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So I believe the recordings are also on med all. So if you missed the session, feel free to go to our med all page to have a look at our um recordings from the previous sessions and we will make. Hm, ok, I'll just introduce um um our speaker today. We have um Doctor Ali here. Um Doctor Ali is um currently in her fy one in Leicester and she is going to present to us um pediatric teachings um today. And so Doctor Ali, I will hand it over to you and um I'll be moderating a chat, uh feel free to pop any questions and a chat. Um So that Doctor Ali will be more than happy to answer them. Go over to you. Thank you. Um Hello everyone. So my name is Hana. Uh and I'm an F one doctor based in Leicester at the minute. Um I am interested in pediatrics. Uh So today's session will be based on neonatology. I'm gonna just try and share my screen so I can just share the presentation should be able to see that. Now, is that right? Yep, I can see it. That's brilliant. Perfect. Um So just, uh, I'm gonna cover neonatology today. Uh It shouldn't be too long the teaching as such, but uh if you have any questions, just probably save it towards the end or just chat, pop it in the chat box and I'll try to answer them as um much as I can just moving on then. Ok. So the topics that I'm going to cover today include uh neonatal baby checks and resuscitation, birth injuries, uh neonatal screening as such uh neonatal respiratory diseases, which basically include the transient tachypnea and the R DS and neonatal jaundice and the management and investigation side of it. So the next one, I've included a newborn baby assessment. You won't be examined in terms of um your writtens as much on this. But it's just good to know because you could be asked uh as an ay station and it's quite popular because we did get a mock station on this back like two years back for me. So I think it could be a possible station that could come up for you guys as well. So, uh I've included a checklist over here which is quite uh informative and it has everything so you could use this as a tool. Um I'll just start off by saying that before any examination as such. It's good to include a brief history. So, in this scenario where we are taking a newborn baby assessment, it's good to take a brief history from the mom or whoever is present and just ask basic questions like, oh is the baby feeding? OK. Is the baby um quite active uh crying? Uh Has a baby passed Meconium which is a very important question that you could ask the mom and uh questions just uh a brief uh family history with regards to any uh developmental issues, any family history of any congenital uh problems, any down syndrome that runs in the family. And you can just take, it's not a very detailed history that you need to take, but a brief history that um comprises of all of these questions that I've just said. Um and then moving to the actual examination as with any examination, you just move on to the general appearance. So if you have the baby in front of you, it's good to comment on three important things and these include uh the color. So in terms of the color pink is very good. If you see the baby pink moving about uh throwing the arms and legs, it's a very positive sign to show that the baby is active. If the baby is blue, then the baby is cyanotic, which is not a very good sign. And I don't think they'll throw you off by giving you a blue baby uh in an akation. So um it's just good to comment as to these important factors saying, oh, the baby has a strong cry, the baby's tone is good and the baby's pink and quite active, which is a very reassuring sign. And then with uh this type of examination, it's good to work from the top to the bottom. So start off with the head and again, comment on the general appearance, just say uh comment on the size, the shape um symmetry, uh any dysmorphic features as such. And the two important things I think you might be aware of this already as your finals approaching is the uh careful hematoma and caput succedaneum. So I won't cover this right now because the next slide is all about this. So I'll touch on it in the slides to come but not right now. And uh it's also important to comment on the suture lines um and also examine uh the anterior and the posterior fontanels as well. And when you're examining the head, it is also important to just have a look at the uh ears as such because uh just see if there's any low set ears because low set ears uh are indicative of like Down syndrome and see any skin tags, any discharge from the ears, anything like that and comment on the eyes as well. And it is this when you um probably if you have like an ophthalmoscope at the bedside, just use that and see if there's a red reflex present in the baby's eyes because they might ask you in MC Qs because I did remember they did ask us this. Um It was where they gave us a list of conditions and they asked us which condition was the red reflex absent in. So, if you know it, you know it, and it's quite good to know this. Um There are two important conditions that you should be aware of and these include um congenital cataracts and retinal blast tumors. Um and then uh you move on to the mouth as such. So um in this, since you're examining the baby, it's good to use your pinky finger and put it into the baby's mouth and just have a feel of the baby's mouth as well and just comment as