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cool. Thank you so much for the osteo bi team for wanting me to do this presentation. Um, my name's said on one of the pediatric rainy country in the West Middle's, um, Onda. I hope after this recession, you feel more comfortable with pediatrics in general because it's quite different. Um, you get a basic idea of how to approach the key stations on Gopal. I convince you to do a Korean pediatrics, so yeah. Um, firstly, pediatrics. Extremely broad. So it's that covering the whole of medicine. So I'm just going to focus on stations that I think more likely to come up. Uh, but for you, if we do ask me questions about anything after about any other stations or any other topics after a lecture, um, you can post your message is a post. Any questions on the chat, And then after each section out, I'll go through the messages just on deceived. Any questions that I can answer? Um, but yeah. So let's make a start. Um, hum, go. So, um, so this is your first station, your foundation year, one doctor going there in a pediatric emergency department, and you've got a 11 months old boy who presents a li but cough and tachypnea. So your task is to take a focus history Onda initiated management plan, including Governor investigations. So very common presentation to pediatric any on it's probably one of the top of the stations do you get from a pedia perspective, So just a check things off as you normally do. So we'll have some quick questions to see just to warn you guys up. I want the little bit of problem, and I want you to just tell me where you think the diagnosis is. So the first one is a 13 month olds who has poor weight gain. Um, so he's got dropped from the 25th to the second sent. Oh, um, her parents report. She's often chesty that to previous admissions for chest infections, and she's at 6 to 8 bowel motions per day. She's got bilateral ways and course computations and auscultation, so just drop in the chapter on what you think the most likely diagnosis is. Got a few answers coming up here. Yeah, that's perfect. So insisting fibrosis that we should talk a little bit more about later, but yet well done. Next, don't we have a three year old boy who was brought to any with a history of sudden onset noisy breathing. Um, on auscultation. He's got significant. Who is his initially management bronchodilators. But there's no improvement. Um, what do you think it is? The three ounces here group bronculitis foreign body soon allergy, maybe. Also previously Laryngitis. Yeah, old genuine differentials for this question. Um, it's the answer to this. One is a foreign body, and so will go to why, in more detail after this is Well, um, the next one is a six year old boy who has a history of recurrence nocturnal cough, frequent difficulty breathing on exercise. He has excellent, was recently admitted with a moderate ways that responded to bronchodilators. Yeah, so this is more straightforward and probably one of your books down presentations or asthma. Perfect. And then, for the last one, we have a five month old girl who has a three day history of the snotty nose. The cough on a one day history of reduced feeding, an increased work of breathing LRT I flew bronculitis are see all again property friendship's. Yes, it's bronchiolitis and Aristides the most common cause of bronchiolitis. Yep. Um perfect. So that's good. So I feel like everyone's got a general favor of if Well, we're looking at is the first station will focus on these. So we'll go to the first main differentials resin, and we'll go through how to approach in our speciation reason. Difficulty breathing. So that one, the main things I was mentioned a lot on that we have a sample of his Well, it's bronchiolitis bronc you like. This is a infection that's mainly depth diagnosed in Children under the age of one. Um, typical histories. The preceding viral symptoms. Um, the typically worse in day 47 of illness left the peak of the illness. Generally, there's you can get a low grade fever with it, but the main whole marks are just this. The preceding viral symptoms of the snotty nose. Um, the the vial cough onda. Obviously, with babies, it's hard to see how well they're. So we always use feeding and weapon at peace is aware of, um, calculating that so they will be a history of reduced. What nap is a pretty it's feeding, and it was a history of widespread crackles examination. So the physiology between bronculitis, which is important now in terms of how you treat it is. It's not because of bronchospasm ast compared to a viral induced weeks, or ask me which will come to you in a second. It's because of mucous plugging in the lower, smaller airways. So actually giving bronchodilators is not going to help. Um, the major. The main cause of bronchiolitis is the viral infections, the main cause of respiratory. Since that your virus, they get other viruses causing bronchitis such as adenovirus or rhinovirus on like this of the keyhole mark to know why you need to diagnose someone is bang collapses. It didn't respond to bronchodilators in the management decisions after, but we'll come to that in a sec. So that's our first main differentials. The key points that you need to remember. But bronculitis is less than one year, um, and history of reduce nappies. Uh, but not be sorry. Preceding viral symptoms and and the the main causes our city of this belly. Since that you are. So those are our yield court appoints. You're stepping most common differential that you see very commonly in a emergency department. It's viral induced. We's so This is mostly in Children over the age of one tends to be a pro 5 to 6 years of age. Um so again, very similar history as populated to start off with usually but symptoms of an upper respiratory tract infections or things like cough cold coryza and then progresses to a lower respiratory attack. General elections You get a low grade fever on. There's a result again of the mucus bilaterally. Um, you get wheezy on examination. The difference is that a viral induced ways response to bronchodilators because there's a level of broke a constriction that happens as well. Um, so it's called viral industries because the virus creates a lot of kind of picture and stimulates bronchospasm. Then, um, you get this week's effects on exploration. So Hallmark is greater than one year viral symptoms, and we use that response bronchodilators and then the last one that we have, which is the most common presentation that gets talked about his asthma. So there's a lot of discrepancy on when you can diagnose asthma, and it's still no set age. But as a general rule of thumb over the age of four or five is when you could start diagnosing Children with asthma. So you get a typical history of which is generally an acute history in response to an allergen. Oh, our response to a viral infection where you get wheezy and shortness of breath. Um, there's classically. They shouldn't be any fevers of the ship. What's your differentiate of a bottle industries to asthma? Because you wouldn't get a Stephen asthma because it's pretty early bronchodilator. There's no infective process happening. You get a bilateral ways and examination, um on can be associated viral infection. But then again, there's a bit of a crossover between, but he's asked myself. But the key things to note in asthma is there's going to be a history of recurrent episodes. You can't diagnose asthma, obviously from one not to individual episodes of someone presenting the wheeze. Um, there's a history of a toupee or allergies. Oh, history of a to be infested your relatives. These all contribute to a diagnosis of asthma, and we'll come to that. But for there was well against a high yield points for asthma from a ski on the situation exam situation is generally go to the year age of five. Um, acute acute history of reasons, shortness of breath and a history of those ATP recurrent episodes and allergies. All making ask more likely is the diagnosis. And yet so we talked about three main cause, I thought quickly mentioned some other very causes and the high yields kind of criteria that will help you spot them quickly. And I'm sick use on stations. So one of them assistant fibrosis that we talked about earlier in the vignettes statistic fibrosis is caused because of the mutation in the CFTR gene. Um, and that encodes see it something called a CFT uh, protein, which is ultimately, and colds a chloride channels still a ATP gated chloride channel. I'm going to all of it just because it helps me remember the symptoms better. So the channel is present in several parts throughout the throughout the body, so the main ones being in the pancreas and the sweat glands and the pancreas is usually pancreas is multiple functions, or one of them is an exact cryin gland to give things to digest fats and proteins. Um, so because you have a defect in this chloride channel because of a defect in the CFTR gene and you know, the pancreas aren't able to absorb chloride, so from bloomin into the cells and there's a result aren't able to. So um so ah so, yes, it is a potential chloride, and because of that you get you get really thick mucus plugging and remember in the in the capillaries in the membrane. So you get that defect producing these exact crying hormones because all getting blocked up. So that's why you get problems with gastroenterology symptoms and fairly it thrive. And they classically presented steer steatorrhea so fatty stools at foul smelling stools and fairly had tried because they're no absorbing fat and protein quite well. And the classical test full. Um um, assisting five books is the sweat test, because again you're not able to absorb the put. The channel isn't aloeing for chloride to be absorbed into the cells, so it resulted. Get a build up of fluid outside, and so you know it's helping story my best to get a build up of sodium chloride and so classic on the sweat test, you'll have an increased concentration of sodium. Chloride is compared to normal just because your cells in order to solving it so that's the classic diagnosis. But from a MCQ point of view, the main symptoms are recurrent respiratory infections because it's plugging the airways because off the increased take mucus production failure to try because of gastroenteritis symptoms on. But, um yeah and the sweat test. The next one is primary ciliary dyskinesia, so we'll spend less time talking about this because it's probably one of the rare causes. But it's basically because of the defect in the cilia on the protein that I called the serious. So either you get absence of severe or you get a defect in the way the study of moves on because cilia really important. It's several organs years one of them the years, your Sinuses, your airways, Um, so if you get a defect and you know able, the body's not able to push or pull the mucus in the right areas to get a build up of mucus in one area, causing against similar symptoms since the F where you get a build up of mucus and bacteria causing recurrent infections on the same thing, call Carter Jennison Room, which is basically a trailer dextrocardia recurrent blockages and respected tract infections, and you get that because actually, doing embryology silly is really important for moving specific cells in one direction or another on. But because of the abnormal action of the cilia. Actually, the cells leading to the embryology off the heart on the lungs don't get moving in the right direction. So actually a form on the other side where they already originally base leading to Dextrocardia. So then that's again a key points on MCQ looking for recurrent infections because of the fairly of the cilia to move dextrocardia, um, and recovered things like otitis infections and sinusitis and foreign body so foreign body again common and Children. And so the typical history be hyper or do you don't set? So it'll be a child was definitely playing with toys, and Mom's in a different room and then suddenly develops a cough or we or difficulty breathing. Um, it's a very typical history because it's a very acute onset, like just started. There's no obvious trigger that the parents able to identify or which is playing around. What's important to note is that the symptoms actually are based on the degree of airway obstruction. So if you have, if the child is one of the toy that's not quite big, and so isn't blocking the whole of the air will. When it goes down one side and blocks of a smaller is, they're going to have a progressive we's that gets worse because of the progress of obstruction. Actually, they're still be able to breathe at services knowing the cause, accused choking or obstruction. So often you'll find if they swallow a really small toy in their lungs, as where they they'll come in with a long term ways and recurrent chest infections without an obvious cause. Because that's just built up, then block of the airways so again. But tea points know for foreign body or acute onset of