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Presenters can share, but I don't know if you've given me that. Let me just Oh yeah, there we go. Perfect two seconds, folks. So how long guys? Technical difficulties? All right. Can everyone see the slide and see it changing? Yeah, we can see the slides. Perfect good noise. I'm not going to be able to see the chat. So I just got up on the phone here beside me. So you have any questions as we go, just kind of pop them into that and I'll get them as we go. All right, Grant. So today we're gonna talk about some of the pediatric specialties. Um So a little bit about myself. So I'm not an S T three uh in Northwest London. I did my training in Glasgow and then my foundation years up there as well. Uh took a couple of years out to work in Australia. So work in Adelaide in the South Coast. I did two years out in that part of the world and then came back in 2020. And since then I've done jobs in kind of emergency medicine pick you. Uh And I've now I wrote here to Hillingdon where I'm doing my final S H O job from even on the registrar in Gen Pedes and the units. Um So today we've got quite a lot of topics to go through. So I said we've got pediatric gastroenterology, neonatal, jaundice, nephrology, common rashes and pediatric infections. Now, um these in themselves are massive topics. Um and very much what I'm going through is going to be very, very brief kind of snippets of information that you're going to need potential for your examination. So a lot of this will be kind of covering the bigger things in small detail and giving you kind of the highlight points that if it comes up in this way in the exam, this is what the answer is gonna be potentially. Um But this isn't going to be enough information for when you go out and work in emergency medicine. Look at pediatrics at that point of view. Um So what we'll do is we'll go through each session, there'll be three kind of sbs at the start. I'll give you kind of 30 seconds to a minute to kind of work through it yourself and then we'll go through each in turn and we'll talk about these components as well, right? So we'll start repeating the gastroenterology to. The first question is, you've got a six week old baby brought in by parents due to persistent vomiting. It's reported to be small and volume after the feeds, the child gets upset during the feeds and we'll arch his back. Oh, hold on. Hyper. Having slide changing issues. Yeah. I don't know. We can see the slides moving. Okay. What about if I this way? Yeah, that's, that's working. Yeah. Want me just to do that and I can zoom in over that. Yeah, that's fine. I think I can see it from there. Yeah, that's open. Okay. Fine. You didn't miss much. Okay. Um, really had a cast withdrawal, you know, to, uh, first question. So you've got a six week old baby brought in by their parents do. The persistent vomiting reported to be small volume after the feeds. The child gets upset during the feeds and arches back but he soon settled on the child is reported to be otherwise well and thriving. So, what is the most likely diagnosis? So, pyloric stenosis, urinary tract infection, gastroesophageal reflux. Hoselton or boil obstruction. Yeah. Yeah. Well, we come to it but yes CC is correct. No spoilers for everyone else. But, um, question too. Um, so we've got a six month old child brought to each of the diarrhea. Call it the abdominal pain and symptoms have occurred recently since starting formula on examination of the soft admin patches of eczema and the Flexeril services. What is the most likely diagnosis? So, we've got a toddler's diarrhea, be gastroenteritis. See celiac disease, the cosmo protein intolerance or e inflammatory boil disease. Yeah, you probably will put your answers in the chat that way. Pizza. Yep. Answer this D and then question three. So we've got a two year old child referred in the clinic after reviewing the community to do faltering growth on examination, the child is small, pale and thin. On review of the red book. The child has crossed multiple sent tiles that is not in a second cental for weight. The reported them loose stools. What is the most likely diagnosis? A celiac disease be per diet? See, hyperthyroidism, the cystic fibrosis e neglect. Yep. So it's good to the answer to that one is a as well. And we'll come to that one last because it's probably the trickiest of the ones, the answer. Um, fine. So we'll move through. So for the first question, um, and I guess a lot of this as well, it's just about a good exam technique and Sony to one of these questions. They've been written exactly that way for a reason and it's always going to sell them. Bear in mind when you do get your, you know, your special day exams or even at the end of final year exams from medical school as well that, you know, every word has been put in there for a reason. So in this case, we got a six year old child with the persistent vomiting, small volume after feeds. So the key word, there would be kind of small volume after feeds, they get upset during the feeds will arch your back but then soon settle down and the child is reported otherwise. Well, I'm driving. So if we were kind of threw water is the most likely diagnosis. Um If this was a pyloric stenosis, the question would probably say still a six week old baby. Um, but you have large volume projectile vomits, they'd also be losing weight. The potentially dehydrated urinary tract infection will come to later on, but this will be a child that will otherwise have an abnormal behavior. So they might be febrile, they might be lethargic. Um And they'll have kind of abnormal observations on examination why this is probably reflux is that it's small volume, it's related to feeds and this can arch in the back and posture is quite characteristic with it as well. And the child can get quite red in the face positive. It's just kind of small volume vomits could definitely be that, but you wouldn't get the upset features afterwards. And then finally, with a boil obstruction, just like an adult to expect kind of large volume vomit, sometimes fecal in nature, not passing stools, none of which is mentioned here in the question. So with your vomiting babies, you kind of the main thing can be thinking about in the exam. So pyloric stenosis which will come to reflux possible gastroenteritis, essentially, you'll have vomiting with diarrhea in the question. Um or maybe a recent travel, but in real life, you don't always get the two of them hand in hand. And then obviously, we want something we can erase intracranial pressure. Um, so, is this potentially like an early onset sign of a tumor? In that case, they might talk about this child having like a large head, they might be er, to build, might have a boat in fontanel, more increased head circumference. And then one you always need to think about in your baby's, is this N A I or have the ingested in toxins as well. But if that's the case, there's going to be some kind of clued a social element as well in the background. So your red flags you think about for babies with vomiting is a projectile in nature, is a bilious or they passing their skills, did their abdomen examine normal? And do they have any evidence of meninges and or other infections? Um Other features of any I which you might cover in other lectures would be, you know, bruising behind the ears, bruising and non bony prominences um or kind of the main ones kind of particular rashes or if they just have a story that doesn't add up over and over again. Um And then we talk about increased head circumference and seizures as well. So moving on to the reflux point of view and so let me just see if I can enlarge that you can actually see the sign on the side. And so everyone gets an element of reflux when it becomes reflux disease is when you start having the symptoms of annoyance off the back of it. So, feed related vomit and the heritable, the back arch and they potentially turn red as well and face. And it's quite common in our babies and it occurs up there with 50% of them. Um And the reason behind that is that they have kind of poor toll in that lower esophageal sphincter. They tend to overfeed quite a bit. So they have natural, better reflux that comes up off the top of that as well. The difficulty that comes to it from a from a treatment and investigation point of view is it's very much a clinical diagnosis um in some of our kids that have quite severe reflux your potential, maybe other health problems going on like cerebral palsy, we might think about doing like endoscopy or, and it can appear it's monitoring off the back of that. And then the difficulty comes in treatment um because not an awful lot of the treatment works and there's quite a lot of mixed messages between what nice guidelines say and then what the European Society of Pediatrics gas withdrawal just say as well. And that makes it very differently, quite unsatisfying to treat with the parents. Um So the main things we kind of say is very much on this and this is what you can write on the exam of this does come up. So avoiding of overfeeding the just in the volumes, you're not giving too much. Um If they're forming a fed, you can think about thickeners, um, breast fed, you can try to Gaviscon and then think about thickness as well. One of the things that they think of whether you need to not confuse us with this is this potentially cause it's not protein intolerance. So, the European Society of Gastroenterologists would suggest that going on a trial of uh avoidance of that first before starting any kind of treatment off the back of it, as opposed to nice guidelines would say, start the treatment first and then think about avoidance afterwards, which makes it very difficult because you'll find that you have a lot of parents come in with the reflux and baby that gets very upset there at the end of their tether, they've tried Gabbas going, they've tried PPI S and nothing really works. And the main thing you can kind of do is reassure them that in most cases as the child gets bigger, they will just grow out of it. So very much in your exam. If you've got a child that has feed related vomiting, the irritable and it's non projectile. This is what you need to be thinking. Has the slide changed know or is it still stuck on the? Yeah, I can still see it's still stuck fine. So moving on to pyloric stenosis. Um So there's quite a common one to come up in the exam. So what you'll get is a male baby because they have a 4 to 1 increased risk of having it. And they will be between the ages of normally six weeks to 10 weeks is when you see it and they'll come in with a tryout, a sense of this projectile vomiting where the parents will say, you know, it'll be quite forceful of a large volume. Um, and no common dehydrated with weight loss and not tolerating any feeds. The rest of the triad is that you can potentially feel a palpable all the shape mass in that upper quadrant where the stomach is invisible paris dialysis as well. Now the times when I've seen this in the emergency department, these Children have come in at that right age have been male with large volume project how Bahman, but none of the rest of the triad with it. But in your examination, that's most likely going to be the stem. Um And then a sense of what happens is the investigations that you'll do an ultrasound. And, and we've got one here and when you got obviously kind of antral nipple sign, so you can see that this is kind of a thick and pylorus