well if there's any cleft, cleft lip, um or a cleft palate present because it's quite important that we do recognize these uh early on itself. And uh whilst doing this, you could also um do the uh feel for the suckling reflex that newborns usually have uh and just comment on that as well because uh it's just good to like go systematically and then moving down your comment on the shoulders and arms. So for the shoulders and arms, you're looking at the symmetry, um if it's asymmetrical, then it could indicate a possible fracture. Most common is a clavicular fracture. And whilst examining the uh shoulders, you'd also look at the baby, most likely the baby would be active, either crying or not crying, but they would be throwing their arms about. So, just comment on the arm movements just say, and this is what you would expect of a newborn and take the opportunity to also feel for the uh pulses at this stage. So the most important pulses that you need to feel for is the brachial pulse and the radial pulse as well. And moving on uh to the hands as such, just take the opportunity to uh see if there's a single palmar crease. Um although it might be normal for the baby, sometimes it is a strong um uh indication for Down Syndrome. So you do the necessary investigations after that, but it, you could comment on the problem. It could be common in the family. Uh but it could, it's a strong indicative factor for Down Syndrome. Um And then you move on to the chest. Um So the chest, you are uh looking for any symmetrical respirations present. Uh take the opportunity to also um me measure the oxygen SATS. So, um I think you might be aware of this already because they must have taught you, uh it's important to measure the preductal and the post ductal saturations. I'm not gonna go into the physiology of it, but then just make sure that you at least verbally mention it and the examiner might stop you at any stage and just, or you can continue, you don't have to do that. But it's important to mention that you would measure like the preductal and the post ductal saturations. And always remember if there's like, uh there should always be a less than 2% difference between these two factors and if it's greater than two, then it's a red flag really. Um And the oxygen sat should be always greater than five and take the opportunity to use a stethoscope and just listen for the breathing and also listen to the heart rate. Uh just to make sure which side the heart because obviously you're doing a newborn baby assessment. Um It's important to characterize which side the heart is on as such and listen to the breath sounds at this stage. Um And I think on visible examination, it, you could also comment on um any visible signs of respiratory distress. Uh is the baby breathing too heavily? Is are they using um the accessory muscles for aspiration? All of these, you can just comment on as you go along. Um and then you move on to the abdomen as such. So abdomen just observe the shape. Uh concave shape is not very good and it's indicated of diaphragmatic hernia. Uh It is a condition where like the uh contents are in the chest instead of the tummy. So uh just make sure you comment on the shape. This is the normal size uh and uh shape you would expect of a new bone and uh say that you don't observe like any abnormal um shapes as such. Um And you would also comment on the umbilical stump. It's not really necessary, but you can just make a comment on it and just make sure there's no like discharge or anything like that, have a feel for the tummy. Um and make sure there's no organomegaly present um and no swelling or any fluid in the tummy or the baby is not in distress when you're actually palpating it. Although it's very hard to tell because newborns cry all the time. Um Next you move on to the genitals. So just um I know it's quite obvious, but then the examiner quite likes to know what you're actually looking for. So just mention, oh, this is a male or a female and take the opportunity to uh palpate for the testes and the scrotum if it's a male baby and uh make sure to mention whether it's undescended or descended and also have the opportunity to inspect the penis at this stage as well. And if it's a female baby, then you would obviously um inspect the opening and the vagina and uh all of that and make sure in both uh you inspect for the anus, make sure it's patent. Um And uh as I mentioned earlier, you would ask the mom whether uh the baby pass Meconium uh if not, then it's a very uh red flag. Uh really? Um And then moving on, you would um inspect the legs, observe the legs as such, look for any symmetry. Uh One hip could be higher than the other and it. That's not really a good sign. And, um, you might be aware of the maneuvers already, but I'll just go through it, the bars and the ois, uh, it's mainly to check for the dislocation hips. Um, a good way to learn this, which I did was basically having to practice plenty. And you can do this either in your pediatric rotation or you could also like, go through youtube videos on this and how they actually do it. I hardly doubt you'll get newborn baby assessment, but then it's just good to know um in case you can get like any MC Qs on it because uh it's a common M CQ question really. And I know it's quite um obvious but count the toes and just mention and the digits as well along with the fingers. Um and then have the opportunity to inspect