symptoms to very typical history. So just drop it on, sir, Um, and you kind of gave me Get him up. This is well because of big problem it, but it has to do with the airways, and the last one of the rare causes gastroesophageal reflex reflux, disease or aspirations of this is where, instead of going down the windpipe, it goes down there. It's off against that. This it's very common in babies, especially under the age of one mostly because one they're spincter between the esophagus and stomach, then developed yet as well on too, because they usually more in a supine position leading to increased levels of reflux And this, um, least driven least absorption of nutrition. So the present daily to thrive, but also, um, because of recurrent reflexes like vomiting, they tend to swallow some of the milk into the airway aspirate, and this can cause coughing ways. And they present with similar symptoms. Actually, they might not present with gastroenterological is in there they might present with the respiratory symptoms, but you'll notice that it's particularly worse after feeds open. They've been lying down for a certain amount of time, for example. So those are the viral causes and just other folks in the high yield points just empties. So ah, we're at the station and where, and we see the scenario someone the trial presents with shortness of breath or we So how are we gonna go about? So the first thing you do is you take a focus history. So for a pediatric resist, really, as with anything else, we start with history presenting complaint. So the duration of illness. So how long has that been going on for? So that gives you like we thought already starts. You start making differential diagnosis on how acute the history. So, you know, was it over a few days on if there was a fever, What was the maximum temperature? So that again, this is more useful in delineating with between a viral in a bacterial infection where you'd expect persistent Parexel were 30 point where, for example, in a significant bacterial infections, combative viral infection. If you responded partially to fall again, same lines Is that in terms of difference And it helps you to know how sick the child is. A swell Any associated symptoms were saying, Are there any is the status inspect aspirin, political symptoms. So, like stare to re eloquent discussed Oh, um, reflux or difficulty feeding? Um, very tired. Um, Andi. The next two questions are very pertinent. Relevant of pediatrics for any pediatric histories. How's the child feeding s? So that's really important. No matter what age they're so after up to the age of 10, you can ask the question because it's a very Children, very obvious of the not feeling. Well, just be off their foods, and that's the first thing that happens. And how many west slash 30 nap is that happening? That's the way of measuring hydration, Children, because you can't measure the urine output in any other way. So these are started questions you asked on a history of sending complaint. Um, your next one you'd look at from a neonatal of development in history is that this is unique to pediatrics. Won't get inadequacy. So things were thinking about any problems. Antenatal list. You're thinking about any maternal history of smoking with the growth scans. Okay, Um, what did Mom have any infections during in neutral, etcetera? Was the child development term a problem during delivery S. So we know, for example, that new ned so delivered by C section half having increased amount of time to adapt a new environment. There a supposed to normal vaginal delivery from with any complications. For example, if you have any shoulder dystocia that can affect their breathing, they have any fractures. Any post natal complications or issues requiring admissions of this is just a question to know. Check the child's and health levels of example. If you know they're having recurrent infections from a very young age of thinking more along the lines of immunodeficiency. Is it separate? So that's an important question to ask. And has the child developed? A port is appropriately for their age again, that just it's a It's a normal screening question that pediatrics, then we head onto past medical histories of this is particularly important when we're talking about Louise S. O N E. You're looking for when you especially when you're think, just diagnosing Children with things like asthma. So that particular screening questions you need to ask. So any previous weeks episode So obviously, red flags for a small increased risk of asthma is multiple previous weeks episodes. Any previous episodes of the Coreg Hospital admission or in particular HD you or PICU admissions? That's really important screening questions as well and is any history of a TB. So that includes things like allergic rhinitis, excimer, um, and, um so. And these put Children increased risk of developing asthma as well. And then from a social of family history. Any recent travels you here with thinking about you know, your classic infections that you get from outside the UK Any family history a to be in the first degree. Relatives that just a matter of your grandfather has asthma or your auntie has asthma. Do your parents siblings have asthma or have any? And a two piece of excema allergic rhinitis? Um, so that's an important criteria. And that's the toe. Many smokers at home both put Children increased risk of developing asthma as well. So these are all really important questions when just doing with the wheeze, obviously in a general pediatric street and also ask about vaccination status. Um, and you asked about more questions of the social history and think something and how they're developing in school, etcetera. Swell. So when you're at the station, you take a focus history to stop it. So these were main points need to cover, uh, and then you move on to the examinations. The examination can be follow a similar ABCDE approach. Although you need to be more opportunistic and pediatrics, you might not always be able to examine the airway. For example, first of the child is screaming you want put them in these, but examine something else first. So the first thing you know when you're looking from an air where perspective so it's in adults. It's easier to probably get, um, an idea of their respiratory function. But in Children, you is a lot of emphasis on how the child is chemically so signs of respiratory distress. And so signs of respected, distressed Berries from the age we can pediatrics things we look out for is so I start from the top of nasal flaring. So especially in infants western, the age of one or two. Um, you need the firing because their obligate nasal graders, um, that you see that they that's a reflex reaction when they're struggling to green. Other things are recession, so you can get subcostal intercostal recession. So even you still sucking underneath the rib. So that's subcostal sessions. In between the ribs, that's intercostal receptions. We can get sternal Recessions is well, which is on top over here, just just over the first straight for under the clavicle. Um, so those are all signs off respect to distress and an infant, and you can also get obviously when they're getting much worse, you get things like tricky old tug where you conceal it dipping in the next year or head bobbing, which is where they're working really hard. So actually to increase the volume of chest expansion, that having to move used a sternal, cleidomastoideus muscles and all their neck muscles to kind of move the head just to increase that title volume. So you get the typical head bobbing, so that's when you should be getting worried about the child. So from progression of symptoms you normally get nasal flaring, followed by subcostal in the cost of recessions, followed by things like bronchial tug on been followed by head bumping. That's how we would look at the airway. That's really important on then. The other things that you look at is obviously tack up near. So it's really in adults. You probably if someone has a respect to age of 2025 years, probably starting to get worried to them. Where is that? The child that probably be normal In some cases, they're probably reading would slow on a respirator 2025. So what I would do Just have a quick look in your in your free time on the rough ranges of respiratory rate, but they should provide that exam anyway. Um, because it's very spray aged groups, for example, that a newborn. I would accept respect rates the 14th of 55 so that's quite high. But that would be normal for a newborn examination and then saturations. So here it's really important to know whether you're measuring pre doctor or post up till Saturday. So what does that mean? So always the babies when they're born, some of them have a persistent PDS. So which is a patient doctor Doctor started. Rios is, um which is a link between your pulmonary artery and you're descending aorta. Um, so obviously, once they come out of the womb on, the pressure is increasing the left side that that PT a tends to close. Um, but if the PDS hasn't closed like it should do, obviously some blood is not going to go through. The lungs is going to go straight to the pulmonary artery into their's, and to the rest of the body is actually the rest of the body is not gonna be receiving as much oxygen as, for example, the blood that goes through the lungs. So and because the Pts in the descending aorta, it doesn't affect and the arteries that come off earlier and they sending out so typically your your right side around. So whenever you measure productive saturations, that's before a pedia you measure on the right side and post Uncle Saturation. Is there anything on the left arm left leg right leg on? If there's a significant difference off more than 3% between the product of the right time and the rest of the body, then there's actually you can suspect that the Risperdal destructs my video to a cardiac problems such as a pa um um, or something underlying that's causing the PGA Tour remain open. And the last thing to note when you're observing a child and assessing that reading is posture. So, for example, um, you might have heard the term the classic prime poor posture. So that's when similar to COPD patients, almost with when the kids are sat on the legs, arms forward. Last think that they're just trying to take as deep breath is possibly with that title rolling, see if they're having a tripod posture. Actually, that's quite a late sign. You probably wouldn't be worried, um, at that point, so that covers airway in breathing. So when you first, is that the trial from the circulation So you checked your central and capillary refill time similarly to, as you do an adult speaking. If the young, you check in slightly different places, so on on babies and 20 just the central you used to use the sternum, so just press there for five seconds. Even it fills up, obviously, and in babies of different races, it becomes a bit more harder to delineate. You can still use the nail beds a swell, but but probably a better marker of circulation is using the pulses on adult radio. Pulses are very obvious, but in babies especially really opposed to them not as easily palpable. See looking at either. The femoral pulses are great, your pulses, Um, so when always feel for femoral pulses because one that will tell you about the fluid status but will also tell you about things that cooptation and stuff so you can. You can check her out simultaneously. You can also look at mucous membranes that will also give you so that the child's got really try. Let's, for example, so that will give you an idea and skin to get. So that's the circulation and then, lastly, systemically examination. So ent exam really important. Been you Focusing on the child is coming with shortness of breath, Louise, because, like we said, things like actually otitis infections can cause a purpose. Breakthrough tract infections which can present, like respect infections, but actually just a year playing up or recurrent or tiredness? Infections in the context of ways we've seen can be a sign of cystic fibrosis or something. Think about rash again. You you get something called a viral exanthem er in Children, which is an extremely common presentation so often when you have a child presenting with the viral illness, they'll have this typically blanching maculopapular rash all over their body. That seems to change all the times that people get quite worried. But actually it's quite common and points towards more of a viral picture and a bacterial picture. Um, Andi, um, helps you do any between viral infection back. You know, actually, you're looking in the respect in so and lastly likely will do 90. You just have a look at the wrap them in this well and hit their You're looking for signs of hepatosplenomegaly to see if they have any things like sickle cell disease of hard because of respiratory distress, Etcetera on overall is really important to look. So when you look at the