here and then this is the bit they say with the actual nipple sign and what you get is a big thick and pylori cause an obstruction and the feet comes in doesn't pass through and come straight back out. And then the character of the blood gas that you see off the back of it is that you get somebody with a hypokalemic hypokalemic metabolic alkalosis and they need to go for surgical management. So in these are six week old boy, projectile vomiting with weight loss, it's gonna be pyloric stenosis unless proven otherwise. Question too. So we've had the six month old child brought in do the diarrhea, colicky abdominal pain and recently started formula and he has a soft adam some eggs when the Flexeril surfaces. So, in this case, um abdominal pain, diarrhea, eczema could be anywhere between cosmo protein intolerance or celiac disease, which is quite prevalent have eczema with that. Um But the reason we put in that a recent form has been introduced to sway toward the as opposed to see. Um similarly a taller diarrhea, this change only six months gastroenteritis. There's no infective symptoms. Celiac disease could be, but they're probably more of a history of kind of weight loss and maybe some other symptoms, inflammatory bowel disease are a little bit too young, but they might have more systemic features as well on top of it. So for diarrhea, you're important differentials to have an exam is is this infection where they would mention fever, celiac cities will come on the talk about inflammatory boil disease. Um and the crime wise or hyperthyroidism is important one to think about um a little bit unusual in message group um but can present as part of some other endocrinopathy disorders as well cause more protein intolerance. Cystic fibrosis is an important one to think about because of their malabsorption. But you'll have a child that has, you know, regular sinusitis, rhinorrhea coughs and also quite small. And in your bigger kids, you always think about drug and juice. So have they got their hands some laxatives and then you have some of the more weird and wonderful stuff like your congenital diarrhea's um or carbohydrate intolerance, like your fructose intolerance as well. Um Finally, constipation with over clothes are very important months. But what you have in that case, the child with infrequent solid boil motions, small watery stools with a bit of soiling potential, some palpable stool in the left iliac fossa. So your red flags you think about would be your poor weight gain, weight loss, um continuous diarrhea or diarrhea at night, which makes you think is there's more of an inflammatory boil disease picture with your blood and mucus in the stools. Then you're always worry about your systemic disease as well. So your holders diarrhea, um it's quite a common reason for Children to present to the emergency department and they'll normally be, normally, we've been kind of 1 to 5 is the outside limits, but normally can have 2 to 4 years old and they'll have quite frequent impressive explosive diarrhea is normally how it's explained by the parents with undigested food. So that will be in your stand if this is the case, but there'll be no other red flag features. So if you've got a well looking child that's completely well grown, which has regular diarrhea. But otherwise you can hit all those milestones, you can probably assume that it's called the diarrhea and you can leave them alone with reassurance. The reason we think they might have this is because if you think about kind of the food that these guys have is a lot of fruit juices. And they've also got like an immature gut and, and all that kind of we linked in the way they just have maybe excess or increased transit through the gut at this time of their life and a law set. Although in as well, your celiac disease and your inflammatory bowel disease, which I'm gonna come on to you, I've not gone too much detail into this because your celiac disease and your inflammatory bowel disease is just going to be the same as adults. So we get the same histological findings. It's mostly the same investigations with it and the symptoms are generally the same um, in our celiac season pediatrics. So you need to be thinking about that kind of after the six months of age and, and the difference mean is that we don't always go straight towards a small boil biopsy. So if they have a raised I G A T T G 10 times above the limit and they have a positive I G A E M A, we normally just go straight towards the diagnosis at that point as opposed to going towards the diet, a biopsy just to save them going through a procedure. And this is from the kind of the S can guidelines as well on the side. So well, see actually easy, they can have either diarrhea or constipation which need to look out for in the stem. But what they will tell you is that no, these Children will have weight loss, they'll have failure to thrive, they'll be peel because of the, the various deficiencies. They might have a peripheral neuropathy off the back of that if the bigger Children, they will have delayed puberty. Um And the other thing they might point you towards is to have, they have dermatitis, herpetiformis or if they have like amfa's authors in the mouth as well. Um And it's linked into a couple specific conditions that you will know about. So, um in particular, if you've got Down Syndrome or Turner syndrome or other autoimmune conditions through your thyroid disease or your type warm diabetes, you are increased. The assistant Jack. So if you've got a child with type one diabetes, they get screened quite regularly for this and then cause more protein intolerance or allergy. Um So another common diagnosis in this age group and it can be kind of I G or non I G mediated and the symptoms are quite vague. So you need to go very much on the history. So when I G media is going to be your anaphylaxis as expected type picture. So, you know, rash, abdominal pain, breathing difficulties, hypertension, dizziness, um and the non I G mediated ones, it's a little bit more vague. So you'll get a bit of nausea, a bit of vomiting or diarrhea, especially around feeds, um food refusal and sneeze and rhinorrhea, bit of conjunctivitis as well. And you can get this in formula or breast fed babies. And that's kind of an important thing to realize. And the advice give off the back of that is then you give hydrolyzed formulas that's partially digested milk to stop them having an allergic reaction to the proteins or breast fed babies, you just avoid the allergen. Um, so where you'll get this is in the exam. If you've got, you know, a baby, they've have kind of generic symptoms, potentially blood and still vomiting, diarrhea, rash. There race introduced a new food, um, will kind of be the key point to take from the history of that and then inflammatory bowel disease. So what's the same as adults will not really go too much into this, but it's as, again, crones also colitis and then in pediatrics, you've got about 15% where they're indeterminant. So we don't really know which way to go and they've kind of got a mixed picture of both. Um, but ultimately, it's diagnosed, the exact seems to do with adults to your barium swallow is your colonoscopy and your endoscopy base. And then you look for your markers of your esr your crp, your symptoms of anemia, signs of anemia. Um I like your ankles and stuff like that. And our management is maybe slightly different in that. A lot of our kids, we manage and actually just on an elemental diet. So when they get admitted, they go for six weeks on these kind of awful protein shakes. Um and the idea is just essentially rest the gut. And the reason behind that is that we as much as possible, we do try and avoid steroids, but in these diseases is quite necessary. And I guess the risk with giving lots of steroids to Children is they can have kind of a knock on effect on the growth. It can cause kind of bruising issues or infection issues as well as the kind of immunosuppressive them, which is quite difficult. Um But yeah, so I think in this case, it's normally older Children will come up on the stem. You might have some blood or mucus and still abdominal pain and maybe some systemic features of kind of arthrology H E I E s. And that's kind of where you need to be thinking is it's inflammatory bowel disease opposed to anything else. But the management is elemental diet, steroids if you need another IV or rectal and then your maintenance the same. So your meth isolate scenes, your thigh. Oh purines and, and protects, you know, the immunological, the biologics like Infliximab, riTUXimab, which we're using for a lot of our Children now with really good effect and obviously your surgical management as well. So if they come in with a toxic megacolon, um so your acute abdominal pain, febrile, the standard admin, understand it and colon, that's what you're thinking about there. I'm finally the last one. So this was the child with faltering growth and they're small, they're pale, they're thin. So there may be anemic and they've crossed multiple sentences well, in the stools. So I guess from this point of view, um, Celiac disease, the number one diagnosis, poor diet is a potential for it. Um But there's maybe not enough in the stem to suggest that they've got a reason for poor diet is somebody neglect. So if there was maybe social aspects mentioned, that's need to push you towards that point of view, hyperthyroidism, you'd expect other features. So, you know, um heat intolerance, sweating, tremor, tachycardia. Um And normally these guys are quite tall as opposed to small and they get accelerated growth, but they are quite thin. So that might put you that way. It's supposed to see ax and then cystic fibrosis is probably the one that's up there most because it would present very much like this in the younger Children. Um But at two years old, you'd expect them to mention, you know, they're having a cough they're having sinusitis, they're having multiple chest infections as well. So we've already kind of talked about the celiac disease. The one thing we kind of want to get through here is that when we talk about someone that's failure to thrive, it's not a diagnosis. So it's a, it's a symptom of an underlying diagnosis. Um and it's because there's something else going on the cause this child not to really reach their markers. And you can think of it as kind of organic or non organic. And only 10% of these guys actually have an organic underlying cause. And it's quite simple. Really? So, are they not getting enough food in? So do they have an upper upper area but oral problems that to somebody, maybe that's got a cleft palate or does somebody have three re palsy where they've got like a pseudobulbar palsy off the back of that? And can't swallow? Do they have quite severe reflux? Do they have a malabsorption issues such as your cystic fibrosis? Um or do they have an underlying chronic health disease, like heart disease or renal problems or cystic fibrosis like that where they're having a high energy output due to recurrent infections causing not to grow or do they actually have a growth control problems? So we're talking endocrine issues more than anything else or underlying syndrome such as you're Down Syndrome or your Turner syndrome and then your non organic causes a bit more common sense So are they really just unable to have a good intake with poor technique? So you're breast feeding babies? Do they have a poor diet? Is there a permit time environment