the back of the baby and feel for the spinal cord. And at this point, you'd comment if there's any spina bifida, um any hemangioma uh that you can see um or any skin tags or any abnormalities of any such. Um and then moving on to the reflexes. So we talked about one reflex that was the suckling reflex. A good way to learn these reflexes or just um know how it's done is just again watching videos or uh asking a pediatric trainee or a pediatric doctor to show you how it's done. They'll be more than happy to help you um a more reflex is basically when the baby is to backwards and arms and legs will just like throw up like that. They'll, they'll just extend and suckling reflex. I've touched on already rooting reflex is basically when you stroke the baby's cheek, you tend to look towards that side. So that's a very positive sign showing that the baby has this particular reflex and grasp reflex is when you just, um, not tickle, but like just stroke the baby's palm. Um And they just grasp it because they like to grasp things. So it's a good indicative factor as well. And a stepping reflex is when you hold the baby upright and they'll make stepping like motions as though they're actually walking, but they're not walking. So it's a very uh good um way to tell whether the patient uh whether the baby uh has this type of uh stepping motion, uh or this reflex as such. And again, conclude your examination by your findings. Um And again, you know, the typical ay scenario, wash your hands and all of that, I won't go through that, but this is um quite important that you know how to do this really. Um And then I talked about Kalo hematomas and the kit succedaneum. So, um I have a picture of these two in the next slide, but uh this is a very, very common um M CQ and the reason being is that they try to test your knowledge based on um whether one crosses the suture line, how quickly it resolves and what is the management like for the both of them? So, the one thing I remembered is um kit succedaneum succeed, succeed means it, it crosses the suture lines. So that's a very good way of remembering it. So, remember, Kit succedaneum is um basically bruising and edema that uh crosses beyond the margin of the skull bone or beyond the margin of the um sutures as such. And this is very common in babies which have like a prolonged delivery and those babies that are delivered by the vs because of like the suction. And um usually you don't have to worry too much about this because it's resolved in a few days. And usually there are no complications as such. But uh it's important for like doctors to recognize this and just uh make sure the baby is treated properly. Um And the next one is hematoma. So as the name suggests, hematoma is basically bleeding, all right. Um And in this, uh unlike the previous one, it is well confined within the sutures itself. So it doesn't cross the sutures. And usually, um this, it does take like a prolonged time to resolve and usually it's about like a month, 4 to 6 weeks. And um although there are no complications of this, it is very, very crucial to recognize so that the baby is like treated promptly and just taken well, like well is taken care of essentially. Um And the complications um can be serious um as if it's mentioned here. Um So the main two things to remember is succedaneum. It crosses su lines and keo hematoma is confined well within the su lines and the time period um both take to resolve really. So this is a good um picture. Uh because over here, you can see this is the suture line and since it's crossed, this is the suture line over here, it's crossing the suture line. So that means it's succeeding it. So it's capped succedaneum. Whereas over here it's confined well within the suture line and it's basically like a bruising beneath the skull. And that means it's a hematoma. So it's a kalar hematoma. So, yeah, so I'll be touching on birth injuries as well. Um It, you might not get this. Uh maybe you might get this in genetics. Um not really in pediatrics, but um two important conditions that you should be aware of is herbs, palsy and clumpy, palsy and the nerve roots associated with it. And which um whether it involves upper or lower trunk. So, uh S palsy um involves AC five C six. So essentially that's upper trunk and clump case involves a lower trunk, which is AC eight and the T one. And you need the one very important uh presentation that herbs palsy presents with is the waiter, uh tips posture and it's very common. You might see in, uh you might hear this from uh TN O doctors all the time, like the waiter's tip posture. Was it associated with? And that would be herbs palsy in which nerve roots it would be C five C six. So you can see over here the baby has an internally rotated and abducted arm. Uh, abduction means um it's towards the thing and it's an extended and pronated forearm with a flex strip. So you can see the, you can see the picture over here. That's the typical appearance of like herbs, palsy, that's see a baby. Um really and in clump case, palsy again involves the lower roots, which is the C eight and T one. And over here, you would, this is quite distinctive and diff you can clearly differentiate between the two. And over here, you can see like the MCP joints extended with the interphalangeal joints flexed really over here. So that's the difference between both of them. Um And then I would move on to the neonatal blood spot