we often safe adults, you look at the examining the end of the bed. So by similar with Children, you see they're active playing, eating, actually really good marker. How off, How ill a child? Their babies? Because someone who's going to respect your rate of 50 But it's actually quite planes comfortable. That wouldn't be as worried about the might not treat as Crestor ble the child with same respiratory but is looking very tired. So that's really important to know. Cool. So we've talked about the history. So when you go into stage, you take a focus history and then you do an examination focusing on these things, looking at some of the respiratory distress, etcetera. And now you, um so this is this apartment. So we've done the history presenting complaint with taking a history of relevant past medical history and all the negatives of recover summary of our examination findings that we've just seen, um, what's really important? You know, it's parent. I'm concerned. So I think this in adults. Obviously you can ask them questions directly so it makes a big difference. Um, so he is really important to get a parent of use and think What? What? What do they think is actually going on? Actually gives you extra marks and ask is open. You're using the parent and involving them. The discussion of diagnosis, because office, they might add something that you've missed out on the history on exam. Um, so it's really important to do on your top of your friendships and why, that is, and then, obviously your other differential. So this is how you go about presenting your history and examine the end of that process for respiratory exam? Um, so once you've done his history and examination and you thought about the differentials, the next question will be Okay, So what investigations you gonna do? So obviously, in a child presenting with cough or you think it's something like bronchiolitis, you might not do any investigations. I think the only thing that's patent, probably the on skis, is doing a peak flow when you're trying to diagnose asthma, only looking at it as my severity. So we just go through death on I think it's a very common osteo scenario to be asked to explain to apparent or to a child on how to use the peak flow meter, so we just go through it very similar to how it is. And adults, Um, so you do your trunk in check. So you make sure that, um your regularly giving small bits of information and checking whether the parents understanding of the child understands and you start with your general questions. So do you know where you've come in today and what do you know about the procedure? And General Open Question is, do you explain the reason for the procedure and you position the patient appropriate place in terms of Children? You want them standing up? Um, I'm not. I'm not sitting down. And then you explained the procedure. So you start from the beginning to ensure the peak flow meter. Is that cirrhosis? That's really important than position yourself. I was sitting up or standing straight. Eso in Children with first standing straight, um, and then take the deepest breath you're capable off. Hold the peak for me to hire low to the floor, position your mouth around the mouthpiece, so it's really important to say. Maintain a tight seal around, um, from the meter on the mouth piece of the big peak flow meter, and then exhale is forcefully as you can, Um, and as fast as you can you're able to. Then you're not the reading on the big flow meter, which is a condition in the system in it. Then repeat the steps again, 1 to 2 times more. And then you take the highest reading and three attempts. That's your results. You don't take the average of the three readings. You take the highest reading, and that's your final results. A big flow is going out of fashion because one, it's very hard to get Children to. Do you speak for meters Little. Another dose? Um, so it used to be a regular part of the guidelines, and it's still part of the guidelines where it's not the primary means of diagnosis anymore. So ask my, uh, used to be diagnosed based on expected peak flow readings. But that's now especially going out the fashion so after the procedure. So there's two things you can do so you can save. Once it expensive procedure, you can tell them. Okay, go home, maintain a peak flow or diary. And that's really important because you're looking for that typical Donald Variation and asked most of the difference between morning and nighttime. Um, and then you can also compare post broncho dilators. That's another key part of the diagnosis. You give them some salbutamol and how can you objectively check that that's worked to you? Do another peak flow and you can see it there. Readings have improved. So that's basically how you do a peak flow station. Um, quite straightforward on Bennett. The end of this, they might ask you to interpret some people values. So in things like asthma, you're looking at a more obstructive picture of the restrictive picture because of the accumulation. So your FPB one, which is the amount of add to do X. Let's, um, give out over the 1st 2nd is a lot less compared to your FEC. Um, ask him. And there is an a restrictive picture. The racial company remains the same. So yeah, so we've talked about So we talked about history, examination and examine. Ask you what investigation would you do? And, um, generally, in the respect examples, no further things you need to do it by the bedside. The only thing you would do is is a peak full. Let me discuss. And then they ask you How did you manage this patient? So I thought we'll talk about the two most common conditions. Um, if you're likely to get to the first one is bronculitis so bronculitis management. So, um, remember I said how it's important to know how long of the pathophysiology of bronchiolitis. Uh, because actually monkey, like, is just supported treatment. This means we don't give any active pharmacological drugs or treatments that we don't give him any bronchodilators. Um uh, anything to help with that Because they're not gonna have an effect. And actually, they're probably cost things like tachycardia, which will make it worse. It's really important to avoid that. So what you should do is the conservative management. So you give them oxygen is quite based on their oxygen saturations that we measured and feeding support. So now this is really important in Children because, um, in adults can breathe and solo the same time. But infants, especially smaller babies, can't swallow on, But, um, breathe the same time. And also, if that tummy is full, actually, you can imagine that the overall chest cavity is quite small. There. Tell me their stomach tends to push up the thrust, a cavity reducing their full potential of title. William Sec. So it's really important, actually, that if a child is having severe bronculitis, then we take them off or feeds. You can either put them on IV fluids or NGO feeds based on the extent of bronchiolitis in. And by doing this, you're just trying to take the load off the tummy, and you're trying to take the load off them, having to breed on swallow simultaneously. And then you could consider gentle suctioning it. There's lots of secretions, so the main things so supportive treatment so you can get them. Oxygen is acquired on feeding support, and that's just to make it easier for them to great. So those of the do's and bronchitis the don'ts like we discussed me avoid bronculitis the avoid steroids. We avoid antibiotics near Avoid any for nebulizer therapy because actually, there's no evidence for any bronchoconstriction, um, in bronchitis, and all this will probably only make it worse. So we don't want to give a child any drugs or medications that it's not going to be helpful and can open things that nebulizer. This could be quite distressing with infants that might make their respiratory distress worse. Uh, yeah, so that's bronculitis management. Uh, so now we come to asthma's asthma. Um, in terms of management also said the first leave. The thing we do is we stratify. Asthma is a moderate, severe life threatening very similar to adults, so there's a mild as well. That's not included here. So in in moderate asthma. So again, um, for your exams, units, remember your pee excessively experience. Tree floor rate will be greater than 50% of the predicted value. You have normal speech, but by this I mean that they're chatting to you. The nice and happy. It's a question that the moderate exacerbation in an acute cvx faster patients who have a peak flow reading of 33 to 50% of the predicted value. So you base that on the height age, settle in their gender on. This should be charged for that on you looking for signs of respiratory distress, fel tachypnea in a village to be complete sentences in one breath and saturations that are greater than 91% and also accessory muscles to use that that causes their intercostal of sub cost of the sessions. When you using your muscles, you can see them, um, use the intercostal muscles or they're like little master of muscles, for example. So this all counters acute severe asthma, then the life threatening asthma is when they got a take experiencing for less than 32%. Although in a real life situation, you'd never do a peak peak flow meter on someone with life threatening asthma, Um, oxygen saturations of less than 92% and unaltered sensory is altered consciousness. Just exhaustion of the child actually is not breathing very fast now. So a low respectfully rate about 20 onda silent chest where you can't be contrary Any air entry are all very, very read that sentence lifeguarding has been That's what you should be really worried. So, in terms off treating asthma, eso I've created a simple algorithm that you can follow. So this is based on nice guidelines plus textbooks. So, um, you do your normal his speech, clinical examination and vitals and then you stratify them as mild, moderate, severe. Based on what we just discussed So it's a moderate, moderate exacerbation, which then you. The first thing you do is you give them. Give him 48 puffs off salbutamol with MG. I put spaces. The MDI is basically meted dose inhaler. So it's just been in the head with a spacer, and then you review after you give the drug and then you re assess I was still working as hard. Is that still a ways? Um, are these still short of breath? There's a good response in this normal examination or distress. You've been discharged home with South Beach more. But if there's an inadequate response over going to adjust your breathless, I'm still working a bit hard. Um, then you can give themselves eat more with inhaler for the three times, and you do this every 20 minutes on. But if they're still no improvement, you give, you can give them or prednisolone, and if there's still more improvement, then you move on to the severe exacerbation pathway. Um, so I just like to mention just of ah ah, lot of people tend to use nebulizers first steps to the evidence we using nebulizers or inhalers. Um, there's no advantage of using nebulizers of inhalers. They used to be a big misconception that nebulizer more effective. But actually, um, it's better to use inhalers for two reasons. One, you get them used to using inhaler and hospital so that when they go home, that's all they're gonna have access to see you. Do you practice good practice in hospital and day, comfortable using the inhaler at home, so that could be really helpful in preventing ambitions? The hospital, um, but to, uh, the nebulized a lot more uncomfortable for Children because you have they have to wear the mask. Um, Andi, it's It's quite uncomfortable on their face, so inhalers are generally preferred and there's no evidence for inhalers. Oh, it nebulizers the Ventolin painless. So the child comes in with severe or life threatening exacerbation of asthma. So if you're a GP, if you know GP setting or outpatient setting, I just put that yellow box. Since you give themselves you tomorrow and stories early and you transfer him is only it's possible. Ah, here we would give nebulizer albuterol, and that's because, you know, if you remember in a severe life for exacerbation, your oxygen saturation is unless the 92%. They need oxygen and you can't give oxygen within inhaler. You have to give it here and nebulizer or face mask. So we did the nebulizer. Beautiful. You give them our patrol Pee in or prednisolone is Well, um, and then you review and reassess. See, there's an improvement if there's not that many to do a blood gas and then, in terms of escalation of people from there would immediate in our skin situation. You'd say at that at this point, there's no response to subway eat more on or bitterness alone. I patrolled him. I would contact my senior urgently. I would think about giving things like IV, magnesium sulfate, um, IV dexamethasone and I behind a cortisone. But these are things that you shouldn't be doing on your own anyway. And we need proper monitoring cardiac monitoring with it. Um, so