at home? So you're thinking about, you know, is there are lots of stress is going on or they're multiple Children? Is there may be a single parent household and you need to always think of what your neglect as well. So just from a very quick run through the pediatric gastroenterology, does anybody have any questions from that point of view? Um I guess the things that we've not really covered is more the surgical aspects of things. So like your Hirschprung's your cause of constipation, which are all probably follow things that potentially come up on the exam. Um or your meckel's diverticulum as well. Intussusception are all quite valid. Any questions at the minute? No. Okay. Okay. So neonatal jaundice and so this, well, a lot of us will come into contact with if you through GP or emergency medicine or if you have a new job in pediatrics and it becomes kind of your bread and butter with it. So we'll go on the question once we've got a two day old baby referred into the hospital by the health visitor due to jaundiced appearance, they returned normal delivery with new antenatal concerns on review. They had a Billy Ruben above the threshold for phototherapy and they're admitted and commenced on treatment. Initial investigations show no evidence of hemolysis on blood film. And the child examines otherwise well with normal observations, what is the most like a diagnosis we've owned? The next one you've been asked to review a 12 hour old baby who is profoundly jaundice on the postnatal ward. They're lethargic, they have poor tone and they've got evidence of respiratory distress. What is the most likely diagnosis? A HBO incompatibility be early onset neonatal sepsis? See physiological jaundice, the hereditary sphere cytosis or E G six PD deficiency. Mm The last one. So we've got a question. 33 week old baby has been referred in the emergency department to persist and jaundice there. The first baby of non consigned witness parents, they have pale stools and dark urine. What is the most likely diagnosis? Airing their needle sepsis? Be heredity serious cytosis? See biliary atresia, depressed mood jaundice or e choledochal cyst. Mhm. Good stuff. Okay. Right. It's a question mom. Uh So this is a two day old baby referred in the hospital. They had term normal delivery of know antenatal concerns and they had a belly written above the threshold before the therapy and they, they didn't comment on treatment. So the initial blood films with no Evans hemolyzes uh and they examined well. So uh so this is physiological Doremus. Um and we're going to talk about that now. So I guess the reason is not the other one. So be I've not really told you that the breast fed. So we can't really assume that it's just kind of down the exam technique, neonatal sepsis. I told you to examine well, and it doesn't look like there's any risk factors. Uh ab oh, incompatibility potentially. But I've told you that there's no evidence of hemolyzes on the blood film. And finally, e hepatitis, there's nothing to suggest that in this them, what you'd be thinking there is potentially no recent travel, no antenatal care um or potentially some social concerns off the back of it or if they've got other people unwell at home, if you're thinking of hepatitis A for example. So Nene all jaundice. So I don't know if you have done your pediatric rotation yet, but hopefully you have all kind of come into contact with it. So it's horrifically common. So occurs in about 60% of our term infants and about 80% of her preterm infants, which just as a refresher is any baby under 37 weeks. And the reason we get really stressed about neonatal jaundice is that it can actually cause connect risk, which is where the Billy Ruben crosses the blood brain barrier barrier and causes in an n careful apathy off the back of it. And it can be quite severe resulting kind of lifelong disability, even death and the symptoms that you get up. John is there quite non specific. But apart from the obvious jaundiced appearance, which can be quite difficult at times to tell. So the best way to kind of notices from the kind of sclera off the child, but it usually starts from the head down, them, progresses that way. And these babies then become quite lethargic and as a result of quite poor feeding off the back of it, and the manager you can see here is that we put them under the phototherapy lights. So the graph that you've got up here is what we use for our treatment threshold. So it's dependent on the gestation. And normally then depending on the time of life along the bottom of the cross, the blue line, you then you put on phototherapy. And if you cross the red line, you get then referred for an exchange transfusion at that point. Um The phototherapy itself is here so it can be done on the postnatal ward and it's got a light over the top of it and it's not UV UV light is very close to on the spectrum and doesn't really have any kind of negative long term effects as far as we're aware at the minute. So the investigations are nice thing you need to do with these guys is you do a slip belly ribbon, which is essentially look for a conjugated, conjugated Billy Ruben to figure out where the Johns is coming from. You want to do a group and uh that which a sense you want to look at the maternal and baby's blood group ancestors, an HBO incompatibility and then do a full blood count as well because we're looking for signs of infection. Um We're also looking for signs of paralysis with a low H B and in physiological jaundice who from what I've read, only about 1.2% becomes sufficiently jaundice enough for, but it figures they've got an awful lot higher on the postnatal ward. Um And the reason these guys get physiological John, this is that they have red blood cells which have a like a shorter lifespan, normally kind of 40 to 70 days. Um So they've got that increased turnover of mosses in the first couple of days of life. And on top of that, when babies come out, if you know, had a bit of traumatic delivery, they're being a bit bruised and beaten, you've got blood broken up from that point of view, they've also got quite an immature liver on top of that. And, and in the first couple of days they're feeding isn't fantastic. So their inputs not wonderful. And as a result of not having a good input, they don't have a fantastic output. So whatever, Billy Ruben, they are converting across in the liver, they're not excreting the back of them. Um and these breast that babies then can also have higher bilirubin levels that can go for longer. And when we talk about breast milk on this, um it can last for maybe four or five weeks off the back of it. And the reason that we think this is is that in the breast milk, there's beated look arana days there, which we think increase the reabsorption of Billy Ruben. But these guys don't normally tend to need phototherapy. So they just tend to kind of sit along with like a low level of Billy Ruben that doesn't really need treated and they need to be a very well thriving child. So when your stem, if they tell you, you know, this is a one week old with John, this their breast fed, they examined beautifully. That's when you need to be thinking about that. Um if they don't mention breastfeeding. Um and I and it's there may be a little bit earlier in life. Ted Hensley go along the physiological jaundice route, the red flags that you guys need to be aware of for John, this is the sense that if it happens in 24 hours or if it happened after two weeks and the reason we were able to happen within 24 hours, we were thinking, is this the hemolytic picture that's occurring or if it's progressive after 4, 14 days were thinking, is there an obstruction somewhere or is there something a bit more weird and wonderful and genetic or metabolic going on underneath the surface? If they have people, then if they have a set up for like an Avi or Reese's and compatibility and internationally, if you've had a sibling that has done if you're more likely the needful of therapy as well off the back of that and, and if they've obviously got a history off in a red cell defects, so your G six PD, your steroid psychosis or if they have any set up for sepsis is big things you need to be concerned about. Um So then question too, when we want to talk with the different types of kind of jaundice that you're more likely to see. So this baby is essentially septic. So we've got to join this child who's auth or Jik poor tone has evidence of respiratory. This address and John, this can be a sign of late or early onset sepsis in the neonatal population. When we come to talk about neonatal sepsis. Later on, they can present horrifically vague. So sometimes quite difficult to tell what, what and they're under 12 hours old. So this could definitely be an aviall compatibility because they're on the 20 over told pretty normal manager Catholic. Um hum and you just kind of lead. Uh So it normally kind of goes away by itself and you and you just yeah, you just monitor it. Um So in that case, what your word was, it is subgaleal, which is a different area where the bleeding is because you have shared in the vessels. But a Catholic hematoma is kind of a contained better bleeding from birth trauma that blood breaks up over time. Blood breaks up causes jaundice and, but then it will eventually resolve the normal and there's not really any kind of underlying issue with like propped concerns with the brain or the skull itself, but these guys get super jaundice. So that's kind of why you, you keep an eye out for it. So you can prepare the parents that if you go home, there's a good chance he might be coming back, just keep an eye out for it. Um So humanlike disease in a newborn is another one you can happen. Um And under the 24 hour period, so it could be kind of A or D or potentially e because they're all hemolytic pictures. But in that case, you'd be explained that there's a blood film or they've got a low hemoglobin or there's a set up somewhere in the family for it. Um So that's not the case. So hemolytic disease of the newborn. And so what I always kind of struggle with when I was a student was getting this one mixed up with the kind of A B O incompatibility as well on the top of it. So, in hemolytic disease of the newborn, you've essentially got antibodies that I've been foreign against the baby's blood. And this happens in the second, normally pregnancy or onwards. And what happens is unique kind of a sensitization event to occur in the previous pregnancy or sometimes it can happen during the pregnancy itself. So if you think about if mom's had like a maternal trauma or they've had like an Anthony know procedure where there's mixing of the blood or she's had like an antenatal hemorrhage, like a P H and, and the main, when you think about is kind of the recent ones we all know about, but there's other, more weird and wonderful antibodies as well so that you're anti C E, Kell and Duffy. Um, and the way they kind of present that is prevent this by giving anti D to the mom's. But I'm sure that will be covered more in the obstetric portion of things. And the reason we're stressed about this is that um these babies become quite anemic and so either anti in Italy or after they're born, they have quite high jaundice. So normally kind of closer above that exchange transfusion and it can be quite resistant to treatment as well because the antibodies hang around for for some time. So even though if you bring the jaundice levels down, you take them off the lights and then