasound, possibly ultrasound if the it's a second line. If they were this on, well, Emergency Surgical Review and the I just mentioned end interception are thinking about abdominal in obstruction in the sense of vomiting and Children. Or there's other options that you can have mild irritation for any other reason. And Children with dance and drama more risk of my rotation volvulus. So just think of it in that same way and that you would have this obstruction picture, and it's a very what we would do is similar to this for any of them on. Then the surgeons will be able to leave that you're totally sentence. We'll we'll take it from there. But it's just figuring out your stick Children who are vomiting and changes so the main things I wanted you to take. Sorry and take home from this presentation. Waas Thinking about history. Is this true vomiting you want to know is positing Are are we actually dealing with a Decadron vomit? Very limiting pyloric stenosis or ability, obstruction. And with regards to reflux, I really want to encourage you to think about conservative feeding advice. Think about smaller volumes more frequently. Think about keeping baby upright every 30 minutes and really encourage mums to keep breastfeeding. If they are breastfeeding that they can be demoralizing and in terms of counseling, protein allergy avoid over diagnosis because it can have consequences. So think, think about other things first, really get to grips with your history. In terms of water, the precipitating factors have the excreted everything. Have they reintroduced it on? Do stop mums on babies excluding things from their diet, which could have nutritional impacts and for no reason. Um, for pyloric stenosis, older sounds really good. Diagnostic tool. So in a knees. Sorry. They are thinking more about using point of Carol to sounds and for to diagnose with outside you develop some. You could do so much in Children. You could do crazy world percent if you have done more sounds. And but it's a really good diagnostic tool on often quite quick to get, and every radiologist will do it as well. It's not like you've got to convince them it's radiation. So I would say that don't rely on gas is all sounds really good and think about your red flags is a final take home message. Serious cases can be serious. Causes could be GI. I don't want to be I onda not mentioned in this presentation. It would just be impossible to go through everything. But really think about your intracranial causes, your meningitis, it's nor hydro capitalises. Think about any change in vision. Any developmental delay. Think about measuring your head circumference. Think about feelers. Irritability on. But don't just think got think brain as well on, but I would love to take any questions if anybody has got any. Otherwise, this is the QR code for the feedback on. I'd be really grateful if you could fill that in that hopefully will enjoyed it on down and feel free to ask any questions. James will pass them on to me through the chapped. Okay, Thank you very much. I know. I I certainly learned quite a few things during that talks. That was really useful. Yeah, absolutely. Guys do fill out the feedback form A Z. Well, is the QR code here? Um, there is a link in the chat to the feedback form similarly on Facebook in the event there is a link there. Um, but do you go back and do this? The electoral will be available on YouTube on metal as a recording. Um, yeah. Lets know what you think is useful for us for our own portfolios, but equally allows us to improve the Webinars week on week and produce more great free content for review. Um, so from the chair, the only thing I've got so far is Ah, thank you. Great lecture. Um, which is always nice to hear. Glad to be appreciated. Um, other things. Just to give people a minute or so to come with any questions they do have, That's what See? Fine. Yep. Next week, I will be doing a lecture on pediatric prescribing. Um, I will Spam. You will buy a Twitter Facebook. However, I can get in contact with you to publicize the event. Um, on also, if anyone is interested in writing articles on pediatrics, we've up just like a loaded a whole other topics to the mind believe website to do. Go on their check out on if you're interested in right and get in contact case. Ah, we've got many thanks. Instructive and interesting. Thank you so much. Ah, sorry. Could you explain the high bicarbonate on the file or extend OSIs, please News? Um, sorry. Let me just work out. So you let me think. Sorry. The renal physiology is not my strong point. So you lose chloride irons because you are you using hydro forecasted because you're vomiting on that gives you an article excess because all right makes you acidosis. It after dot it on then you from my knowledge, you then lose bicarbonate. But then that would make you more. Let me let me see if I can find out because I understood it before. And now I'm thinking about it too much. I don't understand it with me. Way can always I can always post the like a worked answer. Yeah, Nietzsche in the either the Facebook group on metal. Yeah. Yeah, because it is Yeah, it's always best to get that with, um, if we don't know, 100% sure, because yet the complicated physiology is certainly not my strong point. Either. Know it's really confusing cause there's lots of different and there's lots of different. Um, because you know, the electrolyte things are going with lots nurses that can get really confusing. So it's the fact that basically the low chloride levels reduce the kidney's ability in the bill, it reduce the kidney's ability to excrete bicarbonate. So I think it's a George water like a bicarbonate chloride transporter. So if you've got low blood chloride, then you're unable to. Your kidneys are unable to exploited bicarbonate because the gel transport with work okay. Yep, that makes sense. Okay, Hopefully, Maria, that answered your question. Um, I can't see any other questions coming in. Um, but no, thank you very much. They shouldn't think you're a room for joining us on a Tuesday evening. Yeah, hopefully see you all next week.