that would be to be moved a hate to you setting or a night to you setting but important to mention and ask you that you would escalate to your senior at this point when you have a severe exacerbation. Cool. So any questions at all? We've just talked about wheezing. Mainly. Look at books anything. Anyone have any questions? So it's a cigarette exacerbation? Um, it's in an osteo situation with the city exacerbation. I would just say, actually, I would escalated my senior immediately. Once it start initial treatments, you start this albuterol in the old steroids. But at that point, I would also escalate my senior if they've got signs of and see very destination. So I wouldn't quit very long Something just responding to these messages that are coming to me directly cruel have. And that's pretty much the main one. That thing, all the questions are quite similar. So we move on to the next topic, which is also over spiritually based. Um So here's the next case, Vigna. So, you know, foundation here, one doctor, you in the pediatric emergency department this time you get 11 month or boy who presents any with cough strider and fever Million Inject folks history and initiate a management plan is a role for, um an awful um in the future, Asthma and Children there is on. Actually, if you have time in your osteocondroma shin, that new further discussion RV aminophylline is used. All of the evidence is, um not very good for it. So they have been recent randomized controlled trials actually have shown there's not a huge benefit from It was only used as a last ditch effort is for your IV steroids and things haven't worked in your IV myself. Hasn't worked yet, but it is still used. Some centers still use it. But you again, you need to be in a hate to you, or I do setting to use that. Cool. All right, So, uh, the next the next one is 11 month old boy presents to any cough, strider and fever. So we'll go through just like we did before, since spot diagnosis, to just shatter where you think it is. So a nine month ago has had coryza symptoms of the past two days. And don't develop the horse barking cough with increased respiratory effort, she has a temperature of 38.1 and sat 97 group group group lots of croup. Yes, yeah, yeah. So that group very important to delay between violent other forms of croup. Viral being the most common. Yes. The next one is an 18 month old girl who was brought to the emergency department. But that to our history of fever and strider. She has a temperature of 39 degrees Celsius. She's sitting in a tripod position and is truly she looks very drowsy. Be a lot, I just Yet these are all quite straightforward and your high yield questions so very typical history, yet smashed it. Everyone's got that right that the glossitis next 13 year old boy presents with the acute history of difficulty breathing strider, swollen lips and a wide spread rash. Teacher schools are made peanut before the onset of symptoms. Yeah, spot on and phylaxis. And the last one is a six month old girl presents with a three month history of worsening steroid. Or that's worse when she's lying down and she's otherwise happy and thriving. This is, Ah, a bit more different. Would like to see what people come up here. It GERD during the malacia. Just this during normal a share. So all good differential. So it is laryngeal Malaysia on now speak about loving relationship. Better wine fits this case yet. Yeah, well done. So cool. That's responding everyone. So it's like we did before we go to the main differentials we think about, um child Presenting with Strider Strider is basically your inspiratory noise that you hear from an upper airway. Um, can become experience tree in severe strider, but it's mainly a sign of upper airway obstruction. Where's the wheeze is a sign of lower airway obstruction. So the first one that we have is croup. Croup typically presents the A plastic a history of a violin violinists before most commonly caused by the parent flu ends of virus. Um, so for if you remember certain things remembers, um, yeah, as quick points is that bronchiolitis is caused by honestly, croup is caused by Perilymph Lewenza virus, and epiglottitis was caused by him off the list Influenza B. So these the most common cause of these conditions? You get a typical barking cough with, ah, with group. There's no toxic appearance. Often the Children quite well actually to start with and relatively fast onset of symptoms over 12 to 48. The next officials. Epiglottis is so primarily a bacterial infection. We don't see much of epiglottitis any morning because of the vaccination protocol that now includes vaccination against him. Awful, it's influenza B. You get a audible strider, you get a toxic appearing. So what this means is like a very ill looking child. So someone a child is very tired. You see them? They're lower respiratory effort, high grade fever on. Do you see them drooling just because of the large epiglottis is blocking their way. And then I able to swallow much into this off because I receive the rebuilding. So and it's usually acute on certain progression of symptoms. Courses epiglottitis that's was foreign body. So foreign body like we discussed, um, accidental aspirations. So with a foreign body to spend depends a very large is so obviously but large in the lower always airways, it's gonna cause the wheeze. But if it lodges in the upper airways is things like it trickier? Your main bronchitis. Um, it's going to cause a stride off so you can get a choking strider a cough on, like we discussed before the symptoms of based on the extent of the airway obstruction so it could be partially complete. On that tells how bad you stride always will be. And for access is, everybody knows about his ah, high brochi don't also occurs within seconds. Two minutes, um and then significant. There were compromised because of rapid inflammation of your upper airways. Get multi system presentation like we saw on the vignettes over the rush facial swelling, etcetera. And it is really important to administer. I am adrenaline, I wonder. Just make a note that the doses off adrenaline are different in Children, and it's really important to know the doses, um, very super Age group and based on country and guidelines. But the general rule of thumb is if they're over the age of 12, you put them in like an adult. So you get the same dose if they're 6 to 12 years of age and you give them 300 micro guns, if there less than that, when you give them 150 micrograms of adrenaline, they give it. I am just like, uh, have you could another differential. That's much Rivera, But also present is a retropharyngeal abscess. To get neck with retropharyngeal abscess is usually because off and a cup for respiratory tract infections that just spread into the lymph nodes in the back of your tonsils. On this card. This buildup, but a instructive and kind of infection that causes significant inflammation of the gland is you get neck a cemetery unilaterals burning, and it's very, very painful. So you'll see symptoms of torticollis where spoke to distressingly and the neck would typically be held in a extensors position probably won't be able to flex it, because be off the pain. Last thing, um, way like we discussed is laryngeal malacia. So laryngeal malacia is a congenital abnormality off the off the off the laryngeal cartilage, and this causes increased laxity of and there. Because of that, you get the collapse of supraglottic structures on because you have the increased laxity of cartilage. Anything above that tends to collapse more easily on respiration or inspiration. That's why you get that airway obstruction causing stridors. So it's a congenital abnormality, which causes weakness of the off the cartilage, causing collapse off the structures above the cartilage. So every time you breathe in that negative pressure causes the collapse of the structures, and you get that strider usually begins with around two months of age peaks. In terms of how about it sounds, uh, at 6 to 8 months. But the key differentiating factor is that the Children are usually not hold it by it there, well, and thriving infants. It doesn't affect the oxygenation. They don't really have any other signs of respiratory distress. It does get worse when they're agitated or when they're crying or feeding, um over in the supine because the pressure is that different. Um, and so you will see parents all complain to say, Actually, it's much worse that nighttime, um, or when they when they start calling on the feeding, they can hear it a lot worse than parents get quite panic. But actually, with laryngeal malacia, you don't do anything about it. You leave it as it is, is conservative management and usually self resolves. But I run two years age. Um, so um, it's, uh, it's been on condition, of course, of those that those remain differentials so similarly to when we talk about ways and respect, you just rest. Here we take a focused history of the Strider, so Noski stations that the question will be slightly different. You know when you get the one that strengthens the first week, has a child has spread or since birth year, you're thinking of your congenital causes, so other congenital causes that we can talk about things like vascular rings, which is basically where you get a double aortic arch that kind of encircles that took here and it's off. It's causing construction, causing, um um causing strider. And that's that's something to really look harmful because that's most of it and that needs to be treated. Didn't have features of an upper respiratory viral. Listen, is that contributing? Is that what's causing stridors or croup? Like you said, you get. Like I said, you get the typical um, vial prodrome or phase of the snotty nose. The cough them progresses onto just causing croup that the child being well in their Selves. So this you're doing in overall to see how well are unwell there. So again you're looking sounds by proxy looking child. Any other associated symptoms? And how's the child feeding So again, is it worse with their feeding of the feeding well again? It's not only a measure of how well the child is, but again things like gastroesophageal reflux disea that some people mentioned, or things like Lyrica relation worse with their feelings. It's an important question to us then, here it's important to ask for a vaccination development of history, so vaccination, because now the UK vaccination schedule has haemophilus influenza. B is part of it, so I actually should be getting it and shouldn't be getting a big clot. Itis um, any development of normality is a syndrome. So Children with syndrome, which is down's Nunes, for example, um, more likely to have recovered spiritually tract infection. So that's important to know about as a child developed appropriately for their age. And so again, that's just a general screening. Questions for Children, past medical history, any previous surgeries, any history of upper lower respiratory tract infections. And finally, with your social history, similar to questions that we ask for the asthma, any recent travel, no recent history. Way to pee. So once you've had a focused history for stride Oh, um, we haven't mentioned examination here because it is very similar to the examination we do for a week. So you take the focus history, you do an exam, and then you start thinking about your differentials. At this point, like seven, ask you What do you mean differentials? Actually, the most tool, if you're going to take away, just do things in the courts. Strider most likely to get either croup epiglottitis because these are high yield questions and things they probably want you to know about. I've just got a little audio clip here to play. Just I thought I'd be quite useful to know what croup sounds that cause everyone always says barking cough. But no one's actually, I mean, as a medical student is I haven't heard what, sir, that stride. Oh, and the last bit is the barking cost. I just pray that against the first part of the only place is your typical strider. And actually, that's what we call a bi phasic story. Because you can hear the obstructive upper airway noise both as can you hear it or can't hear party. That is no good, That's why. Okay, give me a second. Really? Yeah. Okay. Okay, That's a shame. And it would be it would have been useful. Try sending a link later on. And but I think it's quite useful to know just what it sounds like. Um, think you need to click on settings and share or dear right sound? No, I mean, if you didn't have this. Yeah. So I played that from the start again. So the first better strider on the second bit is the barking cough that group, So that's very typical. And if you hear that emergency department, you just go back. It needs Dex. So, um, thank you, too. Who suggested that I see here, Thank you where it was, really appreciate it. So in a group, you get that typical barking cough. So you want to for the treatment of croup. It's purely