testing uh or the heel prick test. So this is very common. Uh I don't know if you've seen this on the ward uh when you're doing your rotations. But um it's quite interesting and how newborns uh we take their blood, especially for this one, just prick their heel and uh collect the sample. And the reason being why we do this, especially in the, this is mainly done in the 1st 5 to 9 days of life is mainly to rule out, um, important conditions. Uh, that could be very, very dangerous to the baby. And they might probably ask you in ays name a few of these conditions or which are the most common thing you'd like to rule out, uh, with the herick test. And, um, I've included a n, uh pneumonic here. I didn't really use this but, um, I just found it recently and I thought probably it's helpful for you guys. Um in terms of the diseases you need to know about sickle cell disease because um it helps identify and really you can manage it early on rather than finding out later in the life. Uh sickle cell disease, congenital hypothyroidism, um cystic fibrosis, phenylketonuria, uh the medium chain acyl dehydrogenase deficiency, the MSUD, which is the Maple Syrup urine disease iso vidia. And uh homocystinuria is one of the most important ones as well. So you don't have to know all of them, but I would say like sickle cell congenital, hypothyroidism, cystic fibrosis, um PKU, phenylketonuria, homocystinuria, you can just mention these, especially like uh if they ask you in a oy setting or like, just remember these, if they ask you, uh I'll give you a list of um M CQ options and just so that you're aware really. And uh it's important that babies do have this test and nearly everyone has it within the first um nine days of life So the next one I'll be touching on is the neonatal respiratory diseases. So, uh the two most important ones that you should be aware of is the respiratory distress syndrome, the R DS and transient tachypnea of the newborn. Uh It's important to differentiate between both of them uh because their management um could be different. Uh and the investigation wise is different on the chest X ray as well. So it's important to differentiate both of them and know the differences because uh they might come up in exam questions and uh most often they will ask you this. So R DS, um how is it caused? Um So it's mainly caused because of surfactant deficiency due to premature birth. Um So again, predisposing factors, uh one would be prematurity because uh when a baby is born premature and not a full gestation, um there's lessor produced and due to that, it's a very predisposing factor. Um And the baby can go on to develop like the RDS symptoms and uh typically go into the distress syndrome and it's also known that males are affected more than females. Um And C sections are also a risk factor for babies developing R DS based on um just uh studies and uh maternal diabetes is also very important risk factor and hypoxia as well. So, if a baby goes into arrest immediately after they're born and they're hypoxic for a long period of time, that could be a quite a strong um predisposing factor for the baby to develop, develop rds within the next few days. Really. And uh an X ray is typically done for these patients. And uh what you would expect in these X rays would be a ground glass appearance. So you get a lot of past med questions uh as well as to what you see in the chest X ray of uh a baby affected by R DS. And this would be by the Irish Show over here. It's a crown glass appearance as you can see. So in terms of treatment, it's really prevention. So, um moms who are known to have um in the previous deliveries, um premature births or those moms who for some many reasons in fact, um have to uh deliver the baby early. They are given um anti steroids and that's dexamethasone. Um because dexamethasone, what it can do is it, it can increase its effect and production in the baby and therefore reduce the incidence and the severity of the R DS in the baby as such. So it is preventative rather than um actual treatment. Uh because in actual treatment with the baby with R DS, it's usually supportive and that includes like um oxygen and uh preventative would be like the steroids, uh CPAP if the baby is very, very critically ill, but mainly you would just manage it supportively with like oxygen manager CPAP. Um And then we will move on to uh transient tachypnea of the newborn. So, um why does this happen? Uh it's because of the delayed clearing of lung fluid that is mainly seen in C section babies. Um And the reason as to why this happens is C section, although they might be at term, they might still have the fluid in the lungs. And the reason being um, babies when they are delivered vaginally, there's uh external push or like a contraction through uh which the baby comes from the vaginal canal. And the lung fluid is supposedly meant to like just move out of the lungs during that time because there's that contraction. Whereas in C section, you don't have that external push and the fluid still remains in the lungs. And that's why um C section babies are more prone to like developing tachypnea and all of that. So, uh the typical symptoms and signs you'd see uh in such a newborn would be again, a apnea, increased respiratory rate and overinflated chest. And um although it might seem uh I don't know if you've seen a baby with this, but the baby looks quite unwell and uh it usually