at Billy Ruben starts climbing again. So you can have these Children being on the war from a week to 10 days as they kind of rebound up and up and down above the treatment lines with it. And in some cases, they need to go for um for exchange transfusion where the sense you just change out all the circulating volume to see if that makes a difference. So how you can kind of tell the difference between the Kenya, your resource wants your A B O and compatibility in your exam is that Reese's Disease. They'll tell you that, you know, they might say mom's negative, they might say that this is the second pregnancy and they have a strongly positive dat test as well or DCT was still written here for your A B U point of view. So mom needs to be oh and the fetus ARB. Um So they'll potentially mention mom's blood group or they might mention baby's blood group and this can be a first pregnancy. So that's kind of how you maybe the friendship between the two, your other hemolytic stuff. You need to think what I've got up on the box. So your G six PD deficiency. So they'll potentially mention that there's a history of this for serious cytosis. They might mention ethnicity. So they might say that, you know, they're Mediterranean or European um or they've got like a sibling with it. Um How you, the kidneys is a lot rare. So it's probably less likely to come up um sepsis and called hemolytic hemolytic picture. So, you know, they'll have other symptoms of being unwell thalassemia. Similarly, they might mention, you know, where the family's from. So they might mention there plenty of Asian or Middle Eastern and that might put you down that point of view as well. This isn't hard and fast rules for win in real life, but I'm quite aware that when you're in the exam, they will write these clues for you and that's gonna point you towards that picture and question three. So this is the prolonged jaundice. So prolonged on this is essentially anything over 14 days in a term baby or 21 days in a preterm baby. And in this case, he's got persisted on this, you know, the parents aren't related. So we're thinking there's probably not like an underlying genetic component here. And they've got pale stools and dark urine, which makes think there's an obstructive picture. So this is gonna be kind of posthepatic. So in that case, need any, those sepsis have not really put you down that line to tell you what they look like. Sphere cytosis, potentially not billary trees is the main one you need to think about for prolonged jaundice with obstructive pictures and maybe choledochal cysts as well. And that's gonna how you go down that route. So your prolonged on this, as we said to anything over 14 days in your term baby and the causes are quite widespread. So they can have your kind of hemolytic picture. So they've got your red cell defects like your G six PD or your sphere, psychosis, you can have structural causes. So that's when we think about our biliary atresia or your choledochal cysts, they can have liver disease. So you have hepatitis or they've got, you know, cmd, any of those kind of infections um And the things you need to look at from that point of view is the family history is the obstructive symptoms. Um I don't know what I found a history in twice. And the main thing that we need to kind of get these aware about is that this needs to be an urgent referral. Um As we come to talk about Hillary Atresia, it is quite a time critical thing because the quicker they can get reviewed and get that ruled out if they do need to go for treatment for Valerie Atresia, the sooner the better. So anything under 90 days, what you're kind of aiming for? Um and this is kind of some of the things that they want you to ask for when you look at it. Um So these prolonged dramas, do they look sick to, they have signs of dehydration, have they regain their birth weight? For example, it's kind of a good sign of how they're feeding school. Um Do they have any issues why they can't feed to a cleft palate? They're quite a severe tongue tie. Um And also then you also want to look from like a G I point of view. So do they, do they have like a patent anus? Is there any kind of malformations? So there that might suggest that everything else in the abdomen is not really formed correctly? So with kids, one of the things you always do want to think about is you know, if one thing is not there or one thing is malformed is anything else malformed with it. And that's one of things need to keep. So biliary Atresia. So 1 17,000 is kind of from the literature that I've been quoted. And what happens is you can either have a congenital absence of parts of the military or you can have destruction of the biliary tree where they have kind of this uh inflammatory Collinge itis, um which results in fibrosis and cirrhosis of the liver if it's not treated. And like I said before, I can have quite a lot of other associations. So it's associate pancreatic issues, cardiac anomalies, intestinal issues or mall rotation. Nearly 100% of these guys have splenic issues. So kind of an asplenia or missing parts of the spleen and it's associated with your Down Syndrome as well as the main ones that tries me. 21. Um So on that note, you know, if you've got a prolonged on this baby and they mentioned they've got Down Syndrome, biliary atresia needs to be up there. Similarly, if they say that, you know, you've got a child who tries me 21 that has um like an obstructed abdomen, sort of picture, then you think it's his duty or atresia because they kind of go hard and hard. So with your ability of trees and you'll get your prolonged jaundice, it's gonna be conjugated and you're gonna have transaminitis and you're gonna have a pattern megaly as well. On the abdominal ultrasound is that leverage of swollen because it can't get rid of the bile. And then it's diagnosed then on a sense of a colon on cholangiography is your main thing to do and potential liver biopsy as well. And the treatment for that is a Kassai procedure which is done with us in Kings. Um And what that is they sent to attach the liver to part of the small intestine so that the by you can drain that way. And why I was saying you that it was time critical is, I don't really know how well it projects across. But if you, your four year and 10 year survival rate is roughly about 50% if you're getting treated within 30 days with your cast I procedure. But if it's over 90 days, you're looking, it drops into anywhere between 15 to 20%. And a lot of these patient's will ultimately go on to need a liver transplant off the back of these as well. So it's one of these ones that were quite conscious about not missing. Um I've not gone into the in's and out's of your sphere. Cytosis zero G six PD cause a lot of stuff will company your hematology point of view. And, but it's just to be aware that, you know, these are one of the big things you need to keep in your mind if you've got a child with jaundice? Any questions from the jaundice point of view? Cool. Ok. Nephrology we're getting in three out of five. So a two year old boy, he's not passed urine since birth, antenatal scan showed bilateral hydronephrosis is. What is the most likely diagnosis? Four year old girl has brought into the emergency department, do the facial swelling, abdominal distension there, a febrile but hypotensive on your in depth there found a four plus a protein. What is the most likely diagnosis? It's a bit of a giveaway because we're in the nephrology section of the question trees. We've got a sexual patient that's brought in the marriage department. You to cook a cola colored urine. They're otherwise. Well, there are no rashes. On examination of note, they had a bad throat infection three weeks prior. What is the most likely diagnosis? HSP hits us? Who strapped the car? Premarin nephritis, aha nephropathy, selling nephritis. Nice, good job. Okay. So, uh to the old boy is not part of urine since birth, ante nose council bilateral hydronephrosis is boston looks like a diagnosis. Quite a nice straightforward one. So I guess if we're looking through this, a urinary tract infection isn't going to give you bilateral hydronephrosis is anti in Italy. And you also have to be really, really unlucky the two day old boy, either urinary tract infection. Um The only time you might think about that is potential if he's got quite severe reflux nephropathy. And he's got the hydronephrosis off the back of that and then he's developed a uti um so potentially an older kid if you've had that, but you have one symptoms of them in a bit more unwell obstructive uropathy makes the most sense of not past year and something's not working. It's likely to be that renal vein from boxes. So this does happen in our, in our babies. Um So what happens with these guys is they can tend to have it when they're very dehydrated or they can have it as a neonate where they've been admitted and they've had multiple kind of umbilical lines put in or they've had an umbilical line, put them and that increases the risk with it. And similarly, that an arterial line and increase the risk of like a renal artery stenosis as well. Um So not an uncommon thing to happen. And what happens to these kids, you might have a palpable mass on the liver side, but you'll have hematuria is the main thing to look out for. So, in this case, they would be maybe slightly older, they have hematuria, potentially a palpable renal mass. Um And they'll have a history of being preterm as well. Put you down that route. Um Tumor, yeah, you know, potentially. Um but with the signs of a bilateral hydronephrosis makes a bit unlike you'd have one single tumor and how that would work. And I plopped disorder is not really appropriate and So just talking through briefly your obstructive uropathy. So most of our babies will pass urine in the 1st 24 hours. And, and that's kind of one of the main things is pediatricians. We can call to see a baby that, you know, they've not paid in the 1st 24 hours and you need to come and look at them. And the main thing that you're worried about is there an obstruction potential to steer urethro bowel, which is what you don't really want to miss. Now, in most cases with this, um they probably have past year and it's just been missed or it's been mixed in with the poo and you can't really, they just kind of missed it. So it's not really too much of a worry and I've only really seen a posterior throw valve once in the knee in it and they were a child that it hadn't really been flagged up that hadn't peed in about 2.5 days, three days. So they were actually quite sick in the end up. Um So things that might suggest you got a uropathy or an obstructive uropathy is the antenatal scans have been noted in the history. So, do they have oligohydramnios because they're not passing urine? Do they have hydronephrosis because nothing's coming out and it's all back flowing up and in posterior refill valves, what happens is in the posterior re throw, they just got like an extra fold of skin, which acts like a functional buyer so that the urine can't go out. So as a result, you get this big hypertrophic bladder and then you get reflux back up into the, your orders and get a bilateral hydronephrosis as well with that. And at that point, it's a quick referral to the pediatric surgeons. They potentially can either pass a catheter in first through the urethra to try and unblock it that way. But normally they get a suprapubic catheter in place and then they get reception further