steroids, but you want to assess how severe the group is, based on what level of stories you want to give. So in terms of assessing stores, do you see whether there's a presence of Strider at rest? So, or is it only when they're talking, playing or the agitated So presence of stride or rescues? A red flag symptom is a respiratory distress or they're not bolded by some things that were in combination with a child is really, well freaks out and on the bottle by Oh, is it by facing So by facing is when you get that, that sound like we heard when you're breathing in on when you're breathing out. And actually that's a sign of late. Later, part of the disease with more severe and the Scots significant airway obstruction and in terms of management, Um, so they dexamethasone is preferred, and it's preferred because one it has a very shocked acting times the a very rapid onset of action. It has a much longer half life than prednisolone. Well, on back. Chew away. It tastes better. So I've had a taste myself. That's not his own taste better than prednisolone. So I preferred for kids is the preferred option. Obviously it is. If you're not getting enough improvement and you're still having significant symptoms with the Dex, you can give prejudice. Well, um, if there's very if a child is very severely got a severe by face X rayed. Oh, um, this significant respiratory distress does not look well. You can use nebulizer prevalence the nebulizer. Ventolin causes vasoconstriction and causes brief relaxation of a reduction in the swelling. But it's not long lasting, only lasts a few minutes, and that's many to buy you time, too, if you want to call it anesthetics, if you're so that even just get your controlling, your preventing significant airway compromised. So that's what nevertheless it Ritalin this for, um in terms of a big lot tighter so we discussed the toxin looking child. So things and how to manage your blood type is the first thing just do is and the glipizide is is a surgical emergency, um, or a medical emergency. Sorry. Eso you. The main thing is to keep the child really still. You don't want anything that's going to make their respective distress worse. You don't want anything that's going to make them great harder than it is, because that's going to cause significant every compromise. I would not You you're not meant to examine the area or do any anti examination because one that can worsen the demon just by causing uncreative vagal response or but irritating the airway to you can irritate the child, making them more set and causing significant respiratory distress. But if you just make it for this, uh, high yield things with the exam, er minimize external stressors. Do not examine the airways. If you suspect someone's got a lot. I just so sick looking child with destroyed or not. Sure, Don't examine the airway. Get emergent anesthetic referral. This is so that you can, um, get ready to intubate if you if needed on and you start them on empirical IV antibiotics. So that's croup. And he goes, Isis after this is the name differential that you probably need to go over. Cool. So before the next section, I thought, Well, just take a quick to second. Great. Doing a break. And I mean, any questions from that section. It'll four or I the dexamethasone or Sorry. Yeah. Can we get this lives after? Please should be able to, um Dexilant zone in. I'll have to leave that to your skis. 18. Can we give oxygen in Epiglottitis? Yes, There's no harm in giving oxygen, but if the mask is going to cause any distrust the child that probably better off without, obviously the situation that low that you have to give it to them. Um, but again, you're trying to minimize contact. Tiled. What kind of improve the antibiotics you would give you that you got is typically wise. Careful of sports, things that kept a taxi, my the first line, that least trust that I've worked at eso good spectrum of response. What is the difference between viral in these reason? Populated. So, good question. So, um, can usually references resource. Um, Well, I've got references on I don't have them just showed that with you, you can send me an email. And, um, you can Yeah, I'm not in any references. What kind of information would be used in people? That just a normal endotracheal intubation? Um, it's a very difficult intubation office. It because of the significant swelling of the people that you wouldn't do anything like a, um, proposed to me or anything like that, You would just you would do a normal See, That's why you need anesthetic support s a difference between violin, the sweets and bronchitis. That's probably really important to know about. Um, the main difference is in the age, so you won't get bronchiolitis in the age group. Um, less than one, um, they in terms of how they present clinically, you have the typical viral prodrome phase, and both of them, But, um, but the but the violent these two ways, as in popularity, is you get ways on crackles when you listen. Auscultation are so far. This was you just get these kind of symptom and you're also more likely to have fever. With this reason, we're probably lighters. And like we said, the bronchiolitis just not responding. Bronchodilators environment is we've got left another way. So sometimes that an emergency department, they to trial occasionally start bit more living those frowned upon. And then if it doesn't work like okay, you know, are Eastern's. I hope that answers your question. Any other questions at all? Cool. I am going to take a two minute to second registered. Bring some water on. You guys can tear and I'll be back in a second. Yeah, hello back. It's got great cope. You guys have had a chance to grab a blast of water, a couple ti, some chocolate, whatever. And biscuit eso we've, we've we've got two more sections left. One is about John. This and the next one is about growth and short stature. I think these are the most common stations that we get for our pediatric stations. That's uncovering. That's quite useful to know about. So let's crack on. Um, so this one will be about neonatal John. This so near little jaundice. Your foundation year to doctor Pediatric emergency department. Um, you're asked to review a 48 hour newborn baby. Looks jaundiced in the post. It would take a focus History and describe in detail how you will examine this newborn and how you will manage people. John. This is something that's quite similar in terms of mean. Um, even though we think it's similar to adults, actually causes the quite different in Children. Had this quite important. Also, we'll just causes a quick sport diagnosis. So two week old baby presents with jaundice, pales, stools and dark urine blood test show conjugated have a bilirubin AMIA, and he takes his biliary atresia. Biliary atresia. Yeah, spot on. That's biliary atresia. That's pretty good. That's one is a term baby boy. He was admitted on Day three. Severe, unconscious gait. John This day 30 the baby was still recurring for therapy. Mother's good blood group was a positive. Babies was a positive, and the direct Coombs test was negative. One, I guess. Hemolytic jungle attentional e immunity disease The newborn definitely can be. So, um, it's cracklin No no syndrome, and I'll come back to why it is in a second. But key thing here is that the baby present on Day three, John Doe's know Day One on day. Actually, the blood groups and the reason is we're all same and they humanistic John. This I would expect potentially the Derek Coombs test to be positive. These are all things that are executed. Probably ask, but we'll go through this in a second anyway. Okay. An eight year old boy goes to his GP following the diarrhea, diarrhea, illness on examination. He has mild jaundice, which he has had before. And his mother says it doesn't bother him. Yes. Jobert's syndrome. Yes. Perfect spot on. Yeah. So Jouberts into a milder form of private. Try Kreidler. Now I just don't know much. Go through the seconds. And then a 13 year old boy of African original sense with acute abdominal pain and jaundice. He's had a school in it to me previously. Hey, take us sickle cell cycle. So? So? Yes. Yep. So, yeah, that's one of the more classical presentations or sickle. So these cool so neonatal jaundice. So Ah, this time, I thought I thought it was the reverse process this time around. So we go through presenting complaints First, eso in terms of, um what you asked on the history of the first thing you're asking. And John, this is onset of John. This the winded record did occur in the first day. They start after day one day, two day three, and I'll explain why that's important. Later, they have any other associated symptoms that just fever pallor, dark urine, pales stools. So those are all obstructive symptoms that we talked about things like biliary atresia Every so in the vineyard. Connector is symptoms. And that's when um ah, when you get a cerebral involvement to do the jaundice and you get are the seizures are floppy and then wait close feeding history and, you know, But these are all really important. So weight loss of feeling histories. Because inadequate feeding babies we will complete a second can ask on from This is well and you're on Apple again just outside after, um, the measure of your hydration status and potentially narrowing down your causes. So in your history, presenting with those the questions that you be thinking about, uh, you also want to her ask about pregnancy and antenatal history. So maternal age, maternal serology. So things like infections that you're thinking about those HIV have the STD's blood groups. So is bug of mom, different baby hypertension or diabetes? The anti D status off the mother so meat or more visas? Disease of the new bone. Any birth injuries? Was it an instrumental Delivery? Um, so we will come to in a second as well. So obviously, if they if the half things like a on Tuesday, every with the use of suction so you can get a swelling in the head because it is just kind of pull that all the blood blood from between the fontanels and then you get significant hemolysis in that area so you can get these, like, careful hemotomas because that because you get a significant, um, all ESIs that breaks down and forms from this So those are all risk factors were and then substitute infection feeding history, some breasters his bottle amount and duration. And if there's been a difficulties of breast feeding and would come come to that in a second wife eating history is really important with jaundice and babies. Um, and family history. So things any siblings with neonatal John this and the liver disease um, a metabolic, a genetic conditions. And as you can tell already the questions that you ask, maybe their Children with John, this very different questions that you asked. Adults withdrawn This just because the spectrum of disease is quite different, that you see in babies off Children, the differentials a different eso just going through that now. So in a baby with John this after you've taken the history so that you think in the back of my mind and what could it be? And one of the differential is, And that's what the examine Alysia so jaundice within the 1st 24 hours of life. If they present to you on day one on delivery with John, this within the first refill. It's always pathological, and I come to what physiological means of pathological means. There's something wrong. Um, so the common causes are pathological. Day one John, This is right, he said. He mellifica disease or a bee or incompatibility or recess disease. The coupons Avio incompatibilities. Basically, if baby is blood will be and mom's boob A. Her blood naturally has antibodies towards, but could be so doing pregnancy. There's a chance. The chance these antibodies transferred to the placenta and attack babies red cells and John, this is a product off breakdown of hemoglobin, which comes from red cells. So you get an increased destruction of the red cells. Oh, maybe on compatibility jaundice. So this words really urgent measurement, bilirubin levels and hemoglobin because where you want to, you don't want all the babies. Red cells were breaking down spontaneously and being attacked by these maternal antibodies, so you might need to give a transfusion on. Do you need to treat the druggist early? If you find jaundice after 24 months of life, it's less likely to be things like maybe a and compatibility or recess disease, and you can't services disease stories. The bone is similar to ideo, but instead of antibodies towards the actual blood group B or A, it's because the presence of the D antigen on the blood cells baby is be negative on Mom. Uh, baby's be positive and Mom is be negative. So she has antibodies towards baby, and typically this doesn't happen with the first pregnancy. This means that so so for his mom's first baby was also be positive and she still be negative. It takes the whole of one pregnancy to develop of response in antibodies towards um, the the adage in