settles within the first day like two days, 24 to 48 hours. And the X ray um done for this baby over here, you could see there's fluid in the horizontal fissure and often it is referred to as a wet lung. So you could see like there is quite extensive infiltration over here or a pacification as such inci opacification. So, it's quite comparative to pulmonary edema um in adults as such because it does look like that with like sparing on either side like here. So it's quite important to uh differentiate between transient tachypnea and cardiac failure um as well. And if necessitated, like if the patient, uh if the baby is pyrexic uh looks quite toxic, um then it might be worthwhile doing a septic screen as well. And the these investigations need to be done like promptly within the next one hour because um literally, they will deteriorate. Otherwise, um in terms of the treatment, it's really prevention. So, um uh I know this might sound weird because obviously, moms who prefer C sections and because of complications, you have no choice. But uh it's just that we need to recognize uh this early and just treat again with supportive care with oxygen, high flow oxygen and just um make sure the baby is doing OK and uh prevent it uh from happening in newborns. So the next thing I'll touch on is neonatal jaundice. So what I'll cover in neonatal jaundice is the pathophysiology of jaundice as such, uh the difference between conjugated and unconjugated because it is very important, especially with conditions associated with the types of jaundice um and the complications as well. So I've included a flow chart over here. Uh I think many of you might be aware of this already, but I'll just go through it quickly. Um The reason why uh say not even babies, but like adults develop jaundice is because of the uh three reasons. Uh you might be aware of that is the hepatic causes the pre HEPA sorry, prehepatic hepatic and post hepatic causes. So just talking about the excretion of bilirubin as such cancer, they're broken down and they release unconjugated bilirubin. So now this unconjugated bilirubin, it has to be conjugated by the liver and liver only. So it goes to the liver gets conjugated and they excrete it by two ways. And that would be via the urine. And the other one would be like um excreted by the bile into the stools and some of it is reabsorbed as well uh through the small intestine. So uh this is the flow chart. You don't really have to know the details of the physiology, but just, just know like how the unconjugated and conjugated bilirubin happens and where it happens, that's mainly in the liver. So the unconjugated bilirubin goes to the liver becomes conjugated. That's the main thing you need to be aware of. And uh I think most of you know this already jaundice, uh what is prolonged jaundice? So jaundice is prolonged when it lasts more than you would expect it to be in as compared to physiological jaundice. So, in terms of units, uh and premature babies, this would be more than 14 days in full term babies and more than 21 days in premature babies. So uh as I mentioned earlier, there are three types of jaundice can be categorized into three that is prehepatic, hepatic and post hepatic. So, prehepatic um as mentioned in this flow chart over here would be the excess breakdown of red cells. So these excess breakdown of red cells will lead to a lot of uh unconjugated bilirubin. So in prehepatic uh jaundice, there would be a lot of unconjugated bilirubin. Next one would be hepatic. So, hepatic is basically the conjugation has um there are issues with the conjugation as such. So in this, there would be either the unconjugated or the conjugated bilirubin that would be high, low. And in the posthepatic, there's an obstruction. So all the obstruction related issues would be the posthepatic. So there's an obstruction of the bile flow. And in this type of uh posthepatic, there could be um uh what is it? Yeah, there could be unconjugated bilirubin that would be very high uh rather than conjugated. So the investigations you would do for jaundice uh in an adult as well as a neonate or baby would be ts mainly you look at the bilirubin. Um and then you would also do the normal bloods as well, but mainly we're looking at the T. So, um I talked to a little bit about the unconjugated bilirubin. So this unconjugated bilirubin can be known as the indirect bilirubin. Otherwise, and the conjugated bilirubin can be called as a direct bilirubin and the total bilirubin that we refer to is basically the direct and indirect. Otherwise, the conjugated and in conjugated bilirubin. So um unconjugated bilirubinemia. So I'm basically like 22 main types that is a conjugated bilirubinemia and unconjugated bilirubinemia. So unconjugated, um there are two main reasons as to why a baby can be uh can be, can have jaundice um due to unconjugated bilirubin. And that would be physiological jaundice being one of the most common reasons. Um So, in physiological jaundice, this happens um not in the 1st 24 hours, but after that. And uh it's mainly because of the immaturity of like the HEPA hepatic conjugated system. And due to which there's high amount of hemoglobin in the blood and because of the high amount of hemoglobin, um and baby's hormone pro dehydration as well. Um the the red cells break down and again, there's high level of um uh unconjugated bilirubin because this happens before the liver and the