on down the line. So in that case, they'll say meal, abnormal antenatal scans, bilateral housing of process, not passing urine is what's going to put you down that way. And then pelvic ureteric junction obstruction is your P U J is short and it's usually one sided and you need to be a little bit unlucky to have both of them. So what happens there is if you've got a unilateral Hytrin or process, but this child is still passing urine. Um And now we'll put you down that uh question too sorry. And I'll actually, I've got a little bit here on urinary tract infections as well. Um And that's just something to kind of be aware of. So, are most common urinary tract infection cause e and how do you check? So you, so you can't really check. Um So you need to kind of go off the history. So what that will be is not passed urine. Um and, and then they will have had antenatal scans which might show hydronephrosis at that point. But normally what happens is if you've got a child that's not passed urine after kind of 36 hours and you should be able to kind of palpate the bladder, which you might maybe be able to feed. There might be kind of real angle masses, but it'll be a quick abdominal ultrasound scan is what you're looking for and referral to the surgeon for further assessment. So it's not something that you can just pick up on examination. Um It's more from that side of it that they've just not past, they're just not past year is what, you know, and renal vein thrombosis is more common in premature babies. It's because we're more likely to put umbilicus venous catheters. Um So if you have done the in age yet, you know, that we'll put um arterial and venous central lines in through the umbilical vein and artery. And what happens is that just means that they're more at risk of having a renal vein thrombosis because we've essentially put something in somewhere where it shouldn't be just like how you imagine, you know, when people have like multiple cannulas or they've had multiple infusions, their veins get a little bit from boost and they get a little bit, you know, corded. It's the same idea except in a premature baby, you've got smaller veins. Um So uti so what you need to know is equal. I main, main one that we're worried about. And so you have a question about most common cause equal to. And in our pediatric population bothers you more likely to get um your infection under six months and then boy cares over six months. Um And the main things that you need to kind of think about the causes of your urinary tract infection. So they could just be a little bit unlucky. But one of the big reasons that goes kind of have that have a constipation and the other things need to look out for is do they potentially have a structural defects? That's when we look at like, you know, your poor urine flow or do they have like a nephrogenic bladder? So, because they probably be an underlying, explain a bifida or neurological problems. So they might have lower Limmer back issues. Um Your antenatal renal abnormalities will go hard and harm the structural issues. Or if you've got like a family history of like cystic polycystic kidney disease. And the things that usually to look out for, I guess is if they ask you, is this maybe in a typical UTIs, your atypical UTIs might be, then do you, do you like Klebsiella is what I can think of off the top of my head? And what makes you think it's something a bit more atypical as opposed to like a straightforward equal. I is, are they seriously ill is maybe a palpable abdominal masturbate. Does. They've got an abscess. Have they got the rain renal function off the back of it or they maybe not responding to treatment and $48. And these guys then all end up needing to have kind of further imaging. They assess for underlying structural issues. So if they have reflux and then assess for renal scarring as well, the dumps a scam and the reason we worry about renal scarring is because that just means you've got to support of the kidney which isn't really working. So then these guys then have issues them with hypertension that are all but in the exam equal way. And then last one that normally likes to come up is Wilms tumor. So this is the one of the most common uh pediatric tumors around 5% with that. It's a solid tumor and it's mostly occurs under 10 years old. And what you'll get in the exam is they'll give you a history of um essentially a mom or a dad has been bathing their child and they found this large abdominal mass and there may or may not be paying there may, may not the hypertension, but usually it's a symptomatic and, and the ultrasound it to look to see where it is and then they go on the CT or MRI and you can see here on an X ray actually that they've got this kind of good going solid mask and on the left hand side, which is pushed kind of the boy up and around. And so in the exams, you know, if they're like a symptomatic abdominal mass found during bath time in an under 10 year old, it's going to be this, they don't need to give you any other symptoms right. Question too. Um, if this wasn't in nephrology section, um, this is maybe a bit more open to interpretation. Um, so you've got a child with facial swell, abdominal distention and there's a fair, right? And hypertensive and they've got urine dip as well. So all, all of these things can result in kind of generalized swelling and so hereditary angioedema, what you might find is they'll be facial swelling, potentially breathing issues, rash and, but they'll not have been any identifiable trigger. They might have had multiple episodes. Anaphylaxis is anaphylaxis. So they'll have said there have been a trigger that have had like a peanut butter and jelly sandwich or something like that. Nephrotic syndrome is this because they've got a facial swell and they've got a cities, they're hypotensive and they've got protein area, okay. Abdominal tumor can give you abdominal distension but shouldn't really give you facials. Well, an acute liver failure could give you a society's as well. Um, shouldn't have facial swelling and protein, your ear. So the Froehlich system is quite a common exam question. It's quite common as well in real life and what your trial that you get this exact same as adults. So you've got protein, your ear, you got low albumin and your, your edematous. And a lot of these kids present with really, really puffy, swollen face is swollen, hands and feet and growing and abdomen, uh edema as well on the city's. Um and the main cause behind this is kind of your idiopathic and fraud extender, more minimal change, disease is what it's kind of caused. But you can get other, more weird and wonderful cause as well. So you get like congenital nephrotic syndrome and our babies, it can also happen as a result of infections or underlying immune disorder too as well. Talk about on the next slide. Uh And the treatment that you guys need to know is essentially started on steroids and the dose for that is quite well known as UK wide. It's 60 mg from meter square per day and that from our point of in London goes for four weeks and then you have a winning program off the back of it. And then the other things that you do for your renal patient. So you start on diuretics for their fluid management and they're low salt diet as well. And these guys potentially go on the bike prophylaxis because in the Frederick Nephrotic syndrome, you've got a big leaky glomerulus and everything is kind of getting lost. They lose a lot of it immunoglobulins as well. So these guys are increasing aggressive like a strep pneumonia infection, um, and various things like that. So sometimes we put them on prophylactic penicillin be if they're not immunized or anything like that and they continue on the Fradique Syndrome. So the things that you need to look out for is the definitions that might come up is with or nephrotic syndrome. They have to go undergo daily, early morning urine dip to look for protein urea. And that helps us guide the management and the important definitions that you need to go is there in remission, if you've had a normal, which is um less than two plus on a urine dip for three or more mornings and then a relapse that I have three plus in protein urea for three or more mornings and then they're relapsing. Frequently. Relapsing is two of these relapses in six months and steroid resistant is when they have no remission after four weeks of treatment. And one of the common questions come then is when do these guys ever need referred for renal biopsy? And so these one that kind of remembers from the age point of view. So anybody less than a year, over 12 years, um if they've got hematuria, which is persistent, another things as well as if you've got a low C three, if they've got signs of renal impairment or hypertension if their steroid resistant as well. Um And the complications that can happen, these guys. So we've talked about the infection. Uh These guys are an increased risk of thrown boost is because they lose and they're antithrombin three and protein C N S in the urine. Um Also the fact that all these guys are in mobile, they're on steroids which are increased your risk as well and they're normally intervascularly dry or depleted. Um What you're kind of the main things to look out for and then question three. So uh all your glomerular nephritis is which is quite good to come up on the exam. So in this case, the character thing that look out for is the Coca Cola colored urine, which is the kind of textbook uh line they used for post streptococcal glomerulonephritis. All right. Um Of otherwise they said they had a throat infection three weeks prior. So we'll talk through each one of these ones apart from sle nephritis in the next couple of pages because they're quite easy, wants to get your head through them, what their differential features are. Okay. So your post streptococcal Premarin and Fridays is, as it says on the 10. So they've had a streptococcal infection um anywhere between kind of one week to three weeks beforehand, know that can be a sore throat or it could be a skin infection, which is something that they can throw in. And these guys think that the immune deposition on the memory light and as a result that gets inflamed about karate enough off the back of that, they'll have the features of glomerulonephritis, which is kind of persistent across all of them. So, hematuria, proteinuria, they might get nephrotic syndrome, hypertension and low urine output as well. And what you find on these blood tests, they might say they've got a positive S O T or they have a Lucy three, which is one of the kind of differentiating features between that and I J nephropathy, um which is sometimes people get confused between them. So, the difference between the two of them essentially is that what you'll find is when you talk about iga nephropathy, and they will either have a respiratory infection or they will be just couple of days after respiratory infection. And that's gonna how you tell the difference between the two from an exam point of view, they get I G A deposition on the camera light, it causes inflammation and then they get glomerulonephritis. Um And these guys, whereas with post at the clock to Oakland Mary in a friend is supportive. These guys get treated with ace inhibitors initially to kind of prevent any renal damage. Um So in your exam, if they say respiratory tract infection a couple of days ago, it's gonna be iga nephropathy. And they might mention you got a normal C three. If