on baby. So it has second pregnancy. If the next babies also positive for the D antigen. Then she gets transferred. There's a chance that she, these antibodies that have now had the time to develop transfer crosstable center and attacker red cells, which are called ability, activations and called races do these people. The recent visit three bones, typically most severe than 80 on, compatible it, So it's really important. Remember, that is a differential. So John Doe's that occurs after 24 hours of life still were talking on Day two Day three. So that could be physiological. Pathological physiological just means it's it's It's a normal life process on. We don't need to do anything about it or pathological means. There's a problem with it the other way. We can also categorized you on this after day two Day three is conjugated on conjugated Hyperbilirubin is too similar to your adults, and we'll talk about these further now. Absolute freezy, a logical John This so there's different things. So, firstly, we look at new bond with crackers so babies haven't increased enterohepatic circulation. All this means is that God doesn't move as fast as a more mature adult gutters and all the child gutters. And as a result, you have an increased amount of absorption bilirubin from the gut because there's a larger transit time. So, actually, now you getting all this conjugated bilirubin that was express created into the bowels. Now getting more eggs option, and that can cause John this. The second thing is that in babies, they haven't increased amount of red cell production. So if you look at the hemoglobin levels is usually put in 1 80 to 202 100 sometimes up to 20 in babies. Obviously they have a higher number of red cells, which means eventually the red cells are going to break down. And that's going to cost on this. Actually, John, this is normally a newborn baby. It's the level of John Disc that can be worrying in the ready to look at other things that can cause physiological jaundice of breast milk, jaundice, the breast feeding jaundice. So I think it's really important to know that breast milk from distant breast feeding jaundice different so breast feeding. John this and we took her first fuckers secondary inadequate feeding of dehydration. So if obviously it takes times for babies to latch on to mom's breast or just offer. Sometimes it takes time for Mom for let down with friends and mom to stop producing enough milk. So actually, there's a period of time where babies aren't getting that much milk on. Because of that, they're quite dehydrated and just out of pure dehydration, just like sometimes with dehydration, you get hyper Nutri Mia. You can also get John this just because of the concentration of John. This is not greater in your blood because of the dehydration levels, and that's what breastfeeding John this is and the typical way off dealing with breastfeeding. John, this is you assess. How long the babies on the breast whether mom feels like a breast heavy, etcetera. And sometimes you might need to give some formula milk for babies. Just talk up the feet to make sure they're getting enough until they start breastfeeding more regularly. So that's how you'd support them. Physiological John. This the the next one story is breast milk from this, so this is because of the breast milk itself. So it's a well known fact that babies who have breast milk increased risk of developing jaundice as competitive babies who have a formula milk on. There's multiple theories. A. So why this happens. So one of the there's some of the resort, for example, it slows down the action off certain key enzymes. The liver, such as you db GT there will be talking about later. All, for example, that there's actually the fact is that increased amount of fatty acids that they're in the in the breast milk and those preferentially bind the albumin more than the, um, John, this in the blood. It's not from the Yeah, in the blood, so that causes the unconscious, gated Hyperbilirubin Neemia. But there's lots of teary, so there's no solid evidence. So why does that happen? But we do know the breast babies of breast milk are more likely to develop personal trainers. So when you talk about physiological dollars, you're thinking about Natural Factor's so increased enterohepatic circulation, increased red cell production and then breast milk, um, breast feeding. So that was really important to get a good feeling. History, when you take your initial history in the exam is well because actually, these are the most physiological. Jonas is the most common cause of jaundice and the baby. I thought we'll do a quick revision off. Um, how how? Ah, John, this is formed. And so you get a bilirubin below movements cycles. You get breakdown off him of hemoglobin of 13 plus globin on the Hemed, then breaks down to form bilirubin eventually, And this is initially unconscious gated. So which means it's not soluble. It can't be excreted. So it's bound to albumin in the blood because if it's not bound albumin than it can easily get across the blood brain barrier. And that can cause things that connect us an effect on your grades. You want to be bound albumin, the then gets into the liver on, and then it's conjugated using engine enzyme called U D P G T, which is blue color. Oh, transferase. And this conjugated the bilirubin. All this means making it solubles. It goes from becoming insoluble to soluble, so it can be not be excreted. The hepatocytes then excrete this conjugated bilirubin into the senior sides, and then those form bile, along with lots of your bile acids and other compliment of the violent those excreted here, your biliary tree that then excreted into the bowels in the bowels. One of three things happens with either get converted to stern ical bilirubins. The conjugated movement either gets converted sternal below below gyn, and that gets created with your feces. And that's what gives your feces the brown color all and some of it gets reabsorbed back into the systems. Of course, back part of your enterohepatic circulation goes very potent vein system and is used to reproduce more bile in the liver. Oh, some of it is convert to your oh Bill Origen, which is then excreted via the kidneys. And that's what gives your kidneys. That color is well, So if you have an obstructive picture, that's why you have pales stools, dark urine because the pale pale stools because you're not getting any stomach allergic on the down to you and because, actually, if you imagine there's a block in the pipe in the in very system, you're getting increased backflow, or this conjugated bilirubin that needs to get out of the body somehow is excreted in the urine. You get a darker color, so and that's the rough life cycle of bilirubin and the blood. Um, we talked about classifying the John. This is John is a pathological jaundice within the 1st 24 hours or jaundiced after 34 hours. John this after 24 hours, either the physiological. Like he said, You do breast milk or breastfeeding or can be due to pathological sisters as well. And the way to categorize the pathological process is is similar to adults. We took over Prehepatic, Patrick and Posthepatic. So we go from the tops of Prehepatic and we go back to our diagram. So Prehepatic just means there's a increased break down in these red blood cells over here that lead to increased amount of production of unconstipated bilirubin. So you're going to get uncontradicted bilirubin India, which is a key and result in flow test and typical causes. So the way I like remember, the cause is of unconjugated prehepatic John, this is, I think, think of the red cell from out in. So if you think of the red stuff on the outsides of things wrong, things that go wrong with the membranes or sickle cell disease, um, or hereditary spherocytosis the things that go on the outside and you go inside the cell, you can get problems with the structure off the hemoglobin molecules of things like Tallassee me a should be taken out with our seniors, and that was a major in minors. Or you can get problems with the enzymes within the cell. So you get things like, gee, six PD deficiency off power. It kind of stiffens. And all of this least increase breakdown of the red blood cells that causes an unconscious, gated Hyperbilirubin media. So you get uncontradicted youngest with these, Then we have have Patrick John this that this is basically when you have a problem with in the liver a pack of John disc and either lead to I'm conjugated Byetta will be anemia or conjugated. We'll go through each one of these causes and more detail. So the first one is your best, and that's your best of them is basically do two a partial deficiency deficiency in this you g t enzyme. Remember, this enzyme is the one that converts the uncomplicated John this into conjugated John This So if you have a partial deficiency of this enzyme actually going to get a build up of uncontradicted on this to get uncontradicted, have a bilirubin Eva on job job s syndrome because it's only a partial deficiency actually doesn't affect most people, and most people will live their whole lives without knowing it. The only time that shows up is when there's other, some form of a stressor. So if the person is ill, um, then they're more likely to have an impaired liver functions leading to worsening and their existing your best and room with existing. You understand reading toe a further, um, country. Have a balloon anemia. We typically don't treat that because if you as long as you treat the primary investor, the infection tends to get better. So Kreidler now just syndrome. So like the vin, Yet that we spoke about earlier is basically a complete absence or problem with the UTI PGD enzyme. And that means that you're not converting any of your unconjugated bilirubin into your conjugated. So you get a you get up. You're unconstipated bilirubin. Neemia Andi. Despite extensive treatment and for the phototherapy, you'd still have an increased uncontradicted bilirubin level. So your signs for Kreidler Raja is a child who's been on treatment for John this, but But by day 10 2030 still having John this, actually, that's a red flag, because they should be, at this point, convert the liver enzymes should be working. Convert some of that one conjugated been beneath, so that's quite a milestone room. Do you been Johnson and Roto said Room of basically problems with excretion off the conjugated bilirubin by the hepatocyte, it's into the senior sergeant makes single to buy last. It's so basically the balloon is not conjugated, but it's not being excreted properly into the Sinus or so into the duct. We're not being next to the bile acids very well. So here you're getting buildup of conjugated bilirubin. But there's backs up into the liver causing a buildup of unconscionable because, well, you got a mixed picture of unconscious gated on conjugated bilirubin. Ah, just like the sugar and crackle in our jobs that even want Johnson and Go to's and drums are voters the most severe one given Johnson is the last CT one after that's important. So does the, uh, the Economist in dorms to know about have been talking about John Grissom. Leave on then. We have things like a tortured vaccine, which is your typical, uh, congenital infections of popular problem OSIs rubella cm the, um so these. These can also cause liver damage, leading to, um, conjugated and unconstipated Hyperbilirubin India. And after 100 types, inefficiency, just like your adult can cause jaundice is well, so these are causes off jobless within the liver, which can present it's uncomplicated or Contrave and post hepatic genders. So this is really important. And Children as a differential is biliary atresia because it's a surgical procedure that can be corrected very early using procedure called the pus eye surgery um, K s I s a I, which is basically where they get a cycle. They put a pipe pastored obstruction point, but directly into the bowel so that the biotin floor from the liver into the Internet on me is normal on That's a you get conjugated bilirubin, the me and obviously, if you have a PSA, if it's severe enough, it came back flow into the liver, causing unconjugated little believe it's well, so I hope that was useful. So we've talked about the history we've talked about. The differentials of what could be and how to classify them is when I asked him exam uh, the investigation. So you want to know a bilirubin prescript a woman but split balloon basically tells you the level of conjugated unconscious gated bilirubin. So obviously, if you're conjugated, bilirubins are quite high and you're thinking about either a hepatic posthepatic picture. If you're on conjugated blooms, are you thinking about a prehepatic picture and your old stinking all those causes off physiological jaundice in the breast milk Breastfeeding John, is that we talked about as well. You want to do an F B C? Because if you get hemolysis, which means just the increased break down the