conjugated component would be very low, which is uh less than 25 usually. And it's not the first diagnosis you would think of, you would rule out the most important causes first. And this is a diagnosis of exclusion initially. And uh in terms of management of physiological jaundice, uh I'll talk about the management as a whole. Uh It depends, it depends on the severity as such again, and uh the clinical status of the baby along with the blood results, but usually it is managed uh on its own like you don't um give anything uh for this. Um And the 2nd, 2nd type of unconjugated bilirubinemia you would see is um moms who breastfeed babies. So, breast milk jaundice. So that's called breast milk jaundice. So, um moms who um breastfeed have an increased risk and this is again, not in the 1st 24 hours. It's after that. And the these, these babies, they might have like a prolonged period of jaundice that may persist like uh 2 to 3 weeks. And over here again, uh the conjugated component is very low in this case. So, uh if they ask you, what are the two main types of jaundice that are associated with an unconjugated side, you would think of firstly, breast milk jaundice, uh is the baby breasts uh fed and uh diagnosis of exclusion would be the physiological jaundice if there's no explanation. And if it's like greater than 24 hours, not in the 1st 24 hours, because that's very critical. If it's greater than that, then it would be physiological jaundice. Next one is uh unconjugated bilirubin again, but this is pathological. So just remember one thing jaundice in the 1st 24 hours is always pathological. And there's a reason as to why the baby is jaundiced or where is the where? Whereas if it's after the 1st 24 hours, that means that it's usually like physiological or there might be a breast milk component adding to the jaundice. So, um if it's within the 1st 24 hours, uh you might be thinking what's really going on here. And uh there are three main reasons first could be sepsis. So the baby could be septic. Um And if you look at the baby, it looks very toxic. This baby is very lethargic. Um there's poor feeding, there's tachypnea, there's hypotension and and if there's signs of shock, basically, you would uh warrant an urgent sepsis screen. And this needs to be done urgently within the next one hour of like having to see the baby as such. Um and risk factor would be maternal history of GBS um as well. And uh there could be a component of D IC as well that could be causing the pathological jaundice, which which is less than 24 hours. And the second most important thing that you should be aware of is hemolysis. So I think you must learn uh you must have known this during the first three years of med medical school, but like a B and compatibility and incompatibility because that's one of the first things you learn physiology. Um So I've, I've put a picture up here. So which explains the process of it. But I'll just briefly explain to you what incompatibility is. Uh and why hemolysis is very important and uh to rule out really, especially in a baby with uh jaundice within the 1st 24 hours. So over here, for example, um we have a mom who is rhesus negative, um who is conceiving for the first time and she's conceived a baby now and the baby is rhesus positive. Um However, you can see over here that the baby is well within the membrane and there's no flow between the baby's blood and the maternal circulation as such. So the there's no chance of both the bloods being mixed up. However, now the baby is now at full term and the baby is being delivered via vaginal delivery. There's a chance that the baby's blood mixed with the maternal circulation. And in that case, uh the mom's body, which is she has the rhesus negative blood cells. She starts producing the antibodies against the uh rhesus positive cells that are introduced into, into her bloodstream. Although this is not very harmful for the mom itself because she's rhesus negative. If she were to conceive uh conceive another baby. Um and the baby turned out to be rhesus positive, then these antibodies that are, that are in the maternal circulation will go and attack the baby. And in that case, there's a rapid and increased red cell breakdown and that causes fetal anemia, as I've mentioned over here. Um it is quite detrimental and life threatening to be honest, uh because it can cause a condition called hydrops, fetalis where the um baby has severe anemia. And there's an occurrence of high output cardiac failure, effusion, and ascites as well, which can ultimately lead to death if not identified. And that's why after the first delivery, the mom is offered anti D um antibodies where it goes and destroys the antibodies so that the baby is protected so that the subsequent pregnancy is protected as such. I hope that makes sense. Um So these are the two important things that you need to be aware of sepsis and hemolysis, uh which are the main causes of pathological um jaundice within the 1st 24 hours. So if they uh so if they ask you, um I had this uh ay station in my finals where um a baby came in, uh a mom came in with her baby and uh the baby was essentially yellow. And uh when you take a history from the mom, you find out that the baby has um around 15 to 16 days of being yellow, essentially having jaundice. So there's one important thing that you need to think of that is a prolonged jaundice can happen in biliary atresia. And