it's post streptococcal, it'll begin weeks after and they'll have a, a low C three as well or C H 50. And they will mention the throat or a skin infection HSP is another good one to come up. And so this is a really typical rash that you see here. Um So with H S B is the most common vascular is that we get in kids. Um 70% of these guys will have some form of renal involvement. So whether or not that is hematuria protein, very or hypertension off the back of it. Um But how these guys present is they'll have abdominal pain, they'll have arthritis, arthralgia, and they'll have renal symptoms with this characteristic rash. So they'll have a mixture of pure, pure uh patiki eye which will involve kind of from the bomb down is where you'll find it. So, and then they might also have recently had a trigger such as a recent respiratory tract infection. We're not really too sure why it happens, but when they, when they biopsy the skin lesions um or when they send off there and they found there's been some immune complexes there, which may have been I G A. So whether or not it's like a hypersensitivity reaction, their previous infection, we're not really too sure. The good news is that we don't need to do anything for it. So you just have to sit and wait, reassure the parents um keep an eye on the renal function. Um If they do develop renal impairment with that, we do think about starting uh steroids. Um But the steroids and the answers are more to help with the abdominal pain or throws er um, and the renal impairment gets managed by our renal tertiary centers here. So, in the exam, if you get a child, normal music, 2 to 6 with abdominal pain, arthritis and uh purpura, the lower limbs HSP is going to be your one up there. The one that you might need to differentiate that against them will be your HumaLOG kick, your Remix syndrome uh which can give you widespread, pure, pure Patiki Eye. But the difference with this is that they'll give you a previous history of recent bloody diarrhea, which might be suggestive of the equal lie infection. So, hemolytic uremic syndrome is this trial out if you're a hemolytic anemia, thrombocytopenia and these guys do get acute renal failure off the back of this. And it's one of the most common causes of us, our Children having renal failure and end up needing dialysis with it. And in the exam point of view, it's associated with this echo I 0157, which is kind of your buzzword that you need to know. And a lot of these guys come in, they are unwell. Um and they end up needing transferred to Great Ormond Street Renal team at that point of view for very close kind of fluid management and potentially going on the dialysis machines off the back of it. So you're difference between the H S P and H E s and it comes up is yes, they will have Patiki eye and purpura, but your H S P will have abdominal pain and a little bit of arthralgia and will otherwise look okay. Your H E S kids will have bloody diarrhea, they will be sick. Uh And they might mention like recently other people being on well in the family or recent travel as well, just a bit of kind of general vision in the corner. So your dialysis criteria is normally of persistent acidosis if you've got persistent fluid overload, despite diarrhetic management, hyperkalemia, refractory. But also I've known that they take people that have like generally quite this deranged electrolytes, even if it's not just the potassium and then symptoms of your email as well as urine, careful apathy. Any questions, no point of it, we're going through this quite quick. So I'm happy to include on and go into more detail that people need. Okay, move on the rashes grant. So with regard to these rashes, I have not gone, I've not talked about eczema or psoriasis or any of those things. Um And the reason behind that is because they're quite similarly managed and quite similar presentation to what you get from the adult population as well. And I would just maybe make sure they use know kind of the different areas that eczema presents between like babies, toddlers and bigger Children. Um Sometimes that can come up in a question, but a sense of your management much the same, you know, emollients steroids uh phototherapy. Uh Not for the therapy if you like. Uh OK. Question one, you're asked to see a three day old newborn to the following rash. What is the diagnosis? So, a or a few meloxicam's be neonatal postule osis melanosis. See, strawberry nearby the salmon patch. E Port Weinstein. All right. Question too. Uh Non vaccinated three year old presented E D Fair Bride with a widespread rash. He has hepatosplenomegaly on examination and in large tonsils. What is the diagnosis? Uh So I can take out, don't back in a bit dot So now a three year old presents the E D February, the widespread rashes, a participant of Meghan examination in large tonsils. What is the diagnosis, er theme of multiform be streptococcal infection, scarlet fever, see er theme of margin at um the er theme of migrants e measles take that and nothing. Uh Question three, we have a four year old child on review in the GP clinic was found multiple flat mark you als. They also found the freckles in the inguinal and auxiliary region noted to have normal development and no evidence of precocious puberty. What is the most likely diagnosis to McCuen Albright syndrome, neurofibromatosis type one C Cipro sclerosis D Sturge Weber Syndrome or E normal variant? Right? Cool. The question one. So this is erythema toxicum. Um So we're going to go through all the different um neonatal rashes that you're probably gonna be asked to see and similarly some of the birth marks as well, which are quite important to be aware of. So, with the earth hemotoxic, um so we can kind of see these we small white postures here, a little bit of redness around it. And similarly on this picture, it doesn't kind of let me see if I can bring a bit bigger, doesn't really sure that, well, we got a bit of redness here, a bit of redness there, there, a new other really defining features with it. Um, um Quite a common rashes completely benign. It's not life threatening and it can occur anywhere in the body. And one of the things you're going to find is that it occurs in the 1st 24 hours and they can kind of process up to the first two weeks. Um, of the family will tell you is that, you know, it moves around, it can sometimes change with regards to heat and position. So if they've maybe been doing skin, skin or breast feeding, you can find that the rash moves around with this with it as well. Um We don't really know what causes it. And the way I kind of explain it to the parents is that it's kind of like the body's reaction and I've been outside the womb, it's nothing really to worry about it. It'll go away by itself and doesn't really leave any kind of lasting issues and it, and there's a rash, it can have a little bit of everything. So it can be posture and the small populous, that kind of flat red macule. Um, and there's really nothing you need to do for it, but it can be quite severe looking and it can be quite scary for the parents, especially the first time. But the note of this, you have a very well looking child, it will be a migratory. It'll be a mixture of rashes and there'll be no setup for infection and that's what's gonna point you towards this. Okay. Uh Neonatal postural oh Smell notice. Um Essentially it's kind of like a branch off erythema toxic on. Um But depending on where you read, they might put them either separate or in the same bracket and you'll get these small kind of posture formations kind of all over the body doesn't really show up here, but they're very much here around the ears and up on the scalp line. Okay. And what happens to these postures that they can burst and they have like clear fluid in the middle of them and then they'll leave like a pigmented area underneath which will fade in time. Um So once again, it's nothing need to do about it. There's no long term investigations, but if you got a picture or they describe a widespread postular rash with no macule and then maybe burst, that's probably something you need to think about. And now we're gonna move on to the birth marks. So uh strawberry nevis or infantile humans. UMA. Um So you've got kind of two different types here. So this is quite a deep one. Um and this is a bit more superficial as well and it's just an abnormal collection of blood vessels essentially. Um And your risk factors for this sort of in a low birth weight, if you've got an advanced maternal age, preeclampsia or present the previous as well. And what you only find there's only really one lesion and normally on the torso upwards. And the way they kind of happen is that they increase in size up until the first year or so. And then they can involute on themselves and they then disappear. Um, the only time we would really get involved is that if it's potentially causing an obstructive symptoms, so potentially know if it's over the eyelid and it's, it's affecting their vision, um, or if they've got multiple ones as well. So if they've got multiple ones on their skin, it increases the risk of having human humans on the organs, you normally abdominal after something at that point. And what you're looking for is signs of like liver, humans, humans, uh, manage me that you can do so they can have surgery to remove them. You can use topical beta blockers, more embolization and really, really big ones and the complications of these guys because they can kind of catch on the clothes so they can become bleeding or ulcerated and then become infective. Um The local symptoms that we're talking about there is the obstructive features. So what will happen is you might get a picture of this and they might say that, you know, it's, it starts off and they say like flat and pale, like a heel. Oh And then the hemangioma grooves on top of it and then manage um itself will be raised. It'll be like red or purplish and it'll be blanching when you talk, when you touch it because you can imagine you're just gonna pushing the blood out of the way. Um And we don't need to really do anything for them unless they're getting the way of other things, your salmon patch, your stork by your nevus simplex, all kind of same words for the same thing is another uh vascular malformation of the capillaries. And you normally find it kind of the base of the hair and it's really, really common in a lot of our babies. So, about 40% of the population have affected by it. And what happens is it normally fades away by kind of the second or third year of life. Um And similarly, as our hair grows out, it covers that area anyway. So it doesn't really cause that much distress. And what that will be described as kind of a flat area with the regular borders on the back of the, on the, on the nape of the neck essentially. And once again, cause it's a basket malformation. When you press on it, it'll blanche. The only time you might do something for this if it's not, not region. So it might be on the face and you can get laser therapy which lightens it, but it never really goes away. And the reason to do that is more from like a social point of view because it's that the child or teenager grew up with it and potentially quite distressing and then finally a port wine stain. So another big one that likes to come up in the examination. So it occurs another 10.5%. It's another vascular malformation and that usually involves the face as well. And what you'll get is this large flat patch of purple