blood, either due to maybe your visas compatibility or any of these things that any of the pre about it causes that also called cause hemolytic. John this then you wanted me to make sure you're maintaining your hemoglobin levels. You doing FBC on the blood group A direct antiglobulin test. So the direct anti globulin test, or used to be called the Direct Coombs test is basically checking for the presence of antibodies on the surface of the baby's red cell. So you're checking to see, for example, if they're little antibodies on the surface of the baby's red cells. That gives you an idea. If it's caused you to things like a deodorant compatibility or recess disease, any autoimmune conditions on that will help you categorize the jungles for that to be zero. Basically investigations that you do on a baby presenting with jaundice further investigations you do is purely based on the causes that we talked about. They do accept excuse to stay with you to infection or throat screen. Looking for those instructions that we talked about? Um, TSH. Because hypothyroidism can also affect the liver and can cause John, this is well, and I'm conjugated. Have a bilirubin. India Abdominal ultrasound will be a first line investigation. If you were thinking about biliary atresia, so that's really important. Know for example, if you're thinking, What's your first line investigation for believing trees after you do the conjugated bilirubin levels in next procedure will be an abdominal ultrasound and your liver function tests. See, there's any help. Participate damage. How's it treated? Work. They've investigated it. So there's a chart like you can see on the bottom left here. The week typically have in the UK um, where you plot your jaundice levels based on the gestation of the baby on. Then it basically tells you there's two lines. If it's above one line Negative, baby phototherapy, and if it's above the other line, the need exchange pontoon. So that's very serious to the blue line, which indicates for the therapy. So Phototherapy is basically when you give at you the lighted certain Waveland on that conjugated the unconscious, gated bloombergan. So next soluble. So it increases the liver absorption bilirubin and decreases your own conjugated bilirubin levels. So it's called light therapy off for the therapy. It's basically where you the increased faith, the particular wavelengths and frequencies of light cause a congregation of the bilirubin, causing it to be absorbed and increased excretion so that releases it. Drawn this level. If it's very severe, you might have to things that can exchange transfusion, but you basically removal of the babies. It's like a dialysis kind of procedure where you remove all the blood and get some more in and or IV I G treatment. If you think it's all TV in cause off jaundice, the things I gave you incompatibility and, uh, recent disease. The newborn waited immune reaction you want, give some IV IgG immunoglobulin cool. Any questions about that at home? Any questions about jaundice? No, that's pretty good. When you're taking your second breather. Cool. Now the I actually got my finally off skin was a pediatric station was based on short stature, which is why I've included and I know people have got it again further. So I think it's quite interesting. How do you say she'll burp? It's It's different to cry, but my job, please. So chill birds, um, is basically a partial deficiency of the U. T. P G T and zone um, that causes, um uh, because it's only a partial deficiency. Actually, it's, uh, people want to and realize they have. It usually presents when they're much. All the Children or some kind of when they're adults would have a concurrent illness. Um, but that that's main difference. Where it's incredible. Naja. Because it's a full deficiency. You're going to have John Doe's right from the get go, because your body's not conjugated any of the bilirubin, and you're not able to. You won't be able to get the bilirubin levels down at all, sir. They'll be very obviously jaundice from the star. Hope that explains that we talked about short stature. Um, so this is your off key station. So you're a A six year old boy presents to connect with concerns regarding his growth. Yeah, so missed. All right for the student. Casper. Basically, you need to take a focus history, examine the patient, corkscrewing potential diagnoses, um, and see what kind of investigations he would do. So spot diagnosis six year old boy is brought in by his mother as she's worried about his height examination. He's found to be short for his age. There are no signs of other organic disease, and there's no features of hypopituitarism or hypogonadism is going to be written there. Do you guys think it is constitutional today? Just short. Yeah, yeah. Could be, Yeah. Um, a constitutional delay spot on next one. A five year old girl is brought in with concerns regarding the height she's noted to have short stature, widely space nipples and dysplastic nails. In Jackson Systolic Murmur is over the right second intercostal space. Yeah, it's a very classical presentation of Turner syndrome. Well done. Then a two day old boy is referred with increased irritability and jitteriness. There's a history of Yujia and he was antenatal. He diagnosed with BSD. Yes, small eyes, then lift up a living. A smooth filled fetal alcohol syndrome, some tries, and 21 this is, ah, fetal alcohol syndrome. So well, them, um, on a 15 month or girl presents with full Creon growth watery, greasy stools. She's been treated twice for otitis media that previous admissions blowers boat docked infections. Yeah, so we talked about this earlier so that that's the closest. Just take fibrosis. Yep. Well, dumb. The cystic fibrosis that has a very white ah symptomology in terms of what it can present, it's It's going to sting anyway. So approach. Too short stature. So when you when you when you've given this history in the exam, what what do you want to do? Just like anything else? The patient details Presenting complaint History examination is very important to ask for growth chart for the child in the exam because that that's what's going to give you lots of information, top differentials and why investigations and other differentials So pediatric short stature is focused questions. When you're talking about short stature, eso history presenting complaint. Has a child always been short of remain short right from the start? Is it something that's happened recently? Is a child gaining weight? Are there any other symptoms on system review. I think this is a really important point on I've seen on the OSTEO. Trust is well is to ask about weight eso when someone comes with a short height, it's really important to ask you about weight. Have brought the weight as well because it actually now is down your differential. Either way, based on that vaccinations, such developmental history has a child which there probably development milestones. We were actually just checking. Is this an overall growth issue? Is there's something underlying age of cute eruption again tells you about where they are good cycle. And how is the child performing at school? Past medical history of your previous respiratory anti infection so similar to see if we're talking about any previous admissions. Any maternal problems in pregnancy, things like IUD, uh, which should have been picked up on the clothes. And so that's intrauterine growth restrictions, um, or fetal alcohol syndrome. A B. So, um, those would be questions that you pick up here and social families of stroke history. So you want to ask. Mom is beating any medications of drinking alcohol in pregnancy. How does it may be sleep or the child sleep on. What's the situation at home? Because things like psycho social factors could actually growth quest, significant, please. And Children, the ones we've taken a focus history. We move on to the examination. See, you just say I want to examine the trials. So from top to toe, see doing general examination CDO weight, height, arm span, head circumference. Head circumference is very important, especially in babies were dealing with both because he's looking for signs of micro macro carefully. And those didn't let's see your causes well. So if the baby's got a big head, a small head but normal size body, it's more likely to be things like infections that are causing it. But actually the head is a normal is the same on the same. Central is the rest of the body is probably a different cause, even for dysmorphic features from the top two, things like a cleft palate year placement, um, size the shape, the hands and feet be moving down so chest a week. In the case of an actor, that was a very difficult example of the white least based nipples you have Internist syndrome. Um, Pectus excavatum, a car, not, um, and breast development. So the the I included Turner syndrome on the top there. Just because, actually, there's been. It's quite interesting. Clinically, the Lantus paste. Children with Turner syndrome don't get picked up because the endocrine function they get picked up because of that girl on. Do you take it easy when they reach puberty, they don't grow a scar us to the other girls when they come in with the growth concerns. And actually, a more detailed history of an analysis turns out the afternoons that's quite important. Remember, breast development again comes in the same category, but they're looking at, um, do you have any underlying endocrinology issues that that's causing hypopituitarism or hypogonadism? And then General Urinary? So Thomas staging. So this is when you look at the size in males would be looking at the size of the testicles to see what stage, um, off of puberty, the air. So the different things you look in town of staging as you look at it sounds a pubic hair. You look at the side of the testicles, you look at the the presence of hand different parts of the lower the cubic regions on growth. All of this together gives you an accurate. They're roundabout. Estimate aware of you. But yes, actually, someone comes to your shoulder. But they don't have any people care then or they just starting to get some people can are exhibiting, you know, then the initial stages of puberty. And you can be sure the parents at the start of the puberty, the more likely to go in general systemic exam. So look at the lungs. Heart of difference with things for, like, murmurs. So here are the main differential that you're thinking of. You looked at history and you've done examination. Now we have a set of defense, your diagnosis of their look. It's a constitutional delay. Is nothing but a delay the onset of puberty. Um so growth doing child, it is within the lower limits of normal. This usually family history of delays go through puberty. So that that, um um, But the important thing is, you know, once they hit puberty, actually that their final end height and is the same and it is unaffected. So that's really what I notice that's important for reassurance boxes and parents on. It's also the most common cause of shorts that in Children you can also get disorders or syndromes that is down syndrome term syndrome noon. We talked about Ernest, for example, here because it's a wonder lying pathological issue you're going to have an abnormal final height is still going to be shorter by the end of it. This is really important to know. Another common cause is chronic illnesses. So here this is this is where it's really important to know to the weight of the child because things like chronic illnesses, such a celiac disease and crone's disease actually use weight faltering as well as height faltering. And then, you know it's more of a nutritional issue with an underlying or moral issue on. But they're usually inadequate, nutritional raised nutrition requirement due to increased metabolic rate, for example. Um, and there's a but the key again. Here is, once you've diagnosed and you start treatment, you see a rapid, um, increasing height back to the normal height that they should have been in almost entire. They should have been after, so that that's what that's for. The the the top three. Then we have some other causes. So endocrine problem So which is rare and Children is compared to the other three that we talked about. So they're more likely to be always things like hypothyroidism growth hormone deficiency off Cushing's syndrome, which is more likely to be I after a gen it's of Children on treatment. It's systemic. Steroids, for example, who have chronic kidney disease have suppression of that growth. Um, and um can be quite short as a result. But again, once you've treated the underlying problem, for example, once you treat it the hypothyroidism or growth hormone deficiency, you have no more height after diagnose of stuff treatments. But again, that's really important. And then, um, displays years called short structure as well. So things are achondroplasia. 