the typical presentation of this is pear stools and dark urine. So, uh in this ay station that I got the baby, uh the mom literally got the baby's nappy and showed us like the pear stools in it. And that was like a strong indicative factor as to like the baby having um Bili atresia and this was a GP setting as well. So, you had to promptly tell the mom to go to the e um or get in touch with a pediatric doctor to arrange an appointment. Uh So that the baby will be seen within the next uh say uh one hour. Um And in these type of babies, they have prolonged jaundice which is greater than 14 days and they also have a poor appetite and growth as such. Uh in terms of the blood results, uh the total bilirubin might be high. Uh sorry. So the total bilirubin is normal and conjugated bilirubin is abnormally very high. So that's why if they ask you what's the most common uh reason as to why the conjugated bilirubin might be high. You need to think immediately of bir atresia which is quite, quite life threatening for the baby. And in terms of investigations, you do normal bloods, uh routine bloods, uh blood cultures lactate as part of the sepsis screen. Um and LFT S as well, which basically tell you about the direct and indirect bilirubin, otherwise the unconjugated bilirubin. And in terms of scans, you can get an ultrasound of the liver and the biliary tree. Um you don't have to know the details of it uh really and in terms of the treatment, just know um it's Kasai procedure or the Hepato and you don't have to know the details of it. They won't ask you most likely, but then you just have to know like Kasai procedure or it's associated with uh high level of conjugated bilirubin um which is commonly seen in BLIS. So, in terms of treating neonatal jaundice, um there are two ways phototherapy as depicted in the picture over here or exchange transfusion depending on the severity of jaundice. So, the reason why we do treat jaundice is because um it's quite detrimental for the baby and we need to avoid uh the baby desaturating. Um really, and we also have to avoid this very important medical condition that you might be aware of already called ectris. So, Ectris is basically when the uh when the bilirubin crosses the blood brain barrier and goes into the brain and causes uh swelling, uh hydrocephalus brain damage, which could be, which is actually permanent, uh if not recognized and treated promptly. Um It's quite, it has a very poor prognosis really if not managed well in time. So the reason why we do take neonatal jaundice seriously is to avoid the conics from happening in baby developing conics as such. And I think if you've done your pediatric attachment, you see babies typically with the eyes uh closed like this in uh having the phototherapy. Uh it's quite interesting to see. Um and uh I would really encourage you to uh see one if you haven't seen one before. So the take home message for jaundice, uh jaundice is quite common in terms of like just a ses that they might ask. Um as I mentioned, earlier, the one I had was Atresia. Uh they might ask you even in MC QS. So just remember, um even if you didn't understand anything jaundice in the 1st 24 hours is harmful, it's pathological and needs urgent investigations and management. Um And neonatal sepsis is the most common cause in the 1st 24 hours. And babies with uh jaundice within the 1st 24 hours need urgent treatment for sepsis and they follow the sepsis six protocol. That is you give three, you take three and um make sure that they uh you record all the clinical features or they have any of the risk factors. Then you do consider taking earlier action than normal for these kind of uh situations. So that's basically it, I haven't covered all aspects of neonatology because of time constraints, but I have included everything else that um they might quiz you on in terms of like just MC Qs and even um AY stations. I hope that was helpful. Um I'm gonna try um breastfeeding jaundice. Is it due to underfeeding, underfeeding uh overfeeding the breast milk or is it due to mixed feeding? So, breast milk, jaundice and breastfeeding jaundice is uh essentially the same thing because um moms who breastfeed their babies, um they are more prone to developing um jaundice. Essentially, it's not pathological because it happens after the 1st 24 hours. Um The mechanism of it really, there's no mechanism as such because it's usually like direct contact with the breast milk and um babies who consume that they have and increased. There's, I don't think there's any mechanism. It's just that there's an increased incidence of these babies developing the jaundice after the 1st 24 hours. And it's not associated with underfeeding or feeding of any sorts. It's just because of like mixed feeding I would say is just because of that and it's not uh pathological at all. It's just physiological and usually moms don't have to worry at all. They're quite concerned obviously because the baby is yellow, but they are uh given, giving, they are given supportive care. They don't have like an immediate need for like um medical intervention as such. Hopefully that, that answered your question. Is that it any more questions? Thank you so much. Um I think the feedback form is just uh in the chat box now, if you guys can uh fill that up, but, um, the slides, uh I think I'll share the slides with Beta and they will most likely help you get these slides as well.