or red skin and it's flat. Um and they do not disappear spontaneously. So they normally refer for treatment. But what you need to worry about with this is it's associated with Sturge Weber syndrome. So what that is is where you've got kind of a Cabarrus man zoom of the trigeminal nerve. And they can also affect kind of the opthalmic division of fat. So you have visual issues and where they still come up, as they might say, they've got a child with a port wine stain, but then they've got the other symptoms off Sturge Weber syndrome, which will be epilepsy. They can have hemiplegia, they can also have learning difficulties as well. And that's just something need to be aware of. So port wine stain, epilepsy, hemiplegia, um 30 difficulties, storage fiber uh question too. Uh So I took out them back to the stuff. I think initially I wanted to put in measles and then change my mind. Um And this is everything multiform. Um So this is the Chinese got like a palace splenomegaly. He's got a large tonsils, he's got an underlying infection, likely EBV. Um And this is where you get everything. Um Multiform and we're going to go through and talk to the rest of these in a minute. So, er, thema multiform. So quite a common one that we can see and what you find with this is, it's self limiting. They'll have read popular gels and they might have target lesions as well with it. So you can kind of see a little bit of the target signs here, whether it's kind of that Paleish area in the middle and it can also involve the mouth. So we can have involved in the lips, the bottom matures in the tongue. And it's just to really be aware of the causes of it. And these are kind of the main ones here that I've written. So they might need to show you a picture of the rash and if they've got infective symptoms with it, so, you know, if it's HSV, they'll say that, you know, there's history of lesion's and if it's E B V like our kid, they'll talk about you know, really bad tonsillitis and then paraspinal megaly michael plasma. They might say you always got a really bad respiratory infection because they can give you a really awful bilateral pneumonia and chlamydia. It can either plan to be a baby who has uh maternal chlamydia or that not represent with ice signs or it'll be like a teenager in the stem drug wise. So, penicillin so far, my eyes are your main ones. So they'll say that this has happened after starting a medication for something else, uh autoimmune. So your sle so they might say, you know, they've got the other features off that they might have lupus nephritis, they might have joined symptoms, they might have the typical mala rash and then malignancy, malignancy. So they'll have other we're N B symptoms, uh scarlet fever. So, quite topical at the minute. Um So this might be likely to come up. And what happens with this is you've got this really characteristic rough sandpaper type rash and, and it does really feel rough to touch and you potentially got a strawberry tongue as well. So you can kind of see is red with the white dots on it. And this typically kind of presents 48 hours after the fever. So they'll have just like a generic, you know, febrile illness. They might have been a coffin about Snorri and then developed this rash off the back of it, uh potentially to complain of a sore throat. Um and then they achieve a penicillin. And then kind of the main reason we worry about scarred a fever and that you probably are aware at the minute is that there's just loads of kind of awful complications. Um So, you know, they can get mastered out is meningitis, your invasive group, a strep. We're seeing a lot of at the minute. So that's kind of looking more of, kind of develop quite bad plural effusions and then the long term stuff you can get. So we've already talked about the post streptococcal glomerulonephritis and you're asthmatic fever as well, which we're kind of going to go on to talk about other big rashes. So earth even margin atoms, rheumatic fever. And so this is kind of one of the diagnostic criteria for it. So nothing occurs in about 10%. And it's quite an easy kind of question to come up. And this is just an immune reaction to group a strep and you treat this with penicillin. So this is where you get like these annular lesion's where they're kind of red on the outside, white on the inside. And they're quite large and widespread and just to kind of review your rheumatic fever kind of major criteria. So these guys will have heart issues with card itis. So they might be tachycardia complain the chest pain, they'll have arthritis in their limbs, the sub cut nodules usually on the back of their elbows and then they've got the rash and then their symptoms, Korea as well. So the choreiform movements. So if you've got a child and they say they brought this rash with any of these other symptoms or even an adult and you're rheumatic fever is going to be your guest. So it's worth knowing. And then another one that loves to come up is this solitary bullseye lesion, um which is a part of Lyme disease and we treat that with doctor cycle. So if it's just got this one big pinpoint with the red area, white and then red on the outside looks like a target. Go with Lyme's disease. I might also say recent travel abroad or through the forests measles, okay. Um So we get to this intermittently. Um And what will probably happen in the stem is that they'll say you'll have an unvaccinated kid. They will also have this prodrome of 2 to 3 days. And then we'll develop this what we call a morbilliform rash and characteristically starts at the head and it works its way down and it, it spares the hands and feet and then you get these kind of path of them on a Koplik spots which don't really present that well, where you get these red spots in the back with kind of a blue or white dot in the middle, but I can't really see the blue or white dots and this is self limiting, but the concerns that you can get quite bad uh meningitis or encapsulitis off the back of it. So, what I've got here is these are kind of the classic uh childhood rashes which give kind of very characteristic pictures which is worth you kind of making sure use know in case they come up. So for a measles, we said, you know, 23 days followed by a rash which go head down and then Koplik spots for your power virus, for example, that is your slapped cheek. So they'll get like this big red face and then Roseola and is your kind of 34 days later they get kind of this red rash over the body after the fever breaks, rebel is the German measles. So it likes looks a bit darker and it's worth known with pictures as well. And I can't remember the in terror virus rash off the top of my head. Um fine, okay. And then this one is sort Cathy a lady spots. And so that's what these are here. So you're kind of flat brown macule all over the body. So going through this, this one's probably a bit more of a weird one. So um describe the cafe ole spots and they've got freckles in the Inguinal auxiliary region, which is one of the diagnostic criteria for neurofibromatosis, which we're going to come onto. Um and he's on normal development. So that kind of excludes tuberous sclerosis and potentially sturge Weber and no evidence of early onset of puberty. So that's from like, you know, all right syndrome because what happens there is you have cafe ole spots, early onset puberty and they've also get their bone lesions as well. So if he gets a child that's as early onset puberty and they're complaining of like multiple fractures and their limbs are really bad bone pain. Um This is probably your bed for it, but it would be very unfair for them to put that in the example because it's very much a peed specialty question. So, neurofibromatosis type one, I'm only going to talk about type one because type two is so rare. And if it's type two, what you'll have is they'll talk more about dizziness and hearing problems, which will put you down that route. But neurofibromatosis is the most common. It's worth 90% it's autism more dominant. Um And the kind of buzzword is chromosome 17 is what you need to know of. And your diagnostic criteria is over six cafe ole spots, not sports and they have to neuro fibromas and they've or one plexiform neurofibroma, which is when you brought the neurofibril, when you press on it, it feels like there's a bit of a depression underneath and it feels a bit lovely and this axilla area I'm gonna fraction which we talked about. They might complain of visual disturbance from an Arctic lipoma lish nodules which are Irish Hammer Touma's obviously, Asians have bone lesions or a family history and they need kind of over two of these to get it. So in this case, they might, other features in neurofibromatosis is like your scoliosis. They've got high BP, they were multi malignancies. They might have macro carefully and there's lots going on. But your clue would be, you know, cafe ole spots more than six and they might be talking about the Franklin or a positive family history and that needs to kind of put you down that route. Okay. Uh tumor sclerosis, another one. So another neurocutaneous syndrome, but this one will have kind of other symptoms with it. With China. They've got epilepsy and intellectual impairment as well. It's also autism more dominant, but it affects chromosome nine. So in this case, you get seizures, developmental delay, uh retinal hamartomas and then they get renal involvement with angiomas there. They cardiac rhabdomyoma and rectal polyps, but they're kind of signs that you might get. So they've got like a adenoma solutions. So this kind of acting like picture on the face then get like the shag green patch here on the back of the spine. And then they can get these like Ashley macula's or hyperpigmented macule um are kind of the words you might hear in the exam question which leads you down this route. Uh And I just kind of got another bit of other cafe ole differential. So uh in case these come up and so you're like a tactic, Telangiectasia. So they'll let you know that uh this is a child that's got maybe an immune deficiency, they're ataxic gait and they might have element of telangiectasia will put you that way. Fanconi anemia. They might say they've got uh like upper limb abnormalities for missing thumbs or something like that or they also have a pan, pan, pan side opinion. Uh you know, bright, so don't mention puberty. Um and they'll mention bony issues. Russell Silver syndrome. They might mention you have been small height, triangular face climate actively. Uh Gaucher's disease, they might mention that there's more of an underlying metabolic issue. Um It's like a paramedic early or normal veteran, sort of an otherwise. Well, child. Any questions on the brief dermatology stuff? Yeah, I'm just gonna whizz three pediatric infections. Um So this one is just that, yeah, there's nobody there. So what is the most common organism called an early onset neonatal sepsis? Uh Two year old presented unwell with fever which is consciousness and a spread to Europe uric rash. What is the most likely diagnosis? Uh Their four year old presents with six days of fever, red eyes, widespread maculopapular rash with swollen hands and feet waters, most likely diagnosis, toxic shock prepared, strip, Kawasaki's disease, juvenile idiopathic arthritis or no virus cool. Okay, fine. So group B strep is the answer. Um Other ones that they can get equal I as in the in it. And what you might find there is that there's been a history of recurrent uti s in the pregnancy with mom Klebs say I was a bit more unusual but does happen more so in a preterm babies. Uh and similarly with our staph aureus or staff ominous, these are normally um possible acquired infections essentially. So if we've got a knee needle child has been admitted to the unit that's had maybe multiple cannulas and lines put in um or like central venous access. That's where they're probably more likely to have that. So, yeah, there is one of the ones very noted, don't. So there's a brief talk on the unit. Oh, sepsis. Um, in case it comes up. So, um, it can be very, very vague in the presentation. Um, it can just be that, you know, the baby is just not quite right there, bit lethargic or they're too awake and irritable. They might not really be feeding, they might have just wetting that base. They might have worked and breathing normal investigations or observations and jaundice, anything that's a bit abnormal. It could be essentially, um, and these are kind of the common ones we think about and the risk factors for neonatal sepsis would be kind of premature if you've got prolonged rupture of membranes over 24 hours. If mom's got a fever because of mom's on, well, they've been linked together for so long that surely babies unwell Hestrie group B strep in the pregnancy or if babies needed help with birth. So if you need a resuscitation of note, what I've got here in the red box is essentially some other causes of kind of unwell babies or congenital infections where if they come up, understand this is what it's going to be. So, a lot of these symptoms, a lot of these infections during the pregnancy will present roughly the same. So you'll get, you know, a small baby, um I U G R and maybe per feeding and then you'll have maybe some other feature that will maybe delineated from the rest of them. So with CMD, they'll get John this, they'll have like a palace splenomegaly, they'll have thrown beside a pina um with rubella, they can get congenital heart disease. So they get like a PA or a VSD. So if they mention, you know, small baby I E G R with the congenital heart disease and then cataracts or deafness concerns, it's gonna be rubella power, power of the virus and the and the pregnancy, it can cause really severe foetal anemia to what it can cause in a high dropsy palace where you can get kind of a normal collection of fluid and other chambers. So they can get uh pericardial effusions or cities or pleural effusions with that. So if they, if they intensely measured like a baby with really severe anemia and there's maybe been an infection in the pregnancy, this is what you're gonna go for. And the one that delineates toxoplasmosis from the other ones that you get a hydro careful with it. So if you've got a small A U G R baby with a hydro careful list and they ask you what the infection is. It's going to be a toxoplasmosis. Um um I'm grand. So this is a fever with just consciousness and spread purpuric rash. So if we talk Kenneth through what these ones could be, so and in careful itis, we'll give you rijs consciousness. The spread purpuric rashes may be moving away from that diagnosis. Meningococcal sepsis is the right one H S P we've already talked about. So you shouldn't really be fair bright or have a riches consciousness. They might have this prep uric rash, nonaccidental injury in pediatric is always something you need to be concerned about. Um But with this idea of fever, um and the fact that the rash is spreading is maybe suggesting otherwise if it was a child comes and reduced consciousness and a pure, pure it rash or bruising and then maybe in a hemolytic uremic syndrome could potentially be that. Um But you may be expected it more of a history of kind of vomiting uh diarrhea with it and maybe mention to be no impairment. I'm not gonna talk women in Chicago meningitis um purely because there's, you know, we all have read much about it. Um It's kind of self explanatory we'll talk briefly about in catholic itis because it is something that kind of happens with our Children uh and just very much on the kind of diagnosis criteria. So when you really need to be thinking about in cath litis, and it's called the reason why mortality of 10% it can be infective or in the immediate id. Um And what you need to think about is do they have an older mental status, lethargy of personality change over the last 24 hours, which is persistent. Um And then do they have evidence of fever, seizures, neurology and then abnormal imaging such as this one? But you need to then exclude kind of other causes for that abnormal neurology. So have a recent had a head trauma. Is there underlying metabolic change, um alcohol on board or do they have a tumor as well? And the main one thing to think about is that your, your HSV. So this is what this one is um why you're classically get on the MRI and it kind of temporal lobe changes um which is what we've got here. Uh CNV can also cause it any of your torch infections essentially. And terror virus is quite a common cause of Catholic this and all your anymore. Once your mom's nieces, rubella can all causing Katha litis as well. And then last question. So four year old percent of 66 days of fever, red eyes, white, spread market popular rash with swollen hands and feet and your prolonged fevers over five days or differential that you need to really be thinking is is this toxic shock which will come to talk about. Is this a group a infection Kawasaki's disease is the answer. And I know it's not uh pediatric infection, but it's a very common cause of five days, over five days of fever. And it's kind of an important one just to be aware of uh JIA. A absolutely can give you systemic features so it can give you fevers, it can give you red eyes, it can give you a rash, it can pretend to give you swollen hands and feet as well. But they might complain of our thrall to joint pains is coming. The main differential with it. Abno virus usually gives you a fever, vomiting, diarrhea, very and respiratory symptoms, but very rarely persists over kind of five days. But these kids can be quite unwell with it. So we'll talk a little bit toxic shock. So uh cause of kind of prolonged fever with it. What happens is you've got like an exaggerated response to the toxin produced normally by other staph aureus or group A strep. And what you're kind of find in the stem of the question is that this child will recently had, you know, tonsillitis to cellulitis or they've had a reason to kind of have maybe um a staph infection. So like they've had a surgical and or a deep abscess previously used to be retained products of conception. But we don't really see that anymore, but they do love throwing that into the questions. And what happens with these Children is that they common septic. So the common febrile, they've got rash, diarrhea, vomiting and they'll be lymphopenia as well. And at that point, what you need to do is kind of treat on the line infection with antibiotics and then try and kind of burst to them in response with uh IV immunoglobulins as well. And then any quite extensive resuscitation and normal intensive care treatment. So what we'll put you towards toxic shock is if the child presents feb right unwell and they've potentially recently had like a surgical wound or they've had a burn, which is quite a common one or a scold. Uh and then they become sick off the back of that. Then you need to be thinking about is this potentially toxic shock syndrome? And then finally, Kawasaki's disease, which always seems to come up. Um So there's an acute self limiting febrile illness. Um But it's the most common cause of acquired heart disease in the UK. So what happens is the whole system gets inflamed and you get a medium sized death of vasculitis. Um and your characteristic feature. So you need a fever over five days, you need bilateral conjunctivitis. We see his eyes are, we got red here, lymphadenopathy. Normally, cervical lymphadenopathy is quite large. They'll have a rash over their body and they'll have kind of red lips and they might be cracked and they'll have either tearing of the hands or feet or swelling of the hands and feet as well as the other things. And the treatment for this is I B I G and the main thing you want to prevent is coronary down your information. And that's the main reason we give the IV I T and with regards to kind of other pediatric infections that we're not really talked about. And you know, the other ones you need to kind of make sure, you know, is your bronculitis is and your various kind of gastroenteritis as well are a good one to be aware of. Um, but I think they'll be covered in future talks. Does anybody have any questions with regards an infection point of view? Great. And so just for my, I know you guys are coming up the final. So, um kind of reasonably good resources that I've kind of used know in my pediatric to non beforehand. So Nelson's books quite in depth. Um, it's more American based, but a lot of the kind of basic sign stuff is completely appropriate from a pediatric point of view. And if this case is quite decent one, it's a lot of small cases with questions in it and a reasonably good basic explanation for you guys going through it, but it also loads a good free stuff online. So don't forget the bubbles is amazing. Pediatric phone med as well if you've got articles on that for what you're looking for. That's exactly what you're going to need. So great. Thank you very much for your time. Does anybody have any questions? Perfect. Thank you very much, Doctor Lindy for that. Fantastic talk. I'm pretty sure if we're in person to be getting a thunderous, a round of applause right now. I have two things guys before anyone has any questions to ask. Please don't drop off yet. In a second sits going to put a link into the chat for the study that methods doing on evaluating peer to peer teaching. I would really appreciate if you guys could take some time to fill that out. And also before you guys leave, could you just make sure if you give me one second to share my screen that you can fill in the feedback for Doctor Lindy? Let me know if you guys can see it up. Yo guys just take scan with your phones or whatever the QR code and walking some feedback that be really appreciated. Thank. Thank you. But if anyone has any questions, you wanna drop them in the chat now as well. Um Let's see if there is any, I think there's a question there, Doctor Lundy on uh the joint dissection on Billy Atresia over colleague Collie Duggal exist. Sorry, I can't seem to see the question the choledochal cyst, it's in the team's chat. Basically, the person's asking why is why is it Billy Atresia over the actual assist uh to be fair, it probably could be one or the other. Um uh And that's kind of why you need to do the imaging. Um And the one you kind of do want to misses the trees, your point of view. So what you kind of get with a cyst is you get a congenital cyst off the biliary tree and that cause is also a functional obstruction as well. So it's probably that mean that I put that in there. Um But it was just kind of highlight that that's also an option if it does come up. Um ask for how you could clinically tell the difference between the two. You would need to go to imaging and then take it from there. But questions, any other questions guys before we wrap up? Uh I don't think there's any questions left. Well, thank you very much, Doctor Tunde. Have a very lovely evening coming to. Thank you very much. Thank you.