12 is, um, skeletal displays. Yes. Um, here again, because the underlying pathological issue you can't really fix, they haven't abnormal final height. No, Mr, besides the social deprivations that things like physical emotional deprivation or abuse at home can cause increase the stress levels on because a short stature as well and again I have kept no more height is achieved of these factors address. So actually, in terms of categorizing causes, I had the cataract is the best time because, like this or if you're seeing the child later on, and in an Oscar station of the show you your growth chart and say What's the most likely be? You can also categorize it based on whether they achieved their height normally or not for the end. Um, and that should give you a better idea. Which category falls into? One thing I haven't mentioned here is also familial short stature. So that's actually the child is quite short, But the parents are also a fairly short a zit. Expect the child will be shot. So that's so familiar. Constitutional delay of the most common cause is off short stature and Children. So you've done your history, you've done your exam. You thought about your differentials and you noted down based on where you have so far, Uh, you just need one last piece of the puzzle, and this point, the examiner says, Do you like to do any investigations like to say anything else you know? Yes, about There's a growth chart so growth chart of really, really, really important. Um, so we go through because you could be on my osteo station. I didn't have to fill in the growth chart, but I had to interpret one. Um, so go how to fill in one first and I'm going to you approach to f it Understanding one to the approach of feeling in once we choose the Vicodin helps you make sure. So this is being taken from the center of disease control from the US So you have a in the UK we use wh your growth charts. So here, um, you make sure that this is has two years or 20 years. Obviously, with the smaller infant, you want a different shot. Choose a plot, the previous parameter. So it's no good just having one off heart. So wait. So if possible, look in their rent book to look in their previous notes to see the previous ideal weight has been recorded. So that gives him over trend in a timeline. Compute the growth velocity so and growth occurs a different velocities and a difference because the different stages of development um hum, yeah, different stages of development. Um, so it's really important to know whether the child is going at the appropriate break for their age on blast. The you calculate mid parents are high, which will go through example of how to do so that you look for is just a million short stature because you say, actually, the presidential don't expect the child the shorts. And if there's any discrepancy between growth, grab this here. For example, if the height is grossly different, the wage of there and very different some tiles and you think you're more nutritional problems, for example, of any of the same was, um, over in the chronology problem. If they're both, if the weight is great and the height is no small, for example, and then the last thing is, then you have a differential diagnosis. So this is the standard approach to you and feeling in the gold charm, so we'll go through a case So 15 year old girl presents with short statues. This could come up in your skin, and the current height is 152 centimeters. The parents are very concerned. She's quite short compared to appears. Father's side is 170 centimeters and mother's side of 167. Is the revolt quite a bit swollen? There the approaches would choose the right growth chart against. We got a female growth charts for ages. Acuity 20 years on, we've brought it. So brought the previous parameters. Like me says, we brought a whole list of values, compute the growth velocity. So this case, it was normal because we can see that it's going across this entire line as expected at the same velocity. And he can't be in mid parental. Height is the formula for mid parental height, which is quite useful to know his father's house, plus mother's height divided by two. And there was, um, if you if the male child, you add seven. It was a female child. You might you subtract seven stuff. Father's side was Mother's height, divided by two either minus seven or add seven. And this gives you a particular height. That is the mid paraglide, but actually you want to see a range that would be normal for the base of the ninth to the 91st. Sent out for that make parent or height is given by plus minus 10 centimeters and boys or plus minus a French fry centimeters and girls if you do the math. So for this, for this girl we did Father's heart. So there's 117 was Mother's height, which is 160 divided by two minus seven. And a condom said that will give you a value. And then if you add and subtract 8.5 centimeters up in the both, you get a range of 149.5 cents majors 266.5 centimeters. And actually, if you look at that, then he said, where this girl is actually within that range. So actually she is within the normal mid parental height range, even though she's shorter than both her parents. Ah, based on the median age, she's within normal range for her parents or lights. And is any discrepancy between growth parameters? Know So here you can see both the height and the weight center aisles are not significantly difference and follow. The same pattern is well, What's important to know here again is she doesn't cross sent out, so it's not like a high was dropping off, and similarly with her weight, that helps now your diagnosis down further. So this go was a had familial short stature, which means just because of the parent heights and genetics, so you don't need to adjust. The answer would be. Actually, don't need to do anything further with this. Go just a reassurance. Nothing's wrong with her. She's just sure uh, I have another case. So here I've got a growth chart here. There's anybody want to tell me what this girl child represents. Potentially have a guess, So to describe it to you, it's a male growth chart. You can see that the height initially was on the lowest entitles dropped off across the tiles. And then there was a sudden pick up in the height. And similarly with the weight, any guesses on what this could signify? Celia. Early puberty, Constitutional underground disorder, which was treated yet There's really good at all, obviously bad a differential. So this is a classical picture of a chronic illness that was then created. So Well, then you've got that eso obviously up till this point, the patient could have been suffering with think such a celiac disease that you guys mentioned and then it was diagnosed and then treated, Um and then actually a high picked up and she regained her normal center that she was on originally And that's really important to know is that she regains a normal growth post treatment. And that's for reassurance is that the red flag sentence that will comfort nutrition here is faltering. Good is that she was crossing some town, so she's crossing more than two sentinels. Initially, there's a dramatic improved both diagnosis in intervention, and the final height is unaffected. So these are all the key heil things that you should know about for exam. Cool. Uh, then once you've done the good shock investigations that he could do further. So obviously it's not familial. It's not constitutional. That you want to look further is what else it could be. So we obviously went through the different causes of these things. That could be So. You do a urinalysis for this for blood count? Yes. Ah, lefties, Calcium serum eyes. This is looking for nutritional abnormalities, things that chronic illnesses, that we might be missing the undiagnosed. And then you look for specific investigations for indications things. If you're most celiac disease to do ttg cystic fibrosis, you do a sweat test like we discussed before Growth hormone deficiency hypothyroidism. You do screen as well or criminal menactra maladies. Just turn as a New Orleans and road from radiology. You can look at bone age is well, and that gives you an idea of what stage of puberty they are. So those the investigations that you could do so going through short stature again take a detailed history like we discussed other points. You examine them, you don't ask her growth chart. And then if it doesn't fit any of the constitutional familiar, quite hear you say, actually, my meter for the blood test look for underlying illness that might be messed with these. The test a wide range of tests we did. That's okay. Any questions about any of them? Do you mind to go to how to prop the growth chart for premature child? Uh, so that I don't have it right here, but fine is right. There's a separate. And so the w h o have it's separate shark. Um, that will be there for just a creature of infants. So it looks very similar to this, But the X axis will be in weeks. So once they reach, uh, 42 weeks of gestation, you then move on to regular chart and start moving this child after So initially, if they're pre term, use that chart and once they get on to a normal gestation he started doing this chart after, um, I can send out a link is world everyone with the reference is close example of how this all up a good job for pre tips. I think the feedback from's posted earlier in the chat. Uh, bye. Okay, so, um, that's it. That's most of it. I've got one last bit to go through, and I thought, um, this is another comment off ski scenarios. So, um, I was a clinical teaching fellow on one of the common ask is sometimes we ask is, um how to give it once a vaccination? Um so vaccination counseling is a big topic at the moment is quite likely to company exam. It's quite easy to get the marks on it because so much thinking more just makes you get there. It's just making sure you take the box terms of points, so just going to very quickly. So if you get it, if you're asked him a scenario, you need to counsel this parent or she's anxious regarding giving her babies of vaccines can you cancel her? So you do the same thing so that anything. So you wash your hands, introduce yourself. Confirmed baby's name, date of birth, cetera. And then you asked from general opening questions as it would have anything. So what's your thoughts for immunizations? Is there anything you're concerned about? What do you know about unionization is really important to ask these questions because actually, you might not need to go through your whole spiel if it will save you time in and examine you. Come back. That's his questions at the end. You told me, Mr Point, What mumps concerns were I mentioned Chunkin check again, because again, you don't want to be talking very much, uh, to the parents. You want to make sure that I understand the information that you're saying and get them to repeat it and ask any questions in between, um, the point that you have to include when you talk about why they should be vaccinated. So you mentioned protection. All seriousness is EAS is so often parents don't know what the disease is. Are we just know the abbreviated terms, the names, the vaccines like MMR or, you know, dtap whatever you tell them, it could cause measles, mumps, rubella and might be worth going through what some of these diseases can do based on which ones they have a problem with. It took well heard immunity that's basically saying to the mom, Listen, actually, vaccinating your child is important for your child, but it also reduces the spread of infections from your choice to other Children of the community on Because of that, it's better for the whole community to be vaccinated cause you're reducing the oral incidents off the vaccination. You re check the parents understanding this point, and then it's also worth explaining the vaccination schedule. But I think a lot of parents anxiety comes from Are they going to get all of them together? What if I miss one vaccine, Um, and how many courses are death of each one? So that's important to these are the on oscal Tech list. You do the first three things, you do the open questions and then you know these questions. Here's a brief. Obviously, if people know about the Androgel Wakefield study, which which happened in the two thousands about it was it was a terrible research study that was reduced of the case case series about the cuz. Patients that seemingly developed autism is a result of the MMR vaccine. It's since been disproved so a lot. But it would surprise you the number of parents that still refused MRI vaccine because of autism. Um, the other day and e. D. I had a parent, and I couldn't convince the otherwise she she was. She was so stuck on. And she said, My parents has told me not to give my child the MMR vaccine book the Waters and, uh and you can you can change some beliefs in Austin. Situation is the kind of feel that I would get. So there was a piece of research published memory. So, um, it's just for you guys to look at